Non-Clinical Articles

The Top Seven Clinically Important Nutrient Deficiencies in Women. Steven Masley, MD. Florida Family Physician; Winter 2010 Issue

During the 1999 to 2000 National Nutrition Assessment, the USDA Center for Nutrition Policy and Promotion noted that only 10% of the U.S. population had an adequate diet, while 74% were rated as inadequate and 16% were rated as poor, markedly increasing the risk for major health problems. Poor or inadequate diets are linked to four of the top 10 causes of death in America: heart disease, cancer, stroke and diabetes; these are strongly related to obesity and osteoporosis. Projections for the 2000 to 2010 national nutrition assessment anticipate the US diet will worsen, making the goal to enhance nutrient intake a high priority.

1. Most of Florida’s women are motivated to meet their nutrient needs yet need proper guidance from Florida’s family physicians to ensure their success. The top seven nutrient deficiencies that are common in women and with correction would make a substantial improvement in health are: Fiber, Vitamin D, Magnesium, Calcium, EPA & DHA (fish oils), Vitamin K, and Iron.

#1: Fiber

The most clinically important deficiency in the American diet is fiber. Fiber intake in the US averages 12-15 gm daily, while nearly all national organizations suggest 30-50 gm. Fiber consumption is inversely associated with insulin levels, weight gain, GI function, and many CVD risk factors (central adiposity, BP, HDL and LDL, fibrinogen, and triglycerides).

Fiber comes in two forms—insoluble and soluble. Both forms are essential; they reduce calorie intake by improving satiety, result in good weight control, and are nutrient dense. Insoluble fiber (good sources are whole grains) enhances GI function. Soluble fiber (found in fruits, vegetables, oats, nuts, and beans) lowers cholesterol and blood sugar levels. Half of our 30 gm of fiber intake should come from fruits and vegetables, such as two pieces of fruit, a salad, and 2-3 cups of colorful vegetables per day.

This deficiency applies to women of all ages and has a large impact on their health.

#2: Vitamin D

Vitamin D is well known to enhance calcium absorption and is essential for maintaining bone density. Low levels of vitamin D are strongly associated with an increased risk for both autoimmune diseases (especially multiple sclerosis and cancer; in addition, treatment with vitamin D in RCTs has been shown to improve outcomes. Vitamin D inhibits the proliferation of malignant tumor cells such as those that may occur in the colon, prostate, or breast. 62% of elderly women’s diets are deficient in vitamin D and 32% of young adults have deficient vitamin D levels (on blood determinations) during winter. Compounding dietary deficiency is the reduction of sun exposure for many Americans. Adequate sun allows the skin to synthesize vitamin D from cholesterol but sun block prevents this production. Concerns regarding both skin cancer risk and skin aging have kept many out of the sun. Vitamin D deficiency exists in most Floridians. Controversy surrounds the current recommended intake for vitamin D; 200 IU has been shown to prevent rickets and is the amount noted on nutrition food labels. Yet at this intake level, rates for multiple sclerosis, osteoporosis, and many forms of cancer increase substantially. Data shows that 1,000 IU daily is the evidence-based intake to minimize disease risk in young adults, and 2,000 to 3,000 IU daily has an excellent safety record and may be required to achieve optimal levels in the elderly. The good news is that vitamin D deficiencies can be easily eradicated at minimal expense if patients ensure adequate intake.

There are times when vitamin D levels (a 25-hydroxyvitamin D level, not 1,25-dihydroxyvitamin D) should be measured to clarify optimal dosing, e.g., suspicions of rickets, osteoporosis, or an autoimmune disorder. Most laboratories list 30-32 ng/mL as a normal level, although the most common expert-opinion goal is a level of 40-70 ng/mL.

#3: Magnesium

Magnesium (Mg) is required for more than 300 chemical reactions in the human body affecting cardiac function, bowel function, blood sugar control, BP, and bone health. Mg deficiency plays a role in cardiac deaths, poor BP control, and GI problems, in particular constipation. About half of Mg stores are intracellular and half are combined with calcium and phosphorus in bone. Only 1% of Mg is found in blood; thus serum Mg levels are a poor reflection of Mg stores and the simplest measure is a RBC Mg level. The RDAs for Mg varies by age and gender but ranges from 300 to 420 mg daily, increasing by 40 mg during pregnancy.

Sources of Mg are green leafy vegetables, whole grains, nuts and seeds, wheat and oat bran, and soy products. Not only are 75%-85% of U.S. diets deficient in Mg (the average diet contains 50%-60% of the RDA) but several common factors lead to Mg depletion, including diuretic use, elevated glucose levels, diarrhea, alcohol intake, and malabsorption related to GI diseases.

Complicating Mg deficiency is that calcium supplements block Mg absorption and worsen what is already a national Mg deficiency. This problem is complicated by the lack of quality clinical outcome studies identifying the optimal calcium/Mg supplement recommendation, but expert opinion regarding combining these supplements ranges from a 2:1 to 3:1 calcium/Mg ratio. Symptoms associated with Mg deficiency include muscle cramps, tingling, numbness, abnormal heart rhythms, coronary spasm, seizures, confusion, disorientation, loss of appetite, and depression. Mg is commonly supplemented in the form of Mg oxide, but this frequently acts as a GI irritant. Better tolerated and absorbed forms of Mg include chelated Mg (protein-bound rather than salt bound), Mg citrate, or Mg glycinate.

#4: Calcium

Calcium (Ca) is well established as essential for bone health and is associated with membrane stability, impacting BP control and cardiac function. More recently, Ca deficiency has

been associated with weight control and metabolic rate. Ca deficiency is of high clinical importance as the average diet contains only 40%-50% of the RDA (800-1,200 mg daily, varying with age and gender). This is especially important for adolescents girls as they must build their life time calcium stores between age 13-21 (essentially their calcium bank account for life). Daily intake of 1,500 mg is recommended for people with osteopenia or osteoporosis. More than 2,000 mg of Ca daily is excessive and has been associated with an increased cancer risk. Too often, physicians recommend Ca supplementation without assessing dietary intake, which leads to inappropriate Ca dosing. Subtracting the amount of Ca in foods ingested from the patient’s Ca-intake will yield the amount of Ca that must be provided from either a supplement or a daily food source. As significant calcium isn’t in a multivitamin tablet, it needs to be consumed in food or may require several Ca pills daily to reach the recommended intake. The most commonly sold Ca supplement is the inexpensive Ca carbonate, which is popular, as it creates the smallest pill size. However, it must be taken with food to be absorbed, may contain lead, and is associated with GI symptoms, including constipation. The best absorbed and tolerated form of Ca is protein-bound or chelated Ca, but it is more expensive and twice the size of Ca carbonate pills. Ca citrate is less constipating than Ca carbonate, does not need to be taken with food, but it remains a large pill, with similar absorption as Ca carbonate.

#5: Long-chain omega-3 fats

Long-chain omega-3 fats, EPA and DHA, come from seafood and have been shown to have multiple clinical benefits. They reduce triglyceride levels and clot formation, improve insulin sensitivity, and lower inflammation in patients with Crohn’s disease and rheumatoid arthritis. RCT studies have shown that fish oil decreases the risk for CVD events and reduce mortality, and increasing fish oil intake is more important than cutting saturated fat intake.

Medium-chain omega-3 fatty acids from plants (soybased foods, ground flax seed, and nuts) are healthy sources of fiber and nutrients and will lower cholesterol levels , but they do not have the same proven benefits as EPA and DHA.

Fish-oil dosing varies with the indication. One gram daily, obtained from eating cold-water oily fish three times/week enhances blood sugar metabolism, reduces the risk of arrhythmias, and lowers CVD risk. Higher dosages (2-4 g daily) are required to lower triglyceride levels and reduce inflammation adequately to treat arthritis symptoms. Good sources of marine omega-3 fats include salmon, sardines, sole, herring and trout, plus cold-water oysters and mussels. Sardines, canned wild salmon and herring are the healthiest and least expensive sources.

While seafood provides many benefits, one of the concerns related to its consumption is mercury intake. Fortunately, many marine foods high in omega-3 fats are low in

mercury. Follow these two rules: Cold-water fatty fish are high in omega-3 fat; large-mouth fish are high in mercury. Thus, keep tuna, grouper, snapper, and bass to <2-3 servings a month and avoid swordfish, kingfish and shark to eliminate most of the excessive intake of mercury.

Fish oil supplements are convenient though expensive. Most brands are free of heavy metals, but many inexpensive brands are rancid, resulting in foul burping, and by increasing lipid peroxide levels pose theoretical harm that has not yet been assessed in clinical trials. To ensure low rancidity, consumers can poke a needle in the first capsule from each bottle and taste the contents; fish oil should be palatable.

One caution with fish oil is that dosages >2 gm daily mildly increase bleeding risk. In particular, patients scheduling surgical procedures should stop high fish oil dosing at least one

week prior, and those being treated with anticoagulation (such as warfarin) should avoid consuming >2 gm daily.

#6: Vitamin K

Vitamin K is a fat soluble vitamin derived from plant sources and is commonly deficient in American women. Vitamin K1 (phylloquinone) comes from plant sources. Vitamin K2 (menaquinone) comes from fermented soy products. The RDA dosage was designed to prevent excessive hemorrhaging (90 mcg females/ 120 mcg males) yet this level of deficiency is rare and usually related to severe intestinal diseases with malabsorption. Much more clinically important than clotting, vitamin K plays a critical role in bone and vascular health.

Vitamin K1 at a dosage of 1,000 mcg daily, the dosage found in one cup of cooked greens, spinach and kale will increase osteoblast bone building greatly by increasing carboxylation of osteocalcin. In Japan, randomized controlled trials with Vitamin K have shown decreased fracture rates and increased bone density (similar to biophosphonates but with no reported adverse events). Although less well studied than biophosphonates, this is a secondary treatment option for patients at elevated fracture risk.

Vitamin K also activates Matrix Gla-Protein (MGP) thereby blocking vascular calcification. Low vitamin K intake is associated with hypertension and calcification of the arterial media. Vitamin K supplementation improves arterial elasticity in humans. The bottom line is that ensuring adequate vitamin K intake with one cup of cooked greens daily appears to help keep calcium in the bones and out of artery walls.

#7: Iron

Iron deficiency is the most common nutrient deficiency impacting growing children and menstruating women. Fatigue is the predominant symptom. Iron sulfate (a salt) is inexpensive and readily available but often causes GI distress. Better absorbed would be amino acid or protein bound iron; although more expensive, it is much better tolerated and absorbed.

Ironically, a much more clinically important problem worth noting isn’t iron deficiency, but iron excess in post menopausal women and in men. Excess iron intake, frequently caused by supplements containing iron after menopause, is associated with increased CVD and cancer risk as iron in excess acts as a powerful oxidant.

Safety First

As a physician, recommending a supplement to meet nutrient needs is challenging as the quality of supplements is often inconsistent. Aim to recommend brands that have the U. S. Pharmacopoeia (USP) or Good Manufacturing Process (GMP) logo for better quality.

Summary

Ensuring optimal intake of fiber, vitamin D, magnesium, calcium, fish oil, vitamin K, and iron will play a major role in preventing the most common diseases in American today. Family physicians are ideal for educating Florida’s women.

1. Masley SC. Revitalize Your Heart, 2010 Submission to a major publishing house for national distribution, application pending.
2. Masley SC. Optimizing Cognitive Performance, Executive Focus, 2008
3. Masley SC. Optimizing Cognitive Performance, Tampa Bay Magazine, 2007
4. Masley SC. Ten Years Younger, Random House, New York, 2005. This book and program has been featured on the Discovery Channel, the Today Show, and with over 200 media interviews.
5. Masley SC. Vegetarian Holiday Feasts, by Steven Masley, M.D., Vitality Books, 2000: A healthy, gourmet vegetarian menu plan for the holidays
6. Masley, SC. The 28-Day Antioxidant Diet Program, by Steven Masley, M.D., Vitality Books, 1998: Nutrition/cookbook
7. Masley, SC. Enhancing Mountain Fun, Nutrition article, Ski News, Utah April 1998
8. Masley, SC. Enhance Your Productivity, Access Destinations, January Issue 1999
9. Masley, SC. Feasting Over the Holidays, Ski News, Utah, December 1998 Issue