One of the recurring themes in this newsletter is the idea that various types of “early warning light” can focus your attention on the things about your life and health that need tweaking, while allowing you to ignore the things that are more or less under control.
We think this is important — so that we can spend as much time as possible getting on with life, rather than obsessing about what might be going wrong!
Examples we covered recently are the brain check engine light, and the fall risk warning light.
Over the last few months, several situations caused us to think about the relationship between diet and exercise and various dimensions of health especially relevant to older adults: for example bone strength, and levels of specific nutrients and Vitamins like Calcium, and Vitamin D.
A recurring theme was the role of “measuring” rather than just “acting”.
This becomes especially important when looking at various articles relating to advice for older adults about things like falls, bone strength, and calcium intake. Because time and time again, the articles talk about all things you “could” be doing, without grounding those actions in some framework of “measuring” that helps you decide whether or not those things are “urgent” or just “nice to haves”.
Measuring can help you decide what is, and what is not, an issue worth really focusing on.
NOTE: This article discusses various health related topics. It should not be taken as medical advice. Consult your physician for how this general discussion relates to you specifically. This work is NOT sponsored by any third party.
Examples that Illustrate the Problem
Here are a couple of real world examples from different Longevity Explorers to illustrate the issue we want to shed light on in this post.
Vitamin Levels
Explorer A described the following situation:
“My routine annual medical checkup involved a blood draw. It showed I had low Vitamin D, and otherwise everything was more or less “normal”.
The doctor told me low Vitamin D was associated with a variety of health risks, and was easily fixable. The recommendation re the Vitamin D was to take a supplement.
“How much should I take?” I asked.
“Well, most papers suggest somewhere between xxx and yyy amounts of Vitamin D”, said the doctor. “I recommend xyzzy IU’s”.”
Note that there was no discussion of “treat, measure, then dose adjust” in this interaction. Maybe this was just an oversight or a misunderstanding by the explorer, but we have found this is a bit of a recurring theme. The idea is “treat” and hope for the best. Rather than “treat”, then “measure”, then “adjust”.
The closed loop approach we prefer is:
start with the “likely appropriate dose” as above; then (after a period of time)
re-measure, and decide if that dose is or is not leading to the desired levels of Vitamin in the blood: then
adjust dose; then
repeat until levels are in the right range.
The importance of measuring
The key thought here is that we are adjusting the dose to achieve some specific measured level of the desired Vitamin — rather than just “dosing according to levels a study found worked well on average”, and hoping that also works well well in a specific individual.
This is a very simple example to illustrate the issue. What follows is a more complex example, with potentially greater risks and importance.
Bone Strength and Osteoporosis and Calcium Intake
Explorer B described the following situation:
After discovering, around age 50, that I had somewhat low bone density (but not “severe*), my doctor has been monitoring it every five years (using DEXA scans). After being relatively stable, but a bit low, for over a decade, in my mid 60’s my bone density started to decline a bit (still not “severe” enough for drugs to be recommended).
Motivated now to “do something”, I found various practice guidelines in the scientific literature (see Ref 1, 2 at the bottom of the page).
Below is an example table from Ref 1.
Caption: Table from Ref 1 (read full reference for context).
(NOTE: you need to read the full reference 1 to put this in context, especially to understand what the words “adequate” in this table mean).
Explorer B continues:
I decided to make sure I was following all these recommendations. This discussion is about the first: adequate intake of calcium.
So, how do you know whether you have an adequate intake of Calcium?
Well, the Ref 1 discusses what an adequate level is, and it varies depending on age and sex. For me, it was 1,000mg / day.
But what is my current intake? How do I figure that out? And what do I do if it is low?
The importance of measuring (again)
Here is where the “measuring” comes in again.
Note that this discussion so far is not about “should I take a Calcium supplement?”.
Instead, the steps are:
What is my current Calcium intake?
How does that compare with the recommendation?
What should I do about it?
But I read that “Calcium Intake Is Not Important”
We were interested to see a series of recent internet articles relating to bone density and risks. One in particular gave the strong impression that worrying about Calcium intake was not helpful, and referenced a publication from 1989 as evidence. You may well have seen that article too (we are not going to link to it).
As best we can tell, this perspective is misleading.
We think Ref’s 1 and 2, which are much more current and represent the consensus of two different physician bodies, are better places to look for “best practices” than the Internet. Those references both definitely include adequate calcium intake as a relevant factor in managing low bone density.
What Explorer B Did Re Calcium Intake
So, here is what Explorer B did with respect to his calcium intake.
(He also did other things relating to the other recommendations in the figure above, but they are not included here).
Step 1:
Use a nutrition “app” to track his food intake in some detail for a couple of weeks as baseline.
As part of that, he tried out several different nutrition apps, and found one worked best for this exercise. Stay tuned for a future post on that topic.
Step 2:
He learned that his typical calcium intake was much lower than recommended. And in reviewing his lifestyle he realized that this had probably been the case for several decades. In other words, he had been eating a diet low in calcium for decades (low compared to the recommended levels).
In the mind of explorer B, this might well be a reason for the low bone density. [When he talked about it to his physician, the doctor said “I see that as a “hypothesis” but one that is untestable”.]
But, regardless of whether this is a primary cause of his current situation, it is definitely “something to fix” — in order to optimize bone health going forward — according to the practice guidelines of Ref’s 1 and 2.
Step 3:
Adjust his daily diet to eat more foods rich in Calcium.
Luckily this was pretty easy. As previously, he ate almost no dairy products, and it was easy to add some yoghurt and cheese to his daily diet.
Step 4:
Repeat the tracking and measuring of step 1 with the new diet for a few weeks.
This showed a very significant change in Calcium intake, and now the levels were much closer to those recommended (although still a bit low).
Step 5:
Plan on keeping the new diet for the long term, and augment it with a low dose of calcium supplement that increases the total daily levels of Calcium to the recommended level.
NOTE: From the literature and from his doctor, Explorer B learned that too much calcium was also a bad idea (having various negative effects), so getting the “right” level was important.
Stay Tuned for More About the Nutrition App
While a bit tedious, the exercise of measuring a diet for a few weeks was pretty interesting for Explorer B.
Among other things, he found quite a big difference among the nutrition apps he evaluated in terms of how useful they were.
We plan to write more about that soon.
Internet Advice Misses “Measuring”
Here is the key takeaway in our mind.
Our daily dose of media intake is full of “advice”.
Typically it involves “here is what to watch out for” listicles. Or “do this, or don’t do that” advice.
The trouble with all this is that it often lacks context. Is this bit of advice really important to YOU.
Here is where the measuring comes in, as in the examples above.
Measuring can help you decide what is, and what is not, an issue worth really focusing on.
Measuring can help you decide what is, and what is not, an issue worth really focusing on.
References
Clinical Practice Guidelines: “AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/ AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS— 2020 UPDATE”. ENDOCRINE PRACTICE Vol 26 (Suppl 1) May 2020. (If you want to find this reference, use this information and Pubmed).
Clinical guideline for the prevention and treatment of osteoporosis (2021); National Osteoporosis Guideline Group. UK. (www.nogg.org.uk).
This is so very important -- whether it is nutrition, medication levels, or allergies. There is far too much "this is the standard" and too little "this is what you need," even with serious illness and medication.
Thank you.
I really like this key point "Measuring can help you decide what is, and what is not, an issue worth really focusing on."
I'm especially interested in measuring trends and notifying family caregivers.