The Bony Triad


Blog post in form of letter with more discussion/information following.  The daughter in question is 9 years old:

Dear Mom and Dad,

How are you both?  Good enough here.  M1’s foot hurts, and there’s a high possibility that it’s a stress fracture, even though nothing showed up on the X-ray.  This makes me very concerned and ashamed because I have not been tracking our calcium intake very well.  I should know better than that.  As you know, we eliminated dairy for symptoms of cough variant asthma requiring Flovent and albuterol, allergic rhinitis requiring Flonase and Xyzal, chronic sinus infections requiring multiple antibiotics, and severe chronic constipation requiring daily Miralax.  Although we are amazingly prescription-free now on a day-to-day basis, in trying to achieve health in these other areas, I believe I have neglected bone health.  Just like all of my medical journals say.  Children who don’t eat dairy products are at high risk of low calcium intake.

Bang.  Shot dead.

Honestly, I have been very diligent about incorporating calcium-rich food sources into our diets, but M1 is my finicky child.  Now that I have started tracking each family member’s calcium intake, I see a huge problem.  M1 only eats half her greens.  M1 only eats half her salmon patty.  M1 snubs canned sardines.  Although the kid will pig out on broccoli, it’s certainly not enough to keep the running balance in the black.  Sadly, she’s not just a little short on calcium, she’s far short.  It isn’t enough to just provide the calcium source if she doesn’t eat it.

And to add fuel to the fire, winter has gripped us for seven long months now.  It’s April 23rd, and it snowed today, adding to our present foot of snow.  That means no intrinsic vitamin D production to help the body absorb and use calcium most efficiently.  That means very little bone building physical activity.  Although I think the body will compensate for deficiencies to a point, I think we’re at the calcium breaking point.  Obviously.

Low calcium.  Low vitamin D.  Low physical activity.  Put them together and what do you got?  A set-up for poor bone health.  No matter how “healthy” we’ve been eating.  Just a reminder to me that “healthy” is all relative.  Guess we don’t know for sure it was a stress fracture unless we get an MRI, which we don’t feel is warranted.  So we’ll just use this as a wake-up call for diligence.

Love to you,


Perhaps an Over Reaching Deficit

Bone health is not as simple as drink your milk.  Take a calcium supplement.  Eat your greens.  If any person, medical or otherwise, tries to make it appear simple, be a skeptic.  It is a complex interaction among calcium, vitamin D, weight-bearing exercise (running, jumping, lifting, etc), vitamin C, magnesium, protein, acid-base balance, vitamin K2, other micronutrients, genetics, body weight, and so many other biological and environmental factors.

I am not trying to overestimate or underplay the importance of calcium, but I want to raise awareness of perhaps overreaching calcium deficits in children who don’t consume dairy.  Like my child.  Perhaps a child can get by on 800 mg daily or 600 milligrams daily or 300 milligrams daily.  But there has to be a line somewhere for our poor bodies, and we just don’t know where it is right now.  In my mind, M1’s 225 milligrams has to be pushing the body’s envelope, literally at a breaking point.

Maximal bone mass is produced in adolescence.

Maximal bone mass is produced in adolescence and throughout early adulthood, when the body is rapidly undergoing growth–and thus why the calcium recommended daily allowance takes a jump at age nine.  Ninety-five percent of my daughter’s bone mass will be present by age 20.  I don’t have much time.

If a child’s body doesn’t get enough calcium, a mineral level the body regulates VERY tightly in the blood, it WILL rob the bones.  Gasp.  My husband and I decided that it wasn’t worth messing around with, and we picked up a calcium with vitamin D supplement for the kids.

“Well, what about…?”  We could dicker all day.

  • Is the recommended daily allowance (RDA) of calcium truly based on any science?
  • Is the RDA set too high?
  • Does calcium supplementation really prevent osteoporosis and fractures?
  • Can a person sustain less calcium intake and not sacrifice the bones as long as they get plenty of sun exposure and good physical activity?
  • Why do cultures with the highest calcium intake have some of the highest osteoporosis rates?

All interesting questions, but I’m down in the trenches being a mom.  I’ve got to come to a conclusion.

So What’s This Mom to Do?

  • Continue intrinsically calcium-rich foods. 
    • Keep serving up the calcium containing foods she likes.  Start putting extra broccoli on her plate.  Make a point to leave out a bowl of almonds out on the counter for spontaneous munchies.  Incorporate kale into soups and smoothies. 
    • Keep providing exposure to the calcium-dense foods she doesnt’ like, in the hopes that repeated exposure and encouragement will triumph.  Things like collard greens, salmon patties, and figs.  Maybe finding some new recipes would help.
  • Add in a basic calcium with vitamin D supplement.  Sure I wanted to acquire it through “honest” nutrition, but we’re not getting even in the ballpark of calcium requirements.  To us, the benefits outweigh the risks.
    • What about calcium enriched orange juice or rice milk?  I can’t help but think of fortified, processed foods as “Food on Botox”.  We don’t routinely use these foods in our home; they are real treats for the kids.  Compared to an orange, orange juice is empty, barren, liquid sugar.  Go for the orange, kid.  They don’t much like to drink rice milk, and we rarely eat cereal.  However, I do keep fortified rice milk in the pantry for odds and ends, and I no longer feel guilty about using it.
    • My kids take a pill supplement without difficulty so this is the path I have chosen, that I may continue to fill their stomachs with “honest” food rather than food stripped of nutrients and then fortified.
  • Try to find time daily for one hour of weight-bearing activity.  Bone formation responds to physical use against gravity.  The squeaky wheel gets the grease scenario.  If the bones are telling the body they need to be stronger to respond to their client’s volleyball training, like muscle builds up with use, so do the bones.  It has to be activity with running, walking, jumping, and lifting.  Swimming and cycling are great exercise, but they don’t build the bones.  Physical exercise is easy in the summer.  What about our seven months of winter?
    • Turn on You Tube or the Ipod and have the kids dance it up to 80s music.
    • Continue our extracurricular activities (dance, tae kwan do, gymnastics).
    • Have everyone bundle up and go for a walk.  Or walk the YMCA indoor track with me.
    • Clean the garage and have the kids jump rope.
    • Have stair races.  Time the kids and see who can get up and down the stairs 3 times the fastest.
    • Create obstacle courses in the house.
  • Continue encouraging whole foods to provide the “minor” (but vital) players in bone health.
    • Citrus fruits for vitamin C
    • A nut mix of almonds and Brazil nuts for magnesium
    • When I learned about vitamin K in medical school, I only learned about one form.  The form we get from dark greens.  The form that reduces the blood thinning effect of Coumadin.  However, there is another form called vitamin K2 that is very important for bone health.  So I’ll try to provide free-range chicken, free-range eggs, and not feel guilty about serving them salami and pepperoni–sources of vitamin K2.
    • Continue our well-rounded consumption of fruits, vegetables, nuts, meats, and eggs to get the copper, manganese, zinc, iron, potassium, boron, silica, and other unknown substances important for overall health and bone health.
  • “Sun, sun, Mr. Golden Sun, shine your light on me.”  Do you listen to the dermatologists here?  Slather on sunscreen?  Wear long-sleeve clothing?  Stay inside during peak sun exposure hours? 

I said, “Let them play.  Protect them early in the summer with sunscreen and clothing until they have a base tan and no longer will burn.”  Orthopedic husband said, “What about skin cancer?”  And I said, “Vitamin D helps cut down on breast cancer and colon cancers.  You can’t see those.”  He said, “Well, what is the incidence of morbidity and mortality of those compared to melanoma, basal cell, and squamous cell?”  And the debate continued on like this.

I do not want my kids to burn.  But I don’t want my kids exposed to unnecessary chemicals in sunscreen.  I want my kids to get intrinsic vitamin D production from the sun.  But I don’t want my kids to get skin cancer.  Since I’m not a dermatologist, I err on the side of vitamin D production from the sun side.  But if I was a dermatologist or plastic surgeon, I am sure I’d switch to the other side.  Here are some articles.  You decide for yourself.  No matter what, the conclusion seems to be that vitamin D is good for the body and bones, and we dont’ get enough.  However, please note that you CAN get too much vitamin D supplementation and overdose.  Not good.  So pay attention.

Given concern about skin cancer, many patients and clinicians are cautious regarding sun exposure recommendations. However, exposure of arms and legs for 5 to 30 minutes between the hours of 10 am and 3 pm twice a week can be adequate to prevent vitamin D deficiency.59  ”

Sunscreen Use: Correctly-applied sunscreen blocks the harmful ultraviolet B rays that cause skin cancer, but it also blocks most of the skin’s production of vitamin D. So people who use sunscreen daily are more likely to be low in vitamin D. But don’t ditch the sunscreen: The American Academy of Dermatologists says that sunlight exposure to unprotected skin increases the risk of skin cancer, and that there’s no safe level of sunlight exposure that allows you to make vitamin D without increasing skin cancer risk. Their advice? Use sunscreen or other sun protection daily, skip the tanning booths, and get your vitamin D from diet or supplements. Some Vitamin D experts take issue with the American Academy of Dermatologists’ hard line on sun exposure, and they recommend a more moderate option: Put sunscreen on your face, and allow your arms and legs to get a small amount of unprotected sun exposure—say, 15 minutes max—before applying sunscreen or covering up. It’s still a matter of scientific debate.”


“We found that daily intakes of vitamin D by adults in the range of 4000-8000 IU are needed to maintain blood levels of vitamin D metabolites in the range needed to reduce by about half the risk of several diseases – breast cancer, colon cancer, multiple sclerosis, and type 1 diabetes,” said Cedric Garland, DrPH, professor of family and preventive medicine at UC San Diego Moores Cancer Center.  “I was surprised to find that the intakes required to maintain vitamin D status for disease prevention were so high – much higher than the minimal intake of vitamin D of 400 IU/day that was needed to defeat rickets in the 20th century.”

In Summary

Although calcium with vitamin D supplementation isn’t optimal, it is the decision my husband and I have settled on for our children due to our nutritional restrictions and choices.  For now.  Hopefully we’ll eventually get the required calcium in via foods.  And move to a sunny paradise.

FYI:  The Calcium Conundrum interviews a Purdue University researcher who has studied calcium intake extensively.  I enjoyed reading her comments knowing she had first hand insight into calcium metabolism.







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