FOREVER  YOUNG  -  from  chapter  five

Vitamin D

Vitamin D is a fat-soluble vitamin that functions as an important hormone. 

Vitamin D communicates to the intestines to increase the absorption of calcium by as much as 80 percent. Vitamin D is also well known for maintaining normal calcium levels. These are just a few of the extremely important functions of this essential nutrient.

Vitamin D Deficiency

In March 2006, Mayo Clinic Proceedings printed an alarming article about the high prevalence of vitamin D deficiency. The highly respected, author, Michael Holick of the Boston University School of Medicine, stated, "Vitamin D inadequacy has been reported in approximately 36 percent of otherwise healthy young adults and up to 57 percent of general medicine inpatients in the United States and even higher percentages in Europe. Low sunlight exposure, age-related decreases in vitamin D synthesis in our skin, and diets low in vitamin D contribute to the high prevalence of vitamin D inadequacy."

Supplemental doses of vitamin D (taken together with calcium and magnesium) and sensible sun exposure could prevent deficiency in most of the general population, according to Holick. In this section we will learn which forms of vitamin D are most effective, starting with the most natural: the sun.

Vitamin D Sources

Sunlight is the best source of vitamin D. It can provide you with your entire vitamin D requirement. Children and young adults who spend a short time outside two or three times a week will generally synthesize all the vitamin D they need. If you are older, you have diminished capacity to synthesize vitamin D from sunlight exposure. Many of us use sunscreen and/or wear protective clothing in order to prevent skin cancer and sun damage, depriving ourselves of vitamin D. In these instances it is important to consider getting your vitamin D from food and supplements. Vitamin D is unique among vitamins in that it can be provided to the body through food or by exposure to the sun. Sunshine is a significant source of vitamin D because ultraviolet rays from sunlight trigger vitamin D synthesis in the skin. I recommend spending fifteen minutes a day in the sun without sunscreen. This will increase vitamin D production, known to reduce the risk of many internal cancers as well as the risk of osteoporosis. Although sun exposure has been greatly vilified in the past decades, exposure to the sun is our most important source of this critical vitamin.

The application of sunscreen with an SPF factor of 8 reduces the production of vitamin D by 95 percent. In latitudes around 40 degrees north or 40 degrees south (Boston is 42 degrees north), there is insufficient UVB radiation available for vitamin D synthesis from November to early March. Ten degrees farther north (Edmonton, Canada), this "vitamin D winter" extends from mid-October to mid-March. According to Dr. Holick, as little as five to ten minutes of sun exposure on arms and legs or face and arms three times weekly between 11 a.m. and 2 p.m. during the spring, summer, and fall at 42 degrees of latitude should provide a light-skinned individual with adequate vitamin D and allow for storage of any excess for use during the winter with minimal risk of skin damage.

Vitamin D Supplements

There are many health benefits of vitamin D, and, as mentioned in chapter 2 and this chapter, I recommend that we get it from sunlight. However, when this is not practical, a vitamin D supplement may be a strategy to ensure adequate levels. But what vitamin D supplement is best?

Since a large body of science shows that vitamin D works closely with calcium and magnesium, it is best to take vitamin D in combination with calcium and magnesium to maintain a proper balance. Recent literature shows that most calcium supplements have too little vitamin D to be effective. And some of them use synthetic vitamin D2. A much better form is natural vitamin D3, which stays in your system longer and with greater effect.

Effects of Vitamin D Deficiency

A deficiency of vitamin D can result in the following conditions:


In infants and children, severe vitamin D deficiency results in the failure of the bone to mineralize. Rapidly growing bones are most severely affected by rickets. The growth plates of bones continue to enlarge, but in the absence of adequate mineralization, the weight-bearing limbs become bowed. Although fortification of foods has led to complacency regarding vitamin D deficiency, nutritional rickets is still being reported throughout the world.


Although adult bones are no longer growing, they are in a constant state of turnover. In adults with severe vitamin D deficiency, the collagen bone matrix is preserved but bone mineral is progressively lost, resulting in bone pain and osteomalacia (soft bones).


Vitamin D deficiency causes muscle weakness and pain in children and adults. In a cross-sectional study of 150 patients referred to a clinic in Minnesota for the evaluation of persistent muscle and bone pain, 93 percent had vitamin D deficiency! Muscle pain and weakness were prominent symptoms of vitamin D deficiency in a study of Arab and Danish Muslim women living in Denmark. Another trial found that supplementation of elderly women with 800 IU per day of vitamin D and 1,200 milligrams per day of calcium for three months increased muscle strength and decreased the risk  of falling by almost 50 percent compared with supplementation with calcium alone. This is an extremely significant finding and a compelling case for supplementation.

Risk Factors for Vitamin D Deficiency

If you are in any of the categories below, you would be well advised to get a blood test to determine your vitamin D levels.


Osteomalacia has been documented in women who cover all of their skin whenever they are outside for religious or cultural reasons. The application of sunscreen with an SPF factor of 8 reduces the production of vitamin D by 95 percent, creating a problem similar to that of covered skin.


People with dark skin synthesize less vitamin D on exposure to sunlight than those with light skin. The risk of vitamin D deficiency is particularly high in dark-skinned people who live far from the equator.


The elderly have reduced capacity to synthesize vitamin D in the skin when exposed to UVB radiation and are more likely to stay indoors or use sunscreen. Institutionalized adults are at extremely high risk of vitamin D deficiency without supplementation.


If you suffer from an inflammatory bowel disease like Crohn's disease, you may be at increased risk of vitamin D deficiency, especially if you have had small-bowel surgery.


Cystic fibrosis and cholestatic liver disease impair the absorption of dietary vitamin D.


Being overweight increases the risk of vitamin D deficiency. Once vitamin D is synthesized in the skin or ingested, it is deposited in body fat stores, making it less bioavailable if you have large stores of body fat.

 A Special Message for Menopausal Women

One of the negative effects at the onset of, during, and following menopause can be bone loss. Women in these groups are more susceptible to all of the maladies associated with weakened bones due to an increase in the rate of declining bone density and the associated loss of bone health.

Getting on the Right Tract

As mentioned, our bone marrow produces both red and white blood cells. Our red blood cells carry oxygen and nutrients to every tissue in the body. Our white blood cells are the foundation of our immune system. Seventy percent to 80 percent of our lymphatic system (immune system, tissue) is located in our gastrointestinal (GI) tract. The digestive system is the first and most important step in processing the nutrients we need to exist. It is estimated that the surface area of the digestive tract is similar in size to a football field. With such a large exposure, the immune system has to work overtime to prevent pathogens from entering the blood and lymph systems. On account of this function, the GI tract is the system in the body that is most at risk from foreign matter in our food and water. It is the site of important life-protecting "recognition and response" signaling and processing, both accepting and processing the beneficial food and drink while rejecting and/or disposing of the potentially toxic.

Since our bodies are composed of food processed by the digestive system, rebuilding the digestive system itself is dependent on the efficiency of this process. It is self-perpetuating, which is why the quality of food and food supplements is so important. This is also why so much of the body's lymphatic system tissue is located in the gastrointestinal tract. A healthy digestive system is essential to healthy immune function and vice versa. And a healthy digestive system is essential to good health. If our GI tract is not functioning at its best, our immune system is also struggling. As a result, declining digestive health and function lead to declining overall health. As stated previously, all of our white blood cells are made in our bones (B cells), some of which are directed to our thymus gland, the master gland of the immune system, to become T cells.

When we contemplate these intricate interactions, it soon becomes clear that the health of our bones is instrumental to our health and longevity in general. This understanding is especially important today, because there are so many toxins and contaminants in the environment and food chain. Keeping our bones and GI tract healthy is the first step to maintaining a healthy immune system, which is vital in protecting us from the epidemics and pandemics that seem to be lurking around every corner.

Red and white blood cell production alone makes maintaining optimal bone health an important requirement for optimal overall health, especially as we age. It is no coincidence that with aging, diminishing bone health is also accompanied by reduced energy, increased fatigue, an increase in digestive problems, and an increase in maladies associated with a weakening immune system. These maladies include such disorders as rheumatoid arthritis, osteoarthritis, irritable and inflammatory bowel disorders, and a host of other chronic inflammatory and degenerative problems—another excellent reason to make sure your diet is rich in high-quality probiotics and foods that are not pro-inflammatory, since pro-inflammatory foods will compound these problems.

During medical school, one of the many basic science course requirements was embryology, the branch of biology that deals with the formation, early growth, and development of living organisms. As we studied the development of the fetus from conception to four months, we learned that all of the major organs of the body, as well as muscle, bone, and other types of tissue, are derived from three basic layers of tissue within the embryo. As you will recall, I learned that both the skin and the brain are derived from the same layer of embryonic tissue, which I call the brain-beauty connection. Bone cells and immune stem cells have a common origin and a functional relationship, just like the skin-and-brain connection known as the osteoimmune relationship. That functional relationship is the basis for the growing field of osteoimmunology. Consider this alarming fact: it is now known that chronic immune system overexertion leads to bone loss and can also promote muscle wasting and increased fat storage.

This unfortunate triumvirate does not have to be inevitable. Muscle wasting/loss of muscle mass in older people is called sarcopenia. As discussed earlier, I had long suspected that there was a strong link between inflammation and sarcopenia and used it as a model to measure and compare the loss of muscle mass seen in those who diet. I was not surprised to discover that patients who suffered from sarcopenia had higher circulating levels of inflammatory markers than those who experienced less loss of muscle mass, while other parameters had insignificant differences. Those other parameters, including levels of growth hormones and sex hormones, were fairly close to the same level in both groups. In simple terms, the subjects with the greatest loss of muscle mass were in an inflammatory state. Inflammatory markers, such as C-reactive protein and cytokines such as interleukin-6, are elevated in the people who suffer the most loss of muscle mass, or severe sarcopenia.

This loss of both bone and muscle mass, in conjunction with increased fat storage, has very special disease implications that reach far beyond the obvious aesthetics. According to Navinchandra Dadhaniya, M.D., a specialist in geriatric medicine at Illini Hospital in Pittsfield, Illinois, a healthy young person's body composition includes 30 percent muscle, 20 percent fat, and 10 percent bone. A person age 75 or over may have 15 percent muscle, 40 percent fat, and 8 percent bone.

Reduced bone density, loss of bone health, osteopenia, and osteoporosis portend much greater risks to the body than the broken hip so common in the elderly. These conditions have a systemic impact, predisposing the body to other potentially very serious disorders as well. For example, in a study presented in June 2008 at the American Society of Clinical Oncology's annual meeting, researchers from Washington University reported that maintaining bone density could be a key to decreasing the spread of breast cancer.

The Weight Loss Dilemma:

Bone Health Is the Ultimate Victim

As we have seen, dieting increases our levels of inflammatory markers, accelerating the loss of precious muscle mass, but that is not the only negative consequence. There is currently an epidemic of aging people who are either overweight or obese. This is especially true for women in the process of menopause. In our efforts to combat this global problem, we run the risk of an often overlooked yet extremely harmful consequence of weight loss: the adverse effect it typically has on bone mineral density (BMD), fracture risk, and functional bone health.

At any moment millions of Americans of all ages are dieting and struggling to lose weight by means of a wide variety of programs and plans. This is particularly true of women; many start radical diets as early as their teens and continue with erratic eating habits throughout the decades. The goal of most weight loss programs is to lose as much weight as possible, as quickly as possible. In virtually all major weight loss plans, whether based on weight loss pharmaceuticals, nutriceuticals, and/or calorie-fat-, or carbohydrate-restricted diets, little or no consideration is given to the kind, as opposed to the amount, of weight that is lost in spite of the adverse, sometimes life-threatening, effects dieting can have on both muscle mass and bone health. People are obsessed with scale weight, but it is not scale weight that is of primary importance. As we saw in chapter 3, "The Metabolic Miracle," we can and will actually weigh more if our bodies are well muscled, because muscle weighs more than fat. 

Weight loss, including that facilitated surgically through either gastric bypass or gastric banding procedures, has repeatedly been documented as depleting bone density and increasing fracture risk.

BMD losses are particularly pronounced in middle-aged or older Caucasian women, particularly those who are thin, petite, and over 40 with a long history of dieting. This should come as a serious and startling wake-up call to women of all ages as they struggle to keep excess weight off. In a study typifying the adverse effects of weight loss, premenopausal and early perimenopausal women who were randomly assigned to a lifestyle intervention lost 3.2 kilograms (around 7 pounds) over eighteen months and experienced rates of BMD loss at the hip that were twice those of weight-stable control subjects. In another study, in spite of a daily intake of 2,000 milligrams of calcium, bone loss occurred at some sites in overweight postmenopausal women because of weight loss. The authors report that daily calcium intake of 3,400 milligrams is more likely to minimize bone loss during weight loss postmenopausal overweight women.

Therefore, evaluation of the overall risks and benefits of weight loss in overweight women should include monitoring its effects on BMD and the potential risks for osteopenia and osteoporosis, especially for women approaching, experiencing, and following menopause. Consideration should also be given to the type, duration, and intensity of physical activity that may retard BMD loss. Perhaps most important, diets need to be focused on decreasing inflammation as opposed to overall calories, as we will see in the next chapter. This means eating adequate high-quality protein, especially cold-water fish, lean free-range poultry, and grass-fed beef and lamb; fresh fruits and vegetables; and healthy fats such as extra-virgin olive oil.

You should do your best to limit your intake of starchy foods, eliminate all sugar, refined starches like white flour, and other processed grains. The prospect of avoiding foods that are so abundant might seem daunting, but you will feel so much better when you drop these foods from your diet that you will not even miss them.


Not Just for Women

More recently, one study tested the hypothesis that weight loss in older men is associated with increased rates of hip bone loss regardless of adiposity (fat) and intention to lose weight. Higher rates of hip bone loss were found in men experiencing weight loss, regardless of body mass index, body composition, or intention to lose weight. Even among obese men (those with a body mass index greater than 30) trying to lose weight, those with documented voluntary weight reduction experienced a greater amount of hip bone loss. Loran Salamone and colleagues examined the effect of changes in body weight on BMD in normal-weight populations. They evaluated the effect of a lifestyle intervention aimed at lowering dietary fat intake and increasing physical activity to produce modest weight loss or prevent weight gain on BMD in a population of 236 healthy, premenopausal women aged 44 to 50. Dual-energy X-ray absorptiometry analyses (DEXA) of BMD at the lumbar spine and proximal femur were made before and after eighteen months of participation in the trial. The researchers found that women in the top quartile for weight loss experienced more than three times the rate of BMD loss compared with all other women.

Alarming facts such as these inspired me to write The Perricone Weight Loss Diet, because with the right food and supplements, you can lose body fat while maintaining precious bone and muscle. As you learned in chapter 3, "The Metabolic Miracle," there is one safe, proven, and effective way to lose weight; this program will not decrease muscle or bone. In all my years of studying this topic, it has proved to be extremely effective in rapidly decreasing body fat, reducing inflammation, and improving overall health.

Almost all nutritional programs targeted at weight loss are based on various types of calorie or fat deprivation tactics, which have been shown to distress bone metabolism and health. Ironically, severe calorie restriction is also one of the only modalities shown to increase life span in animals! As contradictory as this may sound, I believe that if subclinical systemic inflammation, which is the foundation of these problems, can be reduced, body fat can safely be lost without sacrificing muscle and bone.

Studies appear to indicate that the negative relationship between reduced bone health and weight loss is affected by alterations in serum hormone levels, deficient nutritional factors, impaired energy metabolism, immune system distress, the reduction of the beneficial mechanical impact of excess weight, an increase in inflammatory markers, or some combination of these factors. Speaking of inflammation, it also appears that chronic long-term inflammation can have the effect of removing calcium from the bones, weakening and shrinking them. For women, these issues become even more pronounced with the onset and completion of menopause.

Fat Reduction Surgery and Bone Health

Though it may seem extremely radical to the average person, fat reduction surgery is very real, with more and more people who are desperate to lose weight and unable to succeed now choosing this option.

The adverse effects of weight loss on bone are being exacerbated by the tenfold increase in the number of bariatric (weight loss) surgeries performed in the United States from 13,365 in 1998 to an estimated 140,000 in 2004, a rate of increase that appears to have accelerated even more from 2004 to 2007. The American Society for Bariatric Surgery estimates that 220,000 people in the United States had bariatric surgery in 2008. Of the bariatric surgeries, Roux-en-Y gastric bypass (RYGB) is the most commonly performed surgery and appears to have substantially greater detrimental effects on bone health. For example, a prospective study of twenty-five women found that following RYGB, calcium absorption declined by 24 to 36 percent. Another study of 230 subjects found that within the first year following bypass surgery, BMD had decreased by an average of 7 percent.

Clearly, the results of these studies indicate that people who have had bariatric surgery should be screened with bone density testing along with repeated evaluations of their bone health—building nutritional regimens. Research also shows that postoperative bariatric patients most often have lower vitamin D levels, increased parathyroid activity, and chronically higher rates of bone mineral loss than their unoperated-upon counterparts. Therefore, aside from increasing weight-bearing exercise, it is highly recommended that bariatric surgery patients increase their vitamin D3 intake.

I want to drive home the message that you must do everything naturally possible to enhance bone health and make it your most important health priority, especially if you are nearing menopause. For all of you who have a decade or more to go before menopause, now is the time to ensure that your bones are receiving optimal nutrition to protect them now and in the future. If you are a mother with daughters, even better, as you can start them on the road to improved bone and immune health, which will provide them with a strong, healthy body.

The Adverse Effects of Disease and Medications on Bone Health

A wide range of common diseases are known to decrease bone health, including insulin-dependent diabetes, rheumatoid arthritis, inflammatory bowel disease (IBD), celiac disease, anorexia nervosa/bulimia, COPD, endometriosis, hemophilia, hemochromatosis, stroke, multiple sclerosis, Parkinson's disease, spinal cord injuries, long-term immobilization, renal disease, endocrine disorders (including suppressive doses of thyroid hormones), Addison's disease, Cushing's syndrome, sarcoidosis, organ transplants, liver disease (including hepatitis and alcoholic cirrhosis), bariatric surgery, and more. As I have just shown, a number of these disorders are either caused or contributed to by declining bone health. So it appears that there is a vicious circle working here, and one in need of a powerful cease-and-desist order.

It is very disturbing that a number of popular medications being used to treat many of these disorders also contribute to bone loss. A significant body of research has found that a wide variety of medications are associated with reduced bone health in people of all ages. The list includes glucocorticoids and related immunosuppressants, antidiabetic drugs, lithium, Depo-Provera and other contraceptives, cyclooxygenase inhibitors, proton pump inhibitors (pharmaceutical antacids), total parenteral nutrition (this means not administered via the alimentary canal), aromatase inhibitors (letrozole, exemestane, an-astrozole), gonadotropin-releasing hormone agonists (Lupron, Lupron Depot, LH-RH agonists, leuprolide), immunosuppressants, anticonvulsants (phenobarbital, phenytoin), cytotoxic drugs, and selective serotonin reuptake inhibitors (SSRIs), which lead to the issue of stress and depression. The stress hormone Cortisol inhibits the cells that form bone. Excess Cortisol also causes many other negative effects, including the storage of abdominal fat, which you will learn about in the next chapter.

While stress and excess stress-induced depression have been shown to cause loss of bone mass, antidepressant medications have been shown to cause even further significant bone loss. This is another issue of special importance to women going through menopause, who experience a greater rate of depression and its related disorders and who are prime candidates for such medications. This could be a situation where the "cure" is worse than the disease.

In addition to good nutrition, you have to learn to manage the stress that comes with living in the modern world. That is why I have included a chapter with a full yoga workout designed to balance your body and mind.

Another recent study suggests that diabetics who are being treated with thiazolidinedione, an antidiabetic drug, provided "further evidence of a possible association between long-term use of thiazofidin-ediones and fractures, particularly of the hip and wrist, in patients with diabetes mellitus."

Taken together, the information presented in this chapter alone, which is only a small portion of what is available in the medical and scientific literature, continues to confirm that men and women should make bone health a top priority. Women especially need to improve the menopausal transition and minimize the consequences that have become so commonplace.

Now comes the good news—saving the best for last! 

As you now know, the information on bone health, as stated in this chapter, is a genuine wake-up call to the importance of bone health. Almost every system of the body benefits from improved bone health. In fact, improving bone health at any age seems to be an important factor in our ability to slow the clock of aging. It is not too far a stretch to say that healthy bones are the foundation of the fountain of youth—because you can't have one without the other. But what are the best tools to accomplish this feat? Fortunately, we have some very exciting new strategies to introduce, such as vitamin K2 and AlgaeCal.


New and ongoing research provides exciting insights into the importance of a well-functioning skeletal system, the broader range of nutrients than calcium needed to form healthy bones, and the probable advantages of plant-form sources of minerals rich in calcium, magnesium, and a wide range of other naturally occurring cofactors. 

The profound influence of bone health on overall health and well-being cannot be overstated, especially for women approaching, experiencing, and having completed menopause. Healthy bones are a foundation and prerequisite for healthy blood, strong immunity, energy, vitality, and optimal health.

The growing body of research into plant forms of minerals demonstrates that a number of different vitamins, minerals, and cofactors are needed to optimize bone health, enhance the body's immune system, and reduce the body's automatic propensity to store fat. Plant forms of minerals also contain indigenous phytonutrients that contribute to bone health. In looking to natural, "user-friendly" forms of minerals, we may have found the key to stopping bone loss while dramatically improving our overall health regardless of our chronological age.

Armed with this life-changing knowledge, you can reinvigorate, restore, and protect yourself, while giving the term "great bone structure" a whole new meaning.