May 13, 2013

Ask the Nutritionist: Calcium Supplements, Yes, No, WTF?

Got questions about healthy eating and nutrition?

Well, today starts a new feature at Cranky Fitness: Ask the Nutritionist!

It could also rightfully be called "Ask the Dietitian," since both the contributors are RD's. I almost did call it that, but then decided to play it safe in case either of these two knowledgeable and articulate experts figures out what a silly blog this is and decides to bail.  What if I need to find someone new and have to cast a wider net?

 No certification, but pretty darn sensible!

Plus, half the time I spell it "Dietitian" and the other half "Dietician" and that was driving me kinda crazy.

Anyway, so today's topic is calcium supplements.  Used to be simple, right? If you weren't getting tons o' dairy, and especially if you were female, you were supposed to take 'em.

And my doctor still says I should, and studies are confusing. But even Jane Brody of the New York Times, not exactly known for going out on a limb with controversial advice, points out the risks of calcium supplementation, which include a higher likelihood of heart attacks and strokes.

So what's the deal?

Since Crabby is incapable of keeping things simple, by say, asking "should you take calcium supplements if you don't eat a lot of dairy?"... please stand by for a long-ass compound question:

What are the best strategies for non-dairy calcium?

Studies seem to suggest calcium supplementation has risks. Yet many folks are avoiding dairy either due to allergies, intolerances, vegan leanings, primal or low carb diets, or traumatic cafeteria experiences in 3rd grade. When you start to add up supposedly "good" sources of non-dairy calcium, it seems like you need to eat about a football field full of leafy greens and other dairy alternatives to hit the requirements, or else resign yourself to supplements and risk croaking from cardiac arrest or strokes. Post-menopausal women in particular seem to struggle with what to do about it.

What are some strategies for optimizing calcium intake, and how dangerous do you think supplements really are?

And what about "fortified" foods that don't naturally contain calcium, like almond milk or orange juice? Are these any different from taking a calcium supplement in tablet form when it comes to risks of strokes or heart attacks?

So let's meet our dietitians and see what they have to say!

Marsha Hudnall

Marsha Hudnall, MS, RD, CD, is president and co-owner of Green Mountain at Fox Run, a healthy weight retreat in Vermont that is exclusively for women. Forty years ago, Green Mountain pioneered the non-diet, mindful/intuitive eating, healthy living approach which includes a team of registered dietitians, psychologists and exercise physiologists. Marsha is a frequent speaker to both lay and professional audiences and has written for a wide variety of popular and professional publications. She serves on the board of The Center for Mindful Eating and the Binge Eating Disorder Association. Her newest book "Eating Happy: A Woman's Guide to Overcoming Overeating" will be available summer 2013.

This is an excellent question to kick off Ask-a-Nutritionist on Cranky Fitness. That's because, to me, it epitomizes the confusion people have around nutrition.

I want to say first that Laura is probably much more supplement-savvy than I am, as most of my work is in helping women learn how to feed themselves well with real food. I gladly point this out because I think it is critical to know what you are doing when taking supplements. There are tons of potential interactions that could spell trouble when people take supplements indiscriminately, especially in large doses. So, imo, it is very important to work with a knowledgeable professional to guide you.

To answer your question about calcium and calcium supplementation in particular, though, it's pretty clear that eating sensibly such as with a Mediterranean-style diet gives you your best start on getting the nutrients you need and optimally utilizing them, including calcium. You can read more about the Mediterranean diet and calcium here.

We all know, however, that most Americans don't eat like the Mediterranean diet suggests. The good news is that even though it leaves a lot to be desired in other areas, the average American diet that doesn't include dairy foods still contains about 300 mg or so of calcium a day. To boost that without using dairy foods, you can add things like canned fish with bones, tofu, or other foods fortified with calcium, such as plant milks like almond, soy, etc. That football field of leafy greens you mentioned? Actually, a cup of a cooked leafy greens like kale or bok choy or cabbage provides almost as much calcium as a glass of milk. Those leafy greens are also good sources of magnesium and vitamin K, which is important to calcium absorption and utilization. Adequate vitamin D is also important.

If you do supplement, experts agree to not take large doses, such as 1000 mg or more a day, to avoid any of the problems that recent studies suggest may be associated with larger supplemental intakes. If you're eating as I described above, you shouldn't need more than 250 to 750 mg/day (higher needs for menopausal women) in supplemental form to meet recommended intakes. That keeps you well within what is considered a safe range. You still need to be getting the other nutrients I mentioned above, though. Otherwise, you won't be optimally absorbing or using the calcium you take.

Laura Lagano

Laura Lagano is a holistic registered dietitian who counsels individuals about nutrition in Hoboken, NJ. What makes her service unique is the location – her kitchen. As opposed to an office or clinic, Laura’s “Nutrition in my Kitchen” program shows clients how to put her recommendations into practice. Applying the principles of functional medicine to nutrition and lifestyle counseling, Laura develops food and health plans by addressing the underlying triggers of disease, rather than symptoms. She also has a New York City nutrition office and offers Skype appointments. Reach Laura at or 917-829-0250.

Though Vitamin D is the current darling in the nutrient line-up these days, calcium is still talked about just as much as ever. More people are shunning dairy and not simply because of an allergy or lactose intolerance. In some nutrition circles, dairy elimination is synonymous with better health. Dairy proponents, however, say that avoiding this food group will result in poor calcium intake. No one will debate that dairy products are currently a primary source of calcium for most Americans. If you do not eat dairy products for whatever reason, how do you get your calcium?

Consider these facts. One, the calcium amount indicated on food labels is listed as a Percent Daily Value based on an intake of 1000 mg, which hovers around the Dietary Reference Intake (DRI) for adults. All of these numbers are most helpful for population, not individual, guidelines. Differences, for example, in health status, genetic variability, biochemical individuality, and lifestyle habits can change your personal, optimal nutrient intake.

Two, the DRI for calcium considers the Standard American Diet, also known as SAD. This is the actual acronym used by nutrition professionals. And sad it is. Because processed food and carbonated beverage consumption with its excessive amount of phosphorus is so high in the US, the DRI value for calcium is higher. That’s because calcium and phosphorus need to be in proper balance with one another for optimal functioning.

In my private practice, I rarely recommend calcium supplementation. Excessive calcium can cause more harm than good. Too much has the potential to displace magnesium and potassium, both vital to heart health. Though we associate low calcium with osteoporosis, many other minerals contribute to bone loss.

Before we review foods that are good sources of calcium, keep in mind that we are what we digest and absorb rather than what we eat. Calcium, like all minerals, requires a very specific gastrointestinal environment for absorption. As Americans the three major factors that interfere with absorption are (1) drinking carbonated beverages, (2) taking antacids, and (3) low hydrochloric acid. You can change numbers 1 and 2 easily. Low hydrochloric acid, commonly referred to as stomach acid, can be rectified with appropriate supplement therapy of betaine hydrochloride under the supervision of a healthcare professional. Calcium intake is not simply about eating calcium-containing foods.

For those who still ask what foods are good sources of calcium other than dairy, let’s take a look at milk alternatives. What would you pour into that bowl of granola or buckwheat groats (I’m not kidding; they’re delish!) if cow’s milk wasn’t part of your food plan? The choices are much wider and more available nowadays. All of these beverages are available in calcium-fortified versions and some contain calcium put there by Mother Nature.

Non-Dairy Milk Alternatives:
• Coconut milk
• Almond milk
• Hemp milk
• Rice
• Hazelnut
• 7-Grain
• Oat milk
• Soy (look for a verified Non-GMO label)

Perhaps you don’t drink milk of any kind. You still need calcium, so what do you eat? Pound for pound, leafy greens beat out dairy every time. Yes, that would be a lot of greens. Remember, it’s not only about the calcium you eat or drink, it’s about several other things that influence your absorption of this mineral. To pack a wallop of calcium, my suggestion is to have a green smoothie (check out my recipe below), green juice, or trail mix as often as possible. Check out my recipes below.

Great Non-Dairy Calcium Foods:
• Kale
• Turnip greens
• Dandelion greens
• Mustard greens
• Collard greens
• Arugula
• Broccoli
• Figs
• Sardines
• Canned salmon
• Soy beans (look for this label)
• Sesame seeds
• Almonds
• Brazil Nuts
• Flax

The Greenest Smoothie

3 ounces baby kale or dandelion greens (remove fibrous stems)
2 cups plus additional purified water
3 ounces arugula
4 stalks celery, cut into large pieces
1 small bunch parsley leaves
1 avocado
1 green apple, cored and sliced
1 lemon, peeled & seeded

1. Place kale or dandelion greens in high-speed blender. Add 2 cups water and blend on low, increasing speed until liquid.
2. Add additional ingredients one at a time until liquefied.
3. Add water to reach the 64 ounce mark.

Makes 4 16-oz smoothies

Bottomline Tips for Optimizing Calcium Absorption:
1. Limit how much processed food you eat.
2. Stop drinking soda!
3. Cut out the antacids.
4. Make sure your stomach acid is adequate. Consult with a dietitian/nutritionist who is trained in functional medicine to help you figure this out.
5. Drink a green smoothie or green juice as often as possible. I start my day with one every morning.
6. Toss canned fish in a salad with high-calcium greens.
7. Make a trail mix of raw almonds or Brazil nuts, sesame seeds, and cut up dried figs. Carry it with you for a high-calcium, high protein snack throughout the day.
8. Be creative. Make a pizza with goat cheese (okay, this is dairy) and sliced fresh figs. After it’s baked, liberally cover with arugula.
9. Make edamame, a preparation of immature soybean pods briefly steamed. Make certain any soy products you use do not contain genetically-modified organisms.
10. Add ground flax to cereals, salads, protein drinks. Go slowly at first because flax can really move things along in your digestive tract.

Thanks, Marsha and Laura!

So what do you folks do about calcium? Or is it something you even think much about? Got any questions for future columns?

Knudsen photo: Lileks
Bunny: all over the web; original source unknown


  1. Good to know. I don't supplement at all, but sometimes worry that I'm not getting enough of what I need. But I feel fine, so I'm just wishing myself well. :)What do you guys think about multi-vitamins? I don't take those either, but most of my friends do. Worth it, or unnecessary for those of us already eating a healthy diet?

    1. Great question about multivitamins Gaye! Maybe a question for a future post.

    2. Gaye, I generally don't recommend multivitamins if someone is eating well. Even when they aren't, part of me hesitates. I just like to have more specific information about a person's needs, to tailor supplemental intake. Recent studies have called into question the effectiveness of multivitamins, and my take is that's because they aren't tailored to a person's needs. That said, a standard multivitamin generally doesn't contain high enough levels of any nutrient to cause a problem, so I probably wouldn't worry about it. But they may not be doing any good either.

    3. While I do believe in taking certain supplements, I tend to think that if you eat a nutrient rich healthy diet, you really don't need to take multi-vitamins. However if you have poor eating habits, multis can probably help as you are most likely deficient in certain nutrients.

      I once experimented following an expensive vitamin supplement plan for 6 months. I didn't notice any difference except for expensive gold urine. :o) To be fair, at that time I was in peak level of fitness, so any health benefit would be more difficult to notice than someone you had less than optimum fitness/health.

  2. Interesting, I was just talking to someone about this last night.

    My opinions are these:

    Men should not take Calcium supplements. They raise the incidence of heart disease.
    Women can take them, although getting calcium from food sources is best.
    Dairy is not my choice of foods with calcium, I prefer dark greens.

    1. Another sensible vote for dark greens! Still seems like a LOT of freakin' kale to make up a days worth...

    2. Dr. J, the association with heart disease may be an association with chronic inflammation. Which dark greens does a great job in helping to tame. So double win as far as the green stuff goes!!

  3. I'm not an expert on calcium supplements, and for now I mostly protect my bones by doing strength work at the gym and eating my greens, but this article reminded me of two "supplements-for-women-related" incidents in my life.

    1) During pregnancy: "They" insisted on me taking iron supplements without even looking at my hemoglobin levels (which were through the roof, as they always are - even back in the days I was a complete vegetarian!) Come on.

    2) After giving birth: "They" insisted on me taking metamucil and asked me to drink liters of prune juice BUT I could not get a slice of whole wheat bread if I begged (the hospital gave us WHITE bread). COME ON!!!

    1. Too funny HSH! Well, actually not all that funny, when hospitals push supplements and shun real food. Grrr...

  4. Thanks for the info. I have the worst trouble keeping straight what supplement I need to absorb calcium.
    Fun fact: coca leaves are a great source of calcium. (One River: Explorations and Discoveries in the Amazon Rain Forest by Wade Davis.) Too bad that a) there's no hope in hell we'll ever get them here and b) it's likely lost during the denaturing to make Coca-Cola.

    1. Interesting about the coca leaves Leah! And yeah, not thinking drinking Cokes would exactly be a clever strategy. :)

  5. This is a great idea, this "ask the nutritionist", especially since you've got both a satisficer-type and a maximizer-type, to meet the skill sets of those who really don't give a s*@t but don't want to screw up too badly and those who are really into exploring the use of food for its intended purpose of nourishing one's body. Thank you, Marsha and Laura!

    I am, obv, in the first category, so I was pleased to learn that I have a fantastic calcium intake via both plenty of dairy and really quite shocking levels of daily broccoli intake (you know those pre-cut bags at the grocery store with like eight servings of broccoli that you can just microwave and nom the whole thing down for lunch although you're really starting to piss off your coworkers with the smell?). But even so, I don't have to worry about heart disease or whatever other horrors of too much calcium because I continue to drink lots of diet soda whatever anybody says. Yay!

    1. Trabb's boy, I'd never heard heard the "satisficer vs maximizer" distinction before you introduced me to it, but it's a very handy conceptualization! Though it's lacking the "don't-give-a-crapizer" 3rd category, for people who don't even worry about nutrition or whatever else the variable is.

      And too funny about the broccoli... I eat salads in a portion size more suitable for an entire family, so know the feeling...

    2. I've never heard the term "satisficer" before, but I like it! I think it describes Laura and I well. Like your third category, too, Crabby!

  6. I love your new feature (with the nutritionist!!).
    Perfect starter question for me since this is something I've been struggling with. Because of my history of stress fractures (and family history) every time I go to my DR, she tells me to take Calcium. I just don't know if I really want to because I've read so much about absorption issues and stuff. I try to incorporate calcium into my diet (without milk and yogurt) but probably don't always do a great job. I love those tips at the bottom - gonna give them a try for sure!!!

    1. Your doctor pushes calcium too, Kime? I hate to ignore a doctor's advice, but I wonder if they're taking the new research into account?

    2. Unfortunately, most physicians have very little training in nutrition. :(

  7. You can find calcium in many plant-based foods, from almonds to tofu. Here is a list of some calcium-containing foods that are dairy-free, with the amount of calcium you’ll find in a single serving.

    Food Serving Size Calcium
    Collard greens 1 cup, boiled 357 mg
    Fortified soymilk 1 cup 368 mg
    Black-eyed peas 1 cup, boiled 211 mg
    Firm tofu (made with calcium sulfate) 1/2 cup 204 mg
    Calcium-fortified orange juice 6 oz 200 mg
    Blackstrap molasses 1 Tbsp 172 mg
    Baked beans 1 cup, canned 154 mg
    Kale 1 cup, cooked 94 mg
    Chinese cabbage 1 cup, raw 74 mg
    Oranges 1 cup 72 mg
    Almonds 1 oz 70 mg


    1. Thanks Anna!

      Although dang, the only greens that seem to add up fast are collard greens, which I hate. Like Kale but wouldn't that be 7-plus servings a day??

      I'm hoping the fact that all these lists are including fortified milks mean these don't count as "supplements."

      I'm just hoping I have the right stomach chemistry to get a lot of calcium bang for the buck.

  8. Awesome!!!! What a great new series and a great start. I love this statement, "Calcium, like all minerals, requires a very specific gastrointestinal environment for absorption".
    This is the piece I've been chasing for a long time now.
    Love the suggestions too.
    I'll probably re-read this.
    And try that smoothie (as soon as I can find my blender!)

    1. I'm with you Tree, hadn't gotten the piece about gastrointestinal environment before. Guess we have to be environmentally conscious internally as well as externally!

  9. This is interesting. Right now I only take a multi-vitamin. I absolutely love the picture of that bunny!

  10. I take a calcium + magnesium supplement before bed because it theoretically helps with Restless Leg Syndrome. It does seem to help most of the time, but I don't know how much of that is psychosomatic. I always figured it wouldn't hurt me, and it might help...

  11. Greens, greens, greens! Plus a 500mg supplement. This summer, when i have my first bone density scan, i'll find out if it's working or not.

  12. I'm still not sure whether to supplement my calcium or not! I was diagnosed with arteriosclerosis a few years ago. I have heard that people who have that and take calcium supplements are at a much higher risk of heart attack or stroke. When I asked my specialist who had put a double stent in a blocked artery about it he said "you're in your 50's so yes you should be taking a supplement".
    I guess I'm just confused as to who to believe!

  13. I don't really think about calcium much since I drink lots of milk and have dairy.

  14. Like the new 'Ask the Nutritionist' feature!

    Supplements continue to be a dark-art of mystery and wonder to me.

    I go through phases of taking multi-vits, and more recently a calcium and Vitamin D combination.

    For anyone (the pregnancy thing aside) who eats a balanced diet and exercises now and again, I'm sure no supplements are required. (But we just never know!) Dam it.

    I've never feel any different whatsoever after a spell of supplementation, and yet I still fall for the marketing gimmicks. I now have a bottle of ouderless garlic pills on my kitchen shelf! Why? I really do not know!

    I do grind flaxseed and sprinkle that in my smoothies and on cereals etc. But at least this is a whole food, which contains a host of nutrients and essential fatty acids - plus it's really cheap!

    1. I know how you feel. You almost have to be a nutritionist to get the whole picture. Our diets and needs vary so much. Your bone doctor may say "take calcium" while your heart doctor says "avoid calcium", and ads are always screaming about the importance of a bunch of stuff you don't understand -- probiotics! antioxidants! phytochronomic rectoproteins! It makes you want to sit in a corner and eat oreos forever.

  15. GREAT POST!!! Thank you Jan!!! I am lactose intolerant AND I work out like a fiend AND I am in menopause AND I find it hard to eat enough leafy greens & not the biggest fan of the alternative milks plain.. I do mix then in some things..

    Anyway, I take a Calcium/Magnesium supplement BUT I take 2 pills a day vs, the 3 recommended so I get some from food & some from the supplement..

    Have to reread this! :)

  16. I hope I'm not the only one who loved the bunny picture....Really.

    A great idea Ask The Nutritionist!!! Plus - the "D" word - for probably me, only - to connote more of a notion of a hospital orientation.

    As much as I want answers, I'm also in the camp of "we're all an experiment of one" on alot of this stuff. So,I take all the info with a grain of salt (pun intended) and tyr to see what works or does not just for me.

    That said - I LOVE hearing from bonafide experts who have actual scientific backgrounds. Thanks!!!

    1. Ultimately, Anonymous, that is the best approach. We are definitely all unique, and the best a nutritionist can do is to look at you as an individual, offer what she/he knows about nutrition that may be relevant, then wait to hear back from you. You are the expert in your own body!!

  17. Good to be aware of this. I generally worry about my iron levels not my calcium. But I am taking a multivitamin, so hopefully my calcium levels shoud be fine.

  18. Im so so so old school.
    I still do the TUMS :-)

  19. Wow - a lot of great information.
    I like the idea of leafy greens.
    I question anything added and the real effects it will have.


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