Considerations When Choosing Supplements

By Maya Shetty, BS


Key Takeaways

  • The supplement industry operates with minimal external oversight. Thus, it is critical for consumers to rigorously assess the actual need and proven efficacy of a supplement prior to its use.
  • Most supplement claims lack scientific evidence. Consumers should only consider supplements with solid scientific backing.
  • Opt for brands verified for purity and bioavailability by third-party organizations.
  • Supplements should supplement—not replace—a healthy diet and lifestyle. Emphasize whole foods, physical activity, and balanced health practices over seeking quick fixes.

In an era where every shelf in the wellness aisle promises a solution to your health concerns, supplements stand out as both suspects and saviors. The market is flooded with options: B12 promises to energize you, omega-3 asserts it will curb inflammation, vitamin C and zinc vow to enhance your immunity, and greens powders claim to do everything in between. With so many claims, it’s important to learn how to navigate the supplement world with a critical eye and an informed mind. Stanford Lifestyle Medicine Registered Dietician Marily Oppezzo, PhD, MS, RDN, DipACLM explains how to approach the supplement market and make informed choices for your health.

What is a Dietary Supplement?

Dietary supplements are ingestible products that contain “dietary ingredients” intended to supplement the diet, including vitamins, minerals, herbs, amino acids, fatty acids, live microbials, and protein powders, among many others. Navigating this expansive world requires an understanding of their nature and regulation—or lack thereof. Though many claim to be from natural sources, supplements are essentially laboratory-created entities designed to alter our physiology, underscoring the importance of approaching them with the same level of scrutiny as any medication.

“Just because a supplement is labeled as ‘natural’ or derived from natural sources doesn’t make it healthy, or even safe,” states Dr. Oppezzo. “This is particularly relevant when considering the unnaturally high concentrations [of the nutrient] often found in supplements.”

Despite their widespread use for health-related purposes, dietary supplements are in a regulatory gray area. When it comes to most supplements, the Federal Drug Administration (FDA) is not responsible for ensuring safety, efficacy, purity, or potency. These aspects are managed by the supplement manufacturers themselves (per the Dietary Supplement Health and Education Act of 1994). This means that supplements are exempt from the rigorous testing and validation process mandated for pharmaceuticals, with the FDA stepping in only if enough post-market reports indicate adverse effects. This regulatory gap makes it challenging for consumers to navigate the supplement aisle, emphasizing the importance of thorough evaluation when considering the necessity of a supplement.

Evaluating the Need for a Supplement

While many individuals view supplements as a way to meet their basic nutritional requirements or as a convenient method to optimize health, the reality is that there are relatively few situations where supplements have proven beneficial.

Before taking any supplement, Dr. Oppezzo recommends pausing to consider several key questions: 

  • What is my reason for believing I have a nutritional deficiency or need to take this supplement? Have I spoken to my doctor or taken a blood test to confirm this deficiency? Is there even a test to confirm this?
  • Has a credible source such as a Registered Dietitian or Doctor recommended this to me, or am I influenced by persuasive advertising?
  • What benefits do I expect to gain from taking this supplement? Is there any scientific evidence that this supplement will help me?

Of course, there are circumstances where supplementation can be beneficial. Age, certain medical conditions, and specific lifestyle choices can impact our body’s ability to absorb or synthesize vital nutrients. For instance, older adults might struggle to produce enough vitamin D or B-12 naturally. Athletes engaging in intense training may require additional iron or protein or calories to support their performance levels, while those following vegan or vegetarian diets might need nutrients less common in plant-based foods, such as B-12, omega-3 fatty acids, calcium, and vitamin D.

The most reliable way to determine your nutritional needs is through a professional consultation with a dietitian. This approach allows for a tailored assessment for needs, evaluation of evidence behind supplements you are interested in, and ongoing monitoring to adjust as necessary. 

Assessing Supplement Claims

A significant portion of supplement usage is driven by misconceptions and marketing rather than genuine need. “The wellness industry often races ahead of scientific validation, promoting products with claims that outpace the available evidence,” states Dr. Oppezzo. “They aren’t cutting edge, they are flying out way past the cliff of evidence.”

Addressing this challenge, Dr. Oppezzo encourages consumers to first look for any peer-reviewed studies backing the “need” or the claim of a supplement. Ideally, ask an expert to do this for you. 

While certain supplements, such as vitamin B12, are actually essential nutrients, supported by extensive research, others, like various greens powders and phytochemical blends, lack robust evidence demonstrating their effectiveness throughout the body. The absence of any regulation allows many products to make exaggerated claims without solid proof. As such, many supplement labels contain a hodgepodge of wellness buzzwords, such as “immune booster,” “supports gut health,” and “promotes health aging,” without any science to back up the claims.

Secondly, Dr. Oppezzo urges us to think about its bioavailability—the extent to which it can be absorbed and utilized by the body. Imagine being in the shoes of a supplement itself, considering all the gauntlets it has to pass to do the thing you think it will do and deliver the marketed effects.

Like any ingested substance, supplements are first broken down by the stomach, absorbed in the gut, processed in the liver, incorporated into the bloodstream, and then transported to organs and cells throughout the body. The critical question is whether the supplement can survive this journey in a form that retains its intended benefit and reaches the organ or cell where you think it will do its purported job.

“Let’s put essential vitamins and minerals aside for a moment. Even if there is evidence some supplement or chemical will do something if you dropped it on your cells in a test tube, you don’t know that this translates to your real live body. Further, you don’t even know if the supplement will even succeed at getting inside your body in the first place, let alone maintaining its original ‘active’ structure after it gets inside,” states Dr. Oppezzo.

It’s important to approach supplements with a healthy dose of skepticism and informed judgment. Not all supplements are inherently harmful; some can offer significant benefits when used appropriately. Yet, the decision to incorporate them into your health regimen should be made with careful consideration, guided by credible evidence and, when possible, professional advice. Once identifying the need for a supplement, Dr. Oppezzo recommends the following framework to decide the appropriate brand, dosage, and context for its consumption.

Framework for Choosing a Supplement

 

1. Assess the Safety and Efficacy

When it comes to supplements, third-party testing is a gold standard for ensuring product safety and efficacy. Organizations like ConsumerLab, US Pharmacopeia, and NSF International offer unbiased supplement evaluations, checking for purity, potency, and safety. Consumers can either check these websites to find a trustworthy supplement brand or look for products that bear their certifications. While some manufacturers conduct their own testing, third-party validation is preferable for an impartial review. Also, the supplement landscape is ever-changing, so checking for updates regularly is wise. 

However, it’s important to understand that these organizations do not directly test the efficacy and safety of supplements. This information can only be provided through clinical trials. According to Dr. Oppezzo, these organizations primarily verify the product has the amount that it claims on the bottle, has the supplement in at least a bioavailable form that can get absorbed into your body, and that it is free from high levels of known contaminants. 

2. Dosage Matters

The saying “more is better” is not necessarily true for supplements – or even essential nutrients. Both inadequate and excessive consumption of nutrients can have detrimental effects on health. Although the body is capable of excreting surplus nutrients, fat-soluble vitamins can accumulate in the body to toxic levels if consistently consumed in large amounts. On the other hand, overconsumption of water-soluble vitamins usually leads them to be excreted through urine, which is inefficient, costly, and known as “expensive urine.”

Therefore, it is crucial to adhere to recommended dietary allowances (RDAs) as a starting point and tailor intake based on individual responses. Importantly, consistently exceeding 100 percent of the RDA can result in nutrient imbalances. One example is selenium, a nutrient where both insufficient and excessive intake have been associated with hair loss. Ironically, many products marketed as “hair vitamins” contain selenium levels surpassing the RDA, potentially worsening the very issue they aim to remedy. 

3. Consider the Chemistry

The effectiveness of a supplement can also depend on its chemical form. For example, vitamins that are fat-soluble achieve maximum absorption when consumed simultaneously with a source of fat, such as a small portion of nuts. Additionally, the interaction between nutrients is important; for instance, copper and zinc compete for absorption, and an excess of one can lead to a deficiency in the other. Supplements can also have harmful interactions with certain pharmaceutical medications, so it is important to consult with healthcare providers before starting a new supplement. 

Another important consideration is the degradation of these compounds. For example, there is an oxidation potential of omega-3 and other fatty acid supplements. This means they have the potential to go “rancid” and lose their efficacy, especially when exposed to heat or open air. This vulnerability stems from the unsaturated nature of these fats, which contains double bonds in their molecular structure that are more reactive with oxygen. 

Indications of rancidity include a strong, fishy odor or an unpleasant taste in fatty acid supplements. Additionally, you can look for information on the peroxide value (PV), a common measure of its oxidation potential. This can be found on some supplement labels, as well third-party testing reports, such as NutraSource. Dr. Oppezzo recommends supplements with PV levels less than 8 mEq/kg.

Supplements Are Not Substitutes for a Healthy Diet

Regardless of whether supplements are part of your daily routine, it is important to remember supplements should be seen as supplemental and not taken at the cost of eating whole foods. While they can sometimes fill nutritional gaps, supplements should be distinct from other health behaviors, such as eating well and moving often.

Moreover, focusing on single ingredients or specific nutrients without considering the holistic picture can lead to misconceptions about what supplements can achieve. Just taking vitamin D, for instance, won’t fully address bone health if it’s not combined  with strength training and a calcium-rich diet.  Good health is about the synergy between multiple  health practices and how they complement each other.

“The allure of a quick fix or ‘magic pill’ is an enticing narrative in our fast-paced world, yet it’s important to remember that there is no replacement for a good diet and regular exercise,” states Dr. Oppezzo. “The foundation of healthy aging always has and always will be a direct result of the choices we make on a daily basis, which is what lifestyle medicine is all about.”

 

Vitamin D: Benefits, Sources, Deficiency

By Maya Shetty, BS


Key Takeaways

  • Vitamin D affects the health of bones and also plays a role in our muscles, immunity, and prevention of some diseases.
  • The most common form of vitamin D is synthesized in the skin after exposure to sunshine. Vitamin D can also be found in some foods naturally as well as supplements and fortified foods.
  • Vitamin D insufficiency is defined as less than 30 ng per mL of blood. Strive to maintain sufficient vitamin D levels through a balanced diet, sensible sun exposure, and supplementation as needed. 
  • When choosing a vitamin D supplement, D3 is recommended over D2, and should be combined with a fat (such as a handful of almonds or an Omega-3 supplement). You should not take more than 4,000 IU (100 mcg) per day due to the potential for toxicity unless recommended by a medical professional.

In a nation saturated with supplements, vitamin D commands the spotlight as one of the most widely taken across all age groups, second only to multivitamins. 

“Ever since vitamin D deficiency was found to be the root cause of rickets, we have long recognized its role in bone health. Now research is looking at this vitamin as a panacea for numerous ailments, from the common cold, to even cancer,” states Robert Oh, MD, MPH, Chief Wellness Officer of the VA Palo Alto Healthcare System. 

As ongoing research peels back the layers of complexity surrounding this vitamin, the scientific landscape becomes dynamic and subject to rigorous debate.

Where Does Vitamin D Come From?

Vitamin D distinguishes itself from other vitamins due to its unique ability to exist as both a dietary nutrient and as a hormone. Sourced from sunlight exposure, food, and supplements, this fat-soluble vitamin accumulates in the body’s fatty tissues and liver, available to be released as needed.

Sunlight

The primary source of vitamin D is the production that occurs in our skin from cholesterol precursors when exposed to the sun’s ultraviolet-B (UVB) rays, earning its nickname “the sunshine vitamin.” Considering the pivotal role sunlight plays in vitamin D production, daily exposure is beneficial.

Some plants and animals also possess the ability to synthesize vitamin D, contributing to the vitamin’s content in various foods and supplements. In plants, vitamin D is in the form D2 (ergocalciferol), while in animals, including humans, it is in the form D3 (cholecalciferol). Both forms are absorbable by humans; however, there is evidence suggesting that D3 has a more substantial and prolonged impact.

Food

High amounts of vitamin D3 are found in oily fishes such as salmon, mackerel, and sardines, whereas small amounts are found in eggs, red meat, and liver. 

Vitamin D2 is found in specific mushrooms, but its concentrations vary significantly based on exposure to light. Mushrooms, much like our skin, require sunlight for vitamin D production. “Since commercially available mushrooms are typically grown in dark conditions, they contain minimal amounts of vitamin D and organic mushrooms will contain almost none. Exposure to UV light through irradiation, which is not allowed in organic food production, will substantially increase conventional mushroom vitamin D content,” said Rachele Pojednic, PhD, Stanford University nutrition and exercise scientist.

Due to the limited natural food sources of vitamin D, many products, including breakfast cereals, dairy items, and plant-based milks, are fortified with vitamin D2 and D3. For a comprehensive list of vitamin D content in specific foods, refer to the U.S. Department of Agriculture (USDA) list categorized by nutrient content and food name.

Supplements

Vitamin D2 and D3 can be found in supplement form. Due to the potentially higher bioavailability, D3 supplements are typically recommended over D2. 

Dr. Pojednic emphasizes the importance of considering the fat-soluble nature of vitamin D when taking a supplement. “Vitamin D absorption, especially when consumed in concentrated doses, will be significantly enhanced when taken in conjunction with dietary fat, such as a handful of almonds or an omega-3 supplement,” she says.

When determining the appropriate vitamin D supplementation dosage, keep in mind that higher is not better. Toxic levels of vitamin D can arise from excessive supplement intake, a risk not associated with sunlight exposure due to the skin’s ability to self-regulate production. Therefore, Dr. Oh advises consulting with a physician or dietitian before taking high-dosage supplements. “Too much vitamin D can cause health issues, such as too high calcium levels or even kidney damage, so work with your care team if you are taking high doses of vitamin D,” he says.

Health Benefits of Vitamin D

Vitamin D is crucial for human health. While primarily recognized for its role in building strong bones, new findings suggest that this fat-soluble vitamin may exert a broader influence throughout the body. 

“We now know that the majority of organs and tissues in the body possess vitamin D receptors,” states Dr. Pojednic. “This finding suggests vitamin D has effects beyond the skeletal system, sparking considerable research in the potential benefits of vitamin D for multiple health conditions.”

A substantial portion of this research focuses on the effects of vitamin D supplements, rather than dietary and sunlight sources. However, this by no way means the benefits of vitamin D are found solely through supplementation. Additionally, it should be noted that many studies have not compared outcomes in individuals with sufficient versus deficient vitamin D blood levels, which make conclusions from many supplementation studies difficult to interpret.

Bone Health

Vitamin D stands as a key player in sustaining the structural integrity of our skeletal system by facilitating the absorption of calcium and phosphorus—the building blocks of our bones. Through the process of mineralization, these minerals are incorporated into our bones to maintain normal bone density. Inadequate vitamin D levels can result in insufficient mineralization, which can lead to weakened bones and conditions such as osteoporosis, as well as more severe disorders like rickets and osteomalacia. 

While the adverse effects of inadequate vitamin D on bone health are well-established, the evidence concerning the impacts of supplemental vitamin D over-and-above sufficient levels remains inconsistent.

In 2007, the US Agency for Healthcare Research and Quality synthesized the research on vitamin D and determined daily supplementation of vitamin D (≤ 800 IU) with calcium (≥ 500 mg) resulted in small increases in bone mineral density in older adults. 

There is additional evidence that suggests that vitamin D supplementation lowers the risk of fractures in institutionalized older adults (700-800 IU vitamin D) and female navy recruits (800 IU vitamin D and 2000 mg calcium). However, both groups were initially at a high risk of vitamin D deficiency, and their levels were likely insufficient to begin with.

 On the contrary, the largest vitamin D study to date, Vitamin D and Omega-3 Trial (VITAL), showed that daily supplementation of 2000 IU vitamin D did not reduce fracture risk in more than twenty-five thousand midlife and older adults who had sufficient vitamin D levels on average.

The current body of evidence indicates that vitamin D supplementation offers the most significant benefits for individuals with deficiencies. However, for those already meeting their vitamin D requirements, the benefits of additional supplementation are less clear. This suggests the need to approach vitamin D supplementation for bone health as a targeted strategy—aimed at maintaining sufficient levels rather than striving for excessively high, or supramaximal, levels. Such a focused approach ensures supplementation benefits those who need it, without unnecessary excess in those already meeting their vitamin D requirements.

Dr. Pojednic underscores the importance of a proactive approach, stating, “Ensuring sufficient intake of vitamin D and calcium serves as a foundational preventive measure to mitigate bone mineral loss and reduce the risk of osteoporosis later in life.” This strategy is particularly crucial early in life, as the foundation for peak bone mass, particularly for women, is established in our twenties. By achieving and maintaining optimal levels of vitamin D and calcium from a young age, individuals can maximize their bone strength and preserve it as they age.

Muscle Health

Our muscles need vitamin D to function and develop properly. Studies have established a correlation between deficient vitamin D levels and muscle weakness, pain, and atrophy. While the precise molecular mechanisms of vitamin D’s influence on skeletal muscle necessitate further investigation, cell culture studies indicate that vitamin D administration can alter cell pathways related to muscle contraction, cell proliferation, differentiation, growth, and inflammation.

An increasing body of research suggests a positive impact of high and low vitamin D supplementation on physical performance and injury prevention, particularly in vitamin D deficient adults and athletes. Research has identified a negative correlation between blood levels of vitamin D and biomarkers of muscle damage and inflammation, as well as number of injuries. 

“These findings indicate the potential of vitamin D as a supplement for aiding recovery in injured or overtrained athletes,” states Dr. Pojednic. “However, further research is required to determine the optimal dosages and interventions for effective recovery.”

It has also been hypothesized that vitamin D may reduce the risk of falls in older adults by enhancing muscle strength and coordination, thus improving balance and postural sway. An analysis of multiple studies indicates that daily vitamin D supplementation may decrease the risk of falls in older adults with low vitamin D levels. However, this protective effect was not observed in individuals with sufficient vitamin D levels, a conclusion supported by the VITAL trial, which administered 2,000 IU of vitamin D daily.

The current evidence regarding vitamin D and muscle health suggests that the benefits of supplemental vitamin D are, again, primarily observed in individuals deficient in the vitamin, mirroring patterns observed in bone health. However, it may also have some benefit for athletes and others struggling with muscle damage and recovery. Overall, more research is needed to understand the optimal level of vitamin D for muscle health and determine whether these levels exceed what is required for bone health.

Immune Function

Vitamin D plays a crucial role in immune health, demonstrating various effects on inflammation, autoimmune diseases, and infection rates. The VITAL study revealed that healthy individuals taking vitamin D (2,000 IU per day) were less likely to develop autoimmune diseases such as rheumatoid arthritis and psoriasis, with a 22 percent reduction in incidence over the five-year supplementation period. However, these protective effects were no longer evident after participants discontinued the vitamin D supplement. This implies that vitamin D needs to be consistently taken for long-term prevention.

In the context of respiratory health, a comprehensive meta-analysis demonstrated that daily or weekly vitamin D supplementation lowers the risk of upper respiratory tract infections, especially in very deficient individuals. During the COVID-19 pandemic, studies revealed that low serum levels are associated with a higher risk of COVID-19 infection.

These findings underscore the importance of maintaining optimal vitamin D levels for immune health and the long-term prevention of autoimmune and respiratory diseases. “Similar to muscle and bone health, supplemental vitamin D has the most consistent benefits among those with deficient levels at baseline,” states Dr. Oh. “However, the new findings suggest supplemental vitamin D may reduce autoimmune disease risk even in individuals with already sufficient vitamin D levels.” Therefore, further research is warranted to identify the optimal vitamin D level for sustaining long-term immune health.

Diabetes

Research has consistently found an inverse relationship between vitamin D blood levels and diabetes risk. Vitamin D deficiency may influence key biochemical pathways involved in the development of prediabetes and diabetes, impacting beta cell function in the pancreas and contributing to inflammation.

In a noteworthy observation from the Nurses Health study, women who regularly consumed higher daily doses of vitamin D (>800 IU) and calcium supplements (>1,200 mg) experienced a remarkable 33 percent lower risk of Type 2 Diabetes compared to those with lower doses (400 IU vitamin D, <600 mg Calcium).

Further evidence comes from randomized control trials, which have shown that the benefits of vitamin D supplementation are most pronounced in individuals with low levels of this nutrient. In a randomized clinical trial involving 2,000 adults with prediabetes, participants received daily high doses of vitamin D (4,000 IU) over two years. The study discovered a significant risk reduction for diabetes among those with severely low vitamin D levels. However, this beneficial effect was not observed in participants who already had sufficient levels of vitamin D.

Cancer and All-Cause Mortality

Epidemiological studies have revealed a connection between insufficient vitamin D levels and an increased risk of cancer and all-cause mortality, prompting significant research into the potential role of vitamin D in cancer prevention and overall longevity.

Laboratory studies showcase vitamin D’s ability to inhibit cancer cell growth, while epidemiologic investigations suggest that inadequate vitamin D levels correlate with a 30 to 50 percent increased risk of incident colon, prostate, and breast cancer, along with elevated mortality from these cancers. Despite these findings, clinical evidence remains mixed. The large-scale VITAL study reported a reduction in cancer-related deaths over five years of daily vitamin D supplementation (2,000 IU), but not a decrease in the risk of developing cancer. However, a recently published secondary analysis of the trial data revealed that participants taking the vitamin D supplement had a 20 percent lower likelihood of developing advanced cancer, defined as metastatic or fatal.

A review of several clinical trials further substantiated the link between low vitamin D levels and risk of mortality, more broadly showing a seven percent reduction in all-cause mortality with daily vitamin D supplementation (median dose 800 IU).

Many unknowns continue to surround vitamin D and its relation to cancer risk and overall mortality. “Significantly more research is needed to determine if low vitamin D levels are a risk factor for cancer and whether supplementation can impact overall longevity,” states Dr. Oh. “Nevertheless, the present data does suggest that individuals at risk for cancer may consider supplementing with vitamin D.”

How Much Vitamin D Do I Need?

There is controversy over the levels of vitamin D considered to be sufficient; however, it is widely acknowledged that 25-OH vitamin D levels below 30 ng per mL of blood (50 nmol/L) are insufficient to maintain bone health. 

Optimal levels of vitamin D vary among individuals based on factors such as age, race, metabolic differences, and physiological condition. Adding complexity to this understanding, Dr. Pojednic emphasizes that most vitamin D recommendations are based solely on bone health, and levels required to support other tissues may vary. As such, there is no universally accepted optimal vitamin D level for overall health.

Dr. Oh recommends optimizing natural sources of vitamin D first, such as averaging about 30 minutes in the sun most days, and including a few servings of vitamin D-rich foods in their diet. 

Dr. Pojednic adds that achieving these levels does not need to be a daily practice. “Since vitamin D is a fat-soluble vitamin, our fat cells can store excess for weeks. Therefore, it is more important to consider average sunlight exposure and vitamin D consumption rather than focusing on daily intakes,” she says.

Because vitamin D is stored in fat cells, excessive doses can build up to toxic levels, therefore taking high doses of vitamin D (i.e. more than 4,000 IU per day)  can be dangerous and should be avoided. Symptoms of vitamin D toxicity include weight loss, irregular heart beat, hardening of blood vessels and tissues due to increased blood levels of calcium, potentially leading to damage of the heart and kidneys.

Common Risk Factors for Vitamin D Deficiency

Although it seems easy to absorb 30 minutes of sunlight per day , vitamin D deficiency is common in the US. There are many factors to explain this, including limited geographical location, time outdoors, age-related changes, skin color, restrictive diets, and certain medical conditions. Those affected by these factors may need supplementation to ensure they meet their body’s vitamin D requirements.

1. Sun exposure

During the winter months, people who live in areas above 37 degrees north latitude, which includes cities such as San Francisco, Seattle, Denver, St. Louis, Philadelphia, New York, Boston, and Chicago, do not receive sufficient UVB exposure to produce the necessary amount of vitamin D.

“Vitamin D synthesis in our bodies occurs only at specific wavelengths,” explains Dr. Pojednic. “Thus, geographical location is an essential factor in determining the best way to maintain your vitamin D levels.”

Even people living in sunny areas can experience deficiency related to sun exposure. By spending significant time indoors or consistently wearing clothing that covers most of the body, our skin will not receive necessary exposure for optimal vitamin D synthesis. Moreover, while many believe they get sufficient sunlight through car or office windows, most windows filter out the UVB rays necessary for synthesis. 

Of course, there are many concerns surrounding direct sun exposure, most notably skin cancer. Using sunscreen and limiting sun exposure are still very important measures to protect the skin. While the role of sunscreen in contributing to low vitamin D levels is subject to debate, evidence indicates that the typical use of sunscreen does not significantly impact the body’s ability to produce vitamin D. This means that for most individuals, wearing sunscreen during exposure to sunlight still allows for the synthesis of vitamin D.

2. Age

The skin’s ability to produce vitamin D diminishes significantly with age, declining at an estimated rate of 13 percent per decade of life. Additionally, as we age, our body becomes less efficient in absorbing and utilizing vitamin D.

3. Skin color

Individuals with darker skin often exhibit lower blood levels of vitamin D likely due to the pigment melanin acting as a natural shade, reducing the production of vitamin D. Consequently, low vitamin D levels are particularly prevalent among Americans with darker skin tones. 

4. Diet

Individuals who cannot tolerate or choose not to consume milk, eggs, and fish, such as those with lactose intolerance or those adhering to a vegan diet, face an elevated risk of vitamin D deficiency. “The exclusion of these food sources, which are rich in vitamin D, makes it challenging for individuals in these groups to obtain sufficient levels of this nutrient from food alone,” states Dr. Pojednic.

5. Certain medical conditions

Individuals with inflammatory bowel diseases, such as ulcerative colitis, Crohn’s disease, celiac disease, and chronic pancreatitis may encounter difficulties in maintaining optimal vitamin D levels. This is because the absorption of vitamin D, a fat-soluble vitamin, is contingent on the digestive tract’s ability to absorb dietary fat, and inflammatory conditions within the tract can impede this process. Additionally, certain liver and kidney conditions may impair the metabolism and utilization of vitamin D within the body.

“Signs that your body may need more vitamin D than it is currently getting include bone pain, especially of your chest, shins and even overall chronic pain. For athletes, any bone stress injury like shin splints and poor healing stress fractures may indicate a vitamin D deficiency,” states Dr. Oh. “Finally if you have muscular weakness or pain, especially of your upper legs it would be reasonable to check your vitamin D levels with a blood test.”

Supplements for Healthy Aging

By Matthew Kaufman, MD


Key Takeaways:

Here are a few supplements that our health professionals recommend for healthy aging for individuals in midlife and beyond:

  • Creatine – To maintain and build muscle mass and potentially improve cognitive performance.
  • Vitamin D – To promote muscle and bone strength. 
  • Magnesium – To promote restful sleep and brain health.
  • B12 and B9 (folate) – To promote brain health. (B12 is particularly recommended for vegans since it is primarily found in animal products).
  • Multivitamin that is FDA-regulated or third-party tested. Unregulated supplements may not contain the active ingredients to live up to their advertised claims and may contain harmful ingredients.

As we age, taking too many supplements may be taxing to our liver and kidneys, so it’s best to screen to assess where we are deficient and supplement as needed.

Lifestyle choices are most important for maintaining good health as we age, and supplements do not replace a healthy diet and daily exercise.


As a Physical Medicine and Rehabilitation resident, my patients often ask me, “What supplements should I take as I get older?” While it is a complicated question without a clear answer, it’s important to consider. 

Rather than investigating how a supplement affects the entire body as we age, researchers study how supplements impact specific aspects of health, such as sleep, muscle mass, and brain health. However, we all know that we don’t age in only one domain–the aging process affects many parts of the body. Therefore, there are multiple supplements to consider, and which supplement you take depends on your individual goals.

So, whenever I am posed with this question, I always respond with these two questions: 

1) What are your goals regarding aging? Is it just a longer lifespan, or do you also want to feel good in your 70s and 80s and maintain high-quality interactions with people and places? 

2) What aging concerns do you want to address or avoid? Some examples include optimizing your bones and muscles for sustained athletic ability, brain health and cognition performance, and your ability to have restful sleep on a consistent basis.

Which Supplements Should I Take for Healthy Aging?

Supplements to Maintain Muscle Mass and Bone Strength

As we age, the most important things we can do to maintain muscle and bone strength are resistance training at least twice weekly and consume adequate protein, especially from food (both plant and animal sources). Without these two things in place, supplements alone have not been shown to be helpful. 

Regarding protein, I recommend consuming 1.2 – 1.6 grams per kg of body weight per day. This translates to approximately 0.65 grams of protein multiplied by your body weight in pounds, to be consumed evenly over three to four meals per day. 

To maintain and build muscle mass as we age, I also recommend creatine. Consuming between 5 – 25 grams of creatine per day (either as a supplement or in food) has been shown to increase strength and muscle protein synthesis, and maintain lean body mass.

Vitamin D supplementation also has substantial evidence showing improvements in muscle and bone strength in older adults.

Supplements for Brain Health and Cognitive Performance

Some studies show that vitamin D may improve brain health and cognitive performance. Also, magnesium and higher doses of creatine have emerging evidence suggesting they could also be helpful. B vitamins like B6, B12, and B9 (folate) have also been shown to help with cognition prior to diagnosis of mild cognitive impairment and Alzheimer’s Disease.

Many people take omega-3 supplements intending to improve cognition; however, the data is not as strong as many people suspect. Some studies suggest that these supplements are effective, and some don’t. Most experts believe that getting omega-3s from food (such as fatty fish, walnuts, and chia seeds) is preferable to getting them from a supplement in that they are better absorbed in the body. For my patients, I recommend consuming omega-3s by eating more salmon and enjoying a low-inflammatory diet, such as the Mediterranean diet.

Supplements for Sleep

There is not currently a supplement that the American Academy of Sleep would recommend, however, melatonin is the most popular sleep supplement. If you find melatonin helpful, it’s important to use it at the minimum effective dose to prevent circadian rhythm shifts. There is also recent evidence that magnesium is helpful for sleep.

Lifespan vs. Healthspan

 Lifespan is the number of years we are alive, whereas healthspan is how many of those years we feel good (physically and mentally) and are healthy enough to live independently and free from debilitating diseases. 

Although there is no magic pill for a longer life, these supplements may improve your healthspan by increasing your levels of functioning and slowing the progression of chronic conditions. Healthy aging is not only about preventing illness or falls; it also encompasses the ability to engage in activities we enjoy, spend quality time with people we love, and maintain a sense of purpose and excitement as an older adult. 

When choosing a supplement, it is crucial to remember that the FDA does not regulate most supplements. Therefore, there is minimal oversight regarding the ingredients in these supplements and whether they live up to their advertised claims. Without regulation, some supplements don’t contain the active ingredient, and they may even contain ingredients that are harmful, such as heavy metals, not listed on the bottle. Therefore, it is essential to go with supplements that are third-party tested or recommended by health professionals you trust and not just rely on advertising.  

Lastly, it is most important to recognize that supplements cannot replace a poor diet or lack of exercise. We must take supplements in the context of other healthy lifestyle choices, such as adequate nutrition, sleep, exercise, and working with a medical professional to treat any medical conditions. 

Supplements for Elite Athletic Recovery

By Caitlin Aguirre, Adrian Vallejo, Matthew Kaufman, MD


Key Takeaways:

  • It is recommended to consult with a medical professional before taking the supplements listed in this blog.
  • Branched Chain Amino Acids stand out as a well-supported supplement for athletic recovery, aiding in faster physical recovery, decreased fatigue perception, and maintenance of lean mass. Recommended dosages range from 10 – 30 grams per day.
  • L-theanine shows promise in mental recovery post-exercise, with suggested doses ranging from 50 – 200 mg per day. 
  • N-acetylcysteine’s role in reducing perceived muscle soreness remains uncertain, with doses of 1200 – 1800 mg per day utilized for supplementation within existing studies.
  • Turmeric shows promise in alleviating muscle soreness at doses ranging from 1.5 – 5 grams of turmeric extract daily, although research is conflicting. Supplementing with piperine (black pepper) may enhance its effectiveness.
  • Ashwagandha holds the potential to reduce muscle soreness and improve athletic and mental recovery at a dose of 600 mg daily. While research on its effects is limited, current evidence suggests it’s generally safe for supplementation.

For high-performance athletes, achieving peak performance is not solely a result of pushing one’s physical limits. Even the best competitors experience fatigue, musculoskeletal pains, exercise-induced muscle dysfunction (EIMD), and delayed-onset muscle soreness (DOMS) that may impact their ability to sustain maximal training efforts and combat injury. In response to these physical ailments, often a sign of our bodies adapting to higher training loads, high-performance athletes have mastered the practice of athletic recovery.

The principles of athletic recovery can be thought of as a pyramid having a base of quality sleep, balanced nutrition, and hydration. These elements are the foundation upon which adapting to the demands of intense training is built. However, as committed athletes refine their sleep hygiene, prepare macro-friendly meals, and hydrate appropriately, they often look to ascend this metaphorical “athletic recovery pyramid” by utilizing nutritional supplements to gain an edge over their competitors. Previous literature has estimated that 40 – 100 percent of trained athletes have employed nutrient supplementation, depending on the definitions of trained athletes and supplementation.

In this blog post, we’ll explore the role of popular anti-inflammatory and antioxidant nutritional supplements, including BCAA’s, L-theanine (LTE), N-acetylcysteine (NAC), Turmeric, and Ashwagandha, and what role they may play in athletic recovery.

What are Branched Chain Amino Acids (BCAAs)?

BCAAs are a specific class of amino acids that have branched side chains. These include amino acids like leucine, isoleucine, and valine. Studies suggest that BCAAs are among the most commonly used supplements in trained athletes. These essential amino acids are broken down for fuel during exercise, and supplementation has been thought to provide substrate for anabolic (muscle-building) processes to prolong energy sources and protect against muscle damage and fatigue. Rather than a supplement, you may also consume BCAAs by eating foods high in leucine, such as salmon, chicken, cottage cheese, eggs, nuts, lentils, and beans.

Potential Benefits of BCAAs for Athletic Recovery

Our Recommendations

BCAAs are a supplement well supported by scientific literature that can shorten recovery time and decrease perceptions of fatigue. As an athlete, this may maximize athletic results by supporting the ability to continue long training sessions and return to sport quicker!

Dosing

Studies have shown positive outcomes with BCAA supplementation ranging from 0.087 – 0.22 grams per kg of body weight per day for at least eight days. Positive effects were also shown when the athlete took 20 grams one hour prior to exercise. While there’s no apparent consensus on the optimal dosing strategy, studies show that taking between 10 – 30 grams per day had no noted ill effects.

What is L-theanine (LTE)?

LTE is a non-proteinogenic amino acid that is structurally similar to glutamate. It is a primary component of the Camellia Sinensis plant, which is used to make green tea, and can also be found in smaller quantities in other foods, such as mushrooms, apples, and red wine.

Potential Benefits of LTE for Athletic Recovery

Our Recommendations

Since mental restoration following strenuous training or competition is vital for preventing burnout and enabling athletes to maintain a consistent level of high-intensity training, we recommend a supplement that provides mental recovery. Current evidence shows that LTE has the potential to aid mental recovery, however, further studies on larger sample sizes of athletes may be necessary for a comprehensive recommendation. 

Dosing

Although there is no clear agreement regarding the best dosing strategy for LTE, the studies examined in this review have demonstrated physiologic benefits with doses ranging from 50 – 200 mg per day. Within this range, LTE is considered safe for consumption and has demonstrated no toxic effects in both human and rodent studies.

What is N-acetylcysteine (NAC)?

NAC is a synthetic derivative of the naturally occurring amino acid L-cysteine. In the body, L-cysteine and NAC have direct antioxidative properties and serve as precursors to glutathione (GSH), another powerful antioxidant that prevents excessive molecular damage.

Potential Benefits of NAC for Athletic Recovery

  • May reduce perceived muscle soreness – Numerous studies evaluating the effects of NAC supplementation have shown mixed outcomes regarding the benefits of its antioxidative properties and ability to reduce muscle soreness.

Our Recommendations

Further investigations are necessary before clear conclusions can be drawn about whether NAC supplementation improves athletic recovery by decreasing perceived muscle soreness. 

Dosing

While there is no standardized dosing strategy for NAC supplementation, existing studies evaluated doses between 12001800 mg per day, with a loading period of at least three days. It’s important to note that exceeding 70 mg per kg of body weight may lead to negative side effects, including gastrointestinal upset, so it’s essential to monitor dosage and potential reactions carefully.

What is Turmeric?

Turmeric, Curcuma longa, is a commonly used medicinal herb that contains curcuminoids, including curcumin. Curcumin has been shown to have antioxidant effects and is associated with pain reduction, anti-inflammation, and chronic disease prevention and treatment.

Potential Benefits of Turmeric for  Athletic Recovery

  • May reduce perception of muscle soreness – Despite conflicting literature, numerous studies evaluating the effect of turmeric on whole and lower-body soreness and single-leg squat pain scores have found that its supplementation significantly reduced measures of muscle soreness. However, one recent meta-analysis found no significant effects on exercise-induced muscle damage or delayed onset muscle soreness. 
  • Taking piperine (black pepper) along with turmeric has been shown to potentially increase its bioavailability and may increase the efficacy of this supplement.

Our Recommendations

According to the literature, turmeric, or curcumin, seems to be a safe supplement for potentially reducing perceived muscle soreness following exercise. However, further study is needed to confirm the extent of turmeric’s efficacy due to the presence of conflicting research. It’s worth noting that simultaneously supplementing with piperine (black pepper) may positively influence its effectiveness.

Dosing

There is no standardized dosing strategy, however, doses ranging from 1.5 – 5 grams of turmeric extract daily, perhaps with piperine (black pepper), may be helpful in exercise recovery. Higher doses of 10 mg and above have been shown to produce mild negative side effects, including headache, diarrhea, yellow stool, and rash. Take caution when consuming higher doses is warranted as the literature on safety and side effects is limited. 

What is Ashwagandha?

Ashwagandha, or Withania somnifera, is an adaptogenic herb commonly used in Ayurvedic medicine. It has gained traction within the fitness community due to some preliminary studies showing an association between the supplement and enhancing muscle strength, muscle endurance, and cardiorespiratory fitness while counteracting chronic fatigue, weakness, nervous exhaustion, and premature aging. The mechanisms by which ashwagandha may improve physical recovery in humans are not well understood but are hypothesized to be at least partially due to antioxidant properties and endocrine effects.

Potential Benefits of Ashwagandha for Athletic Recovery

  • May reduce perception of muscle soreness – Supplementation has been found to decrease one’s perception of muscle soreness after exercise. This effect on muscle soreness is attributed to its antioxidant properties and its hypothesized ability to be converted into testosterone and DHEA, however, further study is needed to elucidate the exact mechanism.
  • May reduce recovery time – While evidence for this effect is minimal, two studies found significant improvement in participants’ perceived athletic recovery experiences. 
  • May promote mental recovery – One study found that supplementation lowered participants’ perception of general stress, fatigue, and lack of energy and improved general well-being scores compared to placebo.

Our Recommendations

The literature on the effects of ashwagandha on athletic recovery is minimal, however, current studies suggest that it is a safe supplement that may reduce one’s perception of muscle soreness and improve athletic and mental recovery following exercise. 

Dosing

There is no standardized dosing strategy, however, studies show that 600 mg of ashwagandha daily may be helpful in exercise recovery. Common side effects may include drowsiness, epigastric discomfort, and loose stools. Less common effects include mild CNS depression, increased thyroxine levels, hallucinations, blurred vision, vertigo, nausea, decreased appetite, constipation, hyperacidity, nasal congestion, dry mouth, hyperactivity, nocturnal cramping, skin rash, and weight gain.

Marily Oppezzo, PhD: The Heart and Soul of Stanford Lifestyle Medicine’s Head of Nutrition

By Sharon Brock, MEd, MS

“Sorry, Dad, I’ve fallen in love with Valerio and I’m not coming back,” said Marily Oppezzo, then 19, who spent the summer before her junior year of college studying art in Florence, Italy.

“Valerio? That’s absurd,” exclaimed Oppezzo’s father. “You are coming home and finishing college, young lady!”

Oppezzo followed her father’s wishes, kissed Valerio goodbye, and returned to Santa Clara University, where she jumped from one major to the next. Since the age of five, Oppezzo wanted to be a veterinarian, but then, in college, she pursued becoming an FBI agent, switched to art history while doing Pre-Med, and settled on majoring in Health Psychology with a double major in Italian (just in case).

After graduation, she continued her training by earning a master’s degree in nutritional science at San Jose State, working at the Veterans Affairs Hospital, and completing a three-year program to become a registered dietician nutritionist. In 2012, Oppezzo earned a PhD in Educational Psychology at Stanford University, with post-doctoral studies at the Stanford Prevention Research Center in Behavioral Sciences.

“Having health information is only half the battle,” said Oppezzo. “I also wanted to learn how to help people incorporate the information into their lives. If you don’t understand the psychology of building new habits, you’re just a walking textbook of information.”

Valerio’s loss was Stanford’s gain, as Oppezzo is now leading the Nutrition Pillar of Stanford Lifestyle Medicine and facilitating groundbreaking research in exercise and nutrition.

An Unexpected Emergency

During Oppezzo’s first year of doctoral studies, an astute nurse practitioner detected a heart murmur during a routine check-up. The following quarter, a Stanford cardiologist discovered several congenital abnormalities that caused her heart to pump most of her oxygenated blood from her lungs back to the wrong side of her heart. Just two weeks after the discovery, Oppezzo underwent open-heart surgery. Although she took only a quarter off from her studies, it took more than two years to recover fully.

“My cardiologist said I was lucky to still be alive at the age of 30,” said Oppezzo. “Now that I’m recovered, I deeply empathize with anyone who has to go through this. Cardiac rehabilitation was so painful.” 

Her father was there for her during this arduous, multi-year rehabilitation process. He was a health education teacher and coached football, baseball, basketball, and track at Mountain View High School. He was an inspiration to many students and believed everyone had an inner athlete with the ability to overcome life’s obstacles.

“I owe my full recovery to my family–especially my dad,” said Oppezzo. “He was my support system and my coach through my physical therapy. It was slow progress, and I got frustrated really quickly–but he was so patient and positive the whole time.”

Turning Pain into Purpose

Returning to her doctoral studies at Stanford, she added heart disease prevention and cardiac rehabilitation to her docket of interests. Also, due to her experience of post-surgery depression, she began to study mind-body modalities, such as yoga and lifestyle medicine.

Oppezzo’s holistic–but realistic–approach to health is shown in her research. Her current study on “Exercise Snacks” encourages sedentary office workers to get out of their chairs a few times per day and perform a two-minute exercise (i.e., running up the stairs or jumping jacks at their desks) for both physical and mental health.

Research shows that it only takes two minutes of high-intensity exercise to reverse negative changes found in those who sit for more than three hours at a time. Another similar study showed that running for 10 minutes three times during the day conferred similar VO2 max benefits to running for 30 minutes continuously. In her research, Oppezzo also focused on behavior change and sought to understand how to motivate people to complete these exercise snacks during their work day.

“I like to find ways to support folks who are busy. We get it in our heads that we will go to the gym and do cardio and lift weights for hours; we have these huge goals. And then we get down on ourselves when we don’t do it, and think ‘why bother’ if I can’t do it all,” said Oppezzo. “But research shows that these two-minute exercises do still count—a lot! And the bonuses are that you don’t need a shower after, and you don’t need ‘enough time’ or resources to go to a gym.”

Future Goals

 Oppezzo was recently awarded a two-year Clinician Scientist Fellowship at Stanford’s WuTsai Human Performance Alliance, where she will develop and test the “Stronger” program to help menopausal women start a muscle training practice to maintain and grow muscle mass. Oppezzo will also incorporate best behavioral science practices to empower women to start and maintain this as a lifelong “lifestyle” and improve both physical and psychological strength.

“I love working with the WuTsai and Stanford Lifestyle Medicine teams because it’s a chance for health professionals from various disciplines to come together and collaborate,” said Oppezzo. “In the future, I’d love to see more interdisciplinary collaboration in research to promote health in a more holistic way. We are more than our physical bodies—we need to look at the health of our minds and spirits, too.”

 On a personal level, Oppezzo is very close with her family, which includes her mother, sister, and nephews, all of whom live in the Bay Area. Unfortunately, her father tragically passed away from a rare disease five years ago. “My dad meant so much to me,” she said. “He beat many odds, went out on his own terms, and lived and passed as a heroic example of someone who not only loved and cared for people deeply, he also embodied and practiced all the pillars of lifestyle medicine his whole life.”

When not working, lifting weights, or hanging out with her partner and rescue dog, Oppezzo loves to escape into the mountains for backpacking trips. “You can’t get closer to capital ‘L’ life than being in the mountains,” she said. “I cherish the enormity, awe, and blissful exhaustion I get to experience there. Hiking while being surrounded by nothing but huge peaks and glass-mirror lakes, I think about my dad and feel grateful for his inspiration and presence, which stay with me, always.”

Whole Foods vs. Greens Powders (and Other Supplements)

By Sharon Brock, MEd, MS

Stanford Lifestyle Medicine’s nutrition experts, dietitians, and supplement researchers recommend getting nutrition from your food rather than a supplement as much as possible. For example, rather than drinking water with greens powder for lunch, eating a salad with a variety of vegetables is recommended to ensure that you’re getting the nutrition you need in a form that’s bioavailable (still useful) in the body.

“You can’t supplement your way out of a poor diet,” says Rachele Podjenic, PhD, Stanford nutrition and supplement researcher. “Even though fruits and vegetables are technically in many greens powders, since these whole foods are no longer in their original structure, we don’t really know if the nutrients are bioavailable once they are absorbed. There are a lot of claims being made, but almost no data to support them. In my opinion, greens powders are just a waste of money.”

If you’re eating healthy but want to be sure you’re covering all your nutritional bases, our experts recommend taking a multivitamin, and perhaps a couple other supplements (like vitamin D and B12) for healthy aging.  Dr. Podjenic says that it’s important that every supplement you take be third-party tested by organizations such as ConsumerLab, US Pharmacopeia, and NSF International. 

“We need to see supplements as a supplement in our already healthy diet, not as a substitute for eating well,” says Dr. Podjenic. “If you’re already eating healthy and a blood test shows you’re still deficient in a particular nutrient, that is where supplements come in.”

How do we get nutrition from our food?

Below is a graphic listing common supplements with their food equivalents. We aren’t suggesting you stop your supplements altogether (especially if your doctor or dietician recommends them), but to recognize that when we eat whole foods, we consume these nutrients in a more bioavailable form.

 

 

 

Everything You Need to Know About Creatine

By Carly Smith, BS, MPH(c)

A recent analysis done by members of the Stanford Lifestyle Medicine team on how different supplements impact sports performance, highlighted creatine since it has been vastly researched and shown to improve muscle strength.

“What many do not realize is that supplements, like creatine, can be beneficial for more than just professional athletes and bodybuilders,” says Matthew Kaufman, MD, member of the Stanford Lifestyle Medicine Exercise and Movement research team and lead author of “The Impact of Supplements on Sports Performance for the Trained Athlete: A Critical Analysis.”

What is Creatine?

So, what is creatine? Creatine is a natural amino acid that people can gain in their diet with foods high in protein or through supplementation. Mechanistically, creatine supports powerful muscle contractions, which is why it is popular among bodybuilders. After digestion, creatine-phosphate is stored in skeletal muscle until the onset of quick, intense physical activity. Once activity is initiated, it is used to rapidly phosphorylate ADP into ATP, which drives fast-twitch muscle contractions, the primary drivers of quick, forceful exercise movements like weight lifting and sprinting.

According to the analysis, athletes that also depend on fast, powerful movements and mobility, like soccer and basketball players, may also benefit from increasing their creatine intake. Its ability to heighten muscle performance is continuing to be tested and is being used by many to increase the size and strength of their muscles.

“What’s nice about creatine, especially compared to other supplements, is how much it has been studied. It has robust, promising data that shows it can really improve athletic performance and muscle composition,” says Dr. Kaufman. “Plus, it can help muscle growth and performance for all different types of people.”

Creatine Is Not Just for Bodybuilders!

Creatine may also be a good supplement for plant-based athletes. The analysis found evidence that vegetarian athletes improved more than omnivorous athletes with creatine supplementation in terms of muscle power output and lean muscle mass, therefore plant-based athletes could consider supplementation to support their athletic performance.

Creatine is also recommended for older individuals to support muscle sarcopenia. With age, many people experience a loss of muscle vitality, which heightens risk of falling and injury. Research published in the Journal of Clinical Medicine indicates that creatine supplementation may help older adults maintain muscle vitality. It suggests that there could be significant benefits from supplementing their diets with creatine for an “anti-aging” effect for the body.

How Much Creatine Do I Need?

Whether taking creatine supplements for athletic performance or daily functioning, it is important to know what the International Society of Sports Nutrition’s (ISSN) recommended dosing strategy is. Their recommendation begins with all individuals taking 5 grams of creatine, four times per day (20 g total per day) for about a week. This first week is called the loading stage, which helps many people adjust to the supplement before experiencing any physical changes. Next, ISSN recommends maintaining a dose between 3-5 grams daily. Males and larger athletes may need 5-10 grams daily to maintain their body’s creatine stores.

People considering taking creatine should be aware of some potential side effects. Studies report the possible side effects of increased water retention and airway sensitivity in elite athletes, the latter suggesting the need for further research on how creatine affects those with asthma. We recommend consulting with your physician ahead of time so they can tailor the ISSN’s dosing recommendations for your specific needs.

Overall, creatine supplementation may be promising for many individuals, bodybuilders or not, looking to improve the power of their muscles.

Alcohol: Is There a Healthy Way to Drink?

By Maya Shetty, BS

“Salud!” If you’ve ever raised a glass to your health, you’re not alone. For decades, many have believed that minimal alcohol consumption is potentially beneficial for your health. However, not every researcher would agree. A growing body of evidence reveals health concerns about alcohol use, making it crucial to understand the spectrum from harmless to harmful levels of consumption to keep your body healthy. 

“Alcohol will impact everyone’s health differently,” says Douglas Noordsy, MD, Clinical Professor of Psychiatry at Stanford University School of Medicine and Assistant Director of Stanford Lifestyle Medicine. “Rather than a daily habit, drinking alcohol should be seen as an indulgence, something you have once in a while to celebrate.”

Experts have conflicting views regarding how much alcohol carries risks. Some believe that drinking in moderation is safe, while others believe that even light drinking can cause harm.

“While many believe light to moderate alcohol intake is safe and even healthy, this reality is far from true,” states Cindy Kin, MD, a colorectal surgeon and Associate Professor of Surgery at Stanford University. “In fact, no level of alcohol can be considered beneficial for our health.”

Isn’t One Glass of Red Wine Good for the Heart?

“Studies have gone back and forth, with some suggesting potential cardiovascular benefits of light drinking, while others point to increased risk of cancer and liver disease even when consumed at low intake levels. As a result, many are confused about headlines proclaiming alcohol as either good or bad for health,” says Dr. Noordsy.

The origin of this belief traces back to the 1980s, rooted in a concept known as The French Paradox–the observation that despite consuming a diet high in saturated fat, France had a low incidence of heart disease. Researchers of the era decided that this unexpected trend was attributed to the widespread consumption of wine in the region. This correlation led to extensive research into wine and the identification of polyphenols, thought to be responsible for wine’s apparent cardioprotective potential. 

Since then, numerous observational studies have claimed that light to moderate wine intake has beneficial effects. “However, these studies overlooked some crucial factors,” says Dr. Kin. While early observations indicated poorer cardiovascular outcomes for non-drinkers than for moderate drinkers, researchers overlooked that many non-drinkers abstained due to existing health conditions that led to overall poorer health outcomes. Additionally, those self-identified as light drinkers were more likely to lead healthier lifestyles overall. This oversight has fostered a misleading impression that associates better cardiovascular outcomes with light drinking, falsely implicating alcohol as the causal factor. As a result, enjoying a glass or two of wine a day has become widely accepted as a  healthy habit. 

While red wine contains antioxidants like resveratrol, found in grape skins as well as in peanuts, dark chocolate, and blueberries, which might have heart-healthy benefits like reducing cholesterol and lowering blood pressure, the quantities are often misunderstood. To achieve the levels of resveratrol observed beneficial in mice studies, one would need to consume an impractical amount of red wine—somewhere between a hundred to a thousand glasses daily. Thus, while the idea of resveratrol’s benefits is enticing, the practical reality makes it an unrealistic source for therapeutic effects.

How Much Alcohol is Too Much?

Many people believe alcohol becomes a concern only when consumed excessively. “Excessive alcohol use” is defined as exceeding the US Dietary Guidelines’ recommendations, which advise males to limit themselves to two drinks per day and females to one drink per day, on average. Two-thirds of adult drinkers report drinking above this level at least once a month.

However, a growing body of recent research shows that even modest quantities of alcohol can be harmful to our health. Such consistent findings have prompted the World Health Organization to assert that “when it comes to alcohol consumption, there is no safe amount that does not affect health.”

The main issue with alcohol is that it enters the bloodstream and quickly spreads throughout the entire body (especially when consumed without food). Unlike most substances, alcohol is both water- and fat-soluble, allowing it to permeate nearly every cell and tissue, including the highly secure blood-brain barrier that protects our central nervous system. 

While the liver does most of the alcohol metabolism, other organs also process alcohol, such as the kidneys and lungs. As our organs work to break it down into a usable fuel source, acetaldehyde is produced, which is toxic due to its ability to damage and kill cells indiscriminately. As acetaldehyde enters the brain, it causes a disruption in our neural circuitry that creates the sensation of “tipsiness” associated with alcohol. And, the more “tipsy” one feels, the greater the amount of toxic acetaldehyde in the blood.

Rather than following strict guidelines about how much to drink, Dr. Noordsy recommends that individuals take note of their personal perceptions of intoxication and pace themselves accordingly. He recommends using the feeling of being “tipsy” as the signal to slow down or stop drinking. “The ‘tipsy’ feeling is the indicator that blood alcohol levels have risen to the point that you’re starting to put your health at risk. And the more ‘tipsy’ you become, the higher the risk,” states Dr. Noordsy. “If you’re having alcohol with food, your blood alcohol level won’t be as high as compared to having drinks by themselves. So, if you’re enjoying a glass of wine as part of your meal, that’s a very different thing than drinking in a way that’s leading to the feeling of intoxication.”

Health Concerns Linked to Alcohol Use

Recent data from the World Health Organization reveals that each year, alcohol contributes to three million deaths globally and accounts for 5.1 percent of the worldwide burden of disease and injury. Alcohol’s detrimental effects span more than 200 disease and injury conditions, encompassing everything from alcohol dependence and liver cirrhosis to a range of non-communicable diseases (such as heart disease, cancer, chronic respiratory disease, and diabetes) and mental health disorders.

Liver Disease

Acetaldehyde, a derivative of alcohol metabolism, inflicts significant harm on the body’s cells, especially within the liver. Given the liver’s primary role in detoxifying our bloodstream, it bears the brunt of the detrimental effects of alcohol metabolism. This continual strain can result in the buildup of fat, chronic inflammation, and potentially irreversible damage to the liver. 

A study analyzing the livers of 3,649 participants discovered a concerning correlation: as daily alcohol intake increased, so did the accumulation of fat in the liver. Alarmingly, no identifiable threshold existed below which these harmful effects were absent, suggesting that even individuals who consume alcohol in minimal amounts are not immune to the accumulation of liver fat.

Fat accumulation hinders the liver’s vital metabolic functions, including blood sugar regulation, cholesterol processing, and nutrient absorption. It also increases the risk of inflammation around the liver, known as alcoholic hepatitis. 

“The good news is that abstaining entirely from alcohol can reverse these changes, however, continuing to drink alcohol can lead to irreversible damage, scarring, liver dysfunction, and in advanced cases, liver failure,” states Dr. Kin. “This is especially concerning because fatty liver often presents no early symptoms, with individuals potentially unaware until it advances or results in serious complications.”

Another important consideration is that people who have non-alcoholic fatty liver disease, caused by obesity and other metabolic syndromes, have a much higher risk of developing alcoholic liver disease. 

“This means that even small amounts of alcohol will cause the same level of alcohol-related liver disease (fibrosis, cirrhosis, etc.) as would larger amounts of alcohol consumed by someone without underlying fatty liver,” explains Dr. Kin. “Therefore, people who are already dealing with metabolic diseases should be extra cautious around alcohol because their livers are working extra hard already.”

Cancer

Alcohol is designated as a carcinogen by the International Agency for Research on Cancer due to its association with higher risk for many common cancers.

Alcohol increases cancer risk specifically in areas it is in close contact with, such as the mouth, pharynx, and digestive tract. It also has carcinogenic effects throughout other parts of the body,” states Dr. Kin.

Underlying its harmful effects, chronic inflammation from alcohol consumption elevates cell turnover, heightening DNA mutation risks. Additionally, alcohol is believed to promote tumor growth while inhibiting tumor-suppressive molecules.

In 2017, the European Union reported nearly 23,000 cancer cases tied to light to moderate alcohol use, with half attributed to female breast cancers. Even at levels as low as three drinks per week on average, there is a slight but measurable increase in breast cancer risk. Notably, raising daily alcohol intake by just 10 grams—equivalent to what’s in a standard beer or wine—escalates the risk of breast cancer by 10 percent.

Cardiovascular Health

Despite popular belief, alcohol consumption, regardless of the amount, is linked to an increased risk of cardiovascular disease. A comprehensive study of 371,463 individuals found that as alcohol consumption increased, so did the risks of conditions like hypertension and coronary artery disease. Light alcohol intake (less than 8.4 drinks per week) led to a minimal but noticeable increase in cardiovascular risk. Researchers also found that when accounting for various lifestyle factors, the perceived protective benefits of modest alcohol intake against cardiovascular risks diminished significantly.

There are numerous reasons hypothesized for these detrimental effects, especially surrounding the metabolic effects of alcohol. “Alcohol offers no nutritional benefits; it’s essentially empty calories that are consumed on top of the calories required by your body. On top of this, alcohol interrupts the body’s regular metabolic functions. As the body prioritizes removing this toxic substance, it compromises processes like nutrient absorption and fat metabolism. This disruption promotes the storage of visceral fat, the harmful fat surrounding organs,” explains Dr. Kin. “This fat increases inflammation and poses significant risks, especially around the heart.”

Hormone Imbalance

Alcohol consumption raises estrogen levels in both males and females by increasing the activity of the enzyme responsible for converting androgens to estrogen. This accelerated conversion can lead to issues like gynecomastia (enlarged breasts in males), decreased libido, and increased fat accumulation. Additionally, consistent alcohol exposure can reduce testosterone levels over time, which is associated with reduced libido, fatigue, decreased bone density and muscle mass, and potential fertility issues in both males and females.

Additionally, regular alcohol consumption of more than 3.5 drinks per week for males and 2.6 drinks per week for females can cause chronic changes and reduced control of the hypothalamic-pituitary-adrenal axis. This disturbance may lead to an increase of the stress hormone cortisol released throughout the day.

Microbiome Issues

Alcohol also disrupts the gut microbiome by killing beneficial bacteria and other essential microbes. Additionally, alcohol’s pro-inflammatory properties trigger the release of inflammatory cytokines, causing gut inflammation and making the intestinal lining more permeable. This increased permeability can allow undigested food particles to enter the bloodstream. Over time, chronic alcohol consumption can further imbalance the gut microbiome, promoting bacterial overgrowth and dysbiosis. These disruptions can trigger immune responses, increasing susceptibility to food intolerances.

Brain Health

When alcohol is consumed, it enters the brain and suppresses neural networks involved in memory formation and storage. Through chronic consumption, this disruption can have permanent effects. A study involving over 36,000 middle-aged adults revealed that even moderate drinkers, consuming one to two drinks per day on average, displayed thinning of the neocortex and other brain regions, indicating neuron loss. This research also found that increased alcohol consumption correlates with diminished brain volume and reduced gray matter, which are the areas of the brain highly concentrated with neurons. As alcohol intake rose, so did the severity of these detrimental effects. 

Fortunately, for most casual drinkers, abstaining from alcohol for two to six months can reverse damage to the prefrontal cortex and neural circuitry. However, chronic users may only experience partial recovery and might endure lasting effects.

“As alcohol consumption increases, so does one’s risk of cognitive decline and dementia,” states Dr. Noordsy.

Mental Health

As anxiety and depression continue to rise in the US, alcohol use also increases as individuals self-medicate to reduce stress. Also, the nightly glass of wine may cause more stress the following day since it impairs cognitive and physical performance, reducing one’s ability to cope. “During the pandemic, we observed a startling rise in cases of alcohol-induced hepatitis, indicating a growing reliance on alcohol as a coping mechanism,” says Dr. Kin. 

One study, however, showed that light to moderate alcohol consumption may be beneficial to mental health by offering short-term relief by reducing stress signals in the brain. Although Dr. Noordsy acknowledges this study, he states that “learning to manage stress through physical exercise, mind-body and mindfulness practices can lead to safer and likely more effective mediation of impacts of stress than relying on alcohol use.” 

Is There a Healthy Way to Consume Alcohol?

Given the extensive research on the detrimental health effects of alcohol, both Dr. Kin and Dr. Noordsy recommend abstaining from alcohol, or at least drinking very rarely, if one is experiencing or has a family history of liver disease, cancer, cardiovascular disease, hormone imbalances, gut microbiome issues, dementia, or mental health disorders, including addiction.

The precise amount of alcohol that is harmful is difficult for experts to confirm because it’s different for each person. Therefore, when it comes to alcohol and health, Dr. Noordsy recommends a balanced, personalized approach keeping in mind one’s individual risk factors and health goals.

“While heavy, regular consumption is linked to health problems, an occasional drink with meals may pose little risk for most adults,” says Dr. Noordsy. “However, individuals with personal or family histories of certain cancers or other conditions may need to be more careful with alcohol intake. We put thought into our nutrition and exercise habits, and we need to be just as thoughtful about the role that alcohol plays in our lives and make informed decisions regarding how much is the right amount for ourselves.”

Although less inclined to recommend light alcohol consumption, Dr. Kin acknowledges that it is an ingrained part of people’s social and cultural lives, similar to many other things that individuals consume that do not contribute to health. So, she encourages individuals to reframe their mindset around alcohol. 

“Rather than viewing alcohol as a daily routine, consider it a treat reserved for special occasions or celebrations, much like enjoying a slice of birthday cake,” she says.

 

Protein Needs for Adults 50+

By Sharon Brock, MEd, MS

This blog is part of our Nutrition newsletter. If you like this content, sign up to receive our monthly newsletter!


Key Takeaways

  • For adults aged 50+, we recommend consuming 1.2  – 1.6 grams of protein/kg of body weight per day (0.54 – 0.72 grams/pound body weight per day). For a 165-pound adult, this translates to roughly 90 – 120 grams of protein per day.
  • To build muscle past the age of 50, we need to eat enough protein AND do weight training, and consume 30 – 35 grams of protein within two hours of the workout.
  • Due to anabolic resistance, which increases as we age, it’s recommended to increase protein intake per meal to roughly 30 – 35 grams.
  • Here is a detailed list of the protein content of various foods.

While looking at the menu at your favorite café and deciding whether to add salmon to your salad, it’s important to remember that we should strive to eat protein with every meal for optimal health. Protein is found in animal products, such as meat, fish, eggs, and dairy, as well as beans, tofu, nuts, and many vegetables. In your daily life, protein is the milk in your coffee, the eggs and cheese in your omelet, the chicken and beans in your burrito, and the handful of almonds as your afternoon snack.

Protein is essential for a multitude of functions in the body. Not only does protein support the building of our muscle mass, it helps the body repair tissues and cells, makes immunoglobulins and antibodies to fight infection, and drives metabolic reactions like digestion for energy production. It also makes up hormones, like insulin, provides structure in the body, such as bone and collagen, balances fluids and pH, as well as transports nutrients throughout the body, like blood sugar and cholesterol.

“It’s important to learn about protein and make sure we are eating enough because it’s a major building block of our bodies,” said Marily Oppezzo, PhD, MS, RDN, DipACLM, Nutrition Scientist and Head of the Stanford Lifestyle Medicine Nutrition Pillar. “We need to eat enough protein every single day to get the essential nutrients necessary for optimal health and functioning.”

How Much Protein Do You Need Every Day?

The federal guideline for individuals aged 19 and older is 0.8 grams of protein per kilogram of body weight. For a 165-pound adult, this translates to roughly 60 grams of protein per day (equivalent to consuming an 8oz salmon fillet and a handful of almonds). Many nutrition experts, however, believe this amount is too low, especially for those over 50.

“There is a growing body of evidence, particularly by researcher Stuart Phillips, that shows health benefits of consuming higher amounts of protein as we age, including slowing down age-related loss of muscle mass,” says Dr. Oppezzo. “There’s a difference between just surviving and thriving. For those over 50, I’d recommend between 1.2 grams / kg of body weight to 1.6 grams / kg of body weight, which is roughly double the federal recommendation.”

A recent study recommended that adults aged 18 to 30 consume 0.8 – 0.93 grams of protein per kilogram of body weight, with an increase of 0.85 to 0.96 grams / kg after the age of 30. For those over 65, another study recommended 1.2 – 2.0 grams / kg of body weight per day.

Dr. Oppezzo says that eating protein is not sufficient for building muscle—we must also strength train as we age. Researchers from this study recommend a protein intake higher than 1.6 grams / kg of body weight per day combined with resistance training to improve muscle strength. “Protein is important, but strength training is THE most important way to prevent age-related muscle loss, and it’s important to consume around 30 grams of protein within a couple of hours after working out,” she says. “First, give your body a reason to get stronger and build muscle (lifting weights), then give it enough materials (consuming protein) to build.”

Why Do We Need More Protein as We Age?

Starting around age 30, our body goes into maintenance mode, and our muscle mass starts to decline roughly one to two percent per year. And, as we age, the rate of decline increases by three to 10 percent per decade. Once we reach our 60s and beyond, the accumulated decline of muscle mass can increase the risk of falling, bone fractures, hospitalization, and earlier death, making the topic of protein consumption relevant to longevity.

“As we get older, we move less, and we eat less, and if we are not paying attention to our activity level and protein consumption, we can become frail,” says Dr. Oppezzo. “This becomes more important as we age because we become more anabolic resistant. Anabolic resistance is basically a reduced stimulation of muscle protein synthesis to a given dose of protein—it’s like you need to speak louder (more protein) for your muscles to hear (grow).”

Over the last ten years, there have been many studies on anabolic resistance. One study measured the amount of muscle synthesis between men aged ~22 and men aged ~71. The researchers gave each group a meal containing 20 grams of protein and then tested the degree of muscle synthesis. In the same sitting, both groups ate an additional 20 grams of protein, followed by a second test of muscle synthesis.

For the ~22 aged men, there was no difference in muscle synthesis between eating 20 or 40 grams of protein in one sitting. But for the ~71 aged men, their muscles were unresponsive to 20 grams of protein; they needed 40 grams. Specifically, the ~71-year-old group needed 0.4 grams / kg of body weight per meal, whereas the ~22  year-old-group only needed 0.2 grams / kg of body weight.

“The men in their 70s needed more than 20 grams of protein at a time to get their muscles to listen,” says Dr. Oppezzo. “Though they didn’t do this same elegant study in women, I imagine it is the same.”

Since protein consumption supports just about every function in the body, the body will utilize the amino acids where they are needed, such as the functioning of the brain, liver, immune system, or gastrointestinal tract. Unfortunately, maintaining muscle strength can be last on that list. Therefore, individuals over 50 need to consume enough protein to maintain the healthy functioning of their organs and keep their muscles strong.

“Within a meal, we must eat enough protein to wake up our muscles and say, ‘you have enough protein and calories to build,’ but in older adults, maybe the body is instead going to use that protein for energy or to support another function,” says Dr. Oppezzo. “I think muscle growth is a bit like remodeling your kitchen. You don’t remodel your kitchen if you can’t afford your utility bill. And, I think—as we age—the remodelers require more up-front cash.”

How Much Protein Do We Need Per Meal?

One study shows that there is no “upper limit” to the amount of protein we should eat in terms of our muscles’ ability to utilize it. However, Dr. Oppezzo suggests that we still spread out our protein throughout three meals a day.

Eating 20 grams of protein per meal might be enough if you’re 25 years old, but for those aged 50 or above, Dr. Oppezzo recommends 0.4 grams / kg of body weight per meal (which translates to 30 grams of protein per meal for a person who is 165 pounds).

Dr. Oppezzo says there are occasions when individuals may need to eat more towards the 1.6 grams / kg of body weight end of the range, such as competitive athletes or those recovering from an infection, hospitalization, or surgery. She also urges people who are intermittent fasting or on a very low-calorie or restrictive diet to make sure they are still consuming adequate protein.

“If we don’t eat enough protein during the day, where do we get our amino acids from? From our muscles!” exclaims Dr. Oppezzo. “I wouldn’t panic about a single day, but it’s not a great long-term plan.”

What are the Best Sources of Protein?

Luckily, every food has some protein in it! And most would agree that getting protein from a whole food source is always better than getting it from a powder. Whole foods have many other nutrients that are part of the package, and since we chew, swallow, and digest whole food at a specific rate, protein-rich foods enter the body more naturally than powders.

If you need to supplement with a protein powder, Dr. Oppezzo recommends whey protein or pea protein (vegan option). The most important amino acid needed to build muscle is leucine, which is found in high quantities in whey and milk. Researchers from this study found that leucine enhanced muscle protein synthesis in women aged 65 to 75, suggesting that older women should ensure that leucine is part of their protein intake.

“Although my mom, who is in her 70s, exercises every day, I’ve tried to supplement her activity by emphasizing eating enough protein every day and lifting weights weekly to keep her strong,” says Dr. Oppezzo. “I’m passionate about getting this information out there. It can help many people in their 50s and beyond maintain optimal health and live their best lives as they age.”