Category Archives: Bone Health

Chondroiton Sulfate and Glucosamine is effective in moderate-to-severe knee osteoarthritis.

lo res cartilage structure copy GlucosamineCombined chondroitin sulfate and glucosamine on Knee osteoarthritis

The MOVES trial tested whether chondroitin sulfate (CS)  plus glucosamine hydrochloride (GH) has comparable
efficacy to celecoxib after 6 months of treatment in patients
with painful knee osteoarthritis.

MOVES study for Chondroiton Sulfate and GH  < LINK to study

  • The trial tested 606 patients with moderate-to-severe knee osteoarthritis (OA) based on a WOMAC (Western Ontario and McMaster osteoarthritis index) scale >301 (range is 0-500). Treatment with 400 mg of CS and 500 mg GH three times a day was compared with the effects of Celocoxib 200 mg once a day for 6 months.
  • The results: Both treatments were equally effective. For CS/GH Vs.  Celocoxib, both treatments resulted in decreasing pain by 50% as well as joint swelling.
  • In summary: Using either Celocoxib or GH/CS had equal effect in decreasing joint stiffness, pain, functional limitations, and joint swelling after 6 months in the treatment of OA of the knee.
  • Be certain to obtain your GH/CS from a trusted source which can be checked on line at Consumer Lab  or the US Pharmacopeia.
  • Side effects of Glucosamine may be an increase in glucose levels, so be careful if you are diabetic. Also if you have an allergy to shellfish, Glucosamine can be derived from materials in shellfish, so again be careful.
  • Recommended daily doses of Glucosamine is 1,500 mg ans 1,200 mg of chondroiton.
  •  Glucosamine, Chondroitin Sulfate, and the Two in Combination NEJM  GAIT trial < link to gate trial. A prior study in the New Englandd Journal of Medicine had shown results hinting that CS/GH work best in moderate-to-severe disease, but not so much is lesser OA pain.In the study discussion, it was noted:  Analysis of the prespecified subgroup of patients with moderate-to severe pain demonstrated that combination therapy significantly decreased knee pain related to osteoarthritis, as measured by the primary outcome or by the OMERACT–OARSI response rate. We did not identify significant benefits associated with the use of glucosamine or chondroitin sulfate alone. Although the results for glucosamine did not reach significance, the possibility of a positive  effect in the subgroup of patients with moderate-to-severe pain cannot be excluded, since the difference from placebo in the OMERACT–OARSI response rate approached significance in this group. Treatment with chondroitin sulfate was associated with a significant decrease in the incidence of joint swelling, effusion, or both. We did not find an increased risk of ischemic cardiovascular events among patients who received celecoxib or among patients with diabetes who received glucosamine, but this study was not powered to assess these risks… Our finding is that the combination of glucosamine and chondroitin sulfate may have some efficacy in patients with moderate-to-severe symptoms.
  • Be certain to lose weight and exercise.  Obesity places huge stress on knees and ankles and hips. Supplements should complement these steps.


Insane Medicine – Acid in our bodies is a problem – Metabolic acidosis (MA)

Acid is not good
Acid is not good

acid house acid mushroom

  • Our bodies are always in a battle with too much ACID. I discussed this briefly before and am revisiting this topic again because of the metabolic impact metabolic acidosis (MA)  has on our bodies (that is, too much acid)
  • In the process of digesting meats and animal proteins, our body produces acids as well as internal processes that contribute to high acid levels. Our body uses bicarbonate and other  mechanisms to neutralize the excess acid.
  • Metabolic acidosis (MA) affects every system in our body. MA at a chronic level activates bone resorption and can increase the rick of osteoporosis. Treatment of MA can decrease this risk when it is present. Skeletal strength is impaired by MA because the body cannibalizes it’s own muscle to help neutralize the extra acid. Likewise, MA will impair insulin release and insulin receptor functioning. This results in glucose intolerance and diabetes. MA will also cause the progression of kidney failure and impair the functioning of thyroid hormones and it’s receptors.
  • We see metabolic acidosis in 1 out of 30 patients with normal  kidney function. the number affected increases as kidney function declines.
  • BMC Nephrol, 2013 Jan 9;14:4 : Use of bicarbonate to normalize MA can prevent progression of chronic kidney disease. How much bicarbonate and what type of bicarbonate is used? Sodium bicarbonate, in amounts starting at 1300 mg twice a day to get the serum bicarbonate levels to 24 mg/dl. Baking soda has 850 mg of sodium bicarbonate in a teaspoon.
  • Sodium bicarbonate intake does not worsen high blood pressure because the sodium load resulting from the sodium bicarbonate cannot be reabsorbed in the kidney through the usual NACL cotransporter.
  • The body normally excretes extra acid loads produced in the body in the form of ammonia, which is produced from glutamine (an amino acid) When metabolic acidosis is present, the body quickly runs out of glutamine from its usual sources and gets extra glutamine from muscle breakdown. The glutamine then goes to the kidney to be broken into ammonia which absorbs the extra acid.  So metabolic acidosis leads to increased muscle breakdown and weakness.
  • Diet affects the production of acid, especially with the consumption of animal proteins, which results in a lot of acid production in the body. This speeds UP the loss of kidney function in predisposed individuals. It has been shown that fruits and vegetables create little acid production in the body and a vegan diet as such decreases the rate of kidney function decline in patients with kidney failure.


Here is the summary:

  1. Treatment of metabolic acidosis, when the serum bicarbonate level is below 20 mmol/L, using sodium bicarbonate at doses of 1300 mg twice a day to increase serum bicarbonate to 24 mmol/L has positive impacts in multiple fronts as below.
  2. Increased bone density results from treatment of MA, thus decreased fractures and falling.
  3. There is better glucose control by treating MA due to better insulin sensitivity and insulin receptor responsiveness.
  4. Treatment of metabolic acidosis decreases the progression towards kidney failure in susceptible individuals with chronic kidney disease.
  5. Treatment of MA results in better muscle strength and muscle mass.
  6. Eat more fruits and vegetables to decrease your intake of acids.
  7. Have your doctor asses your blood for low bicarbonate (Less than 20 mmol/L)
  8. Consult your doctor prior to initiating any medical regimen as discussed.

Insane Medicine – Arthritis pain and what to do:

Arthritis Pain:


Arthritis affects millions of individuals, reducing quality of life.  There are multiple facets that can be addressed regarding arthritis pain and what to do, but I will address several points:

  • Exercise added to the daily routine is the best way to help combat arthritis. Unused joint cause increased pain. What type of exercise? Flexibility Exercises, strength training, and aerobic exercises all help combat joint pain. They also help an individual lose weight as well, which increases mobility.
  • Range of motion exercises can help with stiffness and can improve mobility. Flexibility  exercises allow one to do this. Tai chi and yoga are examples.
  • Preserve your muscle mass with strength training at least three times a week. This also allows one to lose weight and helps maintain mobility. Muscle training helps support the joint structure and function, such as the knees. This decreases joint stress.
  • Aerobic exercises also add a lot to overall health and diminish joint pain. Swimming is low impact. Walking is another option.

Options to help arthritis pain:

  • Heat application: Relaxes the muscles and increases blood flow to affected areas, helping provide nutrients and oxygen. This is useful in multiple areas such as knee, neck, and back pain.
  • Cold Applications: Cold packs can be used acutely after exercise to decrease inflammation, muscle spasms, and pain, especially in the first 72 hours, after which, use heat.
  • Emotional support: Remember that a large challenge to arthritis is the emotional impact. Cognitive behavioral therapy is an option to help one cope with the pain of arthritis. Remember to keep busy and keep moving. Meditation can help overcome the negative emotions that can actually increase your pain. Pain can increase your anxiety and depression. Insomnia can result from arthritis pain, so the emotional impact is huge as arthritis affects so many facets in one’s life.
  • Acupuncture: This may be an option in some individuals. Consider going online to find a certified acupuncture specialist near you.
  • Spinal Manipulation Therapy (SMT): Look at the entire body and evaluate the triggers that aggravate arthritis. SMT can reduce stiffness and help with joint movement.  These changes in joint mobility have a local effect on the chemical factors that cause inflammation and pain. The joint may be the culprit in causing stiffness or the muscles surrounding the joint may be inflamed or spastic, resulting in lower mobility and pain.
  • Physical Therapy: Consult your physician for a PT referral., which can help you find ways to promote strength and flexibility.
  • Quit Smoking: Smoking lowers bone density.

Remember that muscles support your bones, and it is important to increase your muscle mass as it provides numerous benefits in addition to supporting your joints and your back. The back, in particular, with it’s discs and small facets, is affected over time by pressure, which can be unloaded by stretching and strengthening the spinal muscles through basic exercises like:

  1. Pelvic tilt exercises:

    Pelvic tilt
    Pelvic tilt
  2. One -legged wind releasing

    one legged wind releasing
    one legged wind releasing
  3. trunk lift
    trunk lift
    trunk lift

    You need core muscle strength and flexibility to help preserve your back. The hip muscles need to have flexibility maintained as well for better back health. Consider doing this through the 4.hammerstring stretch:

    hammerstring stretch
    hammerstring stretch


  4. hamstring-stretch-seated
    hamstring-stretch-seated< link to stretching blog – and alternative therapies.


Insane medicine – Vitamin D supplements help reduce cancer and cardiovascular risk

Vitamin D supplementation has huge beneficial health effects. First, lets discuss the physiology of Vitamin D and the effects of deficiency.

Vitamin D

The process starts with ingestion of Vitamin D2 (ergocalciferol) from plant sterols or yeast or with Vitamin D3 (cholecalciferol) obtained from oily fish.. UVB irradiation of skin 7-dehydrocholesterol can also produce vitamin D. These vitamin D precursors go to the liver where they are converted to 25-hydroxyvitamin D (which is what your doctor tests for to see if you are deficient in vitamin D!). 25-hydroxyvitamin D is transferred to the kidney where it is converted to the most active form, 1,25 dihydroxyvitamin D.
vitamin D review vitamin D

The active 1,25-dihydroxyvitamin D will increase calcium absorption by the intestines which increases our calcium reserves
vitamin D balance vitamin D vitamin D deficiency vitamin D metabolism and deficiency vitamin D effects


Vitamin D (1,25-dihydroxyvitamin D) has multiple roles in the body as shown above. There are over 300 different binding sites for Vitamin D throughout the human genome with receptors present in all human tissues.  The parathyroid glans in the neck secrete PTH to activate and regulate vitamin D.

  • Risk factors for vitamin D deficiency include age>65, breastfeeding mothers, insufficient sunlight exposure, certain medications (anticonvulsants, steroids, others), obesity, physical inactivity, liver and kidney disease, and dark pigmented skin. Vitamin D deficiency was historically associated with rickets ( a bone disease)
    Insane Medicine - rickets due to vitamin D deficiency
    Insane Medicine – rickets due to vitamin D deficiency.

    Of course rickets is rare in the U.S. due to fortified foods.

  • Studies are clear that vitamin D is important for health and prevention. There is an inverse association of 25-hydroxyvitamin D serum levels with risk of death due to cardiovascular disease and cancer. In other words, low vitamin D  levels in the body are associated with higher cardiac events and higher risk of cancer!!
  • Supplementation with vitamin D3 reduces overall mortality in older adults!
  • Vitamin D deficiency is based on a blood level of less than 20 ng/mL of 25-hydroxy vitamin D. It appears that correcting vitamin D levels may be on par with health risks such as smoking, alcohol consumption, and physical inactivity!
  • Based on calculations from one study, 12.8% of all deaths in the U.S. can be attributed to vitamin D deficiency. So for every 10 ng/ml decline in serum vitamin D, there appears to be a 16% increase in all cause mortality.  Supplementing with vitamin D3 decreased all cause mortality by 11%. There appears to be no benefit or protection  by supplementing with vitamin D2. Vitamin D2 is less potent and active than vitamin D3. It may be that calcium is needed to be used with vitamin D2 to be effective.
  • You can obtain enough vitamin D by exposure to sunlight (UVB) for 15 minutes a day if you are light skinned. Dark skin requires up to an hour of exposure to create enough daily vitamin D. Our body produces vitamin D in the skin and does so at higher levels in the summer time. Obviously, in the winter time, we are at risk of deficiency due to less skin exposure. Sun block will prevent UVB from reaching our skin and therefore will prevent the skin from creating vitamin D.
  • Vitamin D toxicity (levels greater than 150 ng/ml) result from high intake of vitamin D (greater than 10,000 units/day)
  • The bottom line: Get your 600-800 IU of vitamin D3 every day. Vitamin D3 is the best form of vitamin D. Boosting your vitamin D levels can decrease your cardiac and cancer risks!
  •   <–Vitamin D information!
  • Chowdury R, et al Vitamin D and risk of cause of specific death. BMJ 2014;348:g1903.doi: 10.1136/bmj.g1903

Insane Medicine – Dietary Review!

I wanted to generalize some overall health information in this particular blog and incorporate items that are important for increasing successful strategies for aging and maintaining your health.

  • Remember that circulation is important in your body because it provides energy and sustains life in the various tissues. Regular exercise is a way to keep your body maximally conditioned. Your circulation delvers oxygen and nutrients to your body and at the same time allows toxins to be removed as it passes through the liver, kidney, and lymph systems. So be certain to keep moving and exercise to maximize your health.
  • Eat more plant foods. As a result of doing this, you take in less fat and will increase your fiber intake. This allows more protecting antioxidants to be incorporated into your body. Ingesting more fiber allows for better waste removal, and less fat intake results in a decreased tendency for your blood to thicken and clot, thus decreasing cardiovascular risk. The large amount of protecting agents in plant-based diets results in less inflammation in the body and less cellular damage.
  • Choose plant foods with strong flavors and with bright colors. Have a healthy fat focus in your diet. Chose your beverages you drink wisely, in other words, stop drinking sodas! Try your best to allow your stomach to be empty  and have ‘hunger pains’ for at least two thirty minute periods each day.
  • Remember that the body evolved in a world where salt, sugar, and fat were scarce and are like addictive drugs. Be careful to avoid choosing processed foods when possible and not adding salt and sugar to your meals. Avoid sodas ( which are high in sugar content)! Even noncaloric beverages may be increasing our desire for sweet food and spurring increasing rates of obesity.
  • Fructose in our foods has been a source of increasing weight gain in our society. Fructose and glucose (both sugars) have a differential effect on the brain. Glucose will reduce activation of brain regions that are involved in appetite, motivation, and reward and will increase our sense of satiety and decrease our food seeking behavior. Fructose does not do this. It is sweet, but it makes us want more! Corn sweeteners (fructose) have correlated with rising obesity.
  • Plant-based foods give us phytochemicals which act as protectors. Plant-based foods give smell, taste, and fragrance to our diet. They have an antioxidant effect. Kale, cabbage, broccoli, and  arugula have a sulfur based mustard taste that increase detoxification enzymes in the body. You should get 5-9 servings of colorful, flavorful vegetables in your diet each day – five servings for smaller people and at least nine servings if you are a big person. How much is a serving for vegetables? One-half cup cut up is equal to a serving, in general, for vegetables (for raw spinach, a whole cup is equal to a serving)
  • So again – look for colorful vegetables, as they have higher levels of phytochemicals in them, For example, zucchini has a green outside but mostly colorless interior, and therefore is a poorer choice of a vegetable. Instead, go for the carrots, spinach, broccoli, and yellow squash as options, since they have more color to them and therefore more protective phytonutrients! You will find higher levels of Vitamin A in deep orange vegetables such as carrots. The carotenoids and retinol in these vegetables impart the orange coloring and give the protective qualities of these vegetables.  Cruciferous vegetables have a big, strong flavor with sulfur components. They have powerful antioxidants in them and include arugula, broccoli, brussel sprouts, cauliflower, kale, kholorabi, radish, rutabaga, and turnips. Citrus fruits are high in Vitamin C, which helps fight infection. They also have an antihistamine/anti-allergic effect as well as anti-oxidant effect, which protects cell membranes and DNA in the body from oxidative damage. Vitamin C is important in the production of collagen component of connective tissues such as tendons and ligaments.
  • Eating up to nine servings a day of vegetables was associated with 24% less obesity in one study. Why? Because you eat less of other fatty foods.
  • Fiber rich foods  are very important in the diet. Vegetables, fruits, beans, whole grains are all rich sources of protective nutrients and phytochemicals and have a lower glycemic load as well. Eating foods with high fiber content results in less obesity since people who consume high-fiber foods feel more full. Likewise, higher fiber meals cause increase transit through the gut and decrease carcinogen exposure. This results in less colon cancer risk! Soluble fiber decreases cholesterol levels while fibrous food will increase the amount of protective gut bacteria.
  • We will be discussing the gut biome over time in this blog. Your gut has a population of bacteria that live and thrive but also help us maintain homeostasis. Alterations in the gut biome (bacterial population) can result in inflammation and disease. Immune compromise can occur if the gut biome is altered or destroyed. It turns out that soluble fiber is a food source for these necessary gut bacteria to remain healthy, and hence us as well.
  • We need 25 grams of fiber every day. A rule of thumb is one gets 2 grams of fiber per vegetable/fruit serving, so 5 servings of vegetables equals 10 gm of fiber.
  • Whole grains are a good source of fiber. One slice of whole grain bread is equal to a serving. A cup of cooked oatmeal is considered a serving. A thought for increasing fiber content is to use wheat berries, which cook like brown rice. Adding sunflowers to them can make a nutritious bundle.
    Wheat berries cook like brown rice and taste great when mixed with sunflower seeds!
    Wheat berries cook like brown rice and taste great when mixed with sunflower seeds!

    Cooked beans, peas , and lentils have 6 gm of fiber per half-cup of cooked item. They are excellent sources of fiber.

    Consider adding mung beans, which are bean sprouts that cook like lentils, in a dish with some olive oil, salt, and pepper and placing it over pasta.
    Consider adding mung beans, which are bean sprouts that cook like lentils, in a dish with some olive oil, salt, and pepper and placing it over pasta.


  • Always be certain that you check to see if a bread item is whole grain. Check the ingredient list. You want whole, sprouted, or malted wheat or whole grain on the label. Beware if it says wheat flour, for that is the same as white flour.
  • Put as many vegetables on your salad as possible. Lettuce has very little fiber.
  • Be certain to take in 5-10 grams a day of soluble fiber out of the 25-35 grams of fiber that is needed. Soluble fiber lowers cholesterol levels and feeds the healthy gut bacteria to support our immune system. An orange (medium) has 3-5 grams of soluble fiber, while a half cup of beans has 3-5 grams. Two tablespoons of ground flaxseed has 1.5 grams of soluble fiber. Flaxseed can be ground into flaxmeal.
  • Of note, a high fiber diet provides a low glycemic load, which is great for diabetics, but particle size of the fiber source is important. For example, old fashioned or scottish oats are best for fiber sources, whereas smaller particle sized grain products lose the fiber benefits. It turns out the glycemic index is higher in small-particles of grains (they get absorbed easier).
  • Higher glycemic-load foods are associated with chronic diseases. As people absorb more carbohydrates and gain weight, their insulin level increases in response, which promotes increased fat storage, thereby leading to the need for more insulin to control blood  sugar. This results in diabetes over time. Also cancer is more common in obese individuals as insulin-like growth factor (IL-GF) drives cancer growth. IL-GF is involved in glucose metabolism. A diet with a low glycemic load would include non-starchy vegetables except potatoes. Whole grains are high in glycemic load and make diabetes more difficult to contol. Pasta, rice, potato, and virus have high glycemic loads and are not as healthy. Fruit has high fiber content and a LOW glycemic index. High fat foods also have lower glycemic load. So aim for foods with lower glycemic indices as they allow for better body sugar control.
  • Fats affect inflammation in the body. High body fat content, especially abdominal fat,  is linked to cancer risk, diabetes, arthritis, Alzheimer’s disease, and autoimmune disorders. In an anti-inflammatory diet, one wants to avoid excess fat.  Decrease your fatty food intake, especially fried foods and fast foods. Decrease your dressings and mayonnaise on your foods. Decrease the amount of sweets in your diet, especially cookies and cake. Eat more fish and seafood (not fried) at least 2-3 times a week, except for farmed salmon, which should be eaten only once a month. Avoid sweetened beverages and limit foods with sweeteners. Eat more vegetables, fruits, whole grains, and beans.
    Beans are good!
    Beans are good!


    Use extra virgin olive oil to toss in your vegetable or salad to allow easier coating of the leaves with your favorite dressing. By doing that, you will use less dressing and spread it out evenly!
    Use extra virgin olive oil to toss in your vegetable or salad to allow easier coating of the leaves with your favorite dressing. By doing that, you will use less dressing and spread it out evenly! Less dressing=Less fat!


  • Fat balance is important in your diet. Avoid the pro inflammatory fats, such as omega-6 polyunsaturated fats (PUFA) such as corn, cottonseed, soy, safflower, and sunflower oils, which are high in omega-6 oils. decrease your meat intake and decrease fish intake that are fed these products such as farm-grown salmon! Omega-3 PUFA are anti-inflammatory. and are present in flaxseed oil. Also, pasture-fed livestock (‘grass-fed’) have less omega-6 fatty acid in them. Avoid livestock that are fed grain or corn at any time, since that increases the amount of proinflammatoy PUFA in them. ‘Grass finished’ livestock means that the livestock ate grass until they are butchered. Choose grass-fed products only!
  • Some fat-health guidelines include avoiding fat soluble contaminants by eating food items lower on the food chain, such as smaller animals (fish) and avoiding farmed salmon. Eat only organic products. Avoid saturated fats, present in processed foods and dairy products or red meat. Avoid rancid fats by limiting aged cheese and meat (deli meat) in your diet. Chose healthy fats, which increase satiety and help absorb fat soluble vitamins. Healthy fats include avocados, olive oil, sardines, nuts, seeds, and olives.  Larger animals have more time to get contaminants in them. Chicken and sardines, which are lower on the food chain, live short lives. low in the food chain, and accumulate less toxins. Don’t eat fats that are solid at room temperature,. Avoid processed foods and meats (deli meats)
  • Rancid fats add oxidative stress to your body.Increase your monounsaturated fat intake such as avocado and olive oil, which are heart-healthy.  It was found that people who eat less saturated fat and more monounsaturated fats in their diet have better cognitive performance and verbal memory over time!
  • Osteoporosis prevention: Increase the following: exercise, calcium intake, vitamin D, protein and potassium . They all help build healthy bones! Protein is needed to build the bony matrix. Avoid caffeine (>300 mg a day) and avoid smoking and excessive sodium intake. Avoid being too thin. These factors all impact bone health in negative ways. Excessive sodium in the diet causes the kidneys to waste calcium in the urine. Be certain to get 1200 mg of calcium a day in the diet. For example, 1 or 2% no-fat milk has 300 mg of calcium per cup, while yogurt has 250 mg in 6 ounces. Please note that not all tofu has enough calcium in it, so check the labels. Also, corn tortillas (traditional mad with lime) has calcium in it ( fiver per day provides a lot of calcium)
  • Calcium bioavailability in the diet depends on the source of the calcium. There is calcium carbonate, calcium citrate, calcium malate, calcium phosphate, calcium gluconate, and calcium lactate. Tums has calcium carbonate in it and excessive use can decrease digestive enzymes and increase bloating gas production as a result, so avoid excessive tums. Avoid calcium from dolomite, bonemeal, and oyster shells (they have lead contaminants in them). Calcium mixed with Vitamin D and magnesium is an excellent supplement for bone health, especially as a 2:1 ratio (calcium 500mg/magnesium 250 mg). People absorb calcium better in small quantities through the day rather than a single large bolus. Be aware that calcium interacts with many medications and interferes with absorption of some medications, such as tetracyclines, biphosphonates, aspirin, and others. Some medications deplete calcium, such as aluminum antacids, steroids, anticonvulsannts, which deplete calcium supplies in the body. Calcium mixed with thiazide diuretics can lead to high, toxic blood levels of calcium in some people. Of note, a study recently suggested that calcium supplements may increase the risk of heart disease in some people by depositing in the coronary vessels. This appears to be not true.
  • Vitamin D is also an important component to bone health and body health. Deficiency in this vitamin has been associated with Alzheimer’s disease, autoimmune disorders, stroke, and musculoskeletal decline, among other things. Optimally, blood levels should be 30-80 ng/ml. The RDA for vitamin D in people aged 50-71 is 400 IU/day and for those over 70, the RDA is 600 IU/day. You can take up to 4000 IU/day safely per some sources. Vitamin D3 is the most active form of Vitamin D. Vitamin D is neccessary for optimal calcium and magnesium absorption in the gut. Our western style diet results in a high acid intake that leaches our bones. Chronic low grade acidosis in the body with our acidic diet, leads to bone derangement, especially in people with poor kidney function.
  • The shift to eating a better acid-base balanced diet can be made by including more plat foods in your diet (they are rich in alkaline materials). Consider this to boost bone health.
  • The recommended intake of protein is .4-.6 gm of protein per pound of weight. The average protein intake should be 55-100 gm per day. Protein content is high in beans, peas, and lentils (7 gm in a half cup) and high in poultry, fich, and lean meat (7 gm in 10 oz meat). Consider eating nuts and seeds for protein supplementation ( 7 gm in  1/4 cup, especially pumpkin seeds, which have 18 gms!)

Insane Medicine – Wheat products, Grains, Gluten, celiac disease, and your body.

Insane Medicine - Gluten and Gluten free glutenprobs

  • Gluten is a substance present in rye, wheat, and barley. In some individuals, the body gets sensitized to this substance in the form of an autoimmune disease that results in damage of the gastrointestinal tract lining.
  • First we will discuss basic information about cereal grains and grasses. The cereal grains form part of the Gramineae (Poaceae) family and have four subfamilies.
  1. Pooideae – which is subdivided into the Triticeae/Hordeae family (wheat, barley, rye) and Aveneae family (oats)
  2. Ehrhartoideae (rice) subfamily
  3. Chloridoideae (ragi and teff)
  4. Panicoideae: which includes millets, corn, and sorghum
  • Non-cereal grains are grains from families other than the Gramineae family:
  • Amaranth from the Amaranthaceae family
  • Quinoa from the Chenopodiaceae family
  • Buckwheat from the Polygonaceae family
  • A grain is an individual fruit that contains a single seed in which the fruit wall and seed coat are fused and cannot be separated. Wheat, rye, barley, oats, rice, and corn are grains.
  • Seeds can have their coat separated from the fruit
  • Corn originated from the Americas and is the major world grain produces, while wheat originated from the Near East/Ethiopea and is consumed in pasta, wheat noodles, breads, bulgur, and couscous as examples. It is the second most produced grain. Rice originated from China and can be ground into flour and made into rice milk among other uses. Millet is the 6th most produced grain in the world and is grown in the African/Indian subcontinent for bird and cattle feed primarily. Amaranth is consumed in India as a cereal and also is ground into flour or popped into popcorn. Buckwheat (is not related to wheat) is used to make a dark flour in Asiatic and European dishes in the form of crepes, pancakes, bread, and bagels. Quinoa has it’s origin from the Andean regions of Bolivia and Peru.
  • Allergy to wheat is fairly common and is IgE mediated (common from of allergy pathway) to different components in the wheat. In childres, a reaction to the omega-5-gliadin component is the most common cause of allery. In Baker’s asthma, its the alpha-amylase inhibitor that is the wheat component causing the reaction. However, the most common allergen in wheat is the Lipid transfer protein (LTP). Allergies caused by these generaly are in the form of rashes, hives,  respiratory reactions such as wheezing, abdominal pain., nausea, vomiting, and anaphylaxis symptoms. These are more common in childres. It is possible to have reactions to cooking vapors as the grain proteins are volatalized into the atmosphere. Hives can result from toucing certain grain proteins in susceptible individuals.
  • IgE-type reactions have been found to occur in all cereal grains except for sorghum. Wheat is the most common IgE mediated allergen causing food-dependent exercise -induced anaphylaxis at its extreme (where a person gets anaphylaxis upon execising after exposure to wheat) and also Baker’s asthma, in which wheezing occurs during the baking of wheat-containgin items.
  • Rice can also caause IgE mediated reactions in some individuals, especially on exposure to rice dust or from boiling rice.
  • Eczema can result from or be worsened by food alleries. Eggs and milk are the most common culprits, but wheat is the third most common cause of worsening eczema and atopic dermatitis in children.
  • Milk products and wheat products can cause an allergic eosinophilic esophagitis allergic phenomena that causes chronic reflux symptoms (GERD), vomiting, abdominal pain, weight loss, and food impactions.
  • Grains (oats and rice), wheat, and barley can cause a Food Protein Induced Enterocolitis (FPIES) that results in nausea, vomiting, and diarrhea two to four hours after eating products with these grains in them. it can result in dehydration and shock in some. Chronically, a perason can get chronic nausea, vomiting, and diarrhea, with low blood albumin levels.
  • Celiac disease is the most famous process that results form wheat exposure and is the focus of this segment. It is an immune mediated small intestine inflammatory process caused by dietary gluten. The sources of gluten are:
  1. Wheat (breads, baked goods, soup,  pasta, cereals, sauces, salad dressings, and roux)
  2. Barley ( malt, food coloring, soups,  malt vinegar, beer)
  3. Rye ( rye bread,  rye beer, cereals)
  4. Triticale ( a newer source of gluten used in breads, pasta, and cereals)

In summary : Gluten sources include: wheat (durum, emmer, spelt, farina, farro, KAMUT® khorasan wheat and einkorn), rye, barley and triticale.

  • A wide variety of foods and food products may have gluten mixed in the product. Croutons and flour-cereal and brown rice syrup are gluten sources. Imitation seafood, bacon, pasta, and processed lunch meat have gluten, as does self-basting poultry, soupd, stuffing, salad dressing, and communion wafers. Also, play-dough and crayons may have glutenin them as well.

Celiac disease results from an autoimmue reaction to the Gluten component of wheat and results in many manifestations:

  • Anemia, dental enamel defects, osteoporosis, arthritis, and elevated liver function tests (transaminasemia) are vague manifestations. SOme people develop neuroapthy in the form of tingling in theri hands and feet. Abdominal pains, nausea, and bulky stools may be present. Growth failure, weight loss, and vitamin D deficiency can occur. there has been an association of migraine headaches, depression, and eppilepsy with celiac disease. Vitamin deficiendies found in celiac disease include Vitamin B1 (thiamine), Vitamin B2 ( riboflavin), Vitamin B3 (niacin), Vitamin B6 (pyridoxine), Vitamin B12, as well as Vitamins A, D, and E. Also copper, zinc, carotene, folate, ferritin, and iron levels may be low. This is due to malabsorption in the gut from the chronic inflammation.
  • With celiac disease, there is mucosal inflammation throughout the small bowel, leading to vllous atrophy (the absorption of the gut is through the villi) and crypt hyperplasis inthe small bowel. This leads to recurrent diarrhea, malabsorption, weight loss, bloating, and lactose intolerance.
  • There is an association of celiac disease with recurrent miscarriages.
  • Other asscoiated conditions include aphthous stomatitis (canker sores), cerebellar ataxia (incoordination), dental enamel loss, osteoporosis and bone mineral density decrement, atrophic glossitis (burning tongue), pancreatitis, myocarditis, menstrual irregularities, and growth delay problems.
  • There is an increase risk of type 1 Diabetes as well.
  • The incidence of celiac disease is 1:100 – 1:250 in whites of European ancestry. It is rare in those of Chinese, Japanese, and sub-saharan African descent.
  • Testing can be performed by serum testing for IgA/G antitissue transglutaminase antibodies, which are elevated in the disease primarily. There are other serological test as well. If there is high suspicion of the disease, an endoscopy to look at the small intestine, with a biopsy, would be indicated. One should be checked for vitamin deficiencies in Vitamins A, D, E, and B vitamins, as well as copper, zinc, carotene, folate, ferritin, and iron levels.
  • A Dual energy Xray Absorptiometry scan (DEXA) scan can be considered in the right populations to check for low bone mineral density and osteoporosis
  • Be certain that your pneumococcal vaccination has been made up to date, because patients with celiac disease may have hyposplenism ( which has an immune function).
  • Gluten-free diets have become more common lately, especially as gluten has been attributed to causing memory loss, arthritis, and weight gain. People who have followed the diet claim to have better digestion, more weight loss, better immune systems, and lower cholesterol..
  • Gluten-free foods do not necessarily have more nutritional value than regular foods, in fact, many gluten-free foods are not enriched or fortified with nutrients such as folate, iron, and other agents. The gluten that is removed in the gluten-free foods removes certain desirable flavors that are then replaced by  extra fat, sugar, and sodium. This may mean that some gluten-free foods may be worse with respect to their nutritional content than regular foods.
  • Gluten not only adds flavor to foods, it may also have beneficial effects on triglycerides and blood pressure. There are fructan starches in wheat that support healthy bacteria in the gut, so less gluten in the diet can result in an altered gut bacteria biome.
  • Another issue with gluten-free foods is that many of the products have rice flour or another form of rice in them. The problem with this is the arsenic content that this adds. Arsenic is carcinogenic. 17 % of the average person’s arsenic load comes from rice products, but this percentage increases in people who follow a gluten-free diet. It is possible that a person on this diet may be consuming 10 times the normal amount of Arsenic.
  • A gluten-free diet is not a weight loss strategy as most gluten-free foods have more calories, sugars, and fat. The best way to  lose weight on this diet is to replace items with foods that have more fiber. For example, eating an apple instead of a sugary dessert.
  • Be certain you still include grains in you gluten-free diet, so you can replace wheat with amaranth, corn, quinoa, millet, teff, and rice. Also, fruit, vegetables, fish, meat and poultry have no gluten content, so include these in your diet, Be certain to watch out for the fat, sugar and sodium content in your gluten-free food.
  • Be careful that gluten isn’t sneakily present in your ‘gluten-free’ foods. For example, some gluten-free chips and energy bars have malt or malt extract or malt syrup, which are made from barley.
  • Per the FDA, gluten-free foods cannot contain an ingredient from a gluten grain unless it was processed to remove the gluten, and not just a measurement of less than 20 ppm gluten in the ingredient.  < celiac disease foundation


Insane Medicine – Dropping the acid content in your diet improves bone health and muscle health: The PRAL (potential renal acid load)

The foods that we eat produce acid in the body that can lead to increased bone breakdown and increase the risk of kidney stones as well. Certain food, such as cereal grains and proteins are associated increased with overall acid production. Fruits and vegetables produce a net alkaline environment in the body. This has a positive effect on bone health and muscle strength.

  • Too much acid intake from acid producing foods has negative effects in our bodies such as increased bone breakdown and osteoporosis and also muscle loss. In addition, certain types of kidney stones have increased formation when the diet is too high in acidifying food sources.
  • Of interest is that muscle strength can be improved by having a more alkaline diet. In an acidic environment, the body wastes muscle to get rid of the acid. The muscle releases amino acids which neutralizes the acidic hydrogen ions. Hence the muscular system acts like a acid-base status regulator.
  • Bones store calcium and this tends to get leached out in acidic environments. Bone is an alkaline reservoir that breaks down to neutralize body acid. Studies have shown that potassium citrate, when taken orally, breaks down in to an alkali which protects bone from breaking down, thus decreasing fracture risk. Potassium bicarbonate may also do the same.
  • Fruits and vegetables generally break down into alkali. Orange juice (which is acidic in the mouth), gets broken down into alkali in the body. So it is the metabolism of the fruits and vegetables in the body that makes them acidic or alkaline, not the way that they taste.
  • It has been found that diet intake  can acidify or alkalinize the urine. This is beneficial in kidney stones, in which infective stones such as struvite and calcium phosphate stones can be reduced by acidifying the urine with a more acid diet. Likewise, cystine and uric acid stones can have the urine alkalinized to reduce the presence of these kidney stones.
  • The potential renal acid load of foods are listed below as PRAL. Negative PRAL foods (fruits and vegetable) metabolize to alkali in the body, whereas positive PRAL foods (cereal grains, protein)  break down into acids in the body.



Nutrienta content (10) and estimated potential renal acid load (PRAL)b of 114 frequently consumed foods and beverages (related to 100-g edible portion

Food group and food Energy Protein Na K Ca Mg P Cl SO4b PEXb ALEXb PRALb
kcal g ←mg→ ←mEq→
Beer, draft 32 0.3 12 38 11 9 13 32 0.1 0.1 0.4 −0.2
Beer, pale (Vollbier, hell)c 45 0.5 5 38 4 9 28 35 0.2 0.7 0.0 0.9
Beer, stout, bottled 37 0.3 23 45 8 8 17 48 0.1 0.3 0.6 −0.1
Coca-Cola 39 0.0 8 1 4 1 15 10 0.0 0.5 0.1 0.4
Cocoa, made with semi-skimmed milk 57 3.5 70 170 120 20 100 100 1.7 1.6 3.7 −0.4
Coffee, infusion, 5 minutes 2 0.2 0 66 2 6 2 0 0.1 −0.1 1.4 −1.4
Mineral water (Apollinaris)d 0 0.0 43 3 9 10 0 14 0.0 −0.4 1.5 −1.8
Mineral water (Volvic)d 0 0.0 1 1 1 1 0 1 0.0 0.0 0.0 −0.1
Red wine 68 0.2 10 130 7 11 14 18 0.1 0.1 2.6 −2.4
Tea, Indian, infusion 0 0.1 0 17 0 1 1 0 0.0 0.0 0.3 −0.3
White wine, dry 66 0.1 4 61 9 8 6 10 0.0 −0.1 1.1 −1.2
Fats and oils
Butter 737 0.5 11 15 15 2 24 17 0.2 0.6 0.3 0.6
Margarine 739 0.2 800 5 4 1 12 1,200 0.1 0.4 1.0 −0.5
Olive oil 899 0.0 0 0 0 0 0 0 0.0 0.0 0.0 0.0
Sunflower seed oil 899 0.0 0 0 0 0 0 0 0.0 0.0 0.0 0.0
Cod, fillets 76 17.4 77 320 16 23 170 110 8.5 5.4 6.8 7.1
Haddock 73 16.8 120 300 18 23 170 160 8.2 5.4 6.8 6.8
Herring 234 16.8 67 340 33 29 210 76 8.2 6.5 7.7 7.0
Trout, brown, steamed 135 23.5 88 370 36 31 270 70 11.5 8.6 9.3 10.8
Fruits, nuts, and fruit juices
Apple juice, unsweetened 38 0.1 2 110 7 5 6 3 0.0 0.0 2.3 −2.2
Apples, 15 varieties, flesh and skin, average 47 0.4 3 120 4 5 11 0 0.2 0.2 2.6 −2.2
Apricots 31 0.9 2 270 15 11 20 3 0.4 0.3 5.5 −4.8
Bananas 95 1.2 1 400 6 34 28 79 0.6 0.1 6.1 −5.5
Black currants 28 0.9 3 370 60 17 43 15 0.4 0.4 7.3 −6.5
Cherries 48 0.9 1 210 13 10 21 0 0.4 0.3 4.3 3.6
Grape juice, unsweetened 46 0.3 7 55 19 7 14 6 0.1 0.1 1.3 −1.0
Hazelnuts 650 14.1 6 730 140 160 300 18 6.9 5.0 14.7 −2.8
Kiwi fruit 49 1.1 4 290 25 15 32 39 0.5 0.5 5.1 −4.1
Lemon juice 7 0.3 1 130 7 7 8 3 0.1 0.0 2.6 −2.5
Orange juice, unsweetened 36 0.5 10 150 10 8 13 9 0.2 0.1 3.2 −2.9
Oranges 37 1.1 5 150 47 10 21 3 0.5 −0.1 3.2 −2.7
Peaches 33 1.0 1 160 7 9 22 0 0.5 0.5 3.3 −2.4
Peanuts, plain 564 25.6 2 670 60 210 430 7 12.5 9.5 13.6 8.3
Pears, 3 varieties, flesh and skin, average 40 0.3 3 150 11 7 13 1 0.1 0.2 3.2 −2.9
Pineapple 41 0.4 2 160 18 16 10 29 0.2 −0.3 2.6 −2.7
Raisins 272 2.1 60 1,020 46 35 76 9 1.0 1.3 23.1 −21.0
Strawberries 27 0.8 6 160 16 10 24 18 0.4 0.4 3.0 −2.2
Walnuts 688 14.7 7 450 94 160 380 24 7.2 8.5 8.9 6.8
Watermelon 31 0.5 2 100 7 8 9 0 0.2 0.0 2.1 −1.9
Grain products
Bread, rye flour, mixedc,e 211 6.4 537 185 23 0 136 827 3.1 4.7 3.8 4.0
Bread, rye flourc,e 194 6.8 527 291 43 0 198 812 3.3 6.7 6.0 4.1
Bread, wheat flour, mixedc,e 233 6.2 553 177 17 0 127 852 3.0 4.4 3.6 3.8
Bread, wheat flour, whole mealc,e 198 7.0 380 270 63 92 196 585 3.4 4.0 5.6 1.8
Bread, white wheat 235 8.4 520 110 110 24 91 820 4.1 1.3 1.8 3.7
Cornflakes 360 7.9 1,110 100 15 14 50 1,820 3.9 1.3 −0.9 6.0
Crispbread, rye 321 9.4 220 500 45 100 310 370 4.6 8.2 9.4 3.3
Noodles, egg 391 12.1 180 260 28 43 200 277 5.9 5.8 5.3 6.4
Oat flakes, rolled oats (Haferflocken)c 355 12.5 5 335 54 139 391 61 6.1 10.0 5.4 10.7
Rice, brown 357 6.7 3 250 10 110 310 230 3.3 8.3 −0.9 12.5
Rice, white, easy cook 383 7.3 4 150 51 32 150 10 3.6 4.0 3.0 4.6
Rice, white, easy cook, boiled 138 2.6 1 54 18 11 54 4 1.3 1.5 1.0 1.7
Rye flour, whole 335 8.2 1 410 32 92 360 0 4.0 10.4 8.4 5.9
Spaghetti, white 342 12.0 3 250 25 56 190 25 5.9 5.2 4.6 6.5
Spaghetti, whole meal 324 13.4 130 390 31 120 330 210 6.5 8.5 7.7 7.3
Wheat flour, white, plain 341 9.4 3 150 15 20 110 81 4.6 3.3 1.0 6.9
White flour, whole meal 310 12.7 3 340 38 120 320 38 6.2 8.1 6.1 8.2
Beans, green/French beans 24 1.9 0 230 36 17 38 9 0.9 0.5 4.5 −3.1
Lentils, green and brown, whole, dried 297 24.3 12 940 71 110 350 87 11.9 9.0 17.4 3.5
Peas 83 6.9 1 330 21 34 130 39 3.4 3.6 5.8 1.2
Meat and meat products
Beef, lean only 123 20.3 61 350 7 20 180 59 9.9 6.0 8.1 7.8
Chicken, meat only 121 20.5 81 320 10 25 200 78 10.0 6.5 7.8 8.7
Corned beef, canned 217 26.9 950 140 14 15 120 1,430 13.1 3.8 3.8 13.2
Frankfurterse 274 9.5 980 98 34 9 130 1,509 4.6 4.1 2.0 6.7
Liver sausagee 310 12.9 860 170 26 12 230 1,324 6.3 7.8 3.5 10.6
Luncheon meat, cannede 313 12.6 1,050 140 15 8 200 1,617 6.2 6.9 2.9 10.2
Pork, lean only 147 20.7 76 370 8 22 200 71 10.1 6.6 8.8 7.9
Rump steak, lean and fat 197 18.9 51 330 6 20 210 49 9.2 7.1 7.6 8.8
Salamie 491 19.3 1,850 160 10 10 160 2,849 9.4 5.5 3.3 11.6
Turkey, meat only 107 21.9 54 300 8 23 190 48 10.7 6.2 7.1 9.9
Veal, fillet 109 21.1 110 360 8 25 260 68 10.3 8.8 10.1 9.0
Milk, dairy products, and eggs
Buttermilkc 39 3.5 57 147 109 16 90 100 1.7 1.5 2.7 0.5
Camemberte 297 20.9 650 100 350 21 310 1,001 10.2 6.4 2.1 14.6
Cheddar-type, reduced fat 261 31.5 670 110 840 39 620 1,110 15.4 11.2 0.2 26.4
Cheese, Gouda 375 24.0 910 91 740 38 490 1,440 11.7 7.7 0.9 18.6
Cottage cheese, plain 98 13.8 380 89 73 9 160 550 6.7 4.7 2.8 8.7
Creams, fresh, sour 205 2.9 41 110 93 10 81 81 1.4 1.5 1.8 1.2
Eggs, chicken, whole 147 12.5 140 130 57 12 200 160 6.1 6.3 4.2 8.2
Eggs, whitef 36 9.0 190 150 5 11 33 170 6.6 0.9 6.4 1.1
Eggs, yolk 339 16.1 50 120 130 15 500 140 7.9 16.3 0.8 23.4
Fresh cheese (Quark)c 112 12.5 35 87 85 11 165 130 6.1 4.7 −0.3 11.1
Full-fat soft cheesee 313 8.6 330 150 110 9 130 508 4.2 3.1 3.1 4.3
Hard cheese, average of 4 types 405 24.7 620 82 670 24 470 980 12.1 8.2 1.0 19.2
Ice cream, dairy, vanilla 194 3.6 69 160 130 13 110 110 1.8 2.1 3.2 0.6
Milk, whole, evaporated 151 8.4 180 360 290 29 260 250 4.1 5.1 8.1 1.1
Milk, whole, pasteurized and sterilized 66 3.2 55 140 115 11 92 100 1.6 1.6 2.5 0.7
Parmesan 452 39.4 1,090 110 1,200 45 810 1,820 19.3 13.5 −1.5 34.2
Processed cheese, plaine 330 20.8 1,320 130 600 22 800 2,033 10.2 21.2 2.7 28.7
Yogurt, whole milk, fruit 105 5.1 82 210 160 16 130 150 2.5 2.3 3.7 1.2
Yogurt, whole milk, plain 79 5.7 80 280 200 19 170 170 2.8 3.2 4.5 1.5
Sugar, preserves, and sweets
Chocolates, milk 529 8.4 120 420 220 55 240 270 4.1 4.6 6.3 2.4
Honey 288 0.4 11 51 5 2 17 18 0.2 0.5 1.0 −0.3
Madeira cakee 393 5.4 380 120 42 12 120 585 2.6 3.6 2.5 3.7
Marmalade 261 0.1 18 44 35 4 13 7 0.0 −0.1 1.5 −1.5
Sugar, white 409 0.0 0 2 2 0 0 0 0.0 0.0 0.0 −0.1
Asparagus 25 2.9 1 260 27 13 72 60 1.4 2.0 3.8 −0.4
Broccoli, green 33 4.4 8 370 56 22 87 100 2.2 1.9 5.2 −1.2
Carrots, young 30 0.7 40 240 34 9 25 39 0.3 0.3 5.5 −4.9
Cauliflower 34 3.6 9 380 21 17 64 28 1.8 1.6 7.4 −4.0
Celery 7 0.5 60 320 41 5 21 130 0.2 0.1 5.6 −5.2
Chicory 11 0.5 1 170 21 6 27 25 0.2 0.6 2.9 −2.0
Cucumber 10 0.7 3 140 18 8 49 17 0.3 1.4 2.5 −0.8
Eggplant 15 0.9 2 210 10 11 16 14 0.4 0.2 4.0 −3.4
Leeks 22 1.6 2 260 24 3 44 59 0.8 1.2 3.8 −1.8
Lettuce, average of 4 varieties 14 0.8 3 220 28 6 28 47 0.4 0.5 3.4 −2.5
Lettuce, iceberg 13 0.7 2 160 19 5 18 42 0.3 0.3 2.2 −1.6
Mushrooms, common 13 1.8 5 320 6 9 80 69 0.9 2.6 4.9 −1.4
Onions 36 1.2 3 160 25 4 30 25 0.6 0.7 2.7 −1.5
Peppers, Capiscum, green 15 0.8 4 120 8 10 19 19 0.4 0.3 2.1 −1.4
Potatoes, old 75 2.1 7 360 5 17 37 66 1.0 0.8 5.9 −4.0
Radish, red 12 0.7 11 240 19 5 20 37 0.3 0.4 4.4 −3.7
Spinach 25 2.8 140 500 170 54 45 98 1.4 −1.9 13.4 −14.0
Tomato juice 14 0.8 230 230 10 10 19 400 0.4 0.3 3.5 −2.8
Tomatoes 17 0.7 9 250 7 7 24 55 0.3 0.6 4.0 −3.1
Zucchini 18 1.8 1 360 25 22 45 45 0.9 0.8 6.2 −4.6
Key: Na = sodium; K = potassium; Ca = calcium; Mg = magnesium; P = phosphorus; Cl = chloride.

The characteristic postabsorption determinants of PRAL are also presented; these are the primarily protein-dependent urinary sulfate excretion: SO4; the phosphate excess: PEX (PEX [mEq] = PO – Ca – Mg); and the alkali excess: ALEX (ALEX [mEq] = Na + K – Cl). Each is estimated from the corresponding nutrient data by the conversion factors described in Table 1; PRAL (mEq of Cl + P04 + S04 – Na – K – Ca – Mg) also corresonds to SO4 + PEX – ALEX.

Data were derived from reference (32).

Data were derived from the manufacturer’s literature (Apollinaris, Bad Neuenahr-Ahrweiler, Germany; Volvic, Puy-de-Dome, France).

For those processed (ie, salted) foods for which the tabulated Cl contents deviated by more than ± 10% from the values determined under the assumption of an equimolar Na and Cl content, Cl was calculated from the listed Na data on an equimolar basis, ie, Cl (mg) = Na (mg) × 1.54.

For egg white protein, known to have a particularly high methionine and cysteine content, a 1.5-fold higher conversion factor (ie, 0.7332×10−3) was used to estimate renal sulfate excretion. Methionine and cysteine content related to 100 g protein is approximately 1.5-fold higher for egg white than, eg, for beef (32).



Average potential renal acid loads (PRAL)a of certain food groups and combined foods (related to 100-g edible portion

Food group PRAL (mEq)
Alkali-rich and low phosphorusb −1.7
Alkali-poor and low phosphorusc 0
Fats and oils 0
Fish 7.9
Fruits and fruit juicesd −3.1
Grain productse
Bread 3.5
Flour 7.0
Noodles, spaghetti 6.7
Meat and meat products 9.5
Milk and dairy products
Milk and noncheese productsf 1.0
Cheeses with lower protein contentg 8.0
Cheeses with higher protein contenth 23.6
Vegetablesi −2.8
Data represent the arithmetic mean of the PRAL values of the respective foods listed in Table 2.

Beverages (phosphorus <30 mg/100 g) with several times higher sodium + potassium content compared to chloride, for example, red wine, white wine, certain mineral (soda) waters, and coffee.

Beverages (phosphorus <30mg/100 g) with similar sodium + potassium vs chloride content. Cocoa (alkali- and phosphorus-rich) also falls in this PRAL category. Because of a medium phosphorus content (eg, 28mg/100 g) some European pale beers have a relatively high PRAL value (about 1mEq/100 g).

Without dried fruits.

Irrespective of the type of flour (whole meal or white, plain).

Primarily whey based.

Less than 15g protein per 100g.

More than 15g protein per 100g.

Without asparagus (very low alkali excess) and spinach (very high alkali excess).  < Plant based diets can alkalinize the urine.  < PH of foods enhance performance.  < Potential renal acid loads of food and urine PH effect.  < Excessive protein and acid load can effect bone turnover. < renal acid  < Meat and acid base status  < Urine PH and acid load of diet




Insane Medicine – Magnesium enhances physical performance

Insane Medicine - Magnesium at 300 mg a day improves physical performance in women.
Magnesium at 300 mg a day improves physical performance in women.
  • Magnesium supplements improve physical performance in the elderly. Higher intake is associated with reduced coronary artery calcification and decreased risk of transitioning from pre-diabetes to diabetes.
  • Magnesium regulates bone health as well by regulating the body’s use of calcium and hormones involved in bone structuring.
  • The RDA of magnesium is 420 mg a day for men over thirty and 320 mg a day for women over 30.
  • High magnesium foods include beans, peas, nuts, seeds, spinach, green leafy vegetables, and whole grains. Processed grains (wheat) have their magnesium stripped from them. Also consider bananas, avocados, low fat dairy, and soy milk for magnesium- rich sources.
  • Magnesium supplements increased the gait speed of older women by 40 feet a minute. In sarcopenia (muscle mass loss),  a key indicator of worsening function is gait speed. Slower gait speed means poor health and bad outcomes.
  • Older people get less magnesium because they may be eating lower quality foods or take medications such as diuretics or proton pump inhibitors (for stomach acid) which cause magnesium loss. Also malabsorption can decrease the body’s magnesium supplies (for example Chrone’s disease prevents magnesium absorption in the gut)


Insane Medicine – Bone health depends on a lot of nutrients mixed together!

Insane Medicine - Bones need a lot of nutrients
Insane Medicine – Bones need a lot of nutrients

What is your osteoporosis risk? See the calculator in this link:

Bones need more than just calcium. They need Magnesium, Vitamin C, Vitamin D, and Vitamin K. There are medical factors as well that come into play with respect to bone health. For example, there are medications that can wash out your bones, such as prednisone, and diseases, such as parathyroid disorders, that can result in early osteoporosis.  Get checked for these types of issues. From the nutrition point of view, there are measures you can take to help prevent osteoporosis.

  • Calcium: You need 1000-1200 mg a day. This is the backbone of your bones, literally!
  • Magnesium: The RDA is 310-420 mcg (micrograms) a day. Magnesium is tied in with bone health, in that a lower magnesium intake is associated with lower bone mineral density. Supplementation to near the RDA suppresses bone loss in postmenopausal women. Around half of your magnesium stores are in the bones. Food sources high in magnesium include: Almonds, spinach, black beans, kidney beans, avocado, peanut butter, edamame, and whole-wheat bread.
  • Vitamin C:  This is important for the immune system and also linked to less bone loss. the RDA is 75-90 mg a day. Good sources include: oranges, strawberries, red and green bell peppers, kiwi, mango, and others.
  • Vitamin B12: The RDA is 2.4 mcg a day.  Low B12 levels affect the nervous system as well as bone mineral density and osteoporosis. Sources include clams, salmon, haddock, canned tuna, milk, yogurt, egg, cottage cheese, breakfast cereals that are fortified.
  • Vitamin D: The RDA is 600-800 IU a day. It is essential to Calcium absorption in the gut. Supplementing at 800 IU a day decreases the risks of hip and non-vertebral fractures. Sources include: Cod liver oil, swordfish, canned tuna, fortified orange juice, eggs, and sockeye salmon.
  • Vitamin K: The RDA is 90-120 mcg a day. There appears to be a link between vitamin K intake and decreased risk of fractures. Sources of Vitamin K include: spinach, brocolli, green leaf lettuce,kale, swiss chard, collard greens, and brussel sprouts. If you take blood thinners, be careful of interactions with vitamin K. Ask your doctor.
  • Remember to quit smoking and exercise!
  • Fast facts on osteoporosis:

Insane medicine – Osteoporosis: Calcium and Vitamin D with medication choices for treatment.

Insane medicine - Osteoporosis
Insane medicine – Osteoporosis
  • Osteoporosis is diagnosed by bone density tests or fragility fractures. Bone densitometry is reported in the form of a T-score. A normal value is a value that is within a standard deviation (S.D) of a young adult mean bone density value. Anything that is 2.5 S.D.  or more below the mean is osteoporosis.
  • <- A calculation tool, the FRAX model, can help predict a 10 year probability of hip or other osteoporotic fracture based on risk factors and known bone density at the femoral neck.
  • Reviews of postmenopausal women and older men (>70) who took vitamin D and calcium had fewer hip fractures and nonvertebral fractures.
  • Recommendations for calcium: 1000mg for all adults ages 19-50, including pregnant and lactating women, and 1200 mg of elemental calcium a day for women over 50 and men over 70 years old.
  • Vitamin D intake 600 IU a day for men and women up to 70 and 800 IU a day for women over 70.
  •  < — this is a link to calcium content and Vitamin D content in food you eat.
  • Target serum 25-OH-D (25-hydroxy-vitamin D) level is 30-60 ng/ml. This is a measurement of how much vitamin D is in your system.
  • We obtain vitamin D from food sources (see link above) such as salmon, tuna, milk, and many other sources. Calcium is obtained in milk products and vegetables. See the link above for sources.
  • Calcium supplementation: There is no evidence that calcium supplements increase your heart attack risk up to 1000 mg a day when taken with 400IU of vitamin D, based on the women’s health initiative. The choice of calcium supplement would include Calcium citrate if you take anti-acid medications such as proton pump inhibitors or proton pump inhibitors. If your take calcium carbonate, it should be taken with food to increase absorption.
  • treat osteoporosis if you (1) get a hip or spine fractue (2) you have a T score of less than -2.5 at the spine, femoral neck, or total hip area, or (3) if your FRAX risk is > or = 3% for hip fracture and your T score is between -1.0 and -2.5.
  • Options for treatment include Biphosphonates, which are non-hormonal agents that inhibit osteoclasts, which break down bone. Examples are Alendronate (Fosomax), Risendronate, Ibandronate (Boniva), and Zoledronic acid (Reclast). each has various routes of administartion and frequency of administration. You have a choice of once a day, weekly, monthly, or even annual intake of some medications.
  • Side effects that are common with bisphosphonates include heartburn and esophagitis if you don’t drink enough water and stay upright for 30 minutes after taking the pill. Osteonecrosis of the jaw is rare, but more common in immunocompromised patients. If use occurs for longer than 5 years, there is an increased risk of atypical hip fractures.
  • Duration of treatment is not clear, but continuing bisphosphonates beyond 5 years does decrease the number of vertebral fractures, but not non vertebral fractures. Some doctors recommend stopping treatment for a while after 5 years of medication with Bisphosphonates.
  • Denosumab (Prolia) is a monoclonal antibody that inhibits osteoclasts and decreases bone breakdown. It is injected every 6 months and decreases vertebral, hip, and nonvertebral fractures as well as increasing bone density.
  • Estrogen antagonists such as Raloxifine is useful to prevent and treat postmenopausal osteoporosis. It reduces only vertebral fracture incidence, not non vertebral fracture rate. It can reduce the risk of invasive breast cancer.
  • Duavee, a combination of estrogen and Bazedoxifene ( a selective estrogen receptor modulator like Raloxifene), is useful in postmenopausal women with an intact uterus. It increased bone density. There was no increase in endometrial, ovarian, or breast cancer.
  • Contact your doctor to discuss the options right for you.
  • The rate of bone loss increases rapidly after menopause in women.
    The rate of bone loss increases rapidly after menopause in women.

    Osteoporosis and the spine
    Osteoporosis and the spine