Amy Nett: Next question from Amber. Amber says, “I have a 56-year-old female patient. No major health concerns but she does want to lose some weight. Ran the comprehensive blood panel and her homocysteine level is high at 11.” Remember, optimal homocysteine, we’re looking for 5 to 7. “B12 is low end of normal at 563, folate normal at 11.9, methylmalonic acid 0.12, TSH slightly high at 2.3, zinc-copper ratio low, parathyroid hormone high at 66 with vitamin D of 55, normal serum calcium level. All other labs look good.” A couple of questions here. “Number one, is elevated homocysteine common in menopausal women, and when do you just assume it is elevated because of menopause versus other concerns?”
No. Homocysteine, I mean, our goal is 5 to 7 even in postmenopausal women. I would never see a homocysteine of 11 in a postmenopausal woman and just attribute it to that. I think our goal homocysteine is 5 to 7 throughout the lifespan, and some of that is coming from Dale Bredesen’s work on preventing Alzheimer’s disease and dementia. You have room to bump up B12 and folate, so I probably would. I would give a B complex that includes both active forms of the B12 and folate. Also, think about the methionine-to-glycine ratio. I have most of my patients supplementing with collagen peptides. Unless they’re doing a lot of organ meats, I think collagen peptides are going to help balance out … When a lot of people are eating more in the way of muscle meat, sometimes that methionine, the amino acid ratio, gets a little bit out of balance, and I think that can contribute to a higher homocysteine. Sometimes you can also, if those interventions don’t work, you can start thinking about whether or not you want to bring choline in, and so there are sort of other levers you can pull. But I do think that you really want to work on getting homocysteine closer to 7. Again, part of this is we think that homocysteine is an independent risk factor for cardiovascular disease, which of course women are at high risk for cardiovascular disease, depending, of course, on our other risk factors. But I would think about it in the context of cardiovascular disease and also dementia or cognitive decline. I would go after that and then don’t let age sort of talk me out of it.
And then the next question is, “Would you run a methylation test on her?”
I don’t know. I think part of me has moved away from methylation testing. The HDRI panel is just so expensive, and it took so long that it took 12 weeks to get those results. I kind of ended up just starting the methylation support regardless. I think it might be Genova that more recently came out with a methylation panel that we’re sort of looking into. But I think for the most part, it’s safe to do a lot of the methylation support, so I think you could start increasing B12 and folate, get your B complex in there, get the collagen peptides. If she’s not getting dietary sources of choline, think about a choline, or really, a phosphatidylcholine supplement. I more often do some methylation support for a few months before really thinking about testing. But again, that’s partly from a cost perspective, so if cost isn’t an issue, you certainly could do some methylation testing.
And then the next question here Amber asks is, “Could her parathyroid hormone be elevated because of low dietary calcium intake? I was thinking about repeating her parathyroid hormone and calcium in a month or so.”
Yes. I mean, an elevated parathyroid hormone in this setting as you described with a normal vitamin D and serum calcium, my number-one thought is going to be that her dietary calcium is too low. Because remember, if you think about the role of parathyroid hormone, it’s really involved in regulating the blood level of calcium. If you’re not getting enough dietary calcium, parathyroid hormone will increase to drop calcium from the bones so that you can maintain the blood level of calcium, which is much more important for day-to-day existence. I would have her track dietary calcium, and so you can use any sort of food tracker. I think right now we’re suggesting patients use Chronometer, and it can be just five to seven days. But really tracking your food as best you can, measuring it, weighing it, and eating a typical diet for those five to seven days that you get a good representation of what her normal calcium intake is. You didn’t mention if she’s eating any dairy, but dairy of course is a good source of calcium for a lot of people. I think we do have to be cognizant, I think especially in our petite females, whether or not they’re getting enough calcium. I would have her track calcium intake for five to seven days. If it’s low, consider increasing her dietary sources of calcium and/or using a supplement like the Traditional Foods Whole Bone Calcium, which is the ground-up bone, which we think might be one of the safest ways to get calcium.
Calcium supplements are definitely controversial, and looking in the postmenopausal women, even in the setting of osteopenia/osteoporosis, I think the data is pretty mixed on whether or not the risk-benefit ratio for calcium supplementation really pans out. I definitely prefer dietary sources of calcium, and also her vitamin D is optimized, so you want to keep it there and consider getting a DEXA scan to determine her bone density. And if she has osteopenia/osteoporosis, you might want to be a little bit more aggressive in terms of treating the osteopenia/osteoporosis and maybe be a little bit more aggressive about dietary intake of calcium or supplementation with calcium, so making sure you have vitamin K2 on board. Think about exercise, lifestyle, and that sort of thing. I think it sounds like there are a couple pieces with this patient that you could definitely work on in terms of optimizing her nutrients. It sounds like you’re absolutely on the right track there.