Ask Dr. Andro: Are Vitamin Supplements Bad For Me (2/2)? 3+1 = 666! The Raw Data Truth about the "Vitamins Kill!" Offspring of the Iowa Women's Health Study

Image 1: "Please Dr. Andro tell me I can keep taking my essential multivitamin! I am just too busy to eat healthy..."

I must admit that I feel kind of awkward as I am about to defend one of those supplements, I consider to be the most dispensable within the dietary regimen of a physical culturist: the so-called multi-vitamin! In essence these small, and lately more often than not large pills do not even fall into the category supplement. With dose-equivalents way beyond what you would actually need, "multivitamins" are not even "replacements", they are madness or, I should say, the mad outgrowth of the prevalent "more is more" mentality that is beginning to harm us on every level of our society... but I am digressing, here. Let's take a look at the actual study which brought about such an upheaval in the supplement-addicted health community on the Internet.

Dietary Supplements and Mortality Rate in Older Women

Image 2: Is this you? No? Maybe she is "The Average American", then? No? Well, but the study says "vitamins are bad for YOU" and she could be one of the subjects (img. medscape.org)

The title alone, actually made me click the study away, back in the day when I first hit upon it, on one of my regular searches for new stories on the medical databases of the World-Wide-Web; and unless you are an old women (I would hope there were some older women reading the SuppVersity, but I guess there are none), you should have disregarded the study, as well. After all, we all know how the game changes after menopause and guess what, of those women, 98.6% were post-menopausal (in case you ever see studies done on ovariectomized rodents, remember that those are "menopausal", too ;-). Ah, and in case you are a post menopausal women with Africa-American or Hispanic background, there is likewise little reason for you to read on, because 99.2% of the women in the study were white (if you question whether or not ethnicity really matters, when it comes to the health effects of vitamins, I suggest you take a look at some reviews like Carmel. 1999).

Now, if you are still with me at this point, I guess that you either are a post-menopausal white woman, or - and I suppose that this will be the case for the majority of you - you have been agitated by the heated debate on the net (and even regular mass-media) in the last couple of days and want someone to tell you that you did not reduce your life-expectancy by -15% by religiously taking your "essential" *rofl* multi-vitamin, everyday. We will see, whether I can be this person (in case it turns out I am not, I have seen more than enough "gurus" you will tell you exactly that, if you promise to buy their "all natural" or "superior source" product in the future).

The Iowa Women's Health Study - Mrs "not so average" American

So, let's see. What we have here is an offshoot of the Iowa Women's Health Study (IWHS), which is one of those highly over-estimate surveys, the media loves, because they boast of ten-thousands of "participants". In the case of the IWHS, "41836 women aged 55 to 69 years"... well, at least that were the women the scientists send their little questionnaires to back in 1986. Interestingly, this is also where the first bias (i.e. a deviation from "objectivity") came into play:

Respondents were slightly younger, had lower body mass index (calculated as weight in kilograms divided by height in meters squared), and were more likely to live in rural areas compared with nonrespondents.

So instead of the average American "older woman", the scientists suddenly had the "slightly younger" not just as obese, better off American older women, as their study object. Moreover, the number of participants dropped to 38772 women or, in other words, the scientists "lost" 7.3% of their study population even before the study actually began. Now, of those, the Mursu et al. selected 29230, who were the "elite" which responded to both the initial 1986 and the 2nd 1997 follow-up questionnaire.

Failure 1: Not representative of "The Average American"

"Ladies, give me as little information about your supplements as possible, please!"

The latter, i.e. the questionnaire, assessed the use of 13 supplements:

• multi-vitamins; 
• vitamins A, beta-carotene, B6, folic acid, B complex, C, D, and E; 
• iron, calcium, copper, magnesium, selenium, and zinc

Now, the scientists show off their wealth of knowledge and state that "[d]ifferent forms of vitamin D, cholecalcif-erol (D3) or ergocalciferol (D2), were not distinguished". While this is obviously important, it would have been even more important to distinguish between different forms of vitamin B6 (pyridoxin vs. P5P), B complex (you can have a complete one, one with equal doses, one particularly high in one B vitamin, etc.), vitamin E (I suppose you read the first installment?), iron (heme, non-heme, chelated, etc.), copper / magnesium, selenium, and zinc (oxide, chelated, etc.), because we know that these different forms of vitamins and minerals are not only differentially absorbed, but also exhibit differential effects on our health and well-being.

Failure 2: Ignorance towards the fact that
not all vitamins / minerals with the same label are created equal

And as if this had not been enough, the scientists did not even care if the ladies popped 1 or 23 of their beta carotene (I hope you do not still believe you can take endless amounts of that orange poison), magnesium, folic acid and B-complex pills.

Failure 3: Careless ignorance towards dosages

Raw foods are dangerous and so is raw data

Hence, the scientists got a set of data that was full of holes from a group of women who are by no means representative of "The Average American" (let alone every human being) - what did they do next? Well, obviously "raw data" is as dangerous as raw meat (or even raw milk), that is why the next step for every good scientists is data processing. In that Mursu et al. were particularly skilful as far as not revealing what they actually did was concerned:

In the minimally adjusted model, we adjusted the association for age and energy intake; in multivariable adjusted model, version 1, we additionally adjusted for educational level, place of residence, diabetes mellitus, high blood pressure, body mass index, waist to hip ratio, hormone replacement therapy, physical activity, and smoking status. For multivariable adjusted model, version 2, we added intake of alcohol, saturated fatty acids, whole grain products, fruits, and vegetables.

Even, or I should say, especially for a physicist, who is a 75% mathematician, the idea that by some sort of mathematical magic you could reliable subtract out all those influence, so that you get the "real picture" of what is going on, with an average human being is so hilarious that I avoid any further comment. Everything that goes beyond the "minimal adjustment" is so full of speculative hypothesis and mainstream paradigms (like "Whole grains are good for you! The more, the better!") that I will simply ignore this data... unfortunately these results of "3+3 = 666" mathematical manipulation were what the scientists (in their press releases) highlighted as their main results and what was accordingly taken up by the laymen (initially I wanted to write idiots, but that would be unfair, because laymen they are) in the editorial offices of the mass media.

Failure 4: Over-"analysis" of the data

Let's get to the raw truth

This would not be the SuppVersity, if I did not have something to offer that goes beyond the angry rants and criticism (see above) you probably have read elsewhere, anyways. So, I went through the pains of compiling and comparing the "real", i.e. the N=X data and not the calculated hazard ratios for you.

Figure 1: Raw data and minimally adjusted (age and caloric intake) data on the effect of taking vitamin A, beta carotene, vitamin C, vitamin D, vitamin E, and finally the multivitamins on overall mortality (data calculated based on Mursu. 2011)

Now, I want you to take a close look at the data for vitamin A, beta carotene, vitamin C, vitamin D, vitamin E, and finally the multivitamins. I don't know what you see, but I see only vitamin A and beta carotene scratching at the increased mortality margin of 1.0 (cf. dotted red line in figure 1). And, just for a better understand, two examples:

• the 1.04 as for vitamin A (minimally adjusted) in 2004-08 indicates a +4% higher risk and 0.80,
• the 0.80 for vitamin E (raw data) in 2004-08 indicates a -20% decrease in mortality risk

So, what would you say, how "dangerous" is taking vitamin pills if you do not process the data to death? Interestingly, things get really nasty, from here. And moreover, they get nasty, where you probably would not have expected it unless you are a very diligent student of the SuppVersity and are thus aware that messing with the methylation cycle via B6 or folic acid supplementation for no reason is not a good idea.

Figure 2: Raw data and minimally adjusted (age and caloric intake) data on the effect of taking vitamin B6, folic acid, B-complex, calcium, and magnesium on overall mortality (data calculated based on Mursu. 2011)

Given the fact that an increasing amount of "old" people are taking magnesium supplementation, I would say that in this case the age-adjustment is probably necessary - if you also consider that back in the 1980s this bias was smaller, since people were not told that taking mg supplements would be necessary for older folks, the respective adjustment will be "too small" and thus I would simply ignore the fact that the 1996 value still signifies a +2% greater risk of dying when you take a magnesium supplement (add to that that the study participants could have taken magnesium in the 10x recommended dosage and the scientists would not know that /see comment on dosage, above). What really surprises me, though is the enormous benefit that is (even in the raw data) associated with calcium supplements - 22% reduced risk according to raw data and 21% reduced risk with age/energy adjustment - impressive!

Figure 2: Raw data and minimally adjusted (age and caloric intake) data on the effect of taking iron, copper, zinc, and selenium on overall mortality (data calculated based on Mursu. 2011)

Last but not least - the worst offenders, the dreaded "heavy metals" ;-) Ok, I guess iron really is a bad guy (at least for post-menopausal women), but even copper, which has gotten such a bad rep, lately turns out to come pretty handy in the female part of the aging American population, ... interestingly only in the early to late 2000s - how come? I'll leave it up to you to make up your mind on this and other questions, but I assume that now, that you know the raw truth, you will not blindly follow Bjelakovic's campaign to "wake up [regulatory authorities] to their responsibility to allow only safe products on the market" (Bjelakovic. 2011), but rather scrutinize his "invited comment" to the Mursu study, which was published in the same issue of the Archives of Internal Medicine and has caused such an upheaval among the increasingly health conscious American and International public.

Ask Dr. Andro: Are Vitamin Supplements Bad For Me (1/2)? The "wrong" Vitamin E Supplements Increase Cancer Risk.

Figure 1: This is where you, my American friends (and most Europeans), should and would get your "E's" from - it's called "food" (Eitenmiller. 2004)

With the recent publication of two studies on increased all-cause mortality in older women (Bjelacovic. 2011; Mursu. 2011) who took multivitamins (+2.4%), vitamin B6 (+4.1%), folic acid (+5.9%), iron (+3.4%), magnsium (+3.6%), zinc (+3.0%), and the "killer" copper (+18%) and increased risk of prostate cancer due to selenium and/or vitamin E supplements (Klein. 2011) on a regular basis and the huge media attention these studies,

• "Certain Dietary Supplements Associated With Increased Risk of Death in Older Women, Study Suggests"
• "Vitamin E Supplement May Increase Prostate Cancer Risk, National U.S. Study Finds"

have received, I got interested in taking a closer look at what I would usually have discarded as epidemiological guesswork and scare tactics, anyway.

How can a vitamin be bad for you? It's supposed to be a vital nutrient, goddammit!  

In that, I want to start with the 2nd of the two studies, i.e. the one on Vitamin E, which also happens to be a "true" Ask Dr. Andro question. After all, Steven Acerra posted a whole bunch of related questions on my Facebook page (remember you can always send in questions you want to have answered in this column!)

Image 1: Conflicts of interest, as declared in the paper by Klein et al.

Are medical studies "objective"? Being a scientist (in a whole different area of research, though), myself, I am well aware that financing expensive cutting edge science with the meager support from national agencies is impossible, these days. Therefore, I refuse any rash prejudgements based on the openly stated potential conflicts of interest (cf. image 1), as Steven put them forward in a follow-up comment on my facebook page. If you want to blame someone, blame the influential editors of the large journals, including the JAMA, where Klein's paper was published. Their acceptance of a paper determines whether a study appears on the SuppVersity, "only", or is taken up by a journalist from a major popular scientific magazine or, as in this case, even the Health Podcast of Time Magazine.

Other than Steven suspected, the study by Klein et al. that was published in the latest issue of JAMA (the Journal of the American Medical Association which is not particularly well know for being independent of the pharma lobby, cf. red box ;-) - despite its size - actually is a "controlled" trial... Well, as controlled as a study with 34 887 men who were randomly assigned to receive selenium (n= 8752), vitamin E (n=8737), vitamin E + selenium (n=8702) or placebo (n=8696), can be. It is part of, or  I should say, the final outcome of the so called SELECT trial, a large scale intervention that was conducted in the United States, Canada, and Puerto Rico. Data acquisition started on August 22, 2001 and ended three months ago, on July 5, 2011. The fact that the study is over is good news for all participants, because, as the bold headlines would have it, all treatments increased the participants' risk to develop cancer. Yet, what mainstream media didn't tell you is that (I quote directly from the detailed results in the paper; Klein. 2011):

The rate of prostate cancer detection was greater in all treatment groups when compared with placebo* but was statistically significant only in the vitamin E alone group. After adjustment for the marginal effects of vitamin E and selenium, the interaction between vitamin E and selenium was statistically significant (P=.02), indicating no increased risk of prostate cancer when vitamin E and selenium were taken together. The risk of Gleason 7 or greater disease was higher for all 3 interventions [vitamin E + 16%; selenium +21%; combination: +23%] but did not reach statistical significance for any group.

* I suspect this is probably about as far as most journalists read - if they even had the fulltext of the study, when they wrote their sensational and fearmongerish articles

If you compare the real findings to what you may have read in the course of the last week, it is quite obvious that half of the media reports got the results completely wrong. A quarter of the reporters obviously did not know the meaning and importance of "statistical significance" and the lousy rest does not care about information, anyway, as long as a headline could potentially increase sales or pageviews, it makes it into the magazine or onto the website.

No matter what the press says: You better know your vitamins E before taking the wrong one

Figure 2: Natural RRR alpha-tocopherol and synthetic SRR alpha tocopherol which is one of the isomers in the -50% less potent all-rac-alpha tocopherol, which is the "vitamin E" the 34,887 men in the large scale trial conducted by Klein et al. have received at a dose of 400IU per day  (figure from Traber. 2011)

This leaves us with just one "unexpected" result to be explained, i.e. a statistically significant increase in cancer risk with 400IU of supplemental "vitamin E" per day. In case you've noticed the quotation-marks before and after vitamin E, in the previous sentence, you already know where this is heading. After all, you would assume that the scientists would use the most potent weapons from their arsenal in their battle against prostate cancer - wouldn't you? Trial "S0000 Selenium and Vitamin E in Preventing Prostate Cancer" (clinical trials identifier: NCT00006392) sponsored by the Southwest Oncology Group, however, relied on the cheap all-rac-alpha-tocopheryl acetate of which Max K. Horwitt had shown back in 1980, already, that "all-rac-alpha-tocopheryl acetate may have no more than half the biological potency of d-alpha-tocopheryl acetate" (Horwitt. 1980). About, 19 years later Horwitt, then over 90 years old (!), was still fighting a fight against the medical establishment who maintained that the cheap synthetic form of vitamin E would have at least a 73.5% the activity of the naturally occurring form. In a letter to the editors of the American Journal of Clinical Nutrition he writes (Horwitt. 1999):

Now in my 90th y, I doubt whether I will ever see the proper correction made in the official values of the tocopherols. Having introduced the term equivalent as used by committees of dietary allowance, I prefer that this designation be used to describe the potency of the tocopherols. In the recommended dietary allowances, l mg RRR-a-tocopherol has a biological value of 1.0 a-tocopherol equivalents. Accordingly, in modified US Pharmacopoeia vitamin E units, RRR-a-tocopherol should have a value of 1.0, all-rac-a-tocopherol a value of 0.5, RRR-a-tocopheryl acetate a value of 0.91, and all-rac-a-tocopheryl acetate a value of 0.455.

Meanwhile, the USDA has changed their calculations in the USDA National Nutrient Database for Standard Reference, according to release #20 (USDA. 2008), the all-rac-alpha-tocopheryl acetate 
is now officially classified as -55% less potent than natural tocopherol. Now, the chance to pick the worst of the four vitamin E's was 25% and *bang* Klein et al. nailed it. Can this be coincidence - I guess if it was you could call it "bad luck".

Supplementation may offset the natural balance by exchanging natural gamma tocopherols for cheap synthetic alpha-tocopherols

"Bad luck", also because supplementation with high doses of alpha-tocopherol has been shown to hinder "normal" incorporation of gamma-tocopherols into VLDL particles, to increase hepatic clearance of gamma-tocopherols and, in the end, to deplete plasma gamma-tocopherol levels, as well (Jiang. 2011). Now, if you have a less potent type of vitamin E, you obviously have to supplement more (to achieve a potency equivalent to 400IU you obviously need +55% more all-rac than natural tocopherol!)... but does that really matter? Oh yes it does! As gamma tocopherol and not alpha-tocopherol is "the vitamin E" which inhibits cyclooxygenase activity and, thus, possess heart-healthy anti-inflammatory properties. No wonder that Jiang et al. report in a 2001 review that...

1. plasma gamma-tocopherol concentrations are inversely associated with increased morbidity and mortality due to CVD. 
2. serum concentrations of  gamma-tocopherol, but not of alpha-tocopherol, were lower in CVD patients than in healthy control subjects. 
3. in a concomitant cross-sectional study of Swedish and Lithuanian middle-aged men,  plasma gamma-tocopherol concentrations were twice as high in the Swedish men, but that the Swedish men had a 25% lower incidence of CVD-related mortality. In contrast, this inverse correlation was not observed with alpha-toco-pherol. 

... and the list goes on. Now, you will probably say "But Dr. Andro, those men got cancer from vitamin E, not cardiovascular disease!" and, as always, you are right, BUT the evidence that gamma- not alpha-tocopherol (or at least a "natural" mix of both) is cancer protective is even more conclusive than the one on the CVD-protective effect of the former.

What are normal ratios of alpha- to gamma-tocopherol? While we hardly can say which ratios are optimal, we know that the "normal" ratio of serum alpha- to gamma-tocopherol levels for Americans who do not take any supplements is 5:1 (alpha:gamma). According to Chopra and Baghavan his ratio further increases to greater than 20-fold in people taking vitamin E supplements (Chopra. 1999).

High gamma-tocopherol levels reduce risk of prostate cancer by -500% [no typo!]

In 2000 Helzlsouer et al. analyzed the blood of 10 456 male residents of Washington County and found that (Helzlsouer. 2000)...

For gamma-tocopherol, men in the highest fifth of the distribution had a fivefold reduction in the risk of devel-oping prostate cancer than men in the lowest fifth (Ptrend = .002).

With p = 0.002 the chance that this was "coincidence" is exactly  125x smaller (0.2%) than Klein et al.'s chance (25%) to pick the worst alpha-tocopherol variety there is for their large scale intervention. And while this is only an epidemiological study, we have more than enough in-vitro and animal data to confirm the anti-cancer effect of gamma-tocopherol:

Prostate cancer:
• Jiang. 2004:  "... gammaT and mixed vitamin E forms induce cell death by interrupting the de novo sphingolipid pathway in a prostate cancer cell line"
• Campbell. 2009: Growth arrest (40%) in PC-3 prostate cancer cells through the regulation of fatty acid metabolism and PPAR gamma mRNA and protein upregulation was achieved with gamma-tocopherol within 6 h.
• Jiang. 2011: Sphingolipid promoting effects of gamma-tocopherol induces apoptosis and autophagy in prostate cancer cells

Colon cancer:
• Campbell 2006: In-vitro study on human colon-cancer cell lines; "treatment with RRR-gamma-tocopherol resulted in significant cell death for all cancer cell lines tested, while RRR-alpha-tocopherol did not [...] RRR-gamma-tocopherol may aid chemotherapy without toxic effects to normal cells demonstrated by most chemotherapeutic agents"

Other cancers:
• Yu. 2009: Mouse model (human breast cancer) + in-vitro studies > "α-tocopherol not only failed to exhibit anticancer properties but it reduced anticancer actions of γ-tocopherol in vivo and γ-tocopherol and α-TEA in vitro."; what is important to note, though is that the all-trans-variety used in the Klein study did at least inhibit proliferation and increase apoptosis (programmed cell death) in vivo.
• Yang. 2010: "[I]nhibition of inflammation as well as of cancer formation and growth in the lung and colon in animal models" by tocopherol supplement with  57% gamma-T
• Ju. 2010a: "In cell culture, the growth of H1299 cells [lung cancer] was inhibited by tocopherols with their effectiveness following the order of delta-T > gamma-TmT > gamma-T, whereas alpha-T was not effective."
• Ju. 2010b: "... recent results have demonstrated that a gamma-tocopherol-rich mixture of tocopherols inhibits colon, prostate, mammary and lung tumorigenesis in animal models, suggesting that this mixture may have a high potential for applications in the prevention of human cancer"

And directly referring to the "partly negative" outcomes of studies into the potentially beneficial effects of "vitamin E" supplements (which were almost exclusively conducted with alpha-tocepherol-only products), Reiter el al. wrote in a 2009 review (Reiter. 2009):

As pointed out in this review, more and more evidence indicates that γT and other vitamin E forms than αT have unique bioactivities that may be important for maintaining and improving human health (Dietrich et al. 2006; Jiang et al. 2001). For example, γT is a stronger inhibitor of cyclooxygenase and possibly lipoxygenase than αT. Furthermore, γT traps reactive nitrogen species more efficiently than αT. Some of these in vitro effects are slowly being confirmed in vivo, but more studies are needed here. In addition, γT but not αT exhibits anti-proliferative and pro-apoptotic effects on cancer but not normal epithelial cells (Jiang et al, 2004). [...] Thus, despite the undisputed anti-inflammatory effects of α- and γT, the recent large-scale interventional studies aimed at reducing diseases associated with chronic inflammation have been disappointing, but may be explained by the complex interaction of the different vitamin E forms with inflammatory signaling, xenobiotic transformation, and as yet undefined pathways.

I think I do not have to point out that with what we know today about the necessary synergy of the vitamins E (including the tocotrienols, which I deliberately left out, in order not to overcomplicate things) and the results of a 2003 study by Huang (Huang. 2003), which showed that supplementation with 400IU of RRR-alpha-tocopheryl acetate (remember due to the fact that this is the more potent variety, the actual dose in µg was -50% lower than in the Klein study)

reduced serum gamma-tocopherol concentrations by a median change of -58% [95% CI = (51%, 66%), P < 0.0001], and reduced the number of individuals with detectable delta-tocopherol concentrations (P < 0.0001),

initiating a similar study as Klein et al. did 10 years ago, would border physical injury resulting from negligence, today. And although the use of isolated forms of vitamin E, which you will find in most of the cheap multivitamin tablets you can buy at the supermarket, could also be involved in the negative effect "certain dietary supplements" (including multivitamins) were reported to have on the health of "older women" in the 2nd study, I mentioned in the introduction, I will address this issue in an individual installment in a follow up to this post in the course of the next week. So stay tuned for more.

Arms Don't Grow Faster With Leg Training: Stuart M. Phillips Busts Ronnestad's "Hormonal Ghosts"

Image 1: Although Tom Platz had massive
arms, as well, there is little conclusive scientific
evidence that this was a result of leg training.

Usually I am offering you my thoughts and comments on the results of the studies I am presenting here at the SuppVersity. In this case however, I am going to rely on the insightful analysis of Stuart M. Phillips, head of the Department of Kinesiology, Exercise Metabolism Research Group at the McMaster University, who spotted some interesting inconsistencies in a recently published paper by Ronnestad et al. who had reported that (contrary to conclusive findings from dozens of study by Phillips and others) endogenous hormone release from leg training had a major impact on the anabolic response in the arm flexors (cf. news from March, 2nd / I plead guilty of not having seen these inconsistencies, though I must say in mitigation that back in March I only reported, not commented on studies).

As Phillips points out, Ronnestad's conclusion that training legs+arms results in bigger guns or, rather, that without training legs, your arms won't grow at all is funded in

selective reporting (considering only the site of the largest CSA), incomplete statistical analysis (not comparing the changes (in CSA between arms), and questionable MR practices (Phillips. 2011)

In his analysis of the Ronnestad study, Phillips shows conclusively that, according to Ronnestad's own figures (Phillips refers to figure 6 of the paper, in particular), the authors' statement that

only L + A [leg plus arm training—a high ‘anabolic’ hormonal exposure condition] achieved increase in the CSA at the part of the arm flexors with the largest cross-sectional area (p \ 0.001), while no changes occurred in A [arm only training—a low ‘anabolic’ hormonal exposure condition]. (Ronnestad. 2011)

is not sustainable, since "examination of Fig. 6 in their paper reveals that significant hypertrophy did occur at two sites (of 4 measured) in the A arm", i.e. the non-leg-trained arm. By means as simple as drawing a few vertical lines (cf. figure 1) Phillips is able to show that the hypertrophic response to the training stimulus was in fact identical in three out of the four measured cross sections.

Figure 1: Four horizontal lines are all it took Phillips to show that there must be something wrong with Ronnestad's data; after all, it is unlikely that section 8 of the biceps had atrophied in the course of the stud (illustration taken from Phillip's letter to the editor of the European Journal of Applied Physiology)

Phillips makes a point that, unless one assumes that - for whatever reasons - there has been a strictly localized atrophy in section 8 of the arm (cf. mismatch of pre-values in left and right graph of figure 1), the most likely explanation for the mismatch would be that "the pre- and post-training scans were not aligned at the same point along the arm". Smart-witted as Phillips is, he also observed that with the purportedly greater changes in muscle cross-sectional-area in the leg+arm condition it is strictly impossible for the muscle volume to be identical, unless "the authors believe that the A arm got longer". I would assume that you agree with me that even with eccentric muscle training this would be a rather surprising event. Consequently, this is another argument in favor of the obvious absence of measurable effects of an overall more anabolic milieu in the "arm + leg training"-condition on the hypertrophy response to strength training - or, in short, we still have no conclusive evidence that training legs before arms would make the latter grow faster.

Image 2: Make your biceps grow with the SuppVersity EMG series!

Now, if the hypertophy response was identical, it is even more surprising that the "leg+arm" group exhibited "through some inexplicable mechanism" (Phillips. 2011) an overall greater 1RM strength than the control group. Phillips, who does not refrain from pointing out that "this [was] a surprising observation that was not even alluded to in the paper", argues that this result stands in stark contrast to the "central fatigue" hypothesis Ronnestad et al. cite as an explanation for the "dampened" (Ronnestad. 2011) training loads in the "leg+arm" training group. Phillips, on the other hand, speculates that it could be a direct result of a "a superior neuromuscular adaptation" (Phillips. 2011, my emphasis), which would be the exact opposite of what Ronnestad et al. had in mind.

Even if one neglects the questionable measuring practice of Ronnestad et al., in the course of which the "scanned arm [was] stretched behind the head and centered in the middle of the machine" (Ronnestad. 2011), the absence of an "estimate of variability of the procedure they used in their lab" and the questionable reference to "similarities" to magneto resonance scans (note that Ronnestad et al. used CT scans ;-) carried out by Moss et al. (Moss. 1997), the Ronnestad study is a particularly good example for the way research hypotheses can interfere with the "objective results" of scientific studies by establishing a (often unconscious) bias towards "desired" results. Selective reporting, incomplete statistical analysis and ad-hoc explanations for differences to the findings of previous studies are the undesirable, yet completely human manifestations of this phenomenon, I want everyone of you to be aware of - even if this means that my own thoughts and conclusions, which are almost always produced under time-pressure, are about to get more critical comments in the future ;-)

Stronger & Leaner or Fatter & Less Muscular W/ 4,000IU Vitamin D3 - What if Abstract and Data Tell Different Stories?

Image 1: The gap between the purported and the real world effects of vitamin D3 supplementation remains about as wide as the Grand Canyon - if not wider... and it takes a lot of ignorance towards your own study results to fill this divide up :-o

It is astonishing how fast things can change, only last Thursday I said on the SuppVersity Science Roundup on SHR, that hitherto trial after trial with supplemental vitamin D in the form of cholecalciferol (vitamin D3) failed to produce the desired results. And what do I have to tell you today? A group of researchers from the Purdue University and the College of Charleston have just published a study that appears to make it necessary for me, to at least rectify the previous assessment by stating: "With the exception of a recent trial from the Purdue University ..." Upon having a closer look at the actual data, it did yet turn out that the gap between what the abstract, on the one hand, and the real data, on the other hand, is about as wide as the still existent divide between the purported benefits from vitamin D supplementation and the real-world outcomes of respective trials.

It sounds as if Carillo et al. had finally done, what no one else has done before them, ...

Figure 1: Rel. odds ratio you make it to 100, 90-99, 80-89 yrs instead of dying before your 80th birthday - the results are based on a 44-year prospective study investigating the relation between midlife muscle strength and human longevity and found that "centenarians belonged 2.5 times  more often to the highest third of grip strength in midlife" (Rantanen. 2012)

... i.e. it sounds as if they had observed at least parts of the beneficial effects that are constantly being ascribed to vitamin D supplementation in 23 overweight and obese young men and women (age: 26.1 ± 4.7 y; BMI: 31.3 ± 3.2 kg/m²) with low, but not (officially) deficient 25-hydroxyvitamin D (25OHD) levels of 19.3 ± 7.2 (the official normal rage is between 9-80ng/ml):

"Vitamin D supplementation in overweight and obese adults during resistance training induced an early improvement in peak power, and elevated vitamin D status was associated with reduced waist-to-hip ratio." (Carillo. 2012)

So, according to the conclusion both strength and body composition improved n the course of the 12-week training intervention, which consisted of a 5min warm-up + light stretching (see also "Stretching Before Workouts Makes You Weak!"), followed by 8 machine-based (Kaiser Equipment) resistance exercises, namely

• leg extensions, leg flexions, leg presses, 
• hip adductions & hip abductions, 
• chest presses, seated rows & lat pull downs,

at a progressively increasing intensity, starting with 70%RM in the first weeks and 80% of the 1RM for three sets of 8 repetitions (or "momentary muscular failure"), right? Sounds like that, I should say!

Serious training + serious nutrition = serious gains... but what about vitamin D?

Moreover, with the additional protein shake (360 kcal; 8 g fat, 54 g carbohydrate, 20 g milk protein isolate, 100IU vitamin D and 300mg of calcium) every participant had to consume during the hour following the exercise sessions, the scientists rightfully call their experimental protocol "anabolic". It is thus no wonder that aside from ostensible weight loss and strength gain, both of which you would expect in formerly sedentary subjects, the subjects in both groups did also increase their lean mass (see figure 2, right) .

Figure 2: The hushed up truth Part I => "Gain less muscle and more fat with vitamin D" (right) and have a statistical significant, but real world highly questionable correlation between 25OHD and waist-to-hip ratio of R²=0.205, yet not vitamin D3 supplementation (small, insert; all data based on Carillo. 2012)

What the scientist didn't tell you in the afore-cited conclusion to their abstract, though, is that the group which received an additional 4000 IU vitamin D3 instead of the microcrystalline placebo, did gain less lean mass and more fat mass than their peers. And while the inter-group difference for each of these parameters is statistically not significant, I would bet that their ratio, i.e. the ratio of lean mass to fat mass gains, in this case 5.6 kg muscle per 1kg fat in the placebo vs. 1.8kg muscle per 1kg fat in the vitamin D3 group, were! A difference, by the way, which is not simply a result from the greater increase in energy intake in the vitamin D3 group (see figure 2, left), as the latter should have increased both, lean and fat mass gains. What it effectively did, however was exactly the same as a vitamin D supplement in a rodent study it worked as a "fat-synthesizer" (see "Vitamin D3 a "Fat Synthesizer"!? Rodent Study Shows +33% Increased Fat Deposition in Vitamin D3 Supplemented Mice.")

"Something is rotten is rotten, here, and I can tell you Horatio heaven did not direct it"* 

* I hope you like Shakespeare ;-)

Figure 3: If you want lower PTH vitamin D may be worth it, if not, you get only a non-significant worsening of your glucose metabolism; in addition to increases in body fat and lower lean mass gains (cf. figure 2) obviously (Carillo. 2012)!

The fact that we see only increased fat but not muscle gains, however, only adds to a whole list of observations which show that irrespective of how cleverly the abstract tries to make this look like the "break-through study" about the benefits of vitamin D supplementation, we are yet dealing with nothing more but another confirmation of the futility of vitamin D3 supplements. After all, the 4,000 IU of D3 were not even able to increase the levels of 25OHD to a statistically significant (inter-group differences!) degree (see figure 2). If you also take into consideration that

• contrary to the actual vitamin D levels shown in figure 2 (small insert), the provision of 4,000IU/day of D3 did not (!) correlate with a reduction in waist-to-hip ratio,
• the vitamin D3 supplement did not increase serum calcium (see figure 3, top), and
• the participants who received the active supplement, exhibit an allegedly non significant, but still existent worsening of their glucose metabolism (cf figure 3, bottom) 

it must be allowed to ask whether the -34% reduction in PTH, which is the only blood parameter that exhibited a statistically significant inter-group difference, is reason enough to take an otherwise at best ineffective supplement.

"But it does make you stronger!" - Nope, that's another trick!

The latter is all the more true, because the participants in the vitamin D arm of the study may have increased their peak power faster (see figure 3), but the did not increase their overall strength on any of the exercises to a greater extend than the men and women in the placebo arm of the study.

Figure 4: Relative (left) and absolute strength gains (middle) as well as time course of peak power changes
(calculations based on Carillo. 2012)

The notion that this was the case, is simply a consequence of selective reporting (or in this case "highlighting") of study outcomes (cf. Chan. 2004); or, in other words, we are (mis-)lead by the overemphasis Carrillo et al. put on the early (first 4-weeks) increase in peak power, and their corresponding nonchalant surreptitious reference to the fact that "[n]o other improvements were observed with supplementation" (Carillo. 2012). In short, there is a ballyhooed increase in "peak strength" in the early weeks, but this does not change the fact that the participants in the vitamin D3 arm of the study ended up gained more fat and less muscle, and were - at the end of the trial - neither stronger nor leaner (neither in terms of their body fat %, nor in terms of their waist-to-hip ratio, which was not associated with supplementation!)

From a mere statistical perspective, you could even argue that nothing happened. And let's be honest does that vindicate vitamin D supplementation? I don't think so! If you want to make a change, get big and buffed or strong and sexy, get your lazy ass off the couch and out in the sun, work out regularly, prepare your own nutritious food and drop all useless supplements (see "Three Simple Rules of Smart Supplementation") ... but you know all that, already, right?

Image 2: Does "doing science" come down to presenting only those facts that are in line with the orig. research hypothesis, these days? (img. geekology.com)

Some more general remarks: Now, I could hardly care less that this is yet another study showing that vitamin D3 is a supplemental non-starter., but there is one thing that really drives me up the walls and this is the fact that you as an intelligent and critical SuppVersity reader who is determined and willing to question what he reads on the Internet, but in 99% of the cases won't have access to full-texts of papers like this, are being mislead by abstracts, which are written for the sole purpose to tailor to the original research hypothesis

"[...] that vitamin D supplementation during resistance training would result in greater gains in muscle mass and function as well as improved glucose tolerance compared to exercise training alone." (Carillo. 2012)

and that irrespective of the fact that the actual data disproves this hypothesis!

References

• Carillo AE, Flynn MG, Pinkston, C, Markofki MM, Jian Y, Donkin SS, Teegarden D. Impact of vitamin D supplementation during a resistance training intervention on body composition, muscle function, and glucose tolerance in overweight and obese adults. Clinical nutrition (Edinburgh, Scotland) 3 September 2012.
• Chan AW, Hróbjartsson A, Haahr MT, Gøtzsche PC, Altman DG. Empirical evidence for selective reporting of outcomes in randomized trials: comparison of protocols to published articles. JAMA. 2004 May 26;291(20):2457-65
• Rantanen T, Masaki K, He Q, Ross GW, Willcox BJ, White L. Midlife muscle strength and human longevity up to age 100 years: a 44-year prospective study among a decedent cohort. Age (Dordr). 2012 Jun;34(3):563-70. Epub 2011 May 4.

Ask Dr. Andro: "Does Adding Milk to My Tea Reduce Its Health Benefits or Destroy the Antioxidants? Is There a Difference For Black, Green and White Tea?"

Image 1: Monkey milk tea by Conchibi. No matter how decorative it may look, according to various online sources, the milky monkey decoration is just about to annihilate the beneficial health effects of tea at the very moment it mingles with the antioxidant brew... or is this just another urban myth that is reaffirmed by 'gurus' all over the Internet?

Question from Samir Banga (via Facebook): "Just wanted to ask you about tea and if adding milk or cream for that matter disturbs or destroys the antioxidants/good stuff in the tea. Also would this be the same with black, green and white tea?"

Answer Dr. Andro: This is one of the typical cases where just typing in a question in Google produces either answer A "tea with milk = no problem" or answer B "tea with milk = worthless swill" - it just depends on how you formulate the question - or maybe who on whether the milk industry advertises with Google? Who knows.... A more thorough investigation, on the other hand, turns up a whole host of studies, the results of which are similarly conflictive. So what can we do to find out the truth? Well, we will do our very own little meta review. Sounds pretty sophisticated, doesn't it? Certainly something only Dr. Andro can do. Well, not really... take my virtual hand and I will show you that, oftentimes, you can easily answer your questions yourself, if you mix PubMed, Excel and some of your own gray matter and simmer that for a few hours.

First we will have to find some real data related to the question

To "google" the answer would be a highly unreliable undertaking. Too many self-proclaimed experts (like me) run fancy looking blogs (like the SuppVersity) where they propagate factoids - something you will of course never find on the SuppVersity ;-) Our first task is thus to find real data, a process that obviously requires

1. to know what real data is
2. to know where to find this real data
3. to know how to find this real data
4. to have access to this real data

The latter, I assume could unfortunately pose an insurmountable hurdle for some of you, because even scientists, or rather the editors and publishers of the magazines the scientists publish their articles in, need to pay for their tea and milk and tend to charge horrendous sums for a single article (I have seen individual physics papers for >199$), if you do not  have access to the respective journals from a university or public library. So, in case you cannot follow all my next steps minutely do not fret, the number of freely accessible articles is ever increasing and I promise that you will get the answer to Samir's question and even more for free ;-)

'Pubmeding' is 'googling' for smart people

Image 2: By using search tokens, we
were able to limit the no. of results to
138, a simple search for "milk in tea"
would have produced 503 hits and
good (?) old google would have spit
out roughly 96.500.000 predominant-
ly irrelevant if not corrupted results

First thing we will do is go to the medical database of the US National Library of Medicine (www.pubmed.com) - and though I think that much of the dietary advice coming from the US National Institute of Health does more harm than good, the PubMed database comprises almost all medical papers that were published in any serious journal (not only the prestigious ones) from the realms of medicine, exercise, nutrition and beyond. On the PubMed website, we will  type in the following search term "milk AND (coffee OR tea) AND (antioxidant OR polyphenol OR vitamin OR health)". It goes without saying that this will deliver all articles which deal with milk in relation to coffee or tea and their antioxidant, polyphenol, vitamin and caffeine content, as well as diverse health effects. 

Note: You may have noticed that, out of personal curiosity, I have expanded our complex search term beyond Samir's original question to another often overlooked yet similarly healthy caffeinated beverage, of which the average American drinks 3.1 cups each day - coffee! And since I have heard rumors that milk could also influence the pharmacodynamics, i.e. the absorption and effect, of caffeine, when it is added to caffeinated beverages, I also included the term "caffeine" in our complex request. Notwithstanding the complexity of the latter, the use of multiple key words and tokens for their logical connection limits the number of "hits", i.e. studies that match our criteria to 503 (cf. image 1).

From the initial 503 published articles the database has to offer, those papers which actually have our keywords in their title are obviously most likely to contain the information we are looking for. A mouse-click on the "see more" link below the "titles with your search terms" heading in the right column of the webpage (highlighted in image 2) reduces the results by -99.4% and leaves a manageable amount of three studies for us to 'review':

Illustration 1: The way to a manageable
amount of reliable data for a meta-analysis

1: Ryan L, Petit S. Addition of whole, semiskimmed, and skimmed bovine milk reduces the total antioxidant capacity of black tea. Nutr Res. 2010 Jan;30(1):14-20. PubMed PMID: 20116655.

2: Reddy VC, Vidya Sagar GV, Sreeramulu D, Venu L, Raghunath M. Addition of milk does not alter the antioxidant activity of black tea. Ann Nutr Metab. 2005 May-Jun;49(3):189-95. Epub 2005 Jul 13. PubMed PMID: 16020939.

3: Leenen R, Roodenburg AJ, Tijburg LB, Wiseman SA. A single dose of tea with or without milk increases plasma antioxidant activity in humans. Eur J Clin Nutr. 2000 Jan;54(1):87-92. PubMed PMID: 10694777.

And, lo and behold, all three are actually relevant to the question we want to answer! Heureka! Our initial euphoria begins to fade, however, when we have a closer look at the titles. While the most recent study (Ryan. 2010) claims that the addition of milk reduces the total antioxidant capacity of black tea, Reddy et al. (Reddy. 2005) and Leenen et al. (Leenen. 2000) in their studies, five and ten years before, found no reduction in the antioxidant activity of (black) tea.... well, I guess the question would not have been worth being included in the famous *hem* Ask Dr. Andro column if typing in a few words into a search engine would have delivered the correct answer right away*.
* We will have to postpone the effects on caffeine absorbtion and differences between the effects of milk in coffee vs. tea on another Ask Dr. Andro column, though, because the titles of our search results suggest that there won't be any information on these secondary issues in the respective fulltexts.

Its good not to have to rely
on pubmed for the links to
the fulltexts of papers you
are interested in; learn how
to find the FTs right at the
source, the webpage of the
respective journal

How to find a full text, if pubmed does not link to it? Usually the pubmed guys make it pretty easy for you to find the fulltexts to the studies their database contains. Normally, a single click on a button-like image of the logo of the respective publisher in the upper right corner of the pubmed sub-page with the abstract suffices, yet from time to time, the guy who fed the abstract into the database was to lazy to provide a link... and guess what, in  case of the Leenen study, the button is missing. From the cryptic abbreviation  "Eur J Clin Nutr. 2000 Jan;54(1):87-92" that is given in the line right above the title of the article and in the bibliographical information I provided, you do yet know that the paper has been published in 2000 in the 54th volume, 1st issue of the European Journal of Clinical Nutrition. Now, google will tell you that the "archive of " can be found at http://www.nature.com/ejcn/archive/index.html, and a few clicks later (year 2000 > volume 54 no. 1) you can download the study as PDF document, et voila!

Diging into it: Understanding the research design

Since we already know that the antioxidants in tea are good for us - otherwise we would hardly be worried that the addition of milk could "disturb or destroy" them, as Samir put it - the synopsis of the research, an obligatory part of the introduction to any scientific paper, which, in the case of the Ryan paper, focuses on the health benefits of tea and the tea consumption of the average UK citizen, is not really of interest to us. What is of utmost importance, though, is the research hypothesis, which is usually stated at the end of the introduction. Here, Ryan & Petit state three concrete objectives, which are...

1. To analyze and compare the antioxidant capacity of five brands of commercially available tea
2. To determine the effect of infusion time on the antioxidant capacity 
3. To examine the effect of different volumes of bovine milk (10, 15, and 20 mL) and milk of varying fat content (whole, semiskimmed, and skimmed) on the total antioxidant capacity of the 5 teas

In essence, only objective #3 is relevant in the context of the question at hand; yet, knowing how to vary infusion times to maximize the antioxidant content of our tea, in the first place, would certainly be a nice bonus.

Next, we are going to collect relevant information on the actual experimental procedure

• the tea was bought at a conventional supermarket
• content of the tea bags varied slightly (2.7-3.3g) between the 5 commercial brands
• 200ml of 90° hot water were used for infusion
• 6 infusions for all 6 infusion-times (1, 2, 3, 4, 5 and 10 min); thus 36 individual samples for each brand
• individual analysis of concentration effect of squeezing (10s right after removal) the tea bag after 1, 2, 4 and 8min of brewing; another 24 samples for each brand
• addition of 10, 15 and 20ml whole, skimmed and semi-skimmed milk (after cooling the sample by infusion of the same amount of cool water); another 54 samples for each brand
• technique used to analyze the 570 samples: ferric iron reducing antioxidant power (FRAP) assay

Now, the penultimate of these 7 points should make you wonder, whether this would not distort the results, because adding milk to a previously diluted tea would of course produce reduced antioxidant values compared to an undiluted version without milk. Ryan & Petit were however conscious of this problem and used accordingly diluted samples as their references, which increased the number of samples the scientists had to analyze to 588.

Finding and analyzing the relevant data

While obviously, the major results of this large scale investigation can be found in the text, the tables and figures the authors provide are of even greater value to independent thinkers like us. Using some sort of spreadsheet software we make good use of the 'raw' data on the influence of infusion times on the FRAP concentration of the freshly brewed tea. Instead of relying on the confusingly overcrowded and not very informative figure the authors provide, we create our own figure (figure 1) which comprises the FRAP values of tea 1 (median FRAP) and tea 2 (maximal FRAP) after 1, 2, 3, 4, 5 and 10min brewing with and without a tea bag. In that, we go beyond the simple graph Ryan and Petit had to offer, and bring to light how meaningful the negative effect of the tea bag in terms of the total antioxidant concentration of the brew actually is.

Figure 1: Although authors usually provide you with graphical illustrations of their data, it is often worth-wile to plot your own graphs from the data they provide, to illustrate and understand things the authors may have considered ir-/less relevant and have thus not included in their graphical analysis - in this case this would be the effect of the tea bag, which is missing from figure 1 in the original study by Ryan & Petit (data from Ryan. 2010)

If we now have a look at our fancy graph, we will immediately notice that convenience, as so often, takes it toll:

Just because we are too lazy to tinker with the loose tea leafs we give away somewhere between 50% and 5% of the total antioxidant capacity (depending on the brand and infusion time of the tea).

In that, it is interesting to note that the overall effect appears to be much greater with Tea 1 - as it can be seen in figure 1, the FRAP values of teas 1 and 2 are almost identical, if they are removed from the tea bag before infusion, which suggests that the quality of the teabag is an unexpected, yet important factor, when it comes to brewing an antioxidant rich tea. Altogether, these observations tell us that the use of teabags is generally not advisable, if you do not like the bitter taste long-infused teas tend to develop.

Doing some basic math to be able to estimate effect sizes

As interesting (and surprising) as they may be, the insights on the effects of tea bags on the amount of antioxidants are not really relevant for our personal research question, which relates to the effect of milk on the antioxidant activity of tea. Now, before we even bother with the data analysis, imagine, we did not even have data on the antioxidant activity of the tea + milk mixture. In that case, the only, yet questionable way to decide whether the addition of milk reduces the anti-oxidant value of tea would be to analyze the antioxidant value of milk, which is something Ryan & Petit actually did, and do some basic volume-based calculations.

Ryan & Petit found that fresh whole milk, semi-skimmed and skimmed milk had about 68%, 66% and 60% of the maximal FRAP value of (unbagged) tea and that these values declined by roughly 37.5% and 13.75% after 7 and 14days, respectively. Now, if we add a liquid with a FRAP value of say 5000µmol/L (fresh whole milk) to a brew of tea with a frap value of >8000µmol/L (Tea 1, leafs only) we will obviously reduce the total antioxidant level of the mixture. If we simply assume that the pre-cooled tea (20ml cold water added) has a FRAP value of 8000µmol/L (the exact reduction due to the addition of water would only matter, if the author had not used the 'cooled' specimen as reference, anyway), the addition of another 20ml of whole milk with a FRAP of 5000µmol/L would create a 11:1 mixture of high vs. low FRAP liquids, which would then have a FRAP value of 7.750µmol/L, which would obviously be a -3.125% reduction in the total antioxidant capacity of our tea by the addition of whole milk.

The smart SuppVersity teacher and students that we are, we are without doubt aware that this basic calculation oversimplifies our "problem". Yet, imagine the scientists found that the addition of 20ml of whole milk did in fact reduce the FRAP value by no more than -3.125%. In that case, we would have a reduction, but that reduction would be meaningless in view of our research question, because overall you would even get more antioxidants from your 240ml of tea with added milk and water than from your 220ml of tea without milk.

Figure 2: Relative changes in FRAP values of Tea 1 due to milk addition compared to the addition of the same amount of water (data calculated based on Ryan. 2010)

Again, we use our spreadsheet skills and create a graph that represents the relative changes in FRAP values that occur due to the addition of whole, skimmed and semi-skimmed milk to the tea (figure 2) and have to realize that our calculation underestimated the reduction by >2.6%. Consequently, there must be more to the effect of milk on the ability of tea to modulate ferric iron reduction than just a dilutive effect. And what's more, it must in one way or the other be related to the fatty acid content of the milk, with skimmed milk producing an effect that is 'only' 3x more pronounced than that of its full fat counterpart, although the individual antioxidant capacity of the latter is only about 8% greater.

Understanding the results of the study

If we think about the composition of whole, skimmed and semi-skimmed milk two things which are closely related to the fat content come to mind: First, low fat milk contains more carbohydrates than full fat milk. And, secondly, the low fat variety also has more protein on a liter per liter base than its full fat precursor. On the other hand, previous studies Ryan & Petit mention in their discussion found a profound interaction of tea polyphenols and protein.

Polyphenols can not only bind to proteins, but that the "interaction between flavonoids and proteins affects their antioxidant capacity in vitro".

If you are interested in optics you will also know that skimmed milk derives its bluish tint from the absence of fat globules, so that only the rayleigh-scattered high frequency blue light from the casein proteins hits the retina of your eye. If you combine that knowledge with the findings of Luck et al. (Luck 1994) who found that proline-rich proteins such as casein have a very high binding affinity for polyphenols, the answer to the influence of the macronutrient composition of the different types of milk is apparent: The casein fraction which is particularly high in skimmed milk binds to the beneficial tea polyphenols and thus decreases its antioxidant capacity. Well, I guess this would be our answer, then: Adding milk to your tea is not advisable, because its protein content will bind the beneficial polyphenols. And yes, it would be, if there were not the two other studies our initial PubMed search had brought up, which report no effect of milk on the total antioxidant capacity of black tea?

Is the newer study always right? Not one study is like another.

The easiest way to tackle the conflicting data would be to assume that the 2010 study is likely to be more accurate than the 5 and 10 years older studies by Reddy and Leenen, but would that be scientifically valid? I don't think so. So what do we do? We take a closer look at the methodology of the Reddy and Leenen studies... it won't take us long to find that in contrast to the Ryan & Petit, both Reddy and Leenen analyzed serum samples of subjects after ingestion of the respective tea+water / tea+milk mixtures. This major, yet easily overlooked difference is of great importance, because it does not take a rocket scientist to know that one of the fundamental functions of our digestive tract is to disassemble the food we consume so that the cells in the endothelial lining of our intestines can absorb the nutrients and deliver them to our bloodstream. Analyzing the ferric reducing ability of human plasma after the subjects consumed a tea + water / tea + milk mixture is thus completely different from putting the mixtures themselves to test.

With the influence of digestion, it is quite obvious that both the ingestion time, or rather the status of the digestive tract at that moment the subjects consume the samples, as well as the time at which the blood for the analysis is drawn post ingestion of the teas is of paramount importance. In both the Reddy and the Leenen study, the subjects reported to the laboratory fasted, and the studies also share some problems in regard of the tea preparation.

• Reddy, for example used only 280ml of water for the preparation of the tea to which then 70ml milk would be added. Since there is however a saturation level for the maximal amount of antioxidants a unit volume of water is able to hold, the 'no milk reference sample', which had been boiled in 350ml of water, probably had an (unfortunately unquantifiable) 'antioxidant advantage' over the 'milk sample'. 
• In the Leenen study, on the other hand, the milk was just added to an accordingly reduced amount of tea (60ml milk to 240ml tea vs. 300ml tea), which does also reduce the overall amount of tea polyphenols, the subjects in the tea + milk groups were consuming. 

Both of these minor flaws could explain - to a certain degree - why the subjects exhibited slightly lower increases in serum FRAP (-17% Reddy; -23% Leenen smaller area under the FRAP curve sampled in four and five 30 minute intervals after ingestion of the sample, in Reddy and Leenen, respectively) when they consumed their tea with milk.

So what? Does milk destroy the antioxidant value of tea?

Unfortunately, we cannot be sure that the aforementioned methodological crudities in the studies by Reddy and Leenen can adequately explain the milk-induced reductions in total antioxidant uptake. The -23% reduction in total ferric to ferric ion reduction capacity Leenen et al. measured in their study does yet match the reduced intake of tea polyphenols in the 240ml tea + 60ml milk vs. the 300ml tea group (-20% less polyphenols) pretty well. In view of the fact that Leenen et al. also used 2.5 times more whole milk (20% milk in tea vs. 8% milk in tea) than Ryan & Petit in their in-vitro study, one could do another ignorant calculation in order to estimate how effective our digestive system cleaves the proteins from the polyphenols:

5.73% of the total polyphenol content of 220ml tea are bound by the addition of 20ml whole milk; thus 20ml whole milk can bind the polyphenols from 12.606 ml of tea and 60ml of whole milk should be able to bind the polyphenols from 37.818ml of tea, so that the subjects  in the Leenen study who consumed their tea with milk should be missing an additional 15.7575% of the antioxidants, not just meager 3%, which would ultimately mean that their digestive tract recovered >80% of the protein bound antioxidants from the milky brew. [note - this calculation ignores that the milk would have an antioxidant value by itself, as well]

No matter how "scientific" these funky figures with 4 decimal places may appear - in essence the whole calculation did not only oversimplify the matter to a degree bordering bloggerish pseudoscience. It assumes, for example, a linear binding affinity, i.e. more milk = more binding, which obviously goes against what Ryan and Petit have found (cf. fig. 2). More importantly, though, it was also completely unnecessary in view of the fact that the 'missing' 3% we tried to explain are statistically non-significant, because standard error of the mean AUC (area under the FRAP curve) we based our calculations on is 19.64% and thus more than 6x above the loss we were going to lose our sleep over.

Before we go into even more speculative, or should I say outragous (?) calculations on the influence of the ratio of tea to water on the total amount of antioxidants present in tea after 3 minutes of infusion, in order to do similarly meaningless calculations for the Reddy study, we better bring this highly educative issue of our (almost) weekly Ask Dr. Andro column to a close and summarize our results as follows:

• the protein fraction in milk can bind antioxidant molecules in tea
• the antioxidant value of the tea + milk mix is reduced by up to -18% depending on the type and amount of milk you are using
• skimmed, i.e. low fat, 'high' protein milk reduces binds more antioxidants than whole milk
• the effect of milk on polyphenol binding in tea is non-linear or, in other words, if you double the amount of milk you won't lose twice as much of the antioxidants
• in in-vivo studies, i.e. studies that analyze the sera of living human beings after consumption of tea and tea + milk samples, the increase in serum FRAP (Ferric reducing ability of plasma) has been found slightly reduced by the addition of relatively high amounts (20%) of milk, but...
• this did not compromise the desired positive downstream effects on health markers measured in the Reddy study and
• the lower FRAP values after ingestion of the tea + milk mixtures could be reducible to the individual study design

And last but not least, there are the results of the Reddy study, which suggest that the effect is similar in both green and black tea. The effects discussed in this article are thus very likely occuring for the all forms of "tea" (a brew created from camellia sinensis leavey), regardless of how the leaves were treated before you put them into hot water.

Bottom line: No matter which "color" your tea has, be it green, black or white, if you enjoy drinking your tea with milk, continue doing so, but do not use a tea bag! The magic of drinking tea goes way beyond the mere physiological effects of its ingredients, anyway (eg. Keenan. 1996); and having to force your tea down without milk, because you want to "waste" those additional 3% or whatever percent of antioxidants, would certainly do more harm than good. Well... when, I am thinking about it, it would go well with the fashionable dietary self-chastisement that is so popular among the followers of certain self-proclaimed Internet gurus (suggested read Sean Casey's "The Guru I am Not"), these days... whatever, I guess I better shut up and get some tea (lprepared from loose laves, with whole milk!), before anybody feels offended ;-)

Overweight or Just "Heavy Bones"? Recent Studies Provide Insights Into How Your Bones Affect Your Metabolism

Image 1: The yellow bone marrrow fat
turns out to be more than a filler.

In Germany there is a common saying that is predominantly used by the mothers of fat kids: "My son, overweight? No. He just has some really heavy bones." Well, I guess few of these proud mothers will be aware that recent research from the Boston Medical School (Fulzele. 2011) and the University of Toledo suggests that there may be more to the bone-bodyweight connection than even they may have thought.

In a comprehensive review of the latest findings on bone metabolism (Fulzele. 2011) Keertik Fulzele and Thomas L. Clemens state that the "contemporary model [which] assigns IGFs [insulin like growth factor] as central regulators of cell profileration, survival, and organism growth" and reduces the influence of insulin to the "level of regulation fuel utilization, storage, and energy expenditure" is too simplistic to to accommodate the overlapping roles of IGF and insulin in several physiologic processes, one of which is the recently discovered and previously unappreciated skeletal action of insulin. Via skeletal insulin receptors, the latter is intricately involved in

• osteablast [=bone cells] bone acquisition
• osteocalcin production

Of these, the production of the noncollagenous peptide ostecalcin could be of special interest with respect to the metabolic function of bone, as its undercarboxylated form (carboxylation of osteocalcin occurs in the presence of vitamin K and "activates" the peptide hormone, so that it can fulfill its bone-building function), which has a low affinity for bone matrix, appears to function as a hormone on the systemic level. On the other hand, insulin has lately been found to increase the accumulation of undercarboxylated osteocalcin, which "in turn acts in an endocrine fashion to regulate pancreatic insulin secretion and peripheral insulin responsiveness". It is this hitherto unknown mechanism by which your bones factor in the complex hormonal game that is your metabolism and by which skeletal energy-sensing pathways may manage fuel production, storage, and expenditure in a similar vein as their analogues in muscle and fat tissue.

Figure 1: Metabolic and endocrine functions of white (WAT) and brown (BAT) adipocytes in your bone marrow
(based on Czernik. 2011)

As the scientists point out, we are just beginning to understand the sophisticated role our bones play in the orchestration of our metabolism. Questions that still have to be answered relate to the ways, osteablasts "sense" glucose and other fuels, whether they simply burn amino acids and glucose as fuel and whether and to which extent medications that influence bone resorption could also be used for blood sugar management.

Answers to these questions will expand our understanding of the biology of the skeleton and should have implications in the diagnosis and management of patients with metabolic diseases, including osteoporosis and diabetes.

More information on the underlying mechanisms by which your bones directly influence your metabolic rate, and thus your weight, can be found in a Special Issue of the Journal 'Bone', entitled "Bone and Fat". In her paper (Czernik. 2011), Beata Lecka-Czernik elaborates on the possible influence the yellow bone fat, which - believe it or not - occupies a significant portion of your bone marrow cavity, could have on your metabolism, both locally, as well as systemically.

Did you know? The fat distribution in your skeleton is site, age, and gender specific (men have more bone fat than women). In adults the bone marrow cavity of long bone, for example, is entirely filled with fat, while the ileac crest marrow contains only ~40% fat. The overall amount of bone fat can double in the course of your life and the WAT- and BAT-like adipocytes appear to have similar metabolic and endocrine functions as their white (WAT) and brown (BAT) analogues on your hips, your belly and your neck.

In this context, the integrative models of Ferron et al and Fulzele et al. are of particular interest, as they could help elucidate the link between the anabolic effects of insulin signaling in osteoblasts and the regulation of insulin sensitivity in peripheral organs. And who knows, even if its not the "heavy bones" that contribute to the obesity pandemic,"fat bones" could well become a novel target in its prevention and treatment.