Calcium and Vitamin D Supplementation: Who Needs It?

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1 Detail-Document # This Detail-Document accompanies the related article published in PHARMACIST S LETTER / PRESCRIBER S LETTER January 2011 ~ Volume 27 ~ Number Calcium and Vitamin D Supplementation: Who Needs It? Background Calcium is important for bone health. Low calcium intake is also associated with colon cancer, kidney stones, obesity, and hypertension. 1 Recommendations for calcium intake vary depending on age, gender, and guidelinepromulgating organization. In general, 1000 mg to 1500 mg are recommended daily. However, in North America, the median daily calcium intake is only 600 mg in postmenopausal women. Supplements are recommended to make up the difference. 1 However, some health experts, including wellness expert Dr. Andrew Weil, advise taking care not to get too much. 2 In addition, the Institute of Medicine recently called for a reduction in calcium intake and an increase in vitamin D intake compared to their previous recommendations. Health Canada has adopted these recommendations. This article discusses these recommendations and provides information to help healthcare professionals help their patients get adequate and safe amounts of calcium and vitamin D, with a focus on calcium. How Much Calcium is Enough? A recent meta-analysis examined 15 studies of supplementation with at least 400 mg elemental calcium daily in postmenopausal women. Study participants received no more than 400 IU vitamin D daily. Calcium dose and formulation varied. Over 1800 patients, almost half of whom received supplementation, were included. Calcium slightly increased bone density, and there was a nonsignificant trend toward decreased fracture risk. 3,4 A subsequent study using vitamin D 400 IU and 1000 mg elemental calcium daily showed vitamin D) and Porthouse studies showed no benefit of vitamin D 800 IU and calcium 1000 mg. 9 This may have been due to poor compliance, and/or the high-risk populations studied (i.e., too little, too late). The importance of vitamin D intake on fracture risk is highlighted by findings from a review of data from the Nurses Health Study cohort. 10 Adequate vitamin D intake, but not calcium intake or milk consumption, was associated with decreased hip fracture risk. Furthermore, a crosssectional study suggests that if vitamin D intake is sufficient, 800 mg of calcium daily may be sufficient in healthy adults. 11 Several studies suggest that calcium intake of about 1200 mg daily may decrease the risk of colon cancer, hypertension, and kidney stones. 1 Calcium requirements increase with age due to decreased absorption. 1 In women, decreases in estrogen production are associated with bone resorption and increased calcium excretion. How Much Calcium is Too Much? Calcium intake of >2500 mg daily may increase the risk of hypercalcemia and resulting renal impairment. 1 Kidney stones are associated with calcium intake >2150 mg daily in postmenopausal women. 1 Excess calcium can impair absorption of iron, zinc, magnesium, and phosphorus. 24,33 Some cohort studies have found an association between higher calcium intake (perhaps as little as >600 mg daily) and prostate cancer. 12,13 Because dairy products are a major source of calcium, the contribution of some other dairy component cannot be ruled out. 13 However, involvement of calcium is plausible. High calcium levels decreased fracture risk. 5 These patients were suppress vitamin D synthesis, and vitamin D may likely vitamin D deficient due to the northern protect against prostate cancer by inhibiting its latitude in which they lived. growth and metastasis. Several studies using >400 IU vitamin D and There seems to be a link between higher calcium 500 mg or 1200 mg daily have also intakes of calcium and cardiovascular risk. shown benefit on fracture risk. 6,7,8 However, the Taking calcium with vitamin D may mitigate this RECORD (Randomized Evaluation of Calcium or risk. 16

2 (Detail-Document #270102: Page 2 of 5) Dietary Calcium Sources Several foods can provide 300 mg or more of calcium per one cup serving. These include milk (290 mg to 315 mg) and low-fat yogurt (340 mg to 450 mg). For people who wish to avoid dairy products, choices include collard greens (300 mg to 350 mg) and calcium-fortified foods (e.g., soy milk [80 mg to 300 mg], cereal [up to 1000 mg], or fruit juice [225 mg to 300 mg]). Breakfast bars often contain 200 mg to 500 mg. Cheese, canned salmon or sardines with bones, beans, broccoli, cabbage, turnip greens, bok choy, figs, tofu, and almonds are other significant sources. 1 Calcium Supplements The amount of elemental calcium supplied by supplements varies depending on the salt form. Calcium carbonate is 40% elemental calcium. Calcium carbonate is also found in oyster shell calcium and bone meal. There is also concern that some coral calcium products contain excess lead. Dolomite supplements may also contain unsafe amounts of lead and other heavy metals. The lead content of oyster shell and refined calcium products is considered to be a clinically insignificant amount. Calcium carbonate is relatively insoluble, and absorption may be impaired in patients with high gastric ph. This includes patients taking acid-suppressing drugs (e.g., proton pump inhibitors) and the elderly. 14 Calcium citrate is only 21% elemental calcium, but compared to calcium carbonate, its calcium is better absorbed. It may be preferred in patients with high gastric ph. 14 Generally, calcium absorption is enhanced with food. However, certain foods (e.g., spinach, rhubarb, nuts, beans, seeds, grains) or high fat or high fiber meals may decrease absorption. Absorption is best if no more than 500 mg is taken at a time. 14 Vitamin D Adequate vitamin D is necessary for calcium utilization. 1 There is debate about what amount is adequate. Recommendations for vitamin D intake are generally based on correlations between vitamin D levels and biochemical markers of bone disease. 11,26 Calcium intake is a confounding factor. 11 Some experts think vitamin D may be more important than calcium for bone health. 2 However, vitamin D only reduces the risk of hip fracture when calcium supplements are added. 15 Vitamin D deficiency is associated with an increased risk of breast, colon, prostate, pancreatic, and ovarian cancer. Higher vitamin D serum levels seem to be associated with a reduced risk of cancer and cancer mortality in men. And people with higher intakes of vitamin D seem to have a lower risk for pancreatic cancer. Researchers think vitamin D might have antiproliferative effects in these cancers. 22 Vitamin D requirements increase with age. This is due to decreased synthesis in the skin, and decreased renal conversion of vitamin D to its active form. With age, the intestine becomes less responsive to its effects, hindering calcium absorption. 1 Vitamin D 800 IU daily can be recommended for most adults. 1,29,30,34 Doses around 800 IU daily seem necessary for fracture prevention in the elderly. 27 Most experts advocate 1000 to 2000 IU daily. 1,2,17,23,31 The Institute of Medicine recommends 800 IU daily for people over age 70, and 600 IU daily for younger adults and children over one year of age [Evidence level C; Consensus]. 26 They chose these amounts based on data on bone health outcomes. For deficiency 50,000 IU weekly for several weeks (until stores are replenished) has been recommended. See our Detail-Document, Vitamin D Dosing: an Update for details. Many vitamin D supplements contain vitamin D2 (ergocalciferol), but vitamin D3 (cholecalciferol) is better at raising and maintaining vitamin D levels. 1,18 Fracture prevention studies used vitamin D3. 27 The Osteoporosis Society of Canada recommends D3. 25,28,30 Patients with advanced renal disease have impaired conversion of vitamin D3 to its active form, calcitriol. These patients typically require supplementation with calcitriol (e.g., Rocaltrol) 0.25 mcg daily or more. 19 Commentary The amount of calcium intake considered adequate is not definitively known. Vitamin D intake, which is important in calcium homeostasis, is a confounding factor. 10 Furthermore, increases in bone density seen with calcium supplementation may level off after one or two years as bone becomes saturated. 2,10 Perhaps

3 calcium needs decrease thereafter, at least in regard to bone health. The IOM considers 2000 mg a tolerable upper limit for calcium intake. 26 So advise patients to assess their dietary intake before supplementing with calcium. 24,33 People typically get 300 mg per day of calcium from their diet, not including dairy products. 2,33 If they include two servings of highcalcium foods (e.g., dairy), they can get a total of at least 900 mg per day. Supplementation with just 300 mg of elemental calcium daily, or the addition of a third high-calcium serving, will then provide 1200 mg per day. Because of the potential risks of too much calcium (e.g., prostate cancer), Dr. Weil advises no supplementation for men who consume calcium-rich foods. 2 The Institute of Medicine and Health Canada recommend 1000 mg of calcium per day for men up to age 70 and women up to age 50, and 1200 mg per day for women over 50 and men over 70. Kids ages nine to 18 years should get 1300 mg per day [Evidence level C; consensus]. 26,32 Canadian osteoporosis guidelines recommend 1000 mg per day for men up to age 50 and premenopausal women, then 1500 mg per day for men over 50 and postmenopausal women. 25,28 Food is the preferred calcium source because high-calcium foods contain other important nutrients [Evidence level C; consensus]. 1 If a supplement is needed, help patients choose a formulation and dose appropriate for their needs. For more information on calcium supplements, see our document, Comparison of Oral Calcium Salts. Advise taking supplements with a meal to enhance absorption and compliance [Evidence level C; consensus]. 1 Vitamin D is necessary for calcium absorption. The Institute of Medicine and Health Canada recommend 800 IU daily for people over age 70, and 600 IU daily for younger adults and children over one year of age [Evidence level C; consensus]. 20,26 Canadian osteoporosis guidelines recommend 400 to 1000 IU per day for people under age 50 without osteoporosis or conditions interfering with vitamin D absorption or action, and at least 800 to 1000 IU per day for people over Also recommend at least 800 IU per day for women with little sun exposure [Evidence (Detail-Document #270102: Page 3 of 5) contain vitamin D naturally. 1 In fact, Canada s Food Guide now recommends men and women over age 50 take a 400 IU vitamin D supplement daily. 20 Some experts advocate use of supplements containing vitamin D3 (cholecalciferol) over D2. 18,25,28,30 But either form can be used. Consider testing for 25-hydroxy vitamin D to identify patients who are vitamin D deficient. Risk factors include advanced age, being shut-in, wearing sunscreen, malabsorption, obesity, dark skin, liver disease, and renal insufficiency. 1 Users of this document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and Internet links in this article were current as of the date of publication. Project Leader in preparation of this Detail- Document: Melanie Cupp, Pharm.D., BCPS (Original 2007 and January 2011 update) Levels of Evidence In accordance with the trend towards Evidence-Based Medicine, we are citing the LEVEL OF EVIDENCE for the statements we publish. Level Definition A High-quality randomized controlled trial (RCT) High-quality meta-analysis (quantitative systematic review) B Nonrandomized clinical trial Nonquantitative systematic review Lower quality RCT Clinical cohort study Case-control study Historical control Epidemiologic study C Consensus Expert opinion D Anecdotal evidence In vitro or animal study Adapted from Siwek J, et al. How to write an evidence-based clinical review article. Am Fam Physician 2002;65: References 1. North American Menopause Society. The role of calcium in peri- and postmenopausal women: 2006 position statement of The North American Menopause Society. Menopause 2006;13: level C; consensus]. 1 The American Academy of Dermatology recommends avoiding sunlight and getting vitamin D from food or supplements Dr. Andrew Weil s self healing. New: my latest calcium recommendations. Supplements may be necessary because few foods

4 (Detail-Document #270102: Page 4 of 5) (Accessed February 6, 2007). (Article no longer available online as of January 2011 update.) 3. Shea B, Wells G, Cranney A, et al. Meta-analyses of therapies for postmenopausal osteoporosis. VII. Meta-analysis of calcium supplementation for the prevention of postmenopausal osteoporosis. Endocr Rev 2002;23: Shea B, Wells G, Cranney A, et al. Calcium supplementation on bone loss in postmenopausal women. Cochrane Database Syst Rev 2004;(1):CD Larsen ER, Moseklide L, Foldspang A. Vitamin D and calcium supplementation prevents osteoporotic fractures in elderly community dwelling residents: a pragmatic population-based 3-year intervention study. J Bone Miner Res 2004;19: Chapuy MC, Arlot ME, Duboeuf F, et al. Vitamin D3 and calcium to prevent hip fractures in the elderly women. N Engl J Med 1992;327: Chapuy MC, Pamphile R, Paris E, et al. Combined calcium and vitamin D3 supplementation in the elderly women: confirmation of reversal of secondary hyperparathyroidism and hip fracture risk: the Decalyos II study. Osteoporos Int 2002;13: Dawson-Hughes B, Harris SS, Krall EA, Dallal GE. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years or age or older. N Engl J Med 1997;337: Calcium and vitamin D for reducing fracture risk. Pharmacist s Letter/Prescriber s Letter 2005;21(6): Feskanich D, Willett WC, Colditz GA. Calcium, vitamin D, milk consumption and hip fractures: a prospective study among postmenopausal women. Am J Clin Nutr 2003;77: Steingrimsdottir L, Gunnarsson O, Indridason OS, et al. Relationship between serum parathyroid hormone levels, vitamin D sufficiency, and calcium intake. JAMA 2005;294: Chan JM, Stampfer MJ, Ma J, et al. Dairy products, calcium, and prostate cancer risk in the Physicians Health Study. Am J Clin Nutr 2001;74: Giovannucci E, Liu Y, Stampfer MJ, Willett WC. A prospective study of calcium intake and incident and fatal prostate cancer. Cancer Epidemiol Biomarkers Prev 2006;15: Comparison of oral calcium salts. Pharmacist s Letter/Prescriber s Letter 2008;24(10): Avenell A, Gillespie WJ, Gillespie LD, O Connell DL. Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis. Cochrane Database Syst Rev 2005;(3):CD Lacroix AZ, Kotchen J, Anderson G, et al. Calcium plus vitamin D supplementation and mortality in postmenopausal women: the Women's Health Initiative calcium-vitamin D randomized controlled trial. J Gerontol A Biol Sci Med Sci 2009;64: Chapman IM. Nutritional disorders in the elderly. Med Clin North Am 2006;90: Houghton LA, Vieth R. The case against ergocalciferol (vitamin D2) as a vitamin supplement. Am J Clin Nutr 2006;84: Pai AB, Conner TA. Chronic kidney disease. In: Koda-Kimble MA, Young LY, Alldredge BK, Corelli RL, eds. Applied Therapeutics: the clinical use of drugs. 9 th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2009: Health Canada. Vitamin D and calcium: updated dietary reference intakes. December 13, (Accessed December 20, 2010). 21. American Academy of Dermatology. Be sun smart (Accessed December 21, 2010). 22. Rumor vs truth. Vitamin D helps prevent some cancers. Pharmacist s Letter/Prescriber s Letter October 27, Canadian Cancer Society. Canadian Cancer Society announces vitamin D recommendation. June 8, centre/OD- Media%20releases/Canadian%20Cancer%20Socie ty%20announces%20vitamin%20d%20recommen dation.aspx?sc_lang=en. (Accessed December 21, 2010). 24. NIH Office of Dietary Supplements. Dietary supplement fact sheet: calcium. January 19, HealthProfessional/. (Accessed February 1, 2011). 25. Brown JP, Josse RG, Scientific Advisory Council of the Osteoporosis Society of Canada Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 2002;167(Suppl 10):S IOM (Institute of Medicine). Dietary reference intakes for calcium and vitamin D. Washington, DC: The National Academies Press; Bischoff-Ferrari HA, Willett WC, Wong JB, et al. Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA 2005;293: Brown JP, Fortier M, Frame H, et al. Canadian consensus conference on osteoporosis, 2006 update. J Obstet Gynaecol Can 2006;28(2 Suppl 1):S95-S National Osteoporosis Foundation. About osteoporosis. Vitamin D and bone health amind. (Accessed December 3, 2010). 30. Hanley DA, Cranney A, Jones G, et al. Vitamin D in adult health and disease: a review and guideline statement from Osteoporosis Canada (summary). CMAJ 2010;182: Dr. Holick's responses to participant questions during the December 5, 2008 live webinar presentation Vitamin D & chronic disease risk. (Accessed December 2, 2010).

5 (Detail-Document #270102: Page 5 of 5) 32. Health Canada. Food and nutrition. Dietary reference intakes. Reference values for elements. August 4, (December 3, 2010). 33. Jellin JM, Gregory PJ, et al. Calcium monograph. Natural Medicines Comprehensive Database (consumer version). (Accessed December 21, 2010). 34. North American Menopause Society. Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause 2010;17: Cite this Detail-Document as follows: Calcium and vitamin D supplementation: who needs it? Pharmacist s Letter/Prescriber s Letter 2011;27(1): Evidence and Advice You Can Trust 3120 West March Lane, P.O. Box 8190, Stockton, CA ~ TEL (209) ~ FAX (209) Subscribers to Pharmacist s Letter and Prescriber s Letter can get Detail-Documents, like this one, on any topic covered in any issue by going to or

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