1Division of Girls’s Well being – Inner Drugs, Mayo Clinic in Arizona, Phoenix, Arizona.
2Division of Consultative Drugs, Mayo Clinic in Arizona, Phoenix, Arizona.
1Division of Girls’s Well being – Inner Drugs, Mayo Clinic in Arizona, Phoenix, Arizona.
Case Report
A 60-year-old Caucasian feminine with a historical past of hypertension, anxiousness, melancholy, and osteopenia presents for her periodic well being examination. Present drugs embody metoprolol, venlafaxine, and a multivitamin (incorporates 220 mg calcium). She takes calcium citrate with vitamin D (2 tablets=500 mg elemental calcium and 800 IU vitamin D), 6 tablets day by day. Her complete day by day dose of elemental calcium is 1500 mg. She has no private or household historical past of earlier fracture. She doesn’t smoke tobacco or use alcohol. Her weight loss program consists of about 1 serving of yogurt or cheese day by day. Her dual-energy x-ray absorptiometry (DEXA) carried out 2 years in the past confirmed a lumbar backbone T-score of −2.3 and proper femoral neck T-score of −2.4. Bodily examination reveals a physique mass index (BMI) of 28.7 and is in any other case regular. A latest 25-OH vitamin D degree was 32 ng/mL. Her FRAX rating calculation estimates her 10-year dangers at 14% for main osteoporotic fracture and 1.6% for hip fracture. The perfect advice for calcium consumption relating to prevention of osteoporotic fracture is:
Dialogue
Vitamin D and calcium supplementation have lengthy been thought of essential within the prevention of osteoporosis and osteoporotic fractures. In 2011, the Institute of Drugs (IOM) concluded that calcium homeostasis, through which vitamin D has a key function, is important for bone well being. For ladies over 50, the IOM’s really helpful day by day allowance (RDA) for calcium is 1200 mg. The IOM additionally recommends day by day vitamin D 600 IU for grownup ladies lower than 70 years previous and 800 IU for these older.1
In 2013, nonetheless, america Preventive Companies Activity Drive (USPSTF) modified their suggestions relating to calcium and vitamin D dietary supplements for bone well being. The USPSTF now states that supplementation with 400 IU or much less of vitamin D and 1000 mg or much less of calcium has no impact on stopping fractures in postmenopausal, group dwelling ladies with out prior analysis of osteoporosis.2 The group additional finds the advantages and harms of upper doses of those dietary supplements as unsure. In response, some consultants have gone as far as to say, “do not supplement” wholesome, postmenopausal ladies.3
The efficacy of calcium dietary supplements for fracture prevention is way from clear. Latest critiques of the literature have demonstrated that calcium improves bone density however doesn’t present safety from fractures.4,5,6 One assessment did discover small enhancements in fracture threat, however solely with subgroup analyses.7 A big meta-analysis in 2007 demonstrated a lowered charge of bone loss and a 12% discount in fractures, in adults 50 and over who had been taking calcium supplementation.8 Nonetheless one other meta-analysis confirmed no relationship between calcium supplementation on bone density or fracture threat.9
Calcium’s function in osteoporosis is difficult by its affiliation with vitamin D. Calcium dietary supplements are generally paired with vitamin D and research typically assess the efficacy of the 2 collectively. Vitamin D has been controversial, however a latest meta-analysis has proven discount in each hip fracture and nonvertebral fracture in folks ingesting 700–2000 IU day by day.10 The vitamin D requirement amongst particular person sufferers could be variable, particularly in these at elevated threat for osteoporotic fracture. This affected person has an ample serum 25-OH vitamin D degree >30 ng/mL. The present vitamin D complement dosing is properly beneath the protected higher restrict of 4000 IU/day11 and must be continued.
The difficulty of calcium supplementation requires cautious consideration as almost two-thirds of American ladies over 50 take calcium in complement kind.12 Calcium supplementation has historically been inspired, as solely 30% of the U.S. inhabitants ingests ample calcium of their weight loss program.13 The difficulty is additional difficult by the 39% of ladies who’re exceeding the RDA when mixed dietary and supplemental calcium are thought of.12
Whether or not calcium dietary supplements are completely protected is one other consideration. Excessive doses have been related to nephrolithiasis.2,14 Much less clear, and extra probably dangerous, is the connection between calcium dietary supplements and cardiovascular occasions. The 2010 meta-analysis by Bolland et al. demonstrated a 30% improve in myocardial infarction (MI) amongst these assigned to taking calcium dietary supplements. Additional, the quantity of calcium consumption mattered. An elevated threat of MI was solely seen in folks with dietary intakes of calcium above the median of 805 mg per day.15 Evaluation of the Girls’s Well being Initiative Calcium and Vitamin D Examine (WHI CaD) knowledge has been inconsistent. A latest reanalysis did present a modest improve in threat of myocardial infarction amongst ladies assigned to calcium supplementation.16 Preliminary evaluation of the identical knowledge had not proven a rise in MI or cardiovascular loss of life.17 One other evaluation confirmed no distinction in total mortality.18
Dietary consumption of calcium might be not cardiotoxic. Dietary calcium with out further supplementation was related to a protecting impact from ischemic coronary heart illness a long time in the past.15,19 A newer, massive, potential European research demonstrated safety from MI in greater dietary calcium consumption, however a considerably elevated threat of MI (hazard threat [HR]=1.86) in sufferers taking calcium dietary supplements.20 Moreover, calcium complement customers with excessive dietary calcium consumption (1400 mg/day) greater than doubled their threat of mortality (HR=2.57) in a Swedish cohort.21 Within the massive AARP research, calcium complement use was related to elevated cardiovascular loss of life in males however not in ladies. Dietary calcium consumption didn’t have an effect on loss of life charge.22
Whereas this proof is way from definitive, it does recommend the significance of cautious quantification of dietary and supplemental calcium use amongst ladies with desire for dietary calcium consumption.
Reply:The Right Reply Is E
This affected person is taking extreme calcium between her weight loss program and complement, totaling 1720 mg day by day, or 168% of the RDA. She mustn’t proceed this present consumption.
Calcium from meals sources has not been linked to morbidity, so limiting dietary consumption wouldn’t be suggested. With the intention to assist sufferers estimate their common day by day dietary consumption, take into account {that a} single serving of yogurt incorporates about 350 mg of elemental calcium and a serving of cheese has about 250 mg.
Rising her consumption to 2 servings of yogurt or cheese day by day with out addressing her present calcium supplementation would additional improve her extreme consumption. Equally, a advice to easily discontinuing her dietary supplements could be insufficient.
With the intention to keep away from the potential toxicity of excessive dose calcium dietary supplements, reply E is right. The advice must be to lower her complete day by day consumption to 1000–1200 mg, optimally from dietary sources.
Disclosure Assertion
No competing monetary pursuits exist.
References – “calcium 1500mg”
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