Disclosures Current Recommendations for Research support from Tate & Lyle and Calcium and Vitamin D Bariatric Advantage (supplements donated for research studies) Anne Schafer, MD Associate Professor, UCSF Division of Endocrinology & Metabolism Staff Physician, San Francisco VA Medical Center July 13, 2018 Nonpharmacologic strategies to Outline optimize bone health • Quick review of calcium homeostasis • Calcium intake • Calcium • Vitamin D ▫ Recommended intakes • Other nutritional strategies ▫ Food and supplement specifics • Smoking cessation ▫ Controversies • Alcohol moderation • Vitamin D • Weight-bearing & resistance exercise ▫ Recommended intakes • Fall prevention measures ▫ Food and supplement specifics ▫ Controversies 1
Calcium homeostasis Calcium homeostasis Net 175 mg/day All orchestrated Net 175 mg/day by parathyroid hormone (PTH) Calcium: Evidence • Beneficial effect of calcium or calcium + vitamin D on BMD in postmenopausal women and older men 25 OH D = • Fracture data more variable metabolite to ▫ RCTs with key differences in study measure population, baseline intake, dietary intake ▫ Benefit among older adults in nursing home: 1200 mg Ca + 800 IU vit D decreased fracture by 33% 1 Chapuy, NEJM 1992 Holick, Curr Opin Endocrinol Diabetes 2002 2
Calcium: IOM Recommended Intakes Calcium: IOM Recommended Intakes AGE (yrs) Calcium RDA (mg) Calcium UL (mg) AGE (yrs) Calcium RDA (mg) 1-3 700 2500 19-30 1000 4-8 1000 2500 9-13 1300 3000 31-50 1000 14-18 1300 3000 1000 (men) 19-30 1000 2500 51-70 1200 (women) 31-50 1000 2000 >70 1200 1000 (men) 51-70 2000 1200 (women) >70 1200 2000 Institute of Medicine, 2010 Institute of Medicine, 2010 Food sources of calcium Food sources of calcium • Read labels carefully Milk (8 oz) 300 mg ▫ Look at serving size Cheese (1 oz) 250 mg ▫ % is based on 1000 mg intake Yogurt (1 cup) 300 mg Cooked greens (1 cup) 100 mg Dairy-free diet 300 mg Calcium-set tofu (1/2 cup) 400 mg Fortified foods Variable 200 mg calcium 3
Calcium supplements Calcium supplements • Types of calcium supplements ▫ Calcium carbonate ▫ Calcium citrate ▫ Others • Add up diet + supplements • Read labels carefully ▫ Look for milligrams of elemental calcium ▫ % is based on 1000 mg intake 30% = 300mg Potential risks of calcium intake or Calcium: Special populations supplements? • Malabsorption: may need higher intakes ▫ Bariatric surgery: 1200-1500 IU daily after RYGB or sleeve gastrectomy, more for BPD/DS Follow PTH level, 24-hour urinary Ca and adjust accordingly ▫ Celiac disease, short-gut syndrome Mechanick, SOARD 2013 4
Potential risks of calcium supplements Cardiovascular risk? • Nephrolithiasis • WHI RCT: No effect of Ca + vit D on CVD in 36,282 postmenopausal women, ▫ WHI RCT: Increased risk among compared to placebo 1 postmenopausal women taking Ca+D supplement compared to placebo 1 • Two meta-analyses: CVD risk 2,3 ▫ Meta-analysis 1: Ca w/out vit D 2 • Cardiovascular events? ▫ Meta-analysis 2: Only included WHI ▫ Controversy participants not on Ca supplements at BL 3 ▫ Dietary Ca intake ranged 750-1240 mg/d, so total Ca intake was >1500 to 2000 in many participants 1 Jackson, NEJM 2006; 1 Jackson, NEJM 2006; 2 Bolland, BMJ 2010; 3 Bolland, BMJ 2011 Cardiovascular risk? • Three other meta-analyses: no effect 1,2,3 • Prospective observational studies: mixed findings for calcium supplements • Prospective observational studies: Two meta-analyses: No effect 4,5 or protective effect 6,7 for dietary calcium 1 Wang, Ann Int Med 2010; 2Chung, Ann Int Med 2016; 3Lewis, JBMR 2015; 4 Xiao, JAMA Int Med 2013; 5 Van Hemelrijck, PLoS One 2015; 6 Li, Heart 2012; 7 Khan, JBMR 2015 Naghavi, Circulation 2003 5
Calcium: IOM Recommended Intakes Conclusions: Calcium • Calcium plays a key role in bone health AGE (yrs) Calcium RDA (mg) Calcium UL (mg) • Recommended intakes vary by age, sex 1-3 700 2500 • Calcium is a threshold nutrient 4-8 1000 2500 9-13 1300 3000 ▫ No benefit to exceeding recommendation 14-18 1300 3000 • Encourage calcium from food sources 19-30 1000 2500 ▫ Supplements when necessary to attain 31-50 1000 2000 recommended total intake levels 1000 (men) 51-70 2000 1200 (women) >70 1200 2000 Institute of Medicine, 2010 Vitamin D: Evidence for bone health 25-hydroxyvitamin D levels • Beneficial effect of calcium + vitamin D “Deficiency” on BMD in postmenopausal women and “Insufficiency” older men “Normal” • Fracture data more variable ▫ Benefit among older adults in nursing home: 1200 mg Ca + 800 IU vit D decreased fracture by 33% 1 ▫ RCTs with key differences in study 0 10 20 30 40 50 60 ng/mL population, baseline 25OHD levels, IOM – adequate for population achieved 25OHD levels ≥ 30 ng/ml may be considered by some “ expert opinion” Chapuy, NEJM 1992 6
Vitamin D: IOM Recommended Intakes AGE (yrs) Vit D RDA (IU) Vit D UL (IU) 1-3 600 2500 4-8 600 3000 25 OH D = metabolite to 9-13 600 4000 measure 14-18 600 4000 19-30 600 4000 31-50 600 4000 51-70 600 4000 >70 800 4000 Institute of Medicine, 2010 Holick, Curr Opin Endocrinol Diabetes 2002 Vitamin D: IOM Recommended Intakes Vitamin D: IOM Recommended Intakes AGE (yrs) Vit D RDA (IU) Vit D UL (IU) AGE (yrs) Vit D RDA (IU) 1-3 600 2500 19-30 600 4-8 600 3000 9-13 600 4000 31-50 600 14-18 600 4000 19-30 600 4000 51-70 600 31-50 600 4000 >70 800 51-70 600 4000 >70 800 4000 Institute of Medicine, 2010 Institute of Medicine, 2010 7
Vitamin D: Special populations Sources of vitamin D • Malabsorption, obesity: may need Sunshine higher doses Milk (1 glass) 100 IU ▫ Bariatric surgery: 3000 IU daily, then adjust to achieve 25OHD ≥30 ng/mL Egg 26 IU ▫ Some require as much as 50,000 IU Tuna in fish oil (1/2 cup) 170 IU daily Sardine 33 IU Fortified foods Variable Mechanick, SOARD 2013 Vitamin D supplements Vitamin D: Evidence for non-skeletal • D3 (cholecalciferol) benefit? ▫ Most common in daily supplements ▫ Harder to get in high doses for repletion ▫ More efficient at raising 25OHD level • D2 (ergocalciferol) ▫ Most common for high-dose repletion 8
Vitamin D: Evidence for non-skeletal Vitamin D: Non-skeletal benefit? benefit? • Muscle expresses vitamin D receptors • Muscle mass and strength reduced in osteoporotic patients • Vitamin D deficiency thought to contribute to proximal myopathy and to fall risk Myopathy is reversible/improved with vitamin D and calcium supplements Holick, Mayo Clin Proc 2006 Vitamin D: Evidence for non-skeletal benefit? RCTs in progress Thank you! 9
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