Current Recommendations for Research support from Tate & Lyle - - PowerPoint PPT Presentation

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Current Recommendations for Calcium and Vitamin D

Anne Schafer, MD

Associate Professor, UCSF Division of Endocrinology & Metabolism Staff Physician, San Francisco VA Medical Center July 13, 2018

Research support from Tate & Lyle and Bariatric Advantage (supplements donated for research studies)

Disclosures Nonpharmacologic strategies to

• ptimize bone health
• Calcium
• Vitamin D
• Other nutritional strategies
• Smoking cessation
• Alcohol moderation
• Weight-bearing & resistance exercise
• Fall prevention measures

Outline

• Quick review of calcium homeostasis
• Calcium intake

▫ Recommended intakes ▫ Food and supplement specifics ▫ Controversies

• Vitamin D

▫ Recommended intakes ▫ Food and supplement specifics ▫ Controversies

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Calcium homeostasis

Net 175 mg/day Net 175 mg/day

Calcium homeostasis

All orchestrated by parathyroid hormone (PTH)

25 OH D = metabolite to measure

Holick, Curr Opin Endocrinol Diabetes 2002

• Beneficial effect of calcium or calcium +

vitamin D on BMD in postmenopausal women and older men

• Fracture data more variable

▫ RCTs with key differences in study population, baseline intake, dietary intake ▫ Benefit among older adults in nursing home: 1200 mg Ca + 800 IU vit D decreased fracture by 33%1

Calcium: Evidence

Chapuy, NEJM 1992

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Calcium: IOM Recommended Intakes

AGE (yrs) Calcium RDA (mg) Calcium UL (mg) 1-3 700 2500 4-8 1000 2500 9-13 1300 3000 14-18 1300 3000 19-30 1000 2500 31-50 1000 2000 51-70 1000 (men) 1200 (women) 2000 >70 1200 2000

Institute of Medicine, 2010

Calcium: IOM Recommended Intakes

AGE (yrs) Calcium RDA (mg) 19-30 1000 31-50 1000 51-70 1000 (men) 1200 (women) >70 1200

Institute of Medicine, 2010

Food sources of calcium

Milk (8 oz) 300 mg Cheese (1 oz) 250 mg 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

Food sources of calcium

• Read labels carefully

▫ Look at serving size ▫ % is based on 1000 mg intake

200 mg calcium

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• 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

Calcium supplements Calcium supplements Calcium: Special populations

Mechanick, SOARD 2013

• 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

Potential risks of calcium intake or supplements?

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• Nephrolithiasis

▫ WHI RCT: Increased risk among postmenopausal women taking Ca+D supplement compared to placebo1

• Cardiovascular events?

▫ Controversy

Potential risks of calcium supplements

1Jackson, NEJM 2006;

• WHI RCT: No effect of Ca + vit D on CVD

in 36,282 postmenopausal women, compared to placebo1

• Two meta-analyses: CVD risk2,3

▫ Meta-analysis 1: Ca w/out vit D2 ▫ Meta-analysis 2: Only included WHI participants not on Ca supplements at BL3 ▫ Dietary Ca intake ranged 750-1240 mg/d, so total Ca intake was >1500 to 2000 in many participants

Cardiovascular risk?

1Jackson, NEJM 2006; 2Bolland, BMJ 2010; 3Bolland, BMJ 2011

Naghavi, Circulation 2003

• Three other meta-analyses: no effect1,2,3
• Prospective observational studies: mixed

findings for calcium supplements

• Prospective observational studies: Two

meta-analyses: No effect4,5 or protective effect6,7 for dietary calcium

Cardiovascular risk?

1Wang, Ann Int Med 2010; 2Chung, Ann Int Med 2016; 3Lewis, JBMR 2015; 4Xiao, JAMA Int Med 2013; 5Van Hemelrijck, PLoS One 2015; 6Li, Heart 2012; 7Khan, JBMR 2015

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Calcium: IOM Recommended Intakes

AGE (yrs) Calcium RDA (mg) Calcium UL (mg) 1-3 700 2500 4-8 1000 2500 9-13 1300 3000 14-18 1300 3000 19-30 1000 2500 31-50 1000 2000 51-70 1000 (men) 1200 (women) 2000 >70 1200 2000

Institute of Medicine, 2010

• Calcium plays a key role in bone health
• Recommended intakes vary by age, sex
• Calcium is a threshold nutrient

▫ No benefit to exceeding recommendation

• Encourage calcium from food sources

▫ Supplements when necessary to attain recommended total intake levels

Conclusions: Calcium

• Beneficial effect of calcium + vitamin D
• n BMD in postmenopausal women and
• lder men
• 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 population, baseline 25OHD levels, achieved 25OHD levels

Vitamin D: Evidence for bone health

Chapuy, NEJM 1992

25-hydroxyvitamin D levels

10 20 30 40 50 60 ng/mL

“Deficiency” “Insufficiency” “Normal”

IOM – adequate for population ≥ 30 ng/ml may be considered by some “expert opinion”

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25 OH D = metabolite to measure

Holick, Curr Opin Endocrinol Diabetes 2002

Vitamin D: IOM Recommended Intakes

AGE (yrs) Vit D RDA (IU) Vit D UL (IU) 1-3 600 2500 4-8 600 3000 9-13 600 4000 14-18 600 4000 19-30 600 4000 31-50 600 4000 51-70 600 4000 >70 800 4000

Institute of Medicine, 2010

AGE (yrs) Vit D RDA (IU) 19-30 600 31-50 600 51-70 600 >70 800

Institute of Medicine, 2010

Vitamin D: IOM Recommended Intakes Vitamin D: IOM Recommended Intakes

AGE (yrs) Vit D RDA (IU) Vit D UL (IU) 1-3 600 2500 4-8 600 3000 9-13 600 4000 14-18 600 4000 19-30 600 4000 31-50 600 4000 51-70 600 4000 >70 800 4000

Institute of Medicine, 2010

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Vitamin D: Special populations

Mechanick, SOARD 2013

• Malabsorption, obesity: may need

higher doses

▫ Bariatric surgery: 3000 IU daily, then adjust to achieve 25OHD ≥30 ng/mL ▫ Some require as much as 50,000 IU daily

Sources of vitamin D

Sunshine Milk (1 glass) 100 IU Egg 26 IU Tuna in fish oil (1/2 cup) 170 IU Sardine 33 IU Fortified foods Variable

• D3 (cholecalciferol)

▫ 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

Vitamin D supplements Vitamin D: Evidence for non-skeletal benefit?

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• Muscle expresses vitamin D receptors
• Muscle mass and strength reduced in
• steoporotic patients
• Vitamin D deficiency thought to

contribute to proximal myopathy and to fall risk

 Myopathy is reversible/improved with vitamin D and calcium supplements

Vitamin D: Evidence for non-skeletal benefit? Vitamin D: Non-skeletal benefit?

Holick, Mayo Clin Proc 2006

Vitamin D: Evidence for non-skeletal benefit? RCTs in progress

Thank you!