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Nutriceuticals: Over-The-Counter Products and Osteoporosis

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Nutriceuticals: Over-The-Counter Products and Osteoporosis serum calcium levels are too low, and adequate calcium is not provided by the diet, calcium is taken from bone. Osteoporosis: Clinical Updates Long- term dietary calcium deficiency is a known risk Osteoporosis Clinical Updates is a publication of the National factor for osteo porosis. The recommended daily cal- Osteoporosis Foundation (NOF). Use and reproduction of this publication for educational purposes is permitted and cium intake from diet and supplements combined is encouraged without permission, with proper citation. This 1000 mg/day for people aged 19 to 50 and 1200 mg/ publication may not be used for commercial gain. NOF is a day for people older than 50. For all ages, the tolerable non-profit, 501(c)(3) educational organization. Suggested upper limit is 2500 mg calcium per day. citation: National Osteoporosis Foundation. Osteoporosis Clinical Updates. Issue Title. Washington, DC; Year. Adequate calcium intake is necessary for attaining peak bone mass in early life (until about age 30) and for Please direct all inquiries to: National Osteoporosis slowing the rate of bone loss in later life.3 Although Foundation 1150 17th Street NW Washington, DC 20037, calcium alone (or with vitamin D) has not been shown USA Phone: 1 (202) 223-2226 to prevent estrogen-related bone loss, multiple stud- Fax: 1 (202) 223-1726 www.nof.org ies have found calcium consumption between 650 mg Statement of Educational Purpose and over 1400 mg/day reduces bone loss and increases Osteoporosis Clinical Updates is published to improve lumbar spine BMD.4-6 osteoporosis patient care by providing clinicians with state-of-the-art information and pragmatic strategies on How to take calcium supplements: prevention, diagnosis, and treatment that they may apply in Take calcium supplements with food. clinical practice. If unable to take calcium with food or if tak- ing acid-blocking medication, calcium citrate is Overall Objectives recommended Despite the availability of effective prevention, diagnostic, and treatment protocols for osteoporosis, research indicates Spread calcium out that it is significantly underdiagnosed and undertreated 600 mg or less is absorbed best at one time in the general population. Through this publication, NOF Best to take supplement at a relatively low- calcium encourages participants to incorporate current evidence meal and expert recommendations into clinical practice to Chew chewables, swallow tablets improve the bone health of their patients. Take with full glass of water and food Upon completion of each issue of Osteoporosis Clinical Dietary sources of calcium include: Updates, participants should be able to: Dairy products: milk (300 mg/cup), yogurt (300- Recognize current concepts in osteoporosis research 400 mg/cup) and cheeses (138 mg/cup skim cot- and clinical practice Identify implications of these concepts for osteoporosis tage cheese) patient care Fortified orange juices (300 mg/8 oz), breads (150- Adopt evidence-based strategies to study, prevent, and/ ® 200 mg/slice), and cereals (Total brand Raisin Bran or treat osteoporosis 1038 mg/cup); Improve patient care practices by integrating new data Nuts (almonds 75 mg/1 oz, about 25 nuts) and and/or techniques seeds (sesame seed butter, tahini, 64 mg/tbsp) Intended Audience Fish eaten with bones (sardines 325 mg/3oz, canned This continuing education activity is intended for salmon 183 mg/3oz) health professionals who care for patients at risk for or Soy milk (61 mg/cup) suffering from osteoporosis practicing in primary care, Tofu processed with calcium salts (164 mg/quarter endocrinology, geriatrics, gynecology, internal medicine, cup) obstetrics, orthopedics, osteopathy, pediatrics, physiatry, radiology, rheumatology, and/or physical therapy. Green vegetables, such as collards (357 mg/cup) This includes physicians, nurse practitioners, registered Beans, such as navy beans (126 mg/cup) and soy nurses, pharmacists, physician assistants, technologists, beans (261 mg/cup) researchers, public health professionals and health educators Calcium supplements are available in several forms: with an interest in osteoporosis and bone health. calcium carbonate (most common), calcium citrate, 3 and calcium phosphate. Compounds contain different Calcium Safety amounts of elemental calcium. Calcium intake should Concern has been raised about a possible connection be estimated on the basis of elemental calcium in the between calcium supplementation and cardiovascular supplement taken (shown on the nutrition supplement risks. Associations have been observed between calcium label). supplementation without vitamin D and increased risk Calcium in over-the-counter supplements is gener- of myocardial infarction (MI). Using a more powerful ally well absorbed in the various compounds available. tool of combining effects seen in individual studies by Individual users may find that one compound works meta-analysis of randomized trials of calcium supple- better for them because it causes fewer side effects, mentation (minus vitamin D), the same association was such as gas or constipation. Because the body doesn’t demonstrated: roughly a 30% increase in MI, but not readily absorb more than about 600 mg of elemental stroke or mortality.7,8 A similar, although smaller in- calcium at a time, it is best to take calcium supplements crease in MI was observed in meta-analysis of data from with a low-calcium meal and to spread out supple- the Women’s Health Initiative.9 ments, perhaps taking one in the morning and one at Data on calcium taken in conjunction with vitamin D night. Calcium carbonate is absorbed best when taken and pharmacotherapy for osteoporosis, however, have with food. Calcium citrate can be taken anytime. demonstrated no increase in overall mortality and Achieving bone-building and bone-preserving effects of cardiovascular events.10-12 There is still much that is pharmacologic therapies for osteoporosis requires ade- unknown about the risk of high calcium intake on the quate calcium intake. cardiovascular system. The current consensus is that calcium consumed through food intake is the best means to meet daily intake recommendations and is unlikely to have a nega- tive impact. Therefore, individuals should consume as much calcium as possible from foods. Supplements should be used only to bring all-source intake to rec- ommended levels of 1000-1200 mg/day. In general, more calcium than the recommended amount will not provide added benefit and may, indeed, pose a risk. In years past, the main concern about calcium supple- ments was lead contamination in calcium-carbonate based supplements derived from dolomite, bone meal, or unrefined oyster shell. Like other nutritional supple- ments, calcium supplements are not FDA tested for lead content. It is up to the manufacturer to ensure that a supplement meets FDA standards. The FDA Provisional Total Tolerable Intake level for lead is 75 mcg for adults. Several studies have found detectible lead in commercial calcium supplements.13,14 In 2008, the FDA tested lead content in 324 multivitamins sold in the U.S. Small amounts of lead were found in Figure 1. 7KLVFDOFLXPFDOFXODWRULVDYDLODEOHRQWKH12) most of them (320 of 324), but none came close to ZHEVLWH3DWLHQWVFDQXVHLWWRHVWLPDWHWKHLUFDOFLXPLQWDNH the harmful threshold (highest daily exposure was <5 15 DQGQHHGIRUVXSSOHPHQWDWLRQWRUHDFKLQWDNHJRDOV mcg/day). $YDLODEOHDWKWWSZZZQRIRUJDERXWRVWHRSRURVLV SUHYHQWLRQFDOFLXPFDOFXODWRU If the supplement has a USP label, the lead content has been tested and determined to be within accept- able levels. Most major brands of calcium supplements voluntarily meet the USP standards for purity and safe 4 lead levels. CME Program Eligibility Calcium is known to offset the effects of lead by block- Method of Participation in the Learning Process: Clinician ing its absorption (both in the sup plement and in other learners will read and analyze the subject matter, conduct dietary contributors of lead).16,17 Research has shown additional informal research through related internet that blood lead levels are lower in peo ple who take searches on the subject matter, and complete a post-test 18 assessment of knowledge and skills gained as a result of the calcium supplements than in those who do not. Data activity. available to date support the view that patients are safe After participating in this activity, the reader has the taking calcium-plus-vitamin-D supplements from re- option of taking a post-test with a passing grade of 70% or spected manufacturers. Patients should, however, avoid better to qualify for continuing education credit for this supplements derived from dolomite, bone meal, or activity. It is estimated it will take 1.0 hour(s) to complete the reading and take the post-test. Continuing education unre fined oyster shell. Be advised that calcium carbon- credit will be available for two years from the date of ate preparations are currently the least expensive and publication. the most widely available. Alternatives to calcium car- bonate include calcium citrate, calcium phosphate, and Accreditation The National Osteoporosis Foundation is accredited by the (by prescription) calcium acetate. Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Vitamin D and Bone The National Osteoporosis Foundation designates this educational activity for a maximum of 1.0 AMA PRA Vitamin D regulates intestinal calcium absorption Category 1 Credit(s)TM. Physicians should only claim credit and helps
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