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Program Considerations for Calcium

Supplementation

Dr Tahmeed AhmedDirector, Centre for Nutrition &Food Security, ICDDR,B

Professor, Public Health NutritionJames P. Grant School of PublicHealth, BRAC University

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PE affects 7-10% pregnancies, rates higher in

India

Malnutrition, inadequate dietary intakes?

Villar J, et al. Int J Gynae Obstet, 2004

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Bioavailability of Calcium from Different Foods

is a Key Factor

Food Serving size(g)

Calciumcontent

(mg)

Fractionalabsorption

%

Estimatedabsorbable

calcium/

serving(mg)

Servingsneeded to

equal to 1

cup of milk

Milk or 1

cup yogurtor 1.5 oz

cheese

260 300 32 96 1

Beans, dried 177 50 16 8 12

Kale 65 47 59 28 4

Spinach 90 122 5 6 16

Tofu,

Calcium set126 258 31 80 1

Adapted from Weaver, CM, et al., AJCN 70:543S-8S.,1999

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254

159

88.1

68.7 61.8

40.928.7

16

0

50

100

150

200

250

300

Consumptionof

MilkProducts

(Kg/Capita/year)

Consumption of Milk Products

Bhatia 2008, He Y 2007, Darwish 2009, Islam MZ 2003, Wang Y 2008

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962

879

400

211200

0

200

400

600

800

1000

1200

United States Egypt China India Bangladesh

CalciumIn

take

(meanintakein

mg/day)

Calcium intake in Countries

Bhatia 2008, He Y 2007, Darwish 2009, Islam MZ 2003, Wang Y 2008

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Pirgacha

Trishal

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Daily Calcium Intake of Women in

Pirgacha and Trishal, Bangladesh

Age (years) Daily calciumintake (mg)

Pirgacha(n=240)

26.26.7 157 (103, 227)

Trishal(n=236) 29.6

8.8 144 (97, 226)

Islam M, Ahmed T, et al. Unpublished

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The Lancet Series on Maternaland Child Undernutrition

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Interventions with Sufficient Evidence to

Implement in All Countries

Maternal and BirthOutcomes

Iron folate

supplementation Maternal supplementsof multiple micronutrients

Maternal iodine throughiodization of salt Maternal calciumsupplementation Interventions to reducetobacco consumption orindoor air pollution

Newborn Babies

Promotion ofbreastfeeding(individual and groupcounseling)

Infants and Children

Promotion ofbreastfeeding (individual

and group counseling) Behavior changecommunication forimprovedcomplementary feeding Zinc supplementation Zinc in management ofdiarrhea Vitamin A fortification orsupplementation Universal salt iodization Hand washing orhygiene interventions

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13 trials involving 15,730 women

Randomized trials comparing at least 1 g daily

of calcium with placebo

Hofmyer GJ, et al. Cochrane Collab 2011

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Hofmyer GJ, et al. Cochrane Collab 2011

Risk of hypertension reduced with Ca, RR 0.65

(0.53-0.81)

Risk of PE reduced, RR 0.45 (0.31-0.65)

Among low Ca consumers, RR 0.36 (0.2-0.65)

Pre-term birth reduced, RR 0.76 (0.6-0.97)

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Belizan JM, Villar J. Am J Obs Gynecol 1988

Reduced serum Ca

Parathormone & renin

Vascular Intracellular Cain smooth muscle

Vascular resistance &vasoconstriction

Poor Calcium intake

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What is the way forward for introduction and

implementation of calcium supplementation?

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Calcium Supplementation: Early Introduction

Policy &Financing

SBCCstrategy

Pre-

service/in-servicetraining

Clinicalcoverage

Local evidence

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Guidance on Calcium from Exercise:

Early Introduction

Advocate with policy makers using global evidence

Separate national policy or streamline into clinicalguidelines

Develop advocacy plan/ strategy to reduce PE/E Cost deliver calcium in a cheap way; work with

manufacturers to reduce cost

Training of volunteers and health workers Logistics part of essential and national drug list,

supported by USAID, UNICEF, WHO

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Raise awareness of community health workers

Develop IEC materials (benefits to child, lower riskof PE/E)

Carry out social marketing for calcium

Address misperceptions of health workers aboutcalcium

Product compliance, feasibility

Guidance on Calcium from Exercise:

Early Introduction

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Inform prior to pregnancy the benefits of Casupplementation (adolescents, newly weds)

Generate country-specific information on Cadeficiency and intake

Track through monitoring and evaluation

Develop public/private partnerships

Guidance on Calcium from Exercise:

Early Introduction

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Conduct formative research on practices andunderstanding of PE/E; BCC strategy

Develop different formulations of calciumthrough research

Research interactions between calcium and iron,currently testing pill with both calcium and iron

Research on optimal dose of calcium (500 mg?)

Guidance on Calcium from Exercise:

Research

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Next Steps

Fill out country-level maps in your country

MCHIP to follow-up in 3 months on calcium

introduction maps