Calcium and Vitamin D supplementation

Calcium and Vitamin D supplementationDr Hasmukh GalaSevenHills HospitalCalcium 99% of calcium present in bone and teethLess than 1% of calcium present in blood, intracellular fluid & muscleSerum calcium is tightly regulatedBody uses bone as a reservior for, and as a source of calcium to maintain constant concentrations of calcium in blood, muscle & intracellular fluidsCalcium MetabolismBone undergoes continuous remodeling with constant resorption & deposition of calciumThe process of bone resorption and formation changes with ageFormation > resorption in period of growth in children & adolescentResorption > Formation in aged individual & post-menopausal women; increasing risk of osteoporosisRole of Calcium For growth and mineralisation of growing bones

Plays a crucial role in various physiological functions like blood coagulation, neuromuscular transmission, muscle contraction etc.Food sources of calcium

Food sources of CalciumDairy products like milk, cheese and yoghurt- rich natural sources of calcium

Vegetables like spinach, broccoli and cabbage contains calcium- but bioavailability poor

Grains contains small amount of calciumFood itemServing sizeCalcium (mg)

Milk8 oz291Yoghurt 8 oz274Yoghurt (low fat)8 oz400Cheese1 oz150Artichoke, boiled

1 medium

135

Broccoli, chopped cup47Cabbage, boiled cup79Collards, boiled cup110Kale, chopped, boiled cup45Mustard Greens, boiled cup52Okra, boiled cup77Peas, boiled cup20Sweet potato, baked cup32Onion, chopped, raw1 cup40Food itemServing sizeCalcium (mg)Black beans, boiled cup23Chick peas cup38Kidney beans cup34Ragi100 gm344 mgFigs, fresh2 medium36Kiwifruit1 medium20Orange1 fresh52Orange juice8 oz22Papaya, fresh medium36Banana, chopped1 cup8Almonds, dried oz (12)37Sesame seeds, whole, dried1 tbsp88Egg, Hens127Fish, Cod3 oz13Crab, cooked3 oz50Recommended Daily Allowancesof CalciumAgeMaleFemalePregnancyLactation0-6 months200 mg200 mg7- 12 months260 mg260 mg1-3 years700 mg700 mg4-8 years1000 mg1000 mg9- 13 years1300 mg1300 mg14- 18 years1300 mg1300 mg1300 mg1300 mg19- 50 years1000 mg1000 mg1000 mg1000 mg51- 70 years1000 mg1200 mg71+ years1200 mg1200 mgCalcium absorptionAbout 30% of calcium in food is absorbed, but it varies with type of food consumed.Efficiency of calcium absorption decreases as intake increases, therefore it is better to take calcium in smaller doses throughout the day Net calcium absorption is as high as 60% in infants and young children, where as it decreases to 15-20% in adults and continue to decrease as people age

Phytic and oxalic acid in food can decrease calcium absorption

Vitamin D increases calcium absorption

Calcium carbonate is best absorbed with meals where as calcium citrate can be given with or without mealsCalcium deficiencyInadequate intake of dietary calcium does not produce any short term adverse effectOver long term, inadequate calcium intake causes osteopenia and ultimately, osteoporosis. Calcium deficiency can also cause rickets, though it mainly results from vitamin D deficiencyBlood calcium is tightly regulated and hypocalcemia results mainly from medical conditions or treatment

Osteoporosis

Bone health and osteoporosisIncrease in bone size and bone mass occur throughout the period of growth in childhood & adolescence to reach a peak bone mass at the age of 30.The greater is the peak bone mass, the longer one can delay serous bone loss with increasing ageBone health & OsteoporosisTherefore, everyone should consume adequate amount of calcium and vitamin D throughout childhood, adolescence and early adulthoodOther risk factors for osteoporosis are being female, thin, inactive, cigarette smoking, excessive intake of alcohol & family history of osteoporosis

OsteoporosisWeight bearing exercise helps in making muscles as well as bones stronger

Muscle mass is associated with bone strength

Weaker muscle can lead to bone breaking accidents HypocalcemiaIn newborn period- prematurity, asphyxia, infants of diabetic mother & IUGR babies- due to transient hypoparathyroidism and delayed intake of milkIn infancy- intake of cows milk- due to high phosphorus content of cows milk, which has 956 mg/L of Phosphorus.

Hypocalcemia- CausesHypoparathyroidismLack of response to PTHVitamin D deficiencyHyperphosphetemiaInadequate intake of calciumBlood transfusion- Particularly multiple transfusion and exchange transfusion in neonateSymptoms of hypocalcemiaMild hypocalcemia is usually asymptomaticParasthesias, muscle cramps, lethargy, poor apetite, Tetany, SeizureTetany- Carpopedal spasm, seizure, laryngospasmIn infants- seizure may be the first manifestation- brief, recurrent, usually generalisedIn neonates- tremors, jitteriness, lethargy, seizureCarpopedal Spasm

Treatment of HypocalcemiaSymptomatic hypocalcemia in neonate- 1-2 ml (100- 200 mg)/kg of body wt of 10% calcium gluconate stat and repeated every 6-8 hrly IV or alternately given as continuous IV infusion (500- 750 mg/kg body wt of 10% Cal gluconat)Monitor serum ionised calciumGradually switch to oral calcium preparation once symptoms resolves

21Treatment of hypocalcemiaHypocalcemia in infants fed with cows milk is due to hyperphosphetemiaInfant formula contains more phosphorus than breast milkTherapy is to lower serum phosphorus and provide calcium supplementationOral calcium supplement given along with milk feeds helps in decreasing phosphorus absorption and lowering serum phosphorusOral Calcium SupplementStarting dose is 50 mg/kg/ dayVarious enteral preparationsCalcium Carbonate- 400 mg Ca/ gmCalcium Glubionate- 64 mg Ca/ gmCalcium Gluconate- 90 mg Ca/ gmCalcium citrate- 210 mg Ca/gmCalcium lactate- 130 mg/gm

Calcium supplementsCalcium supplements produced from unrefined oyster shell, bone meal, dolomite or coral calcium (mainly calcium carbonate) might contain high levels of heavy metals including lead.

Permissible upper limit of lead- 7.5 mcg per 1000 mg of elemental calciumNeeds Calcium supplementsIf child is on corticosteroids, isonazide or anticonvulsant

Has milk allergy

Very low birth weight babies

Low intake of dietary calcium bellow RDA

Tolerable upper level intake for calciumAge MaleFemalePregnantLactating0- 6 months1000 mg1000 mg7- 12 months1500 mg1500 mg1- 8 years2500 mg2500 mg9- 18 years3000 mg3000 mg3000 mg3000 mg19- 50 years2500 mg 2500 mg2500 mg2500 mg51+ years2000 mg2000 mgHigh intake of calciumHigh calcium intake can cause constipation

Might interfere with iron and zinc absorption

High intake of calcium from supplements, and not food, can increase risk of kidney stoneHypercalcemiaIncreased serum ionised calcium levelRarely results from dietary or supplemental calcium intakeHyperparathyroidism, hypervitaminosis D, excess calcium intakeIncreased release from bone- hypervitaminosis A, thyrotoxicosis, renal osteodystrophy, immobilisationMild (15 mg/dl)HypercalcemiaMild to moderate- most patients are asymptomatic

Symptoms- vomitting, failure to thrive, pancreatitis, lethargy, hypotonia, coma, psychiatric disturbances, polyuria, nephrolithiasis, renal failureCalcium supplement and MICalcium supplement might increase risk of MIPeople who need more calcium should first and foremost try to up the dietary intake of this mineralConcluded that calcium supplements should be taken with cautionDr Kuanrong Li, Heart, June 2012Osteopenia of PrematurityTotal of 30 g of Ca accumulates in fetus, most of it during third trimesterLow maternal Ca intake can cause lower bone mass in neonatesVitamin D & Ca supplementation in pregnancy increases bone mineral mass in infancy VLBW infants & Premature baby < 32 weeks GA fed on unfortified human milk or full term formula rather than preterm formula are at risk of osteopenia of prematurity

Osteopenia of Prematurity (OOP)Osteopenia of prematurity is mainly due to Ca & Phosphurus deficiency rather than Vit D deficiencyAll infants with birth weight 70 years800 IU(20 mcg)800 IU(20 mcg)Sun ExposureApproximately 15-20 mins of sun exposure between 10 AM to 3 PM at least twice a week to face, arms, legs or back without sunscreen usually lead to sufficient vitamin D productionIndividuals with limited sun exposure has to take good sources of vitamin D in the diet or take supplement to achieve recommended level of intake Sun Protection

Sun Protection

Pigmentation

Cloud cover

Sunlight through glass

Shade

Serum 25-Hydroxtvitamin D conc.Nmol/LNg/mlHealth status=20Generally adequate for bone and overall health>125>50Associated with potential adverse effectVitamin D content Vit D (IU/L)Calcium (mg/L)Phosphorus(mg/L)Ca: PRatioBreast Milk25- 78 3501502.3: 1Cow milk4110319631.2: 1Buffalo milk15009601.8: 1Lactogen 13604202401.8: 1Pediasure4809207601.2: 1Vitamin D deficiencyCan be asymptomatic

Causes bone pain and muscle weakness

Low blood levels of vitamin D have been associated with increased risk of cardiovascular disease & certain type of cancerVitamin D deficiencyVitamin D deficiency causes rickets in children and osteomalacia in adultsRickets- failure of bone tissue to properly mineralise leading to soft bones and skeletal deformityHypocalcemic tetany occasionally accompanies rickets, especially in prolong unrecognized vitamin D deficiency

Vitamin D supplementationBreast fed infants Should receive vitamin D supplement 400 IU/day starting from first few days after birthPeople with limited sun exposureDark skin individualsFat malabsorptionObese individual with BMI > 30Vitamin D & Indian populationVitamin D levels of 1384 children & young adults64.4% had low levels(less than 20 ng/ml)26.6% had insufficient levels (20-40 ng/ml)Only 13% had sufficient levels (> 40 ng/ml)

recent study by P D Hinduja hospitalRickets

Diagnosis of ricketsX ray of wrist

S Calcium, S Phosphorus, S Alkaline Phosphatase levels

Serum 25- hydroxy vitamin D3 levelRickets

Treatment of Rickets2000 IU 6000 IU per day of vitamin D3 orally OR 6,00,000 IU as a single dose

Healing usually starts in few days and progress to full bone recovery

Normal intake of calcium and phosphorus or oral calcium supplements for few daysTolerable upper intake levels for Vitamin DAgeMaleFemalePregnancyLactation0- 6 months1000 IU(25 mcg)1000 IU(25 mcg)7- 12 months1500 IU(38 mcg)1500 IU(38 mcg)1- 3 years2500 IU(63 mcg)2500 IU(63 mcg)4- 8 years3000 IU(75 mcg)3000 IU(75 mcg)>= 9 years4000 IU(100 mcg)4000 IU(100 mcg)4000 IU(100 mcg)4000 IU(100 mcg)Hypervitaminosis DExcessive intake of vitamin D can result in hypervitaminosis DSymptoms generally starts 1-3 months after excessive intakeHypotonia, polyuria, polydipsia, constipationHypercalcemia & hypercalciuria, aortic valvar stenosis, osteopetrosis, proteinuria, renal damage, hypertension, retinopathy, clouding of cornea and conjunctiva