Osteoporosis may be a disorder of bone characterized by reduced mineral density and bone mass. Multiple therapeutic regimens are designed to forestall or treat bone loss in postmenopausal women and also the elderly. the primary step within the prevention or treatment of osteoporosis is ensuring adequate nutrition, particularly maintaining an adequate intake of calcium and cholecarciferol. Adequate calcium and ergocalciferol nutrition is vital in people of all ages, especially in children and therefore the elderly within the latter group, as an example, the administration of calcium and viosterol reduces the speed of bone loss and will decrease fracture risk during this same population, calcium and D supplementation also reduces tooth loss Calcium and calciferol supplementation within the treatment of osteoporosis are reviewed here. Detailed information regarding pharmacologic therapy for osteoporosis and also the role of calcium within the pathogenesis of osteoporosis is discussed separately.
— Calcium and vitamin D are necessary for normal skeletal homeostasis. D enhances intestinal absorption of calcium. Low concentrations of D are related to impaired calcium absorption, a negative calcium balance, and a compensatory rise in internal secretion, which ends in excessive bone resorption.
Careful calcium balance studies have shown that calcium balance is said to calcium intake; the less calcium one takes in, the more negative the calcium balance. this will be reversed by increasing calcium intake and maintaining adequate fat-soluble vitamin stores. In general, calcium balance becomes positive at a mean calcium intake of 1000 mg/day in premenopausal women and 1500 mg/day in postmenopausal women who don’t take estrogen The importance of adequate calcium and viosterol intake for skeletal health is supported by several observational studies and by randomized trial data. Observational data — Many studies have shown an inverse relationship between serum concentrations of 25-hydroxyvitamin D (25OHD) and hormone (PTH) The maximal suppression of PTH by vitamin D is one criterion by which the optimal serum 25OHD concentration is defined. Estimates vary widely but range from 20 to 40 ng/mL (50 to 100 nmol/L) Other experts support the thesis that suppression of PTH by 25OHD follows a continuum across a large range of viosterol concentrations, and levels above 20 ng/mL are capable suppress PTH, assuming normal renal function The compensatory rise in hormone, which occurs within the setting of low calciferol, leads to excessive bone resorption. Many studies, including an outsized population-based study (NHANES-III) that included 13,432 participants, have shown a positive association between serum 25OHD and bone mineral density additionally, in an exceedingly prospective cohort study of 1279 community-dwelling older men, those with 25OHD <20 ng/mL (50 nmol/L) had significantly higher rates of hip bone loss over time (approximately 0.5 compared with 0.3 percent/year in men with serum 25OHD >20 ng/mL In several but not all observational studies, lower serum concentrations of 25-hydroxyvitamin D (25OHD, calcidiol) were related to the next risk of hip fracture. In one in every of the most important of those studies, 400 women with hip fracture were compared with 400 matched controls and followed for seven years The mean serum 25OHD concentrations measured at study entry were significantly lower in patients who subsequently had a hip fracture (22 versus 24 ng/mL [56 versus 60 nmol/L]) The increased risk of hip fracture was most apparent in women with very cheap serum 25OHD concentrations (OR 1.7, 95% CI 1.0-2.8 for girls in quartile one [<19 ng/mL (47.5 nmol/L)]) compared with women in quartile four (>28 ng/mL [70.7 nmol/L]). Similar findings were reported in men (hazard ratio 2.36, 95% CI 1.08-5.15 for men within the lowest versus highest quartile of total 25OHD) additionally to hip fracture, serum 25OHD concentrations below 20 ng/mL (30 nmol/L) are related to the next risk of other osteoporotic fractures, including vertebral, wrist, and proximal humerus fractures in a very prospective cohort study of elderly Swedish men (mean age 71 years), serum 25OHD levels below 16 ng/mL (40 nmol/L) were related to a modestly increased risk for fracture (HR 1.65, 95% CI 1.09-2.49 within the aggregate, these observations suggest that calcium and D supplementation could protect bone by preventing bone loss and by healing subclinical osteomalacia. Although the optimal serum 25OHD concentration to keep up skeletal health isn’t firmly established, serum values exceeding 19 to 24 ng/mL (47.5 to 60 nmol/L) are supported by observational studies Randomized trial data — Evidence supporting the advantage of calcium and D supplementation in patients with osteoporosis comes largely from prospective, randomized, placebo-controlled trials Although variety of trials have reported a beneficial effect of calcium or calcium plus cholecarciferol on bone density in postmenopausal women and older men the information on fracture rates are more variable Some trials have reported a discount in fracture but large randomized trials haven’t shown any reduction in fracture risk with calcium plus viosterol In the most important of those trials (Women’s Health Initiative), however, subgroup analysis revealed that calcium and calciferol supplementation was related to reduced fracture incidence in those subjects who were most compliant The Women’s Health Initiative trial randomly assigned 36,282 postmenopausal women ages 50 to 69 years (not selected for low bone density or osteoporosis) to calcium (1000 mg/day) plus D (400 int. units/day) or placebo (personal supplementation of up to 1000 mg additional calcium and 600 units fat-soluble vitamin was also allowed, as was bisphosphonate, calcitonin, and hormone therapy use [over one-half of subjects were taking hormone therapy the subsequent results were seen: • After a mean follow-up period of seven years in a very subset of girls who had bone mass measurements performed, hip bone mineral density was 1.06 percent higher within the calcium-vitamin D group compared with the placebo group.
• The risk of hip fracture with calcium-vitamin D (intention-to-treat analysis) was not up to placebo although this wasn’t statistically significant (HR 0.88, 95% CI 0.72-1.08). However, when only compliant subjects were analyzed (predefined as people who took over 80 percent of medication), a big decrease in hip fracture was seen (HR 0.71, 95% 0.52-0.97).
• In all subjects, the danger of kidney stones was increased with calcium-vitamin D supplementation (HR 1.17. 95% CI 1.02-1.34). The trial had variety of limitations: a greater fracture reduction may need been seen if subjects had been selected on the premise of low bone density or low calcium/vitamin D intake at baseline. additionally, the high percentage of ladies taking hormone therapy may have made it difficult to determine an impression of the calcium-vitamin D on bone, and lastly, the ergocalciferol supplementation may are too low
Calcium versus D
— In many of those trials, it’s difficult to differentiate the effect of calcium from that of viosterol. Randomized trials of calcium only or cholecarciferol only have shown mixed results, likely because of differences in patient populations and study design. A meta-analysis of 5 trials comparing fat-soluble vitamin (400 to 1370 units/day) with placebo in over 14,500 elderly men and ladies reported that cholecarciferol supplementation alone failed to reduce fracture risk (RR 1.03, 95% CI 0.84-1.26) within the same review, a separate meta-analysis of 11 trials comparing calcium (500 to 1200 mg/d) plus cholecarciferol (300 to 1100 units/day) with placebo showed that combined supplementation reduced the danger for total fractures (RR 0.88, 95% CI 0.78-0.99 in a very subgroup analysis, the danger reduction was larger among institutionalized elderly than community dwelling individuals (RR 0.71 versus 0.89) Other meta-analyses of trials comparing calcium, vitamin D, or both with placebo or no treatment reported a beneficial reduction in fracture with calcium and calcium plus ergocalciferol but not with D alone Relative risk reductions for hip fracture ranged from 0.81 to 0.87 for combined calcium plus D supplementation These findings suggest that supplementation with both calcium and calciferol reduces the danger of fracture.
— The optimal dose of calcium and vitamin D is uncertain. during a number of trials that reported a beneficial effect of calcium on bone density in postmenopausal women and older men, calcium supplement doses ranged from 500 to 1200 mg daily Baseline calcium from diet varied from approximately 600 to 1000 mg daily. Thus, total (diet plus supplement) calcium intake ranged from approximately 1100 to 2000 mg daily. a good range of ergocalciferol doses were utilized in the clinical trials. a number of the trials were designed to review intermittent dosing of viosterol, specifically 100,000 units administered every three to four months whereas others used 400 units of cholecarciferol daily One meta-analysis of randomized trials didn’t show differential effects on fracture risk reduction based upon the dose of viosterol However, another analysis showed a big effect of vitamin D dose when the particular fat-soluble vitamin intake (rather than assigned fat-soluble vitamin dose) was calculated during this pooled analysis of patient level data from 11 randomized trials (31,022 persons, mean age 76 years) of oral viosterol supplementation, with or without calcium, compared with placebo or calcium alone, there was a major reduction in incidence of hip (RR 0.70, 95% CI
0.58-0.86) and nonvertebral (RR 0.86, 95% CI 0.76-0.96) fracture within the individuals with the very best calculated actual vitamin D intake (median 800 units daily, range 792 to 2000 units daily) compared with controls. There was no reduction in risk of hip fracture at actual intake levels but 792 units daily. only a few of the trials included within the meta-analysis provided information on baseline and follow-up serum 25-hydroxyvitamin D levels and, therefore, the optimal serum 25-hydroxyvitamin D concentration for fracture prevention couldn’t be established. In two placebo-controlled trials of high-dose (300,000 to 500,000 units) viosterol administered once yearly (without calcium supplementation), vitamin D didn’t reduce the chance of fracture In one in all the trials, the chance of falls and fracture was increased within the fat-soluble vitamin group (RRs 1.15, 95% CI 1.02-1.30 and 1.26, 95% CI 1.00-1.59 for falls and fracture, respectively) within the ergocalciferol group, the median 25OHD concentrations after one and three months were approximately 48 and 36 ng/mL (120 and 90 nmol/L), respectively. Based upon the meta-analyses discussed above, we recommend 1200 mg of calcium (total of diet and supplement) and 800 int. units of fat-soluble vitamin daily for many postmenopausal women with osteoporosis. Although the optimal intake (diet plus supplement) has not been clearly established in premenopausal women or in men with osteoporosis, 1000 mg of calcium (total of diet and supplement) and 400 to 600 int. units of vitamin D daily are generally suggested. We recommend not administering yearly high-dose (eg, 500,000 units) D. These recommendations are in step with the Institute of drugs Dietary Reference Intakes for calcium and vitamin Certain coexisting medical problems may alter these requirements. In patients at very high risk for fracture in whom there’s a clinical suspicion that the standard doses are inadequate (malabsorption, decreasing bone mass), measurement of 25OHD concentrations could also be necessary to make sure that supplementation is adequate. Commercial assays measure total 25OHD, but some labs report vitamin D2 (25OHD2) and D3 (25OHD3) values separately. The optimal serum concentration refers to the combined total. The optimal serum 25OHD concentration for skeletal health is controversial. The Institute of drugs supports 25OHD concentrations above 20 ng/mL (50 nmol/L) but not chronically exceeding 50 ng/mL (125 nmol/L) the next serum concentration could also be necessary for skeletal benefits, particularly in older individuals at greater risk. Thus, some patients require quite 800 units daily to take care of serum levels of 30 to 40 ng/mL (75 to 100 nmol/L Optimal serum 25OHD concentrations are discussed in additional detail elsewhere. Optimal intake may be achieved with a mixture of diet plus supplements. Calcium appears to be also absorbed from supplements as from milk and supplements were employed in the above trials demonstrating get pleasure from increased calcium intake. it’s likely, therefore, that supplements aren’t less effective than calcium found naturally in dairy products. it’s important for patients to remember that calcium and calciferol alone are probably insufficient to forestall bone loss although they’ll be beneficial in some subgroups (the elderly, those with low intake at baseline). ergocalciferol supplementation is important for variety of other reasons independent of bone health; these are reviewed separately .
DIETARY SOURCES Calcium
— A rough method of estimating dietary calcium intake is to multiply the quantity of dairy servings consumed per day by 300 mg. One serving is 8 oz (240 mL) of milk or yogurt or 1 oz of bad luck. farmer’s cheese and frozen dessert contain approximately 150 mg of calcium per 4 oz (120 mL). Other foods during a well-balanced diet (dark green vegetables, some nuts, breads, and cereals) supply a median of 100 mg of calcium daily Some cereals, soy products, and fruit juices are fortified with up to 1000 mg of calcium. While it’s possible to estimate the quantity of calcium in other sources of dietary calcium like green vegetables and nuts, calcium absorption from these sources is more variable.
additionally, vegetables and nuts have much lower calcium content than dairy products in order that way more would wish to be consumed to fulfill daily requirements. Detailed lists of the calcium content of assorted foods are available from the US Department of Agriculture Calcium supplements or increased intake of dairy products should be recommended if dietary calcium intake is below recommended levels. If supplements are needed, it’s important to notice that the intake suggested above reflects the quantity of elemental calcium in supplements, not the entire calcium content. additionally, the overall intake of calcium (diet plus supplements) shouldn’t routinely exceed 2000 mg/day due to the chance of adverse effects ergocalciferol — within the u. s., commercially fortified milk is that the largest source of dietary ergocalciferol, containing approximately 100 int. units of calciferol per 8 oz Thus, cholecarciferol intake is estimated by multiplying the quantity of cups of milk consumed per day by 100. viosterol is additionally found in cod liver oil, but some fish oils also contain high doses of antiophthalmic factor, and so they’re not the most effective source of ergocalciferol Sunlight exposure also increases vitamin D concentrations. However, the employment of sunscreen products effectively blocks vitamin D synthesis. additionally, the skin of these older than 70 years old doesn’t convert D as efficiently as in younger individuals. Thus, fat-soluble vitamin supplements are generally necessary. The safe upper limit for calciferol is unclear but is above 2000 units daily.
— In patients requiring calcium and calciferol supplementation, a daily multivitamin is both convenient and economical. However, most multivitamins contain only 400 int. units of fat-soluble vitamin, which is insufficient, and not all individuals require or tolerate multivitamins .) Postmenopausal women with osteoporosis can even increase viosterol and calcium intake by taking plain ergocalciferol supplements (usually 400 units per tablet) and/or calcium supplements that also contain fat-soluble vitamin, usually 200 units per 500 mg or 600 mg of calcium. it’s important to notice that there’s not an instantaneous linear relationship between supplemental dosing and level of serum 250HD. Individuals with low levels at baseline (<10 ng/mL) generally have a rise in 250HD of 1.0 to 1.5 ng/mL for each 100 IU of vitamin D; however, individuals at levels above 20 ng/mL show an attenuated increase in serum 250HD (ie, usually 0.5 ng/mL for each 100 units). Calcium — the foremost widely available calcium supplements are carbonate and calcium citrate carbonate is cheapest and thus often a decent first choice. However, there are some limitations to its use compared with calcium citrate:
- Calcium carbonate absorption is healthier when crazy meals; compared, calcium citrate is well absorbed within the fasting state and is best or equally absorbed compared with carbonate dotty a meal. this could be particularly important in patients with achlorhydria. Thus, it seems prudent to require carbonate with meals, since it’s often hard to grasp who has achlorhydria.
- Calcium carbonate is additionally poorly absorbed in patients taking proton pump inhibitors or H2 blockers. We usually recommend calcium citrate as a primary line calcium supplement in these patients.
- Many natural carbonate preparations like oyster shells or bone meal contain some lead, and tiny amounts are present in refined (antacid) carbonate or calcium citrate The low lead levels in calcium supplements are unlikely to be a health risk, because calcium blocks lead absorption Dosing — The intake recommendations given above seek advice from the number of elemental calcium . As an example, carbonate is 40 percent elemental calcium, in order that 1250 mg of carbonate contains 500 mg of elemental calcium. The dose of elemental calcium is listed on most supplement labels. Calcium supplementation in more than 500 mg/day should be in divided doses. Higher individual doses are related to a plateau in calcium absorption that will prevent the attainment of positive calcium balance Side effects — normally, concern that prime dietary calcium increases the chance of nephrolithiasis in otherwise healthy patients is unfounded, because the incidence of stone formation appears to be reduced in both men and ladies This issue is discussed well separately. However, calcium supplements are related to an increased risk of kidney stones . The Women’s Health Initiative (WHI) trial described above also reported an increased risk of kidney stones in postmenopausal women who were supplemented with calcium and cholecarciferol compared with placebo Other potential side effects of high calcium intake include dyspepsia and constipation. additionally, calcium supplements interfere with the absorption of iron and hormone and, therefore, these medications should be taken at different times. The effect of calcium supplementation on risk of upset is controversial There is also benefits of calcium supplementation on risk factors, like a discount in weight, pressure, and in serum cholesterol concentrations (of about 5 percent) in patients with mild to moderate hypercholesterolemia. .) within the WHI trial described above, 36,282 postmenopausal women ages 50 to 69 years were randomly assigned to calcium (1000 mg/day) plus fat-soluble vitamin (400 int. units/day) or placebo (personal supplementation of up to 1000 mg additional calcium and 600 units viosterol was also allowed) upset was a prespecified secondary outcome . At baseline, mean calcium intake (diet plus supplements) was approximately 1150 mg/day, and 54 percent of participants were taking non-protocol calcium supplements. After seven years, calcium plus viosterol supplementation had no significant effect on the incidence of myocardial infarct (confirmed in 411 and 390 women assigned to calcium/vitamin D and placebo, respectively; HR 1.05, 95% CI 0.91-1.20) or stroke (362 versus 377 strokes, HR 0.95, 95% CI 0.82-1.10). However, the findings of two meta-analyses evaluating calcium or calcium with or without ergocalciferol supplementation (eight and nine trials, respectively) raised some concern about an increased risk of infarct (MI) in patients randomly assigned to calcium versus placebo (166 versus 130 MIs, pooled relative risk 1.27, 95% CI 1.01-1.59) or calcium with or without D versus placebo (374 versus 302 MIs, RR 1.24, 95% CI 1.07-1.45 . The meta-analyses had several limitations. The trials within the meta-analyses weren’t designed to explore cardiovascular outcomes, which weren’t uniformly collected or adjudicated. Patient level data weren’t available from all the trials. In one in all the meta-analyses, only data from a subgroup of participants within the Women’s Health Initiative (those not taking personal calcium supplements at randomization), instead of all participants, were included within the analysis The baseline dietary calcium intake within the trials ranged from 750 to 1240 mg daily and therefore the addition of calcium supplements raised total intake over 1500 to 2000 mg daily in many patients, which is on top of recommended. Another meta-analysis evaluated the consequences of supplementation with calcium, vitamin D, or both on upset (CVD), including CVD death, nonfatal coronary cardiopathy or MI, and nonfatal stroke in a very pooled analysis of 4 trials, calcium supplementation failed to significantly increase the chance of CVD events compared with placebo (RR 1.14, 95% CI 0.92-1.41). In these trials, dietary intake of calcium ranged from 800 to 900 mg daily and also the dose of calcium supplements ranged from 600 to 1200 mg daily. during a pooled analysis of two trials (one of which was the Women’s Health Initiative and included data from all participants), combined vitamin D and calcium supplementation versus double placebos (RR 1.04, 95% CI 0.92-1.18) and ergocalciferol alone compared with placebo (RR 0.90, 95% CI 0.77-1.05) also failed to significantly increase the danger of CVD, and there was a suggestion of a benefit in CVD reduction with vitamin D alone. As within the meta-analyses described above, none of the trials were designed to assess the consequences of calcium or cholecarciferol on cardiovascular outcomes. A prospective cohort study (23,980 participants with mean follow-up of 11 years) published after the meta-analyses showed a big reduction in MI risk in patients with higher versus lower total dietary calcium intake (HR 0.69, 95% CI 0.50-0.94 for the third compared with lowest quartile of total dietary calcium intake) . in an exceedingly separate analysis using the identical cohort, there was a big increased risk of myocardial infarct in users versus nonusers of calcium supplements (HR 1.86, 95% CI 1.17-2.96). However, there have been only 20 events within the calcium group, which reduced the precision of the analysis. Thus, it’s unclear from the current data whether intake of dietary calcium versus calcium supplements confers different cardiovascular risks. Randomized trials of calcium and vitamin D supplementation with CVD events ascertained as a primary endpoint are required to see if calcium supplementation is related to an increased occurrence of those events . within the interim, we advise combined calcium and vitamin D supplementation, as reviewed above Vitamin D — D is mostly easier to soak up than calcium and it should be taken together dose with or without food. the 2 commonly available varieties of fat-soluble vitamin supplements are ergocalciferol and cholecalciferol. Some but not all studies suggest that cholecalciferol (vitamin D3) increases serum 25OHD more efficiently than does ergocalciferol (vitamin D2 . additionally, ergocalciferol2 isn’t accurately measured all told vitamin D assays For these reasons, we recommend supplementation with cholecalciferol when possible, instead of ergocalciferol. Calcitriol is that the most active metabolite of ergocalciferol. It can frequently cause hypercalcemia and/or hypercalciuria, necessitating close monitoring and adjustment of calcium intake and calcitriol dose. Therefore, we don’t recommend calcitriol for fat-soluble vitamin supplementation in osteoporosis. However, calcitriol or other D analogs are a crucial component of therapy for secondary hyperparathyroidism in chronic nephrosis .)
— The intake at which the dose of D becomes toxic isn’t clear. In 2010, the Institute of medication defined the Safe Upper Limit for viosterol as 4000 int. units per day However, higher doses are sometimes required for the initial treatment of viosterol deficiency. .) it’s important to inquire about additional dietary supplements (some of which contain viosterol) that patients could also be taking before prescribing extra vitamin D [ 83 ]. Excessive D, especially combined with calcium supplementation, may cause hypercalcemia, hypercalciuria, and kidney stones. additionally, chronically high levels of 250HD (exceeding 40 and 50 ng/mL [100 and 125 nmol/L], respectively) are found in some association studies to be linked to a modest increase in risk of some cancers (eg, pancreatic) and mortality. and “Vitamin D and extraskeletal health”, section on ‘Mortality’ .) More studies are needed to define the upper level of serum 250HD that’s safe. Coexisting medical problems — Many individuals with osteoporosis have underlying medical conditions that predispose to osteoporosis. Recommendations for calcium and viosterol supplementation may vary with the underlying condition
. fat-soluble vitamin deficiency
— viosterol deficiency may result from inadequate intake combined with lack of sun exposure, malabsorption, or genetic abnormalities in vitamin D metabolism. viosterol deficiency or insufficiency is commonly overlooked, unless 25OHD concentrations are measured. Commonly used antiresorptive agents, like bisphosphonates, could also be less effective in patients with occult cholecarciferol deficiency. additionally, hypocalcemia can occur in patients with D deficiency who are treated with bisphosphonates, particularly when administered intravenously, before repletion of fat-soluble vitamin Individuals with ergocalciferol deficiency generally require higher doses of viosterol initially, followed by maintenance doses as described above. The treatment of calciferol deficiency is reviewed separately Primary hyperparathyroidism — Adequate dietary calcium (800 to 1000 mg daily) and viosterol supplementation (400 to 600 units daily) is inspired for patients with primary hyperparathyroidism. Cautious calcium supplementation is safe in individuals with poor dietary intake. Patients with overt calciferol deficiency may have more clinically significant hyperparathyroidism and will require cautious supplementation with higher doses of vitamin D Underlying gastrointestinal disease — Patients with malabsorption or short-bowel syndrome may have beyond normal calcium and calciferol requirements thanks to diminished calcium absorption. This problem can occur even with relatively minor disruption of gastrointestinal function, as in patients who have undergone gastrectomy Several factors can contribute to the malabsorption of calcium in these patients:
- Reduced gastric acidity and mild generalized malabsorption thanks to impaired mixing of food with pancreatic secretions and decreased gut transit time.
- Binding of calcium to fatty acids in patients with steatorrhea
- Vitamin D deficiency because of both malabsorption and also the tendency to avoid milk Optimal calcium and D supplementation must be determined empirically and must be adjusted so as to normalize the serum concentrations of calcium, phosphate, alkaline phosphatase, 25OHD, and endocrine, and 24-hour urinary calcium excretion The American Gastroenterological Association (AGA) technical review and guideline for osteoporosis in gastrointestinal diseases yet as other AGA guidelines, will be accessed through Proton pump inhibitor therapy — carbonate is poorly absorbed in patients taking proton pump inhibitors or H2 blockers. We usually recommend calcium citrate as a primary line calcium supplement in these patients. Diuretic therapy — Concomitant administration of diuretics can influence calcium balance. Loop diuretics increase calcium excretion, while thiazide diuretics have a hypocalciuric effect that may protect against calcium stones and possible bone loss. The effect of diuretics on optimal dietary calcium intake isn’t known. monogenic disorder — Patients with advanced monogenic disorder are usually deficient in ergocalciferol, and that they require quite the standard recommended dose for young adults (eg, over 400 int. units/day).
— Individuals with granulomatous diseases, like sarcoidosis, are often treated with glucocorticoids and thus have an increased risk of osteoporosis. However, they also tend to own hypercalcemia and hypercalciuria because of extrarenal production of calcitriol by activated macrophages and consequent increased intestinal absorption of calcium In patients with sarcoidosis and osteoporosis, serum and urinary calcium and ergocalciferol concentrations must be carefully monitored if supplements are required
INFORMATION FOR PATIENTS
— UpToDate offers two varieties of patient education materials, “The Basics” and “Beyond the fundamentals.” the fundamentals patient education pieces are written in plain language, at the 5 th to six th grade reading level, and that they answer the four or five key questions a patient might need a couple of given condition. These articles are best for patients who need a general overview and preferring short, easy-to-read materials. Beyond the fundamentals patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the ten th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to the current topic. We encourage you to print or e-mail these topics to your patients. (You also can locate patient education articles on a spread of subjects by searching on “patient info” and also the keyword(s) of interest.) SUMMARY and proposals — Adequate calcium and cholecarciferol intake may end up in positive calcium balance and a discount within the rate of loss of bone; the effect upon fracture risk is a smaller amount clear, although combined calcium and calciferol supplementation appears to cut back fracture risk. Calcium and viosterol supplementation are relatively inexpensive and appear reasonable to recommend in patients with a coffee dietary intake.
- We suggest calcium and D supplementation in patients with osteoporosis and inadequate dietary intake In postmenopausal women, 1200 mg of elemental calcium daily, total diet plus supplement, and 800 int. units of calciferol daily are suggested. Although the optimal intake (diet plus supplement) has not been clearly established in premenopausal women or in men with osteoporosis, 1000 mg of calcium (total diet plus supplement) and 400 to 600 int. units of calciferol daily are generally suggested. The dose of calcium and cholecarciferol may vary in individuals with coexisting medical conditions.
- Individuals with cholecarciferol deficiency require higher doses of ergocalciferol. The evaluation and treatment of fat-soluble vitamin deficiency are reviewed separately
- In most people, carbonate loving meals is adequate for supplementation and is inexpensive. However, we recommend calcium citrate in patients taking proton pump inhibitors or H2 blockers or who have achlorhydria
- We suggest cholecalciferol (vitamin D3), when available, instead of ergocalciferol (vitamin D2) for calciferol supplementation
- The total intake of calcium (diet plus supplements) mustn’t routinely exceed 2000 mg/day. The safe upper limit for D is 4000 int. units daily