Today's blog is regarding the recent BMJ article concluding that calcium supplementation does not decrease fracture rates in men and women above age 50.
Readers should be aware that there are many limitations in this article and it may not be appropriate to increase/decrease your daily calcium goals based on whats reported here. I will not detail these limitations, but my take home message to all of you is: not every man or woman above age 50 needs calcium supplementation, but in SOME people extra calcium might be necessary for fracture prevention. You should work with your doctor to find out what's the right dose for you.
There are so many factors involved when deciding how much calcium a person needs daily -- and I always believed that recommending one target dose for all men and women above age 50 is not ideal! This is why I am a firm believer in individualizing treatment plans, and hopefully I can convince some of you to do the same.
I liked this article because it proves to me the importance of "patient centered" medicine -- choosing therapies based on the individual patient & less based on guidelines. I try to practice this with my patients as often as possible because every patient or disease is not created equal.
Some women above age 50 may need 1200 mg of total calcium daily, and some may need only 800 mg. The difficult problem is figuring out how much calcium each individual actually needs every day.
You may be wondering why women over age 50 have higher calcium requirements per the guidelines (~1200 mg daily) -- its because after menopause women make less estrogen and without estrogen there is increased bone loss. Some post-menopausal women are able to keep up with their bone loss by drinking a few glasses of milk a day, but others might depend on calcium pills to prevent bone loss that can eventually lead to osteoporosis and/or fractures. Our goal as a provider is to identify which patient needs what type of intervention and how aggressive we need to be with calcium recommendations.
Rather than following guidelines, I would suggest tailoring a patient's calcium needs by looking at the patient's overall clinical picture which incorporates some of the factors listed below.
My recommendations are only for those with normal calcium, normal vitamin d, and normal calcium excretion.
Here are some factors to take into consideration when deciding on a target daily calcium goal (this is only a partial list):
- underlying medical conditions (such as conditions causing lack of absorption of nutrients and minerals (like Celiac Disease), Hyperthyroidism, Inflammatory Bowel Disease...just to name a few)
- fracture history
- family history of osteoporosis or hip fracture (especially when diagnosed before age 50)
- social habits (smoking and excessive alcohol intake are risk factors for bone loss)
- diet (especially in patients with lactose intolerance who take minimal dairy)
- lack of exercise
- medications (like steroids which cause bone loss)
- bone density scan results
- low body weight
First we must attempt to fix the modifiable risk factors (i.e. lack of exercise, tobacco use, excessive alcohol intake, use of certain medications, low body weight, etc.).....and then we should figure out how much daily calcium (through diet and/or pills) is appropriate for the individual (if any).
For those who do not have the conditions described above, one can determine whether or not a person's daily calcium goal is adequate, by measuring 24 hour urine calcium and creatinine. My Endocrinologist colleagues use this often to determine whether or not calcium intake is too high, too low, or just right. Remember this test can ONLY be used in patients who have no medical conditions or risk factors (like medications) associated with hypercalciuria or hypocalciuria (see above).
When I evaluate a 24 hr urinary calcium, I consider values >300 mg/day in women and >250 mg/day in men as high.
A high 24 hour urinary calcium can suggest that a patient's daily calcium goal is too high--i.e. they are either consuming too much dairy, being over-supplemented with calcium tablets, or both. Remember too much calcium in the urine is also a risk factor for developing kidney stones!
If a patient has high levels of calcium in the urine, I would recommend a lower daily goal for calcium depending on the level of hypercalciuria.
If a patient has low levels of calcium in the urine, I would first check 25- Hydroxyvitamin D levels to ensure there is no issues with calcium absorption. If 25- Hydroxyvitamin D levels are normal, only then would I recommend a higher daily goal for calcium depending on the level of hypocalciuria. If 25-Hydroxyvitamin D levels are low, we must fix this number first before advising more calcium intake (since vitamin d is necessary for calcium absorption).
Once a change is made in the daily calcium dose, urine studies should be monitored every 1-2 months with dosing adjustments until the urine calcium levels are normal. If you ever have questions about this, feel free to refer your patient to an Endocrinologist (we specialize in bone disease!)
There are so many factors involved when deciding how much calcium a person needs daily -- and I always believed that recommending one target dose for all men and women above age 50 is not ideal! This is why I am a firm believer in individualizing treatment plans, and hopefully I can convince some of you to do the same.
I liked this article because it proves to me the importance of "patient centered" medicine -- choosing therapies based on the individual patient & less based on guidelines. I try to practice this with my patients as often as possible because every patient or disease is not created equal.
Some women above age 50 may need 1200 mg of total calcium daily, and some may need only 800 mg. The difficult problem is figuring out how much calcium each individual actually needs every day.
You may be wondering why women over age 50 have higher calcium requirements per the guidelines (~1200 mg daily) -- its because after menopause women make less estrogen and without estrogen there is increased bone loss. Some post-menopausal women are able to keep up with their bone loss by drinking a few glasses of milk a day, but others might depend on calcium pills to prevent bone loss that can eventually lead to osteoporosis and/or fractures. Our goal as a provider is to identify which patient needs what type of intervention and how aggressive we need to be with calcium recommendations.
Rather than following guidelines, I would suggest tailoring a patient's calcium needs by looking at the patient's overall clinical picture which incorporates some of the factors listed below.
My recommendations are only for those with normal calcium, normal vitamin d, and normal calcium excretion.
Here are some factors to take into consideration when deciding on a target daily calcium goal (this is only a partial list):
- underlying medical conditions (such as conditions causing lack of absorption of nutrients and minerals (like Celiac Disease), Hyperthyroidism, Inflammatory Bowel Disease...just to name a few)
- fracture history
- family history of osteoporosis or hip fracture (especially when diagnosed before age 50)
- social habits (smoking and excessive alcohol intake are risk factors for bone loss)
- diet (especially in patients with lactose intolerance who take minimal dairy)
- lack of exercise
- medications (like steroids which cause bone loss)
- bone density scan results
- low body weight
First we must attempt to fix the modifiable risk factors (i.e. lack of exercise, tobacco use, excessive alcohol intake, use of certain medications, low body weight, etc.).....and then we should figure out how much daily calcium (through diet and/or pills) is appropriate for the individual (if any).
The only issue here is that not every person we deem as high risk, requires a higher level of calcium. This is why the next step is so important.
Before following the next step please make sure that the person does not have a condition associated with hypercalciuria (too much calcium in the urine) or hypocalciuria (too little calcium in the urine) -- since these patients will have abnormal urine calcium amounts independent of supplementation. Some of these conditions include kidney disease (specifically kidney stones), problems with the parathyroid gland, certain medications (like Lasix), etc. If your patient has a medical condition associated with hypocalciuria or hypercalciuria, they should be seen by an endocrinologist (a specialist in bone and calcium) or a nephrologist (a specialist in the kidney).
For those who do not have the conditions described above, one can determine whether or not a person's daily calcium goal is adequate, by measuring 24 hour urine calcium and creatinine. My Endocrinologist colleagues use this often to determine whether or not calcium intake is too high, too low, or just right. Remember this test can ONLY be used in patients who have no medical conditions or risk factors (like medications) associated with hypercalciuria or hypocalciuria (see above).
When I evaluate a 24 hr urinary calcium, I consider values >300 mg/day in women and >250 mg/day in men as high.
A high 24 hour urinary calcium can suggest that a patient's daily calcium goal is too high--i.e. they are either consuming too much dairy, being over-supplemented with calcium tablets, or both. Remember too much calcium in the urine is also a risk factor for developing kidney stones!
If a patient has high levels of calcium in the urine, I would recommend a lower daily goal for calcium depending on the level of hypercalciuria.
If a patient has low levels of calcium in the urine, I would first check 25- Hydroxyvitamin D levels to ensure there is no issues with calcium absorption. If 25- Hydroxyvitamin D levels are normal, only then would I recommend a higher daily goal for calcium depending on the level of hypocalciuria. If 25-Hydroxyvitamin D levels are low, we must fix this number first before advising more calcium intake (since vitamin d is necessary for calcium absorption).
Once a change is made in the daily calcium dose, urine studies should be monitored every 1-2 months with dosing adjustments until the urine calcium levels are normal. If you ever have questions about this, feel free to refer your patient to an Endocrinologist (we specialize in bone disease!)
So with that.....I will end this by saying -- use guidelines for guidance only, don't let them dictate your care! Individualize patient care by treating every one of your patients differently.....it could lead to better outcomes.
Hope this information helps! Please feel free to email me at DoctorDeenaMD@gmail.com or ask/follow me on Twitter @Doctor_Deena
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