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Dr.Seeva Sivakumaran Senior Staff Specialist The Canberra Hospital 22-08-2007.

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Presentation on theme: "Dr.Seeva Sivakumaran Senior Staff Specialist The Canberra Hospital 22-08-2007."— Presentation transcript:

1 Dr.Seeva Sivakumaran Senior Staff Specialist The Canberra Hospital

2 Calcium and vitamin D: who, when, why and how much? Seeva Sivakumaran Senior Staff Specialist Aged Care & Rehabilitation Service The Canberra Hospital

3 Agenda Osteoporosis size of the problem Calcium and vitamin D in bone metabolism Osteoporosis prevention and management: the roles of calcium and vitamin D Recommended daily intakes Sources of calcium and vitamin D Targeting patients with inadequate intake Conclusions

4 The ageing population In developing countries years 30 % Over 65 years5.5 % But changes are expected…

5 “…a systemic skeletal disease characterized by low bone mass and micro-architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk.” Definition of osteoporosis World Health Organization (WHO), 1994

6 Cooper et al. Trends Endocrinol Metab 1992; 3: Men Forearm Vertebrae Hip Age (years) 4,000 3,000 2,000 1,000 Incidence per 100,000 person-years Women Forearm Vertebrae Hip Osteoporotic fracture incidence

7 normal osteoporotic Trabecular bone Bone quality is not the only factor …

8 STATISTICS OF THE SILENT EPIDEMIC SOURCE (AIHW) AUSTRALIAN INSTITUDE OF HEALTH AND WELFARE 1,014 over 65 died due to accidental falls in ,000 hospitalised due to falls 25 % Australian females & 17% men will develop osteoporosis. 1 in 2 women and 1 in 3 men over 60 will sustain an osteoporotic fracture. Of all # 46% vertebral,16% hip, 16% wrist 50% spinal # do not come to attention! 80% patients with osteoporotic # do not receive preventative RX

9 OSTEOPOROSIS PREVALENCE 2002, 1.9 million Australians had osteoporosis. 65,514 Australians hospitalised with osteoporotic # 2002 = 177 hospitalisations per day Currently a # every 8.1 minutes 2021 one # every 3.7minutes Osteoporosis: as common as hypertension. more common than hyperlidaemia allergies & the common cold.

10 MORBIDITY & MORTALITY 20% with hip # will die wihin 6 months. Death rate due to hip # is > all female cancers combined 50% patients with hip fracture require long-term nursing care. By in 3 hospital beds will be occupied by women with fractures.

11 Bone mass Bone structure Bone quality Fall Risk Impact of fall Skeletal strength Fracture risk Type of fall Energy reduction External protection Neuromuscular function Environmental risks Age Pathogenesis of fragility fractures

12 Calcium and vitamin D in bone metabolism

13 Skeletal roles of calcium & vitamin D Calcium Provides structural integrity of skeleton Everybody needs adequate calcium intake, but especially those at risk for osteoporotic fractures Vitamin D Bone mineralisation Calcium absorption from small intestine Extracellular calcium homeostasis Deficiency predicts falls in elderly women in nursing homes ANZBMS Med J Aust 2005; 182: ; OA & ANZBMS Medicine Today 2005; 6:

14 Calcium and osteoporosis

15 The role of calcium Calcium is required on a daily basis Calcium provides strength to the skeleton 1 Calcium is the substrate for bone mineralisation Skeletal mass cannot be built or maintained if calcium intake is insufficient or calcium losses are excessive 99% of calcium is located in the skeleton 2 Bone is the reservoir for calcium and replenishes extracellular fluid (ECF) losses 2 Calcium plays a role in muscular, neural and most metabolic processes 2 1. Heaney RP. Calcif Tissue Int 2002; 70: FAO/WHO expert consultation on human vitamin and mineral requirements, Update March 2002

16 FAO/WHO expert consultation on human vitamin and mineral requirements, Update March 2002; HP Kruse, Grundzüge der Osteologie, Springer Verlag 1984 Calcium balance (equilibrium) for post- menopausal women reached at intake of ~1000 mg/ day Calcium dietary intake 700 – 1000 mg/d 20-35% 100 – 300 mg/d mg/d 500 mg/d 450 – 900 mg/d Calcium homeostasis Relationship between calcium intake and calcium absorption /excretion Plasma & ECF Calcium 9.0 – 10.5 mg/100ml PTH, 1,25(0H) 2 D PTH - PTH PTH, 1,25(0H) 2 D GH, PO 4, Sex hormones, Calcitonin

17 Calcium in osteoporosis treatment Adequate calcium intake is vital 1 Most osteoporosis treatments tested with calcium supplementation (500–1000 mg/day) Moderately effective as monotherapy 1,2  BMD (approximately 1-2% over 2-3 years) Use calcium/vitamin D in institutionalised elderly to prevent non-vertebral fractures 3 1. OA & ANZBMS Medicine Today 2005;6:43-50; 2. Sambrook PN et al, Med J Aust 2002;176:S1-S15; 3. Chapuy MC et al, N Engl J Med 1992;327:

18 Sub-optimal calcium intake in Australia 87% of women 55 years and older have calcium intakes below the recommended dietary intake (Geelong Osteoporosis Study ) 1 1. Pasco J et al. Aust NZ J Med 2000; 30:

19 Sub-optimal calcium intake in Australia Mean daily calcium intake Geelong Osteoporosis Study 1 646mg/day among women aged National Nutrition Survey mg/day for females aged 65 and over 795.6mg/day for males aged 65 and over Recommendations: NHMRC : 1000mg/day for women aged 54 or over 800mg/day for males aged 64 or more ANZBMS – OA - Ca & Vit D Forum : 1000mg/day for adults 1300mg/day for people over 70 years 1. Pasco J et al. Aust NZ J Med 2000; 30: National Nutrition Survey – ABS National Health and Medical Research Council. Australian Government Publishing Service, Calcium, Vitamin D and Osteoporosis – A guide for GPs – Osteoporosis Australia – In press ► Gap of 400 – 600 mg Calcium/day

20 Calcium supplementation in Osteoporosis Chapuy et al. BMJ 1994; 308: % Patients with fractures 17%* Relative Risk Reduction 23%* Relative Risk Reduction ITT Analysis * p<0.02 Effect of calcium and vitamin D treatment for 3 years on hip fractures in elderly women 3270 mobile elderly women (mean age 84) living in nursing homes Calcium 1.2g/day (in the form of tricalcium phosphate) + Vit D3 800IU/day vs placebo

21 Calcium supplementation in Osteoporosis Evidence to demonstrate a reduction in fracture risk with increased calcium intake alone Reid I et al American Medical Journal 98: Calcium n=38 Mean age : 58+4 yrs 9+4 yrs since m’pause Placebo n=40 Mean age : 59+6 yrs 10+5 yrs since m’pause 78 postmenopausal women completed 4 years of the study

22 Adult men and women1000 mg Women over 50 yrs 1300 mg* Men over 70 yrs1300 mg* Pregnant women 1100 mg Lactating women1200 mg * Generally not feasible from diet alone Recommended calcium intake Osteoporosis Australia. Calcium, Vitamin D and Osteoporosis – A Guide for GPs 2 nd edn

23 Calcium content of common foods Osteoporosis Australia. Calcium, Vitamin D and Osteoporosis – A Guide for GPs 2 nd edn

24 Who needs more calcium? Risk factors for inadequate dietary calcium intake include: 1 old age social disadvantage malabsorption due to gastrointestinal disease corticosteroid use sex hormone deficiency. Intake < RDI for 75%-87% Australian women 2,3 Average 646 mg/day for women >55 years in Geelong Osteoporosis Study (1300 mg/day recommended) Low intakes of cereal, milk, cheese, yoghurt 4 1. OA & ANZBMS Medicine Today 2005;6:43-50; 2. Sambrook PN et al, Med J Aust 2002;176:S1-S15; 3. NHMRC 2003; 4. Jean Hailes Foundn. Med J Aust 2000; 173 Suppl 6 November: S95-S96.

25 Dietary sources of calcium Dairy foods Most readily absorbed form of calcium Main source of calcium in Australian diets RDI =  3 serves per day Calcium-enriched soy drinks Fish with bones (e.g. tinned salmon) Australian Food and Nutrition Monitoring Unit 2001; OA & ANZBMS Medicine Today 2005;6:43-50; Sambrook PN et al, Med J Aust 2002;176:S1-S15; Osteoporosis Australia. Calcium, Vitamin D and Osteoporosis – A Guide for GPs 2 nd edn RDI for older people = 1300 mg = 4.5 glasses of milk

26 Vitamin D and osteoporosis

27 Vitamin D deficiency is common Vitamin D deficiency: an emerging public health problem in Australia 1 (all over the world) Deficiency  bone pain, muscle weakness, osteoporosis, falls, fractures 1 60% of postmenopausal Australian women with osteoporosis had low serum vitamin D (<30 ng/mL) 2* * International study of 2606 postmenopausal women with osteoporosis, including 204 women from Australia 1. Osteoporosis Australia. Calcium, Vitamin D and Osteoporosis – A Guide for GPs 2 nd edn 2. Lips P et al. J Int Med 2006; 260:

28 Vitamin D is a Hormone or a Vitamin ? Vitamin D fits the definition of a Vitamin and that of a Hormone

29 HORMONE A messenger produced and secreted by specific glands or cells within the body of animals. Transported through the blood stream to designated target organs. Binds to its specific receptor delivering its message to a specific set of cells. VITAMIN A substance regularly required by the body in small amounts. The body cannot make vitamins. Must be supplied in diet. Vitamin D : A Hormone & A Vitamin


31 Regulation of calcium homeostasis and bone mineralization Promotes intestinal absorption of calcium Promotes resorption of ca++ in kidneys Mobilizes Ca from bones thereby initiating bone remodeling process at the same time promotes Ca Po4 into rachitic and osteoporotic bones Supplementary functions: Helps to regulate immune system Regulates cell differentiation and cell proliferation Works synergistically with vitamin A to induce certain cancer cells to differentiate in to normal cells and to inhibit cancer cell proliferation Classical functions of vitamin D:

32 Reduction to risk of: Osteoporosis (+ calcium supplement). Senile cataract, glucose intolerance Polycystic ovarian syndrome (+ calcium supplement). Reduced lipid peroxidation and increased enzymes protecting oxidation SAD - Seasonal affective disorder Role and association with: Infection control and inflammatory immune function Infertility Multiple sclerosis, sjogrens, rheumatoid arthritis, thyroiditis, crohns, and some cancers eg bowel, prostate, breast Activated vit D in adrenals regulate tyrosine hydroxylase the rate limiting enzyme necessary for dopamine, epinephrine and nor epinephrine production (? Schizophrenia) Misdiagnoses: Fibromyalgia (Vitamin D deficiency)

33 Early symptoms of vitamin D deficiency (Osteomalacia) Muscle pain mainly shoulder /hip girdle Recurrent falls and difficulty transferring in elderly Recurrent fractures Poor fracture healing Bone pain particularly with bisphosphonates Premature OA Mayo clinic proceedings Dec 2003 Plotnikoff GA QuicgleyJM Prabhala A Arch Intern Med 2000 Al Faraj et al Spine 2003 PfeiferM et al J Bone Miner 2000 M.Hollick Vit D Millinium Perspective J Cell Biochem 2003

34 Latitude > 45 or higher even summer sun is too weak to produce enough vitamin D CANBERRA south BRISBANE 27 south Latitude and Vitamin D

35 Factors affecting Vitamin D production on skin Season Geographic latitude Time of day Cloud /fog Sun screen Ageing skin Excess skin cover Window glass Indoor life style

36 Latitude /Vit D related diseases Multiple sclerosis Breast cancer Prostate cancer Insulin dependent diabetes Colorectal cancer Schizophrenia Heart disease Vitamin D may be more important to colon cancer prevention than previously believed Journal of the American Medical Assocition Vol 290 No 22

37 Recommended sun exposure (minutes) for moderately fair skin Time (adjust for daylight saving or pigmented skin) Dec-Jan 10:00 or 14:00 July-Aug 10:00 or 14:00 July-Aug 12:00 Cairns Brisbane Perth Sydney Adelaide Melbourne Hobart ANZBMS Med J Aust 2005; 182:

38 Point of regulation of conversion of Vit D to active form is by I hydroxylase in kidney Production of Vit D in the skin is determined by latitude Latitude higher than 30 south and north have insufficient UVB 2-6 months of the year at mid day Latitude higher than 40 has 6-8 months devoid of adequate UVB Control of production of active Vitamin D (calcitriol)


40 Who may need extra Vitamin D Infants who are exclusively Breast Fed Older adults Persons with limited sun exposure People with pigmented skin Patients with malabsorption Patients on prednisolone & thyroid supplements and those on antiepileptic Dietary supplements Fact Sheet Vit D National Inst. Of Health

41 Current Problems with Vitamin D administration Recommended Daily Allowance (RDA) is probably set too low Lab normal range is set too low Poor dietary intake -- Diet poor substitute for sun Lack of food fortification High Dose Vit D3 Not available in Australia Calcitriol available on PBS but not appropriate Many patients on bisphosphonates with no Vit D or Ca Caution – for those with sarcoidosis lymphoma renal failure but restoring physiological Vit D levels will help many more pts than it will hurt ! Vitamin D Council

42 Vitamin D supplementation Use formulations with sufficient dose: Ostelin (ergocalciferol 25 µg = D IU) Ostevit D, Blackmores Vitamin D (cholecalciferol = D IU) Ostelin Vitamin D & Calcium (cholecalciferol = D3 500 IU) Doses in calcium and multivitamin preparations too low for treatment of deficiency Cod liver oil contains vitamin A, which may increase fracture risk Dosing Supplementation: 1000 IU per day Moderate-severe deficiency: 3000–5000 IU per day for 6–12 weeks then maintenance. Check blood level at 3 months Costs approximately 24 cents/day for supplementation ANZBMS Med J Aust 2005; 182:

43 Pivotal trials – Calcium and Vit D supplementation TrialCalciumVit D Alendronate 1-3 FIT 1If daily intake <1000 mg/day – 500 mg/day – 82% of patients If daily Ca intake <1000 mg/day – 250 IU/day – 82% of patients FIT 2If daily intake <1000 mg/day – 500 mg/day – 82% of patients If daily Ca intake <1000mg/day – 250 IU/day – 82% of patients FOSIT500 mg/day - 100% of patients Risedronate 4-8 VERT-MN1000 mg/day – 100% of patientsIf <40 nmol/l up to 500 IU/day 34% of patients VERT-NA1000 mg/day – 100% of patientsIf <40 nmol/l up to 500 IU/day HIP1000 mg/day – 100% of patientsIf <40 nmol/l up to 500 IU/day 30% of patients % of patients 80+ Once-A-Week1000 mg/day – 100% of patientsIf <30 nmol/l 7% of patients CIOPrevention: 500 mg/day Treatment: 1000 mg/day – 100% of patients Prevention: NA Treatment: 400 IU/day Strontium 9,10 SOTIUp to 1000 mg/day – to maintain daily calcium intake of 1500 mg IU/day depending on baseline levels TROPOS mg/day. If daily intake <1000 mg/dayIf <45 nmol/l IU/day Ibandronate 11 BONE500 mg/day – 100% of patients400 IU/day Raloxifene 12 MORE500 mg/day – 100% of patients IU Vit D – 100% of patients 1. Black D et al. Lancet1996; 348: 1535– Cummings S et al. JAMA. 1998;280: Pols H et al. Osteoporosis Int 1999; 9:461– Reginster J-Y et al, Osteoporosis Int 2000; 11: Harris S et al, JAMA 1999; 282: McClung M et al, N Engl J Med 2001; 344: Brown J et al. Calcif Tissue Int 2002; 71: Wallach S et al. Calcif Tissue Int 2000; 67:277– Meunier P et al. N Engl J Med 2004; 350: Reginster J-Y et al. J Clin Endocrinol Metab 2005; 90: Chesnut C et al. J Bone Minera Res 2004; 19: Ettinger JAMA. 1999;282:

44 Conclusions RDI for calcium: 1000 mg/day for all adults 1300 mg/day for women >50 years & men >70 years Postmenopausal women are unlikely to receive enough calcium from diet alone Optimum calcium & vitamin D are key modifiable risk factors for osteoporosis Calcium + vitamin D is recommended for institutionalised elderly Vitamin D deficiency is a problem in Australia (World) 25-hydroxyvitamin D assay is indicated in at-risk patients Doctors should consider recommending calcium and/or vitamin D supplementation to all people taking osteoporosis medication (with exception of calcitriol) 5

45 ……….. and GOD said let there be light It is true after all !!!!! BUT LET THERE BE SOME Sun LIGHT ON THE SKIN PLEASE !





50 Thank you for your attention

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