Calcium and Vitamin D supplementation

1. Calcium and Vitamin D supplementation Dr Hasmukh Gala SevenHills Hospital

2. Calcium 99% of calcium present in bone and teeth Less than 1% of calcium present in blood, intracellular fluid & muscle Serum calcium is tightly regulated Body uses bone as a reservior for, and as a source of calcium to maintain constant concentrations of calcium in blood, muscle & intracellular fluids

3. Calcium Metabolism Bone undergoes continuous remodeling with constant resorption & deposition of calcium The process of bone resorption and formation changes with age Formation > resorption in period of growth in children & adolescent Resorption > Formation in aged individual & post-menopausal women; increasing risk of osteoporosis

4. Role 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.

5. Food sources of calcium

6. Food sources of Calcium Dairy 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 calcium

9. Recommended Daily Allowancesof Calcium

10. Calcium absorption About 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

11. 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 meals

12. Calcium deficiency Inadequate intake of dietary calcium does not produce any short term adverse effect Over long term, inadequate calcium intake causes osteopenia and ultimately, osteoporosis. Calcium deficiency can also cause rickets, though it mainly results from vitamin D deficiency Blood calcium is tightly regulated and hypocalcemia results mainly from medical conditions or treatment

13. Osteoporosis

14. Bone health and osteoporosis Increase 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 age

15. Bone health & Osteoporosis Therefore, everyone should consume adequate amount of calcium and vitamin D throughout childhood, adolescence and early adulthood Other risk factors for osteoporosis are being female, thin, inactive, cigarette smoking, excessive intake of alcohol & family history of osteoporosis

16. Osteoporosis Weight 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

17. Hypocalcemia In newborn period- prematurity, asphyxia, infants of diabetic mother & IUGR babies- due to transient hypoparathyroidism and delayed intake of milk In infancy- intake of cow’s milk- due to high phosphorus content of cow’s milk, which has 956 mg/L of Phosphorus.

18. Hypocalcemia- Causes Hypoparathyroidism Lack of response to PTH Vitamin D deficiency Hyperphosphetemia Inadequate intake of calcium Blood transfusion- Particularly multiple transfusion and exchange transfusion in neonate

19. Symptoms of hypocalcemia Mild hypocalcemia is usually asymptomatic Parasthesias, muscle cramps, lethargy, poor apetite, Tetany, Seizure Tetany- Carpopedal spasm, seizure, laryngospasm In infants- seizure may be the first manifestation- brief, recurrent, usually generalised In neonates- tremors, jitteriness, lethargy, seizure

20. Carpopedal Spasm

21. Treatment of Hypocalcemia Symptomatic 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 calcium Gradually switch to oral calcium preparation once symptoms resolves

22. Treatment of hypocalcemia Hypocalcemia in infants fed with cow’s milk is due to hyperphosphetemia Infant formula contains more phosphorus than breast milk Therapy is to lower serum phosphorus and provide calcium supplementation Oral calcium supplement given along with milk feeds helps in decreasing phosphorus absorption and lowering serum phosphorus

23. Oral Calcium Supplement Starting dose is 50 mg/kg/ day Various enteral preparations Calcium Carbonate- 400 mg Ca/ gm Calcium Glubionate- 64 mg Ca/ gm Calcium Gluconate- 90 mg Ca/ gm Calcium citrate- 210 mg Ca/gm Calcium lactate- 130 mg/gm

24. Calcium supplements Calcium 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 calcium

25. Needs Calcium supplements If child is on corticosteroids, isonazide or anticonvulsant Has milk allergy Very low birth weight babies Low intake of dietary calcium bellow RDA

26. Tolerable upper level intake for calcium

27. High intake of calcium High 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 stone

28. Hypercalcemia Increased serum ionised calcium level Rarely results from dietary or supplemental calcium intake Hyperparathyroidism, hypervitaminosis D, excess calcium intake Increased release from bone- hypervitaminosis A, thyrotoxicosis, renal osteodystrophy, immobilisation Mild (<12 mg/dl), moderate (12-15 mg/dl) or severe (>15 mg/dl)

29. Hypercalcemia Mild to moderate- most patients are asymptomatic Symptoms- vomitting, failure to thrive, pancreatitis, lethargy, hypotonia, coma, psychiatric disturbances, polyuria, nephrolithiasis, renal failure

30. Calcium supplement and MI Calcium supplement might increase risk of MI People who need more calcium should first and foremost try to up the dietary intake of this mineral Concluded that calcium supplements should be taken with caution Dr Kuanrong Li, Heart, June 2012

31. Osteopenia of Prematurity Total of 30 g of Ca accumulates in fetus, most of it during third trimester Low maternal Ca intake can cause lower bone mass in neonates Vitamin 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

32. Osteopenia of Prematurity (OOP) Osteopenia of prematurity is mainly due to Ca & Phosphurus deficiency rather than Vit D deficiency All infants with birth weight <1500 g should receive fortified human milk or preterm formula After hospital discharge, these infants should receive preterm formula (with high mineral content) or additional Calcium and Phosphurus supplementation in breast fed babies

33. Osteopenia of Prematurity

34. Prevention of OOP All babies < 1500 gm should receive 100-160 mg/kg/day of Ca, 60- 75 mg/kg/day of P, 400 IU/ day of vitamin D They should be screened for OOP by biochemical tests (Ca, P, ALP), x-ray, DEXA scan

35. Vitamin D Helps in calcium absorption from GI tract Helps in maintaining adequate S Ca and P level for adequate mineralization of bone Maintains bone growth and bone remodeling by osteoblast and osteoclast

36. Sources of vitamin D

37. Sources of vitamin D Sun exposure Flesh of fatty fish (Salmon, Tuna, Meckerel) Fish liver oil Cheese & egg yolk Some mushrooms Vitamin D fortified foods

38. Recommended dietary allowances for vitamin D

39. Sun Exposure Approximately 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 production Individuals with limited sun exposure has to take good sources of vitamin D in the diet or take supplement to achieve recommended level of intake

40. Sun Protection

41. Sun Protection

42. Pigmentation

43. Cloud cover

44. Sunlight through glass

45. Shade

46. Serum 25-Hydroxtvitamin D conc.

47. Vitamin D content

48. Vitamin D deficiency Can 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 cancer

49. Vitamin D deficiency Vitamin D deficiency causes rickets in children and osteomalaciain adults Rickets- failure of bone tissue to properly mineralise leading to soft bones and skeletal deformity Hypocalcemictetany occasionally accompanies rickets, especially in prolong unrecognized vitamin D deficiency

50. Vitamin D supplementation Breast fed infants Should receive vitamin D supplement 400 IU/day starting from first few days after birth People with limited sun exposure Dark skin individuals Fat malabsorption Obese individual with BMI > 30