Calcium and Vitamin D from Shor=alls to Fractures

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1 N a t i o n a l O s t e o p o r o s i s F o u n d a t i o n Calcium and Vitamin D from Shor=alls to Fractures Taylor C. Wallace, PhD, CFS, FACN Senior Director, Science Policy and Government Rela5ons

2 Disclosures Currently employed by the Na5onal Osteoporosis Founda5on (NOF) and Na5onal Bone Health Alliance (NBHA). The data and opinions expressed during this presenta5on reflect research I have been involved with and do not reflect any official posi5on of the NOF or NBHA.

3 Presenta?on Outline Background Calcium and vitamin D intakes in the U.S. Vitamin D with calcium supplementa5on for preven5on of fractures. Final thoughts

4 Why Do We Care? 1/2 women and 1/4 men will experience an osteoporo5c fracture in their life5me. Osteoporosis has an annual cost of $19B to the U.S. healthcare system. 52 million adults 50 y have osteoporosis or LBM Osteoporosis and LBM are highly correlated with nutri?on and physical ac?vity paierns!

5 Osteoporosis and Low Bone Mass

6 Peak Bone Mass During childhood and adolescence, much more bone is deposited than withdrawn, so the skeleton grows in both size and density. ~90% of PBM is acquired by age 18 in females and age 20 in males. The amount of bone 5ssue in the skeleton can keep growing un5l around age 30. At this point bones have reached their maximum strength and density.

7 Nutri?on and Physical Ac?vity Key Nutrients to ensure bone health: Calcium Vitamin D Magnesium Phosphorus Potassium Protein Fiber

8 Dietary Guidelines for Americans The 2010 Dietary Guidelines for Americans recommend 3 c of fat- free or low- fat milk products for those 9+ y, 2.5 c for those 4-8 y and 2 c for those 3-4 y.

9 Other Food Sources of Calcium Calcium absorp5on from dairy is about 32%. Absorp5on from vegetables ranges from about 5% in spinach to 60% in broccoli. High bioavailability of calcium from some vegetables cannot overcome their low calcium content. 2 ¼ cups of broccoli = 1 cup of milk

10 Other Food Sources of Vitamin D Faiy fish (e.g. salmon and tuna) Liver UV- treated mushrooms It is extremely challenging to obtain adequate amounts of vitamin D from food sources alone.

11 Calcium and Vitamin D Intakes in the U.S.

12 NHANES Administered by CDC the survey examines a na5onally representa5ve sample of about 5,000 persons/year. Designed to assess the health and nutri5onal status of adults and children in the U.S. Interview includes demographic, socioeconomic, dietary and health- related ques5ons. Examina5on component includes medical, dental and physiological components + lab tests.

13 USDA Na?onal Nutrient Database Nutrient composi?on informa?on for over 8,000 foods. The Na?onal Cancer Ins?tute (NCI) method allows you to cross link the databases to obtain popula?on level data.

14 Dietary Reference Intakes Es?mated Average Requirement (EAR), Recommended Dietary Allowance (RDA), Adequate Intake (AI), and the Tolerable Upper Intake Level (UL)

15 Prior Es?ma?ons of Intake in the U.S. Bailey RL et al. JN 2010; 140:

16 Prior Es?ma?ons of Intake in the U.S. 43% use supplemental calcium. 37% use supplemental vitamin D. <1% obtain adequate vitamin D from food only. <10% of females and >51 y met recommended intake levels of calcium from diet alone. *This data is prior to the 2011 DRI report. Bailey RL et al. JN 2010; 140:

17 Propor?on of U.S NOT Mee?ng EAR Fulgoni VL III et al. JN 2011; 141(10):

18 Propor?on of U.S NOT Mee?ng EAR Vitamin D Calcium Naturally Occurring 100.0% 54.2% + For?fied Foods 93.3% 48.9% + Supplements 69.5% 38.0% *This data calculated from new DRI s. Fulgoni VL III et al. JN 2011; 141(10):

19 Subpopula?ons of Americans Wallace TC et al. JACN 2013; 32(5):

20 Dairy Intake in the U.S. 3 Male Female Good 2 1 Bad Dairy (cups/d) Age Range (y) Wallace TC et al. JACN 2013; 32(5):

21 Calcium Intakes Food & Supplements 71+ y y Age (Males + Females) y y y 9-13 y 4-8 y Good %<EAR Bad Wallace TC et al. JACN 2013; 32(5):

22 Vitamin D Intakes Food & Supplements Good Bad Wallace TC et al. JACN 2013; 32(5):

23 Calcium Intakes Food & Supplements 1400 Average Intake (mg/d) 1000 Good Bad Wallace TC et al. JACN 2013; 32(5):

24 Intakes of Calcium vs. Race % < EAR Adults Children Black Mexican White Good Bad Race/Ethnicity Wallace TC et al. JACN 2013; 32(5):

25 Intakes of Calcium vs. Income % < EAR Adults Children Low (<$25K) Middle ($25-50K) High (>$75K) Good Bad Household Income Level Wallace TC et al. JACN 2013; 32(5):

26 Intakes of Calcium vs. Weight % < EAR Adults Children Normal (BMI <25) Over (BMI >25, <30) Obese (BMI >30) Good Bad Weight Classification Wallace TC et al. JACN 2013; 32(5):

27 Other Important Outcomes Vitamin D intakes were not significantly different among subpopula5ons, as most were highly insufficient. There were no differences in calcium or vitamin D intakes among vegetarians vs. non- vegetarians.

28 Conclusions Certain subpopula5ons are more suscep5ble to insufficient intakes of calcium and vitamin D. ü Targeted messaging about for5fica5on and supplementa5on may be necessary. Large por5ons of the popula5on, par5cularly middle age to elderly women use calcium and vitamin D supplements for bone health.

29 Vitamin D with Calcium Supplementa?on for the Preven?on of Fractures

30 U.S. Preven?ve Services Task Force USPSTF recommends against daily supplementacon with 400 IU or less of vitamin D3 and 1,000 mg or less of calcium for the primary prevencon of fractures in non- insctuconalized postmenopausal women. hip://

31 AHRQ Meta- analysis Ann Intern Med 2011;155:

32 AHRQ Meta- analysis Ann Intern Med 2011;155:

33 2011 AHRQ Meta- analysis WHI Trial RECORD Trial Ann Intern Med 2011;155:

34 New Data from the WHI Pren?ce RL et al. Osteoporos Int. 2013; 24(2):

35 New Data from the WHI Analysis of those who did not use personal supplements at baseline and who were adherent to >80% of the study pills. 5+ y of vitamin D with calcium supplementa5on resulted in a significant 38% reduc?on in hip fractures. A 10% reduc?on in total fractures was also reported. Pren?ce RL et al. Osteoporos Int. 2013; 24(2):

36 Vitamin D with Calcium Supplementa?on for the Preven?on of Fractures An Updated Meta- analysis from the NOF Weaver C, Alexander D, Boushey C, Dawson- Hughes B, Lappe J, LeBoff M, Looker A, Wallace TC. Weaver C et al (under prepara?on)

37 Methodology Update the AHRQ meta- analysis New data including an NOF sponsored analysis of the WHI (exclude old WHI analysis). The new study looks only at the women who took 80% of their supplements. Random- effects meta- analyses were conducted to generate summary rela5ve risk es5mates for total and hip fracture. Weaver C et al (under prepara?on)

38 Total Fractures: Supp vs. Placebo Figure 1. Calcium plus vitamin D supplementation vs. placebo and total fracture Study name Rate Lower Upper ratio limit limit Chapuy et al Chapuy et al Flicker et al Komulainen et al Dawson-Hughes et al Pfeifer et al Porthouse et al (total) Salovaara et al Grant et al Harwood et al Prentice et al. 2013* Rate ratio and 95% CI Decreased Risk Increased Risk Weaver C et al (under prepara?on)

Total Fractures: Supp vs. Placebo Study name Rate Lower Upper ratio limit limit Chapuy et al. 1992 0.74 0.56 0.97 Chapuy et al. 2002 0.62 0.36 1.07 Komulainen et al. 1998 0.20 0.01 4.

39 Total Fractures: Supp vs. Placebo Study name Rate Lower Upper ratio limit limit Chapuy et al Chapuy et al Komulainen et al Dawson-Hughes et al Pfeifer et al Porthouse et al Salovaara et al Prentice et al. 2012* SRRE Rate ratio and 95% CI Decreased Risk Increased Risk * Data from their Table 6, adherence to assigned pills, no personal supplements Weaver C et al (under prepara?on)

40 Conclusions Calcium with vitamin D supplementa?on significantly reduced the risk of total and hip fractures by 16 and 31%. The findings from this quan5ta5ve assessment support the use of vitamin D with calcium supplements as an interven5on for fracture risk reduc5on in both community- dwelling and ins5tu5onalized middle aged to older adults. Weaver C et al (under prepara?on)

41 Overall Take Aways Vitamin D and calcium intakes across many subpopula5ons in the U.S. are subop5mal. It is extremely difficult to obtain recommended levels of vitamin D from food sources only. Vitamin D with calcium supplementa?on is safe and effec?ve for decreasing the risk of total and hip fractures.

Government Rela5ons Na5onal Osteoporosis Founda5on E: taylor.

42 Thank You! Taylor C. Wallace, PhD, CFS, FACN Senior Director, Science Policy & Government Rela5ons Na5onal Osteoporosis Founda5on E: E: P: C: W:

Changes in Skeletal Systems over the Lifespan. Connie M. Weaver, Ph.D. Purdue University

Changes in Skeletal Systems over the Lifespan Connie M. Weaver, Ph.D. Purdue University Disclosures Boards/Scientific Advisory Committees ILSI Showalter Pharmavite Grants NIH Dairy Research Institute Nestle