What Healthcare Providers Need to Know About Calcium & Vitamin D

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1 What Healthcare Providers Need to Know About Calcium & Vitamin D Berdine R. Martin, PhD Department of Nutrition Science Purdue University West Lafayette, IN Disclosures Today s presentation is being sponsored by American Dairy Association North East Other Disclosures Berdine Martin speaker bureau for the American Dairy Association North East 1

Objectives Review basis for the 2011 RDA s for Ca and Vitamin D Review

for Ca absorption Summarize strategies for educating children, teens,

Lifelong Concern Peak skeletal mass achieved by ages 20-30 Adult

$fracture are to build peak bone mass early in life and to reduce bone$

2 Objectives Review basis for the 2011 RDA s for Ca and Vitamin D Review clinical research in children and teens That identify critical factors for Ca absorption Summarize strategies for educating children, teens, and parents about bone health and nutrient needs Bone Health: A Lifelong Concern Peak skeletal mass achieved by ages Adult skeleton remodeled and replaced every 10 years Growth Peak bone mass Maintenance Menopause Puberty Frailty Old Age Strategies to prevent fracture are to build peak bone mass early in life and to reduce bone loss later in life 2

3 Definitions: Nutrient Requirements Adequate Intake Recommend average daily nutrient intake level, based on experimentally derived intake levels or approximate observed nutrient intakes by a group of healthy people that are assumed to be adequate. Estimated Average Requirement (EAR) Amount of a nutrient per day that is estimated to meet the requirement of half of all healthy people in a particular life stage and gender group Recommended Dietary Allowance (RDA) Amount of nutrient intake per day considered necessary for maintenance of good health in 97.5 % of the population. Tolerable Upper Level (UL) the highest level of nutrient intake that is considered safe for and cause no side effects in 97.5% of healthy individuals in each population group. Slideshow.net 3

4 mg Ca per day 10/10/2018 Calcium Requirements During Childhood and Adolescence: EAR, RDA, and UL y 4-8 y 9-18 y Age Group EAR RDA UL Determinants of RDA s for Calcium * Studies that estimated bone accretion as a result of Ca intake using bone (DXA) measurements Studies that measured calcium retention on varying levels of calcium intake Assumption that the requirements for Vitamin D are being met A factorial method using average Ca accretion and Ca retention *IOM (Institute of Medicine) Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: The National Academies Press ( ). 4

5 IU Vitamin D per day 10/10/2018 Vitamin D Requirements During Childhood and Adolescence: EAR, RDA and UL I IU = mcg Vitamin D 600 IU = 15 mcg y 4-8 y 9-18 y Age Group EAR RDA UL Determinants of Vitamin D Requirements* Based on available literature it was assumed that serum levels of 25OHD can be used to simulate a dose response between Vitamin D intake assuming minimal sun exposure. There are studies that relate bone health to 25OHD so a relationship between Vitamin D intake and optimal bone health can be established. A serum 25OHD level of nmol/l results in maximum Ca absorption Risk of rickets increases when 25OHD levels are below 30 nmol/l *IOM (Institute of Medicine) Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: The National Academies Press. ( ) 5

6 25-hydroxy Vitamin D (25OHD) as Measure of Adequate Vitamin D Intake NOF Position Statement on Peak Bone Mass Development and Lifestyle Factors Writing Team Connie M. Weaver, lead; Catherine Gordon, Kathleen Janz, Heidi Kalkwarf, Joan Lappe, Richard Lewis, Megan O Karma, Taylor Wallace, Babette Zemel Osteoporosis International 27: ,

Bone Mass 10/10/2018 What is Peak Bone Mass? Amount of bone gained by the time a stable skeletal state has been attained Includes bone strength a. Mass b. Density c. Microarchitecture d.

7 Bone Mass 10/10/2018 What is Peak Bone Mass? Amount of bone gained by the time a stable skeletal state has been attained Includes bone strength a. Mass b. Density c. Microarchitecture d. Micro-repair mechanisms e. Geometric properties * Weaver, et al. Osteoporos Int,2016 Humananatomychart.us Dreamstime.com NOF Position on Dairy and Peak Bone Mass Peak Bone Mass Calcium A Vitamin D B Physical Activity A Most others C/D Normal BMC Accrual Suboptimal BMC Accrual Orthopedic Complications Low bone mass Osteoporosis Fracture Weaver et al., Osteoporos Int Age (years) 14 7

$30 to 50% of children have at least one fracture by the end of teenage years a 5 10% difference in PBM may result in a 25 50% difference in hip fracture rate later in life Estimated annual costs$

8 Bone Mass 10/10/2018 Why is peak bone mass important? 30 to 50% of children have at least one fracture by the end of teenage years a 5 10% difference in PBM may result in a 25 50% difference in hip fracture rate later in life Estimated annual costs exceed $131 billion for hip fractures worldwide. Bone Development Adolescence is a critical period of bone development Nearly 95% of adult bone mass is accrued by the age of 20 years Peak Bone Mass Normal BMC Accrual Suboptimal BMC Accrual Diet Sex Race Body composition Physical activity Orthopedic Complications Low bone mass Osteoporosis Fracture Weaver et al Age (years) 16 8

Camp Calcium Metabolic Studies What are calcium

Funded by NIH (NIAMS) Camp Calcium Studies 11

girls Controlled diets for 3 week metabolic balance

Calcium retention (mg/d)= Ca intake (mg/d) Urinary

9 Camp Calcium Metabolic Studies What are calcium requirements in adolescents? Funded by NIH (NIAMS) Camp Calcium Studies 11 metabolic studies, 1990 to 2010 Adolescent boys and girls Controlled diets for 3 week metabolic balance periods Urine and fecal collections pooled by 24h Calcium retention (mg/d)= Ca intake (mg/d) Urinary Ca* (mg/d) Fecal Ca (mg/d) Used Ca stable isotopes to measure absorption *adjusted for creatinine 9

% Maximum Retention 10/10/2018 Study Design Controlled diet High or Low Ca or Salt Crossover Controlled diet High or Low Ca or Salt Washout Metabolic Balance Metabolic Balance Maximal Calcium

10 % Maximum Retention 10/10/2018 Study Design Controlled diet High or Low Ca or Salt Crossover Controlled diet High or Low Ca or Salt Washout Metabolic Balance Metabolic Balance Maximal Calcium Retention as a Function of Intake Over 1 year, represents gain of 4% skeleton Intake (mg/day) Optimal calcium intake for maximal skeletal calcium retention is 1300 mg/d (RDA for adolescents) Jackman et al., AJCN,

11 Total Body Bone Gain (g/yr) 10/10/2018 Effect of Increasing Dietary Calcium intake *Ca oral absorption *Ca IV Intestine Ca Pool Bone formation Bone resorption Bone fecal Kidney V u urine Boys have higher bone accretion than girls Boys Girls Bailey et al., JBMR 14:711,

, AJCN, 84:414, 2006 Calcium retention was greater in white boys compared to white girls but the intake for maximal retention was not

12 Calcium Retention (mg/day) 10/10/2018 Camp Calcium tested whether boys require more calcium for their larger skeletons Boys matched for Tanner Stage to girls ~3.6 Braun et al., AJCN, 84:414, 2006 Calcium retention was greater in white boys compared to white girls but the intake for maximal retention was not different from girls (1140 mg/d vs 1300 mg/d) Girls Boys 171 mg/d Intake (mg/day) Boys retain 171 ± 38 mg more calcium than girls at all intakes Braun et al., AJCN, 84:414,

13 Boys vs. Girls intake *Ca oral absorption *Ca IV Intestine Ca Pool Bone formation Bone resorption Bone fecal Kidney V u urine Role of Race? Pixshark.com 13

Diet and race effects on Ca retention in adolescent girls Black White Ca Intake explained 12.3% and Race explained 13.7% Ca retention in adolescent girls Braun et al.

14 Diet and race effects on Ca retention in adolescent girls Black White Ca Intake explained 12.3% and Race explained 13.7% Ca retention in adolescent girls Braun et al. AJCN 85: , 2007 Camp Calcium Blacks Compared to Whites *Ca oral *Ca IV intake 35% Intestine 22% Ca Pool Bone formation Bone resorption 21% Bone 42% fecal Kidney V u urine 54% 14

15 Chinese American Camp Calcium 16 healthy Asian boys and 15 healthy Asian girls aged y from IL, IN, and MI. Converted residence hall into metabolic ward 15

$Estimated bone gain from our model increasing Ca intake from 800 1300 mg/d: 10 % increase in peak bone mass This could delay onset of osteoporosis by 13 years and decrease risk of fracture in$

16 Calcium retention varies by sex and race Optimal Ca intake is 1300 mg/d (RDA) Blacks acquire more bone mass than whites and boys more than girls Chinese girls require less calcium than white girls Estimated bone gain from our model increasing Ca intake from mg/d: 10 % increase in peak bone mass This could delay onset of osteoporosis by 13 years and decrease risk of fracture in postmenopausal women by 50 % Bonjour et al., Med Sport Sci 2007; 51: 64; WHO

17 Effect of dietary salt in calcium retention Metabolic balance study High (4g) vs Low(1.3g) salt/d Adolescent black and white subjects Matched for size and sexual maturity Palacios, et al. JCEM 89(4): , Results of High and Low Salt Intake Urinary Na Excretion (Mean ± SEM) Urinary Ca Excretion (Mean ± SEM) Whites Blacks Whites Whites Blacks Blacks 0.0 Low Na diet (1.3g/d) High Na diet(4 g/d Palacios, et al. JCEM 89(4): ,

Ca Retention (mg/d) 10/10/2018 450 400 Calcium retention (Mean ± SEM *) * 350 300

$05 for diet and race Why do overweight children have increased risk of fracture?$

18 Ca Retention (mg/d) 10/10/ Calcium retention (Mean ± SEM *) * Whites Blacks Low Na diet (1.3g/d) High Na diet (4 g/d) * p<0.05 for diet and race Why do overweight children have increased risk of fracture? Does obesity influence skeletal calcium accretion? Camp Calcium for overweight boys and girls 18

19 Ca Retention Increases More Across Ca Intakes with Higher BMI Percentile BMI percentile Hill, et al. JCEM 96: , 2011 Conclusions from Camp Calcium Calcium requirements set at 1300 mg/d for adolescents based on Camp Calcium data. Requirements are lower for some racial groups, especially Chinese American girls. Dietary calcium increases absorbed calcium and suppresses bone resorption without altering bone formation.. 19

20 Conclusions from Camp Calcium Dietary salt decreases Ca retention, but vitamin D status (25OHD) > 30 nmol/l has no effect. Obesity augments calcium retention but only if calcium intakes are adequate. Thus, high BMI with low calcium intake is likely partial explanation for increased childhood fracture Added Effect of Physical Activity 20

21 Total body abmd z-score 10/10/2018 Dairy and Bone Mass: An Additive Influence of Physical Activity? Flemish boys and girls ages 6-12 years Dairy consumption measured via food frequency questionnaire - Physical activity measured using accelerometry - Total body abmd measured using DXA High Dairy Low Dairy * - Results: Dairy consumption and physical activity were positively associated with abmd. The relationship between dairy and abmd was strongest in those who were more physically active Low PA High PA Sioen et al., BMC Public Health Exercise is Most Effective During Growth 89 Boys and Girls - Ages: 5-10 Tanner stage: 1 (pre-puberty). Ethnicity: 87 Caucasian, 1 Asian girl, 1 white-hispanic girl. - Anthropometrics: No difference between groups Exclusion criteria Disorders/medications that may affect bone metabolism. Chronic diseases or orthopedic problems. 20% of recommended weight. Presence of menarche. 21

Exercise Intervention: Control Group Mode: Stretching. Frequency: 3x per week.

22 Exercise Intervention: Jumping Group Mode: Jumping off 24-inch boxes. Frequency: 3x per week, 73 sessions took place. Intensity: 8x body weight. Exercise Intervention: Control Group Mode: Stretching. Frequency: 3x per week. Intensity: To the point of mild discomfort. Repetitions: 3-4 upper and lower body flexibility exercises each session. Length of stretches: sec. 22

% Change 10/10/2018 Jumpers have higher BMC at hip and spine vs controls 12 *p<0.0001 *p=0.

001 0 Fneck Area Lspine Area jumpers (n=47; green) vs controls (n=42; pink) Fuchs, Bauer & Snow,

23 % Change 10/10/2018 Jumpers have higher BMC at hip and spine vs controls 12 *p< *p= *p= Fneck Area Lspine Area jumpers (n=47; green) vs controls (n=42; pink) Fuchs, Bauer & Snow, JBMR, 2001 How can we achieve optimum Ca and Vitamin D Intake? Prudent Recommendations 3 cups of low-fat dairy product equivalents/day 300mg calcium supplement for each serving (1 c.) missed 23

Percent Calcium Absorption 10/10/2018 Calcium Bioavailability from Dairy Products 70 60 50 40 30 20 10 0 No Significant Differences Healthy white women

Estimated # Servings Content Fractional Absorbable needed to Food Serving Absorption Ca/serving = 1 c. milk (mg) (%) (mg) Milk, cheese 300 32.1 96.3 1.

24 Percent Calcium Absorption 10/10/2018 Calcium Bioavailability from Dairy Products No Significant Differences Healthy white women aged y Milk intrinsically labeled with stable Ca isotopes Nickel et al J Nutr 126: , 1996 Food sources of bioavailable calcium Calcium Estimated # Servings Content Fractional Absorbable needed to Food Serving Absorption Ca/serving = 1 c. milk (mg) (%) (mg) Milk, cheese Beans, dried Broccoli Cabbage Kale Spinach Tofu, calcium set

25 What s in your glass? Choices are great, but they can be overwhelming. This at-a-glance chart can help you understand what s in your 8 ounce glass of milk. CALORIES AND NUTRIENTS Cow s Milk Soy Almond Coconut Rice Calories Protein 8g 8g 1g <1g 1g Fat 2.5g 4.5g 2.5g 5g 2.5g Carbohydrates 12g 9g 8g 7g 23g VITAMINS AND MINERALS (% daily value) Calcium 30% 45% 45% 45% 30% Phosphorus 25% 25% NA*** NA 15% Potassium 10% 10% 1% 1% 15% Sodium 5% 4% 6% 2% 4% Riboflavin 25% 30% 30% NA NA Vitamin B-12 20% 50% 50% 50% 25% Vitamin A 10% 10% 10% 10% 10% Vitamin D 25% 25% 25% 25% 25% PRICE Per ½ Gallon $2.05 $3.37 $3.28 $4.99 $3.46 Per 8 oz Serving $0.26 $0.42 $0.41 $0.62 $0.43 What are the food sources that contain the highest and most bioavailable amount of Vitamin D? Foods that contain Vitamin D Seafood : Salmon, Herring, Sardines Canned Tuna Oysters, shrimp Eggs Mushrooms Foods that have added Vitamin D Cow s Milk, Cheese Plant based milks Soy, Almond, Coconut, Rice Cereal and oatmeal Orange Juice 25

26 mg Ca per day 10/10/2018 Do our children meet the requirements? Age and Gender Y 6-11 Y Y Age Groups Males Females Food Surveys Research Group, Dietary Data Brief No. 13, September 2014 Do our children meet the requirements? Race and Ethnicity Income Non Hispanic White Non Hispanic Black Hispanic Low Middle High Food Surveys Research Group, Dietary Data Brief No. 13, September

27 Can Supplements Make Up the Difference? Calcium Citrate vs. Carbonate Carbonate is the most common May be more better absorbed when taken with a meal Citrate more easily digested on an empty stomach Citrate larger capsules and more expensive Preferable to take low calcium supplements at several times during the day to maximize rate of absorption Sun vs. Vitamin D from Food and Supplements Sunlight source of Vitamin D is variable Seasons of year Latitude Time of Day Sunscreen, Clothing Skin pigmentation denverpost.com Vitamin D is fat soluble so consistent exposure is not necessary Obtain unprotected, non-burning, sun exposure (M. Holick) Most foods apart from fortified dairy and cereal are not desirable by children and teens Vitamin D is safe when taken in recommended amounts and likely absorbed efficiently in healthy individuals 27

Learn to read labels : the new labels include Vitamin D and actual amount of nutrients Collaborate with teachers,

28 Strategies for improving Ca and Vitamin D Status Educate children and teens about bone health a. Evaluate your diet : Computer programs, validated FFQ b. Evaluate foods for Calcium and Vitamin D c. Learn to read labels : the new labels include Vitamin D and actual amount of nutrients Collaborate with teachers, nutritionists and dietitians to develop resources for educating children, teens and parents. Educate parents about consequences of failure to reach peak bone mass during growth 28

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