all elderly patients should receive calcium and vitamin d latana munang
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All elderly patients should All elderly patients should receive Calcium and receive Calcium and
Vitamin DVitamin D
Latana MunangLatana Munang
FunctionFunction
CalciumCalcium Structure Structure
Bones & teethBones & teeth Cell signallingCell signalling
Vasoconstriction & Vasoconstriction & vasodilationvasodilation
Nerve impulseNerve impulse Muscle contractionMuscle contraction
Co-factor enzymeCo-factor enzyme Coagulation Coagulation
cascadecascade
Vitamin DVitamin D Calcium metabolismCalcium metabolism Cell differentiationCell differentiation Immune system Immune system
modulatormodulator T CellsT Cells MacrophagesMacrophages
Blood pressure Blood pressure regulationregulation
Calcium homeostasis
Vitamin D
25 OH Vit D
(inactive)
1,25 (OH)2 Vit D3
(active)
Vitamin D 25-
hydroxylase
25 OH Vitamin D
1-α-hydroxylase
PTH
Serum calcium
↑ Bone resorption
↑Calcium & phosphate absorption
Adequate Intake (AI) for Vitamin D
Life Stage Age Males
mcg/day (IU/day)
Femalesmcg/day (IU/day)
Infants 0-6 months 5 mcg (200 IU) 5 mcg (200 IU)
Infants 7-12 months 5 mcg (200 IU) 5 mcg (200 IU)
Children 1-3 years 5 mcg (200 IU) 5 mcg (200 IU)
Children 4-8 years 5 mcg (200 IU) 5 mcg (200 IU)
Children 9-13 years 5 mcg (200 IU) 5 mcg (200 IU)
Adolescents 14-18 years 5 mcg (200 IU) 5 mcg (200 IU)
Adults 19-50 years 5 mcg (200 IU) 5 mcg (200 IU)
Adults 51-70 years 10 mcg (400 IU) 10 mcg (400 IU)
Adults71 years and older
15 mcg (600 IU) 15 mcg (600 IU)
Pregnancy all ages - 5 mcg (200 IU)
Breastfeeding all ages - 5 mcg (200 IU)
Adequate Intake (AI) for Calcium
Life Stage Age Males
(mg/day) Females
(mg/day)
Infants 0-6 months 210 210
Infants 7-12 months 270 270
Children 1-3 years 500 500
Children 4-8 years 800 800
Children 9-13 years 1,300 1,300
Adolescents 14-18 years 1,300 1,300
Adults 19-50 years 1,000 1,000
Adults 51 years and older 1,200 1,200
Pregnancy 18 years and younger - 1,300
Pregnancy 19 years and older - 1,000
Breastfeeding
18 years and younger - 1,300
Breastfeeding
19 years and older - 1,000
Calcium contentCalcium content
8-ounce glass of milk 8-ounce glass of milk 300 mg 300 mg 2 ounces of Swiss cheese 2 ounces of Swiss cheese 530 mg 530 mg 6 ounces of yogurt6 ounces of yogurt 300 mg300 mg 2 ounces of sardines with bones 2 ounces of sardines with bones 240 mg240 mg 6 ounces of cooked turnip greens 6 ounces of cooked turnip greens 220 mg220 mg 3 ounces of almonds 3 ounces of almonds 210 mg210 mg
Should all elderly people be given Calcium and Vitamin D supplements?
NHANES IIINHANES IIICalciumCalcium
MaleMale FemaleFemale
nn 24322432 25702570
Non
-sup
ple
men
t N
on
-sup
ple
men
t u
sers
use
rs
Die
t on
lyD
iet o
nly
Mean (mg)Mean (mg) 735 735 ± 11± 11 582 582 ± 11± 11
Median (mg)Median (mg) 690 690 ± 13± 13 523 523 ± 13± 13
Below standard Below standard (%)(%)
7575 8787
Su
pp
lem
en
t use
rsS
up
ple
men
t use
rs
Die
t on
lyD
iet o
nly
Mean (mg)Mean (mg) 789 789 ± 15± 15 632 632 ± 11± 11
Median (mg)Median (mg) 716 716 ± 28± 28 590 590 ± 12± 12
Below standard Below standard (%)(%)
7070 8787
Com
bin
ed
C
om
bin
ed
in
take
inta
ke
Mean (mg)Mean (mg) 909 909 ± 23± 23 864 864 ± 16± 16
Median (mg)Median (mg) 819 819 ± 36± 36 747 747 ± 16± 16
Below standard Below standard (%)(%)
6060 6666
Ervine RB, Kennedy-Stephenson J. Mineral Intakes of Elderly Adult Supplement and Non-Supplement Users in the Third National Health and Nutrition Examination Survey. J Nutr 2002; 132 (11): 3422-7
Vitamin D insufficiencyVitamin D insufficiency
Systematic review of post-menopausal Systematic review of post-menopausal women with & without osteoporosiswomen with & without osteoporosis
30 studies Jan 1994 – Apr 200430 studies Jan 1994 – Apr 2004 Community living 1.6%Community living 1.6% Institutionalised 86%Institutionalised 86% Osteoporotic women 12.5% - 76%Osteoporotic women 12.5% - 76% History of fracture(s) 50% - 70%History of fracture(s) 50% - 70%
Gaugris S, Heaney RP, Boonen S, Kurth H, Bentkover JD, Sen SS. Vitamin D inadequacy among post-menopausal women: a systematic review. QJM 2005; 98(9): 667-76
Cumulative hazard for falls Cumulative hazard for fractures
Calcium & Vit D Calcium & Vit D supplementationsupplementation
Flicker L, MacInnis RJ, Stein MS, et al. Should older people in residential care receive vitamin D to prevent falls? Results of a randomized trial. Journal of the American Geriatrics Society 2005; 53(11): 1881-8
RECORD TrialRECORD Trial
Grant AM, Anderson FH, Avenell A, et al. Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (Randomised Evaluation of Calcium or Vitamin D, RECORD): a randomised, placebo-controlled trial. Lancet 2005; 365 (9471): 1621-1628
Cochrane Systematic Cochrane Systematic ReviewReview
38 trials38 trials Vit D vs. placebo/no treatmentVit D vs. placebo/no treatment
No evidence for annual injection of vit D in No evidence for annual injection of vit D in preventing hip or other osteoporotic fracturespreventing hip or other osteoporotic fractures
No evidence for oral vit D either as a 4-monthly No evidence for oral vit D either as a 4-monthly bolus dose of 100,000 IU or daily doses up to 830 bolus dose of 100,000 IU or daily doses up to 830 IU IU
Further studies indicated with doses of Further studies indicated with doses of ≥≥800 IU 800 IU daily in very high risk populations with low sunlight daily in very high risk populations with low sunlight exposure, such as people in nursing homesexposure, such as people in nursing homes
Avenell A, Gillespie WJ, Gillespie LD, O'Connell DL. Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis. Cochrane Database of Systematic Reviews 2005, Issue 3
Vit D + calcium vs. placebo/no treatmentVit D + calcium vs. placebo/no treatment 700-800 IU vit D3 + 1000 mg calcium reduces the 700-800 IU vit D3 + 1000 mg calcium reduces the
incidence of hip fractures and all non-vertebral incidence of hip fractures and all non-vertebral fracturesfractures
Statistically significant effect seen in pooled data Statistically significant effect seen in pooled data from institutionalised participants, but not in those from institutionalised participants, but not in those living in the community. living in the community.
No evidence that people with a prior fracture No evidence that people with a prior fracture history, irrespective of age, benefit in respect of history, irrespective of age, benefit in respect of hip fracture incidence from vitamin D and calciumhip fracture incidence from vitamin D and calcium
AlfacalcidolAlfacalcidol 3 small trials, same author, evidence inconclusive3 small trials, same author, evidence inconclusive
CalcitriolCalcitriol Benefit unclear, increased risk of hypercalcaemiaBenefit unclear, increased risk of hypercalcaemia
SIGN GuidelinesSIGN Guidelines
In frail, elderly women (aged 80+ In frail, elderly women (aged 80+ years) with a diagnosis of years) with a diagnosis of osteoporosis, with or without osteoporosis, with or without previous osteoporotic fracturesprevious osteoporotic fractures To reduce hip fracture risk, frail elderly To reduce hip fracture risk, frail elderly
women who are housebound should women who are housebound should receive oral calcium (1000-1200 IU daily receive oral calcium (1000-1200 IU daily + 800 IU Vitamin D)+ 800 IU Vitamin D)