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)