Jagoda JorgaJagoda JorgaProfesorProfesor

Specijalista za ishranuSpecijalista za ishranuMedicinski fakultet BeogradMedicinski fakultet Beograd

I Kongres o dijetetskim suplementima, 16.3.2007., SC, BG

SuplementacijaSuplementacija kalkalccijumaijuma-- mitmit iliilipotrebapotreba zasnovanazasnovana nana činjenicama?činjenicama?

ArhitekturaArhitektura kostijukostiju

Normalna kost

Osteoporotična kostNational Osteoporosis Foundation, http://www.nof.org/osteoporosis/bonehealth.htm

PreventibilniPreventibilni faktorifaktori rizikarizika

Ubedljivi dokaziUbedljivi dokaziNeaktivNeaktivnostnostKalcijumKalcijumVitamin DVitamin DAlkoholAlkohol (> 7 pica/(> 7 pica/nedeljnonedeljno))Mala telesna težinaMala telesna težina

Veoma verovatni Veoma verovatni Unos Unos vovoćća i a i povrpovrććaaUnois proteinaUnois proteinaZn,Cu,Mn,Bo,K,Na Vitamin Zn,Cu,Mn,Bo,K,Na Vitamin A, C,K,BA, C,K,B

WHO: Diet, Nutrition and the prvention of Chronic Diseases, 2003

Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis:http://www.surgeongeneral.gov/library/bonehealth

OsteoporozaOsteoporoza i i pikpik kokošštanetane masemase

PikPik se se dostidostižže e sredinomsredinomtretrećće e dekadedekade žživotaivota..

NakonNakon platoa,poplatoa,poččinjeinjegubitakgubitak kostikosti ((okooko 0.3% do 0.3% do 0.5% 0.5% godigodiššnjenje))

Sa Sa menopauzommenopauzom,,žženeenegubegube 3% to 5% 3% to 5% kokošštanetanemasemase godigodiššnjenje

Adapted from Scientific American Online, April 2002

5 5 korakakoraka do do zdravihzdravih kostijukostiju

Promena loših navika

Testiranje koštane gustine & lekovi

Fizička aktivnost

Regularno sunčanje

Optimalnaishrana

Kakva je to ishrana dobra za Kakva je to ishrana dobra za kosti kosti -- teoretskiteoretski

ŠŠta je u praksi?ta je u praksi?

KorakKorak 1. 1. IshranaIshrana dobra dobra zaza kostikosti

IshranaIshrana bogatabogata kalcijumomkalcijumom & & vitaminomvitaminom DD

2 2 –– 4 4 porcijaporcija mleka/mlemleka/mleččnihnihproizvodaproizvodaHranaHrana obogaobogaććenaena kalcijumomkalcijumom

SuplementiSuplementi kalcijuma/vitaminakalcijuma/vitamina DD

HranaHrana bogatabogata drugimdrugimnutrijentimanutrijentima vavažžnimnim zaza kostkost

5 i vi5 i višše e porcijaporcija povrpovrćća & a & vovoćća a KalijumKalijum, , magnezijummagnezijum, , cinkcink, , bakarbakarVitamin K & vitamin CVitamin K & vitamin C

HranaHrana bogatabogata kalcijumomkalcijumom

MlekoMleko, , jogurtjogurt, , tvrditvrdi staristarisirevisireviHranaHrana obogaobogaććenaenakalcijumomkalcijumom ??

Tofu Tofu pravljenpravljen sasa kalcijumkalcijumsulfatomsulfatomSardine i Sardine i drugedruge riberibe sasakostimakostima

SadrSadržžajaj kalcijumakalcijuma u nekim u nekim namirnicimanamirnicima

Hrana Kalcijum

1 čaša nemasnog jogurta 400 mg

1 čaša vocnog jogurta 315 mg

1 čaša nemasnog mleka 300 mg

1 čaša čokoladnog mleka (1%)

285 mg

50 g masnog kačkavalja 300 mg

½ čaše pudinga 150 mg

½ čaše sladoleda 80 mg

½ čaše sremskog sira 75 mg

Dostupnost namirnica po glavi stanovnika na Dostupnost namirnica po glavi stanovnika na našem prostoru u kg/godnašem prostoru u kg/god

2679267927782778kcalkcal

23.523.526.226.215.715.719.219.2ŠŠeeććer i koncentratier i koncentrati

25.725.724.024.015.415.414.414.4MasnoMasnoććee

162.6162.6155.6155.6104.0104.084.484.4MlekoMleko7.57.56.16.19.29.26.26.2JajeJaje

2.02.02.32.33.43.41.71.7RibaRiba

77.977.984.284.252.252.246.746.7MesoMeso

62.562.579.879.846.546.533.633.6VoVoććee

116.0116.099.599.5110.5110.5108.8108.8PovrPovrććee

145.1145.1157.2157.2158.1158.1178.6178.6ŽŽitariceitarice

20022002200120011997199719931993NamirniceNamirnice

* Source: FAOSTAT, http//apps.fao.org

445 ml < 2 šolje

UnosUnos mlekamleka i i mlemleččnihnih proizvodaproizvoda u u SrbijiSrbiji

Glasnik Inst zašt zdr Srb, 2002, 1-2:39-47

UnosUnos mlekamleka popo dobnimdobnim grupamagrupama

Glasnik Inst zašt zdr Srb, 2002, 1-2:39-47

SvakodnevniSvakodnevni unosunos pojedinihpojedinihnamirnicanamirnica u u SrbijiSrbiji

Glasnik Inst zašt zdr Srb, 2002, 1-2:39-47

PreporukePreporuke

PravilnaPravilna ishranaishrana i i balansiranabalansirana dijetadijeta sasa adekvatnimadekvatnimunosomunosom kalorijakalorija susu važnevažne zaza normalannormalan razvojrazvoj kostijukostiju. . KalcijumKalcijum jeje najvažnijinajvažniji nutrijentnutrijent zaza postizanjepostizanjekvalitetnekvalitetne koštanekoštane masemase. . ZZa a odrasleodrasle osobeosobe do 65 do 65 godinagodina 1000 mg Ca/1000 mg Ca/dandanZZa a starijestarije osobeosobe i i ženežene u u postmenopauzipostmenopauzi kojekoje neneprimajuprimaju hormonskuhormonsku terapijuterapiju preporučujepreporučuje se se 1500 mg Ca/1500 mg Ca/dandanMinumumMinumum dnevnogdnevnog unosaunosa kalcijumakalcijuma jeje 400 mg/400 mg/dandan

Delmas PD. Treatment of postmenopausal osteoporosis. Lancet 359:2018-2026; 2002

Granice unosa kalcijumaGranice unosa kalcijuma

Minimum 400 Minimum 400 –– 500 500 mg/danmg/dan

Maksimum Maksimum 2500 mg/2500 mg/dandan

WHO, 2003; 1998 National Academy of Sciences

KoKo jeje kandidatkandidat zaza stalnustalnusuplementacijusuplementaciju kalcijumomkalcijumom??

IntolerancijaIntolerancija nana laktozulaktozu iliili alergijaalergija nanamlekomlekoOni koji nOni koji ne e volvole e i i nene unosunosee mleko/mlemleko/mleččneneproizvodeproizvodeOsobe koje su nOsobe koje su na a dijetamadijetama zaza mrmrššavljenjeavljenjePost Post StarijiStariji odod 5050Na Na dugotrajnojdugotrajnoj steroidnojsteroidnoj terapijiterapiji....

Rane studije

Kralj Gustav III

Kafa je otrov !

Cilj ispitivanjaCilj ispitivanja : dokazati da je kafa : dokazati da je kafa otrovna, letalni ishodotrovna, letalni ishodMonitoriMonitori: studiju pratila dva lekara: studiju pratila dva lekaraRezultat studijeRezultat studije

ZaključakZaključak““kralj ne treba da se meša u kliničke kralj ne treba da se meša u kliničke studijestudije””

•Ispitivana grupaosuđenik pije kafu svaki dan

•Ispitivana grupaosuđenik pije kafu svaki dan

•Kontrolna grupaosuđenik pije čaj svaki dan

•Kontrolna grupaosuđenik pije čaj svaki dan

Da li je medicina zasnovana na dokazima Da li je medicina zasnovana na dokazima izmenila pristup lečenju?izmenila pristup lečenju?

Stari svetStari svet::-- sve što je bilo potrebno sve što je bilo potrebno

lekarima “lekarima “bilo je u njihovoj glavibilo je u njihovoj glavi””-- naučne studije bile su naučne studije bile su

marginalne u odnosu na marginalne u odnosu na kliničku praksukliničku praksu

Novi svetNovi svet::-- lekari koriste nove informacije lekari koriste nove informacije

konstantnokonstantno-- naučne studije i praktični pristup su naučne studije i praktični pristup su

povezanipovezani

Medicina zasnovana na dokazimaMedicina zasnovana na dokazima

Razumna upotreba najboljih dostupnih Razumna upotreba najboljih dostupnih dokaza u cilju donošenja odluke o dokaza u cilju donošenja odluke o

individualnoj terapiji bolesnikaindividualnoj terapiji bolesnika

ReferenceReference

National Academy of Science Institute of Medicine (1999) National Academy of Science Institute of Medicine (1999) Dietary Reference Intakes for Calcium, Phosphorus, Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D & Fluoride. National Academy Magnesium, Vitamin D & Fluoride. National Academy Press, Washington, D.C. Press, Washington, D.C. http://www.nap.edu/catalog/5776.htmlhttp://www.nap.edu/catalog/5776.htmlNational Osteoporosis Foundation, National Osteoporosis Foundation, http://www.nof.org/http://www.nof.org/NIH Osteoporosis & Related Bone Disease National NIH Osteoporosis & Related Bone Disease National Resource Center, Resource Center, http://www.osteo.org/http://www.osteo.org/USDA Nutrient Data Laboratory, USDA Nutrient Data Laboratory, http://www.nal.usda.gov/fnic/foodcomp/http://www.nal.usda.gov/fnic/foodcomp/

Calcium Supplementation on Bone Loss Calcium Supplementation on Bone Loss in Postmenopausal Womenin Postmenopausal Women

SheaShea, B et al, B et al..Cochrane Database Cochrane Database SystSyst Rev 2004; Rev 2004; CD004526CD004526..MetaMeta--analysis of randomized trials in analysis of randomized trials in postmenopausal women, representing 1806 postmenopausal women, representing 1806 participantsparticipantsCalcium was more effective than placebo in Calcium was more effective than placebo in reducing rates of bone loss after two or more reducing rates of bone loss after two or more years of treatment years of treatment There was a trend toward reduction in vertebral There was a trend toward reduction in vertebral fractures, but it was not clear whether calcium fractures, but it was not clear whether calcium reduced the risk of nonreduced the risk of non--vertebral fracturesvertebral fractures

Calcium Supplementation in Calcium Supplementation in Postmenopausal WomenPostmenopausal Women

CHERYL A. FLYNN, American Family Physician, June CHERYL A. FLYNN, American Family Physician, June 15, 200415, 2004Although not statistically significant, there was a Although not statistically significant, there was a trend toward reduced vertebral fracture risk in trend toward reduced vertebral fracture risk in postmenopausal women who take calciumpostmenopausal women who take calciumResults for secondary prevention of fractures also Results for secondary prevention of fractures also did not reach statistical significancedid not reach statistical significanceCalcium supplementation seems like a worthwhile Calcium supplementation seems like a worthwhile approach to bone health in postmenopausal womenapproach to bone health in postmenopausal womenCalcium carbonate at 1,000 mg per day was the Calcium carbonate at 1,000 mg per day was the most common dosage and is a reasonable choicemost common dosage and is a reasonable choice

Calcium for Prevention of Calcium for Prevention of OsteoporoticOsteoporotic

Fractures in Postmenopausal WomenFractures in Postmenopausal Women

R G Cumming el at, Database of Abstracts of R G Cumming el at, Database of Abstracts of Reviews of Effects, 2006 Issue 3, Cochrane LibraryReviews of Effects, 2006 Issue 3, Cochrane LibraryMen and women whose mean age ranged from 57 Men and women whose mean age ranged from 57 to 84to 84yy14 studies of calcium supplements (4 14 studies of calcium supplements (4 RCTsRCTs with with 3,638 participants,18 studies of dietary calcium and 3,638 participants,18 studies of dietary calcium and hip fracture (no hip fracture (no RCTsRCTs), and 5 studies of dietary ), and 5 studies of dietary calcium and other fracture sites (no calcium and other fracture sites (no RCTsRCTs))Calcium supplements and dietary calcium probably Calcium supplements and dietary calcium probably reduce the risk of reduce the risk of osteoporoticosteoporotic fractures in older fractures in older women.women.