Maintaining Postmenopausal Health
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Many women receive less than the recommended daily allowance of calcium—1,000 mg premenopause, and 1,200 mg postmenopause.4,24 Calcium supplementation is not necessary if dietary intake of calcium is adequate. However, some therapies have only been studied with calcium supplementation (eg, alendronate and calcitonin) and therefore should be prescribed accordingly. Reduced-fat dairy products can help women get the dietary calcium they need while maintaining the low-fat diet recommended for a healthy heart. Calcium-fortified foods (e.g., juices, certain breakfast foods, snacks), which are rapidly proliferating, also offer good alternatives for optimizing dietary calcium intake.
If a woman falls below the recommended daily allowance of calcium in her diet, she should be advised to take a calcium supplement. She should also be instructed to examine the supplement’s elemental calcium content in order to achieve total intakes as recommended above and shown in the table below.
Table A Elemental Calcium Content
Calcium (alone or with vitamin D, which the body needs to absorb calcium) is an important adjunct to drug therapies that reduce bone resorption or increase bone formation, but it is not considered adequate monotherapy in blunting accelerated bone loss during and after menopause.25 Calcium has limited ability to slow the rate of postmenopausal bone loss and to reduce the risk of fracture in women with pre-existing fractures (ie, established osteoporosis). Additionally, calcium does not appear to prevent bone loss during the critical early years of estrogen deficiency (the first 5 years after menopause).23
Most people receive adequate vitamin D from sunlight and diet, although the elderly and homebound may be deficient.4,22 A 3-year study cited in the New England Journal of Medicine looked at the effects of calcium and vitamin D supplementation on bone mass density (BMD) and the incidence of nonvertebral fractures.27 The study included both men and women age 65 years or older who were living at home and were given either 500 mg of calcium plus 700 IUs of vitamin D3 (cholecalciferol) per day or placebo. The study found that the difference between the calcium/vitamin D and placebo groups was significant at all skeletal sites (femoral neck, spine, and total body) for 1 year, but was significant only for total body BMD in the second and third years.27 These results indicate that dietary supplementation with calcium and vitamin D moderately reduced bone loss measured in the femoral neck, spine, and total body over the 3-year study period and reduced the incidence of nonvertebral fractures.27
Vitamin D used in conjunction with calcium supplementation further decreases the incidence of hip and other nonvertebral fractures. Women taking estrogen generally do not need such supplements because the hormone increases production and absorption of vitamin D as its activated form of calcitriol.
Between 200 and 400 IU/d of vitamin D is adequate for women under 65 years of age.28 Older patients are at particular risk of developing a deficiency of vitamin D, however, due to decreased absorption, insufficient dietary intake, impaired renal synthesis of the active form of vitamin D, and inadequate exposure to sunlight.23 A recent study in men and women 65 years of age and older looked at the effects of 3 years of dietary supplementation with 500 mg/d of calcium citrate and 700 IU/d of vitamin D3 (cholecalciferol) on various indicators of bone density, as well as incidence of nonvertebral fractures. The study found a moderately reduced bone loss in the femoral neck, spine, and total body, as well as a decreased incidence of nonvertebral fractures.27 This may suggest that higher intakes of vitamin D are advisable in women older than 65 years of age, under the supervision of a physician. Excessive amounts (above 1000 IU/d) can be toxic.23
While calcium and Vitamin D are necessary for maintaining healthy bone structure, caffeine and alcohol can cause low bone density. Both men and women should reduce their caffeine intake to less than two to five cups per day. Similarly, reducing overall alcohol intake will improve the overall health of patients because alcohol may induce nutritional deficiencies of calcium, Vitamin D, and magnesium.7
In addition, women and men should avoid smoking, since smoking has been associated with lower bone mass and increased fracture rates.7
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Selected Dietary Sources for Calcium (References 23,26)
