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What Is the Latest Recommendation Regarding Calcium Supplements?

Published:August 24, 2017DOI:https://doi.org/10.1016/j.jand.2017.06.369
      Dietary supplements are often recommended when there are nutrient inadequacies identified in the diet or for conditions, such as a confirmed deficiency, which may warrant a therapeutic dose. According to the 2015-2020 Dietary Guidelines for Americans, calcium, as well as vitamin D, have been regarded as “underconsumed nutrients” and “nutrients of public health concern” due to the influence of low average intake of dairy.

      US Department of Health and Human Services, US Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. http://health.gov/dietaryguidelines/2015/guidelines/. Accessed May 24, 2017.

      Calcium and vitamin D are well known for their respective roles relating to bone health, and for many people in the past, the addition of a calcium supplement to their daily regimen was the first line of defense for the prevention or treatment of osteoporosis. Due to vitamin D’s role with aiding in the absorption of calcium, many supplements today include both and are marketed for this purpose.
      In 2010 and 2011, meta-analyses raised concerns regarding the increased risk of myocardial infarction in participants taking calcium supplements with or without vitamin D.
      • Lewis J.R.
      • Radavelli-Bagatini S.
      • Rejnmark L.
      • et al.
      The effects of calcium supplementation on verified coronary heart disease hospitalization and death in postmenopausal women: A collaborative meta-analysis of randomized controlled trials.
      • Chung M.
      • Tang A.M.
      • Fu Z.
      • Wang D.D.
      • Newberry S.J.
      Calcium intake and cardiovascular disease risk: An updated systematic review and meta-analysis.
      However, a subsequent review of the literature challenged these findings and determined that the evidence did not support this hypothesis
      • Lewis J.R.
      • Radavelli-Bagatini S.
      • Rejnmark L.
      • et al.
      The effects of calcium supplementation on verified coronary heart disease hospitalization and death in postmenopausal women: A collaborative meta-analysis of randomized controlled trials.
      • Chung M.
      • Tang A.M.
      • Fu Z.
      • Wang D.D.
      • Newberry S.J.
      Calcium intake and cardiovascular disease risk: An updated systematic review and meta-analysis.
      when calcium and vitamin D were supplemented concomitantly by elderly women.
      • Lewis J.R.
      • Radavelli-Bagatini S.
      • Rejnmark L.
      • et al.
      The effects of calcium supplementation on verified coronary heart disease hospitalization and death in postmenopausal women: A collaborative meta-analysis of randomized controlled trials.
      The effectiveness of calcium supplementation, with or without vitamin D, in decreasing the risk of fractures and its role in cardiovascular health has continued to be scrutinized, and the conflicting findings have caused many people to reconsider the use of calcium supplements as a preventive measure. The concerns associated with cardiovascular disease (CVD) risk prompted the National Osteoporosis Foundation (NOF) to request that the US Agency for Healthcare Research and Quality’s (AHRQ) 2009 evidence report, relating to the health outcomes of vitamin D and calcium, be updated by a team from Tufts University
      • Kopecky S.L.
      • Bauer D.C.
      • Gulati M.
      • et al.
      Lack of evidence linking calcium with or without vitamin D supplementation to cardiovascular disease in generally healthy adults: A clinical guideline from the National Osteoporosis Foundation and the American Society for Preventive Cardiology.
      and include a review of the evidence from 1966 through July 2016.
      • Chung M.
      • Tang A.M.
      • Fu Z.
      • Wang D.D.
      • Newberry S.J.
      Calcium intake and cardiovascular disease risk: An updated systematic review and meta-analysis.
      The research appraised the use of calcium supplements with and without vitamin D, along with dietary calcium intake and their effects on CVD risk in healthy adults.
      • Chung M.
      • Tang A.M.
      • Fu Z.
      • Wang D.D.
      • Newberry S.J.
      Calcium intake and cardiovascular disease risk: An updated systematic review and meta-analysis.
      • Kopecky S.L.
      • Bauer D.C.
      • Gulati M.
      • et al.
      Lack of evidence linking calcium with or without vitamin D supplementation to cardiovascular disease in generally healthy adults: A clinical guideline from the National Osteoporosis Foundation and the American Society for Preventive Cardiology.
      The findings indicated that intakes of calcium that do not exceed 2,000 to 2,500 mg/day, which are the tolerable upper intake levels (UL) for adults 51 years and older and 19 to 50 years old,

      Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Ross AC, Taylor CL, Yaktine AL, et al, eds. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2011. 6, Tolerable upper intake levels: Calcium and vitamin D. https://www.ncbi.nlm.nih.gov/books/NBK56058/. Accessed June 21, 2017.

      respectively, are not associated with CVD risk.
      • Chung M.
      • Tang A.M.
      • Fu Z.
      • Wang D.D.
      • Newberry S.J.
      Calcium intake and cardiovascular disease risk: An updated systematic review and meta-analysis.
      Following the reanalysis and update of the AHRQ evidence report, a panel of experts from the NOF and the American Society for Preventive Cardiology (ASPC) was organized, and their mission was to develop a clinical guideline that addressed the safety of calcium and vitamin D in relation to CVD risk.
      • Chung M.
      • Tang A.M.
      • Fu Z.
      • Wang D.D.
      • Newberry S.J.
      Calcium intake and cardiovascular disease risk: An updated systematic review and meta-analysis.
      • Kopecky S.L.
      • Bauer D.C.
      • Gulati M.
      • et al.
      Lack of evidence linking calcium with or without vitamin D supplementation to cardiovascular disease in generally healthy adults: A clinical guideline from the National Osteoporosis Foundation and the American Society for Preventive Cardiology.
      This collaborative effort resulted in a joint position statement, and “the NOF and ASPC adopt[ed] the position that there is moderate-quality evidence (B level) that calcium with or without vitamin D intake from food or supplements has no relationship (beneficial or harmful) with the risk of cardiovascular and cerebrovascular disease, mortality, or all-cause mortality in generally healthy adults at this time.”
      • Kopecky S.L.
      • Bauer D.C.
      • Gulati M.
      • et al.
      Lack of evidence linking calcium with or without vitamin D supplementation to cardiovascular disease in generally healthy adults: A clinical guideline from the National Osteoporosis Foundation and the American Society for Preventive Cardiology.
      The authors clarified this statement by indicating that the total intake of calcium (from food and supplements) should not exceed 2,000 to 2,500 mg/day, based on the updated report.
      • Kopecky S.L.
      • Bauer D.C.
      • Gulati M.
      • et al.
      Lack of evidence linking calcium with or without vitamin D supplementation to cardiovascular disease in generally healthy adults: A clinical guideline from the National Osteoporosis Foundation and the American Society for Preventive Cardiology.
      A review of the evidence also suggested that obtaining the UL strictly through dietary sources would be challenging, so the risks reported previously have only been associated with supplements.
      • Chung M.
      • Tang A.M.
      • Fu Z.
      • Wang D.D.
      • Newberry S.J.
      Calcium intake and cardiovascular disease risk: An updated systematic review and meta-analysis.

      Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Ross AC, Taylor CL, Yaktine AL, et al, eds. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2011. 6, Tolerable upper intake levels: Calcium and vitamin D. https://www.ncbi.nlm.nih.gov/books/NBK56058/. Accessed June 21, 2017.

      The guideline clearly states that “obtaining calcium from food sources is preferred,”
      • Kopecky S.L.
      • Bauer D.C.
      • Gulati M.
      • et al.
      Lack of evidence linking calcium with or without vitamin D supplementation to cardiovascular disease in generally healthy adults: A clinical guideline from the National Osteoporosis Foundation and the American Society for Preventive Cardiology.
      but at the same time provides reassurance for supplementation when dietary sources are lacking, as long as it does not result in excess of the UL.
      Earlier this year, representatives from the Academy of Nutrition and Dietetics reviewed the updated AHRQ report and its methodology, and the House Leadership Team voted in support of the NOF and ASPC joint position statement.

      Academy of Nutrition and Dietetics. Highlights: A Year in Review 2016–2017. http://www.eatrightpro.org/resource/news-center/member-updates/from-our-leaders/year-in-review#December. Accessed June 19, 2017.

      Registered dietitian nutritionists can play an important role by individualizing clinical guidelines, such as this one, with the use of evidence-based practice, as it takes into account not only the most current and applicable research, but also the unique characteristics of that patient/client.

      Academy of Nutrition and Dietetics. Definition of Terms List. June 2017. http://www.eatrightpro.org/∼/media/eatrightpro%20files/practice/scope%20standards%20of%20practice/academydefinitionoftermslist.ashx. Accessed June 20, 2017.

      When applied in conjunction with the nutrition care process, it enables registered dietitian nutritionists to help patients/clients evaluate the appropriateness of supplementation in the context of their overall health.

      References

      1. US Department of Health and Human Services, US Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. http://health.gov/dietaryguidelines/2015/guidelines/. Accessed May 24, 2017.

        • Lewis J.R.
        • Radavelli-Bagatini S.
        • Rejnmark L.
        • et al.
        The effects of calcium supplementation on verified coronary heart disease hospitalization and death in postmenopausal women: A collaborative meta-analysis of randomized controlled trials.
        J Bone Miner Res. 2015; 30: 165-175
        • Chung M.
        • Tang A.M.
        • Fu Z.
        • Wang D.D.
        • Newberry S.J.
        Calcium intake and cardiovascular disease risk: An updated systematic review and meta-analysis.
        Ann Intern Med. 2016; 165: 856-866
        • Kopecky S.L.
        • Bauer D.C.
        • Gulati M.
        • et al.
        Lack of evidence linking calcium with or without vitamin D supplementation to cardiovascular disease in generally healthy adults: A clinical guideline from the National Osteoporosis Foundation and the American Society for Preventive Cardiology.
        Ann Intern Med. 2016; 165: 867-868
      2. Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Ross AC, Taylor CL, Yaktine AL, et al, eds. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2011. 6, Tolerable upper intake levels: Calcium and vitamin D. https://www.ncbi.nlm.nih.gov/books/NBK56058/. Accessed June 21, 2017.

      3. Academy of Nutrition and Dietetics. Highlights: A Year in Review 2016–2017. http://www.eatrightpro.org/resource/news-center/member-updates/from-our-leaders/year-in-review#December. Accessed June 19, 2017.

      4. Academy of Nutrition and Dietetics. Definition of Terms List. June 2017. http://www.eatrightpro.org/∼/media/eatrightpro%20files/practice/scope%20standards%20of%20practice/academydefinitionoftermslist.ashx. Accessed June 20, 2017.