Consuming the right amount of Calcium is key to prevent postmenopausal osteoporosis: EMAS guidelines

Courtesy: Washington post 

Intake of right amount of Calcium, preferably from dietary source is the key to manage bone health in postmenopausal women and anything in excessive may not help, and can be harmful, says the new European Menopause and Andropause Society (EMAS) clinical guidelines published in forthcoming issue of Maturitas.

Postmenopausal osteoporosis is rife throughout the world and despite recommendations about diet and lifestyle changes from societies and governmental bodies, many issues remain unresolved. Calcium is drug which is often consumed as either single supplement or in combination with Vitamin D3 and self-dosing is very common.

Different societies have recommended different doses ranging from 700 and 1200 mg/daily and uncertainties prevail about the most appropriate dose.

Excessive intake of calcium beyond 2000mg/day is linked to increases risk cardiovascular events, dementia, urolithiasis and even fractures, but the issue remains unresolved.

To develop the current EMAS guidelines the authors looked at systematic reviews, meta-analyses, and randomized controlled trials from 2007 till present.

The key recommendations by EMAS are:

The guidelines reiterate the role of adequate intake of calcium in preventing postmenopausal osteoporosis and fracture risk.

The recommended calcium intake should be between 700 and 1200 mg per day after menopause.

Diet should be the preferred method for sourcing the daily requirements, as the intake is uniformly distributed throughout day and avoids the calcium peaks in blood.

Higher than recommended amount is not useful, on the contrary it may do possible harm.

If women are not able to take supplements and the diet also does not supply the recommended amount of calcium, they should have regular physical exercise and take Vitamin D to maintain healthy bones.

The EMAS recommendation of 700 to 1200 mg per day differ from US guidelines in terms of daily dosage. The National Osteoporosis Foundation (NOF) and the American Society for Preventive Cardiology (ASPC) the US Institute of Medicine (IOM) Food and Nutrition Board, and the North American Menopause Society(NAMS) recommends 1200 mg of elemental calcium per day.

The National Institutes of Health (NIH) recommended 1500 mg of elemental calcium per day.

But, the study authors opined that the 300-mg difference between European and US guidelines does not matter much as the real problem starts if the daily intake exceeds 2000 mg or more.

The EMAS recommendations does not apply to women receiving antiosteoporotic drugs, which require concomitant supplementation with calcium and vitamin D. 

Abstract

USPSTF issues draft recommendations on low-dose vitamin D and calcium for fracture prevention

http://www.huffingtonpost.com/ellen-sarver-dolgen/vitamin-d-calcium-supplements_b_3543283.html

The USPSTF today issued draft recommendations for effectiveness and potential harm of prescribing Vitamin D and Calcium in community dwelling men and pre-and post-menopausal women for the primary prevention of fractures.

Aging population, low bone mass and falls all contribute to a substantial health burden of fractures. Nearly 1 in 2 women older than 50 years of age will experience a fracture during her life time.

Currently, Vitamin D and Calcium supplementation are often advised for postmenopausal women to prevent fractures.

USPSTF recommendations on efficacy of Calcium and Vitamin D in preventing fractures are based on data from a total of 41,772 women across eight 8 RCTs with mean age between 53 to 80 years while for assessing the harm it reviewed the evidence from 9 RCTs with a total of 39,659 subjects, which also included 5,991 men.

The review of evidence concluded:

USPSTF found sufficient evidence to recommend against daily supplementation of 400 IU or less of vitamin D combined with 1,000 mg or less of calcium in prevention of fractures in postmenopausal women.

Evidence is also insufficient to make recommendations for greater than 400 IU of vitamin D and greater than 1000 mg of calcium supplementation in postmenopausal women.

At this time, there is insufficient evidence to determine the balance of benefits and harms of prescribing vitamin D and calcium supplementation, alone or combined, for the primary prevention of fractures in men and premenopausal women.

USPSTF found sufficient evidence that supplementation with vitamin D and calcium increases the incidence of kidney stones, although the magnitude of this harm was small.

This recommendation does not apply to persons living in institutional or nursing home care or with a history of osteoporotic fractures or those who are at increased risk for falls. It also does not apply to persons with a diagnosis of osteoporosis or vitamin D deficiency.

USPSTF recommends screening for osteoporosis in women aged 65 or older and in younger women if they have a high fracture risk. Evidence is insufficient to recommend for or against screening for vitamin D deficiency in asymptomatic adults.

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The best agent to prevent preeclampsia: A systematic review and network meta-analysis--News from SMFM 2017, Las Vegas.

Calcium supplements 

Out of various agents used for prevention of preeclampsia calcium supplementation has got the highest likelihood of being successful in bringing down its incidence and perinatal mortality as per a study presented by Sanchez-Ramos L. et al. at the pregnancy meeting, SMFM 2017, Las Vegas.

Preeclampsia complicates approximately 3-5% of pregnancies, accounting for 10-15% of maternal deaths and 3% of perinatal deaths.

Numerous agents have been studied for their ability to prevent preeclampsia and conventional studies have gauged the effectiveness of these agents. But these have been small, single center trials.

This was a systematic review and network meta-analysis of large RCTs comparing the effectiveness of multiple treatment options in preventing preeclampsia. Only data from meta-analysis of large RCTs with more than 450 subjects were included.

The study was registered under PROSPERO,[1] an international prospective register of systematic reviews in areas of healthcare all around the world and guided by PRISMA guidelines.[2]

A search of electronic databases from 1966 through July15, 2016 picked up 27 large multicenter trials with total of 60, 425 pregnant women. This large cohort was used to compare various exposures against Placebo or no treatment for the development of preeclampsia. The secondary outcome studied were severity of preeclampsia and maternal and neonatal morbidity and mortality. The various agents studied were:

• Low-dose aspirin: aspirin given at low doses (50-100mg) during pregnancy
• Calcium supplementation: given at doses of 500-2000mg
• Low molecular weight heparin: anticoagulant
• Vitamin E/C: vitamin supplements in varying doses as defined by the study
• Fish oil: supplement derived from fatty tissue of fish containing omega-3 fatty acids

Direct and indirect pairwise comparison was done using STATA for multivariate random effect models.

It was seen that women who regularly received Calcium supplementation had a 61% and 74% less odds of developing preeclampsia in direct and indirect comparison.

Women receiving calcium supplementation has 68% less likelihood of developing preeclampsia as compared to women receiving fish oil.  

Taking Calcium was also associated with less chances of perinatal mortality as compared to low-dose aspirin, vitamins C & E, and placebo. 

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[1] https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/2046-4053-1-2

[2] http://www.prisma-statement.org/