Calcium 500 with vitamin D3 and K effervescent tablets No. 17

A. Yu. Baranovsky, Professor, Head of the Department of Gastroenterology and Dietetics, North-Western State Medical University. I. I. Mechnikova, St. Petersburg

L. I. Nazarenko, Professor of the Department of Gastroenterology and Dietetics, North-Western State Medical University. I. I. Mechnikova, St. Petersburg

Osteoporosis is one of the most common diseases in its classification group with a particularly pronounced degenerative-dystrophic syndrome, and is also a disease in the diet therapy of which specialists often encounter difficulties and, unfortunately, make mistakes.

Error correction

The causes of dietary errors in patients with osteoporosis, in our opinion, are numerous and depend, as a rule, on the professional competence of a specialist - nutritionist, therapist, rheumatologist, general practitioner - in matters of the causation of the disease in a particular patient, dietary selection of a list of deficient minerals, vitamins , determining in this regard the appropriate products and their adequate quantities in the daily diet.

Important and difficult questions that doctors often face with osteoporosis are: the most appropriate methods of culinary food processing recommended for patients, the prescription of dietary agents aimed at increasing the absorption of deficient minerals in the intestines, as well as rational combinations of foods and medicines that exclude them antagonism. Based on this, we will provide the necessary information that can compensate for the professional gaps of doctors in those basic issues that can cause dietary errors in patients with osteoporosis.

Real situation

So, osteoporosis is a disease of the skeletal system, in which the risk of developing bone fractures increases even with a slight habitual load.

Osteoporosis is one of the most common diseases, which, unfortunately, has not yet found proper understanding in Russian medical practice. According to statistics, 25 million Americans have osteoporosis or are at high risk of developing it. More than a quarter of a million hip fractures and more than half a million vertebral fractures are associated with osteoporosis each year. Osteoporosis mainly affects women (80% of all patients with osteoporosis) and people of older age groups. This is especially important because the life expectancy of the population of civilized countries is increasing. Hip fracture in people over 65 years of age is a high risk factor for death (20% per year after fracture), more than half of patients never return to their original functional state. The financial costs associated with osteoporosis exceed $10 billion annually.

The medical and socio-economic losses are so great that WHO places the problem of osteoporosis in fourth place after cardiovascular diseases, cancer and diabetes. In recent years, more attention has been paid to the problem of osteoporosis in Russia: centers for the treatment and prevention of this disease have been created and specially equipped in large cities, but the problem is far from being resolved.

Cause of osteoporosis

Calcium and phosphorus together form the mineral basis of the skeleton. In most cases, the cause of osteoporosis is a violation of calcium and phosphorus metabolism.

The most important link in providing the body with calcium is its sufficient absorption in the intestines, which is possible in the presence of at least three prerequisites: sufficient calcium in the diet; the body's supply of vitamin D, including its active metabolites; absence of diseases of the gastrointestinal tract with malabsorption. If there is a lack of calcium in the body, the latter is extracted from its own bone tissue. As a result, bone mass decreases and bones become brittle.

There are many factors for the development of osteoporosis. The division into primary and secondary osteoporosis is relative. Primary osteoporosis includes postmenopausal, senile (senile), and idiopathic osteoporosis. Secondary osteoporosis includes a decrease in bone mass as a result of genetic disorders, certain diseases of the endocrine system, rheumatism, circulatory system, kidneys, excessive alcohol intake, prolonged immobilization, taking medications, especially corticosteroids, immunosuppressants, as a result of mental disorders (anorexia nervosa) , as well as insufficient dietary intake or impaired absorption of certain nutrients in the intestine, primarily calcium and vitamin D.

The role of protein deficiency as an independent factor is debated. The most common causes of the development of osteoporosis are violations of the consumption of certain nutrients from foods, the postmenopausal period, senile syndrome, pathological metabolic disorders as a result of taking glucocorticosteroids, as well as excessive amounts of alcohol.

Recommended norms

Special studies have shown that women of all age groups consume significantly less calcium from food than recommended. Men of all ages consume more calcium than women, possibly due to their higher energy intake in general. Less than 15% of women under the age of 50 and less than 5% of women under the age of 70 consume foods with adequate calcium.

Low dietary calcium intake among adolescents is of particular concern because calcium deficiency coincides with a period of rapid skeletal growth. This is an opportune time to gain maximum peak bone mass and protect yourself from the future risk of osteoporosis. Approximately 90% of women's complete bone mineralization is achieved around age 17, 95% by age 20, and 99% by age 26. Consequently, the period for optimization of peak bone mass by calcium decreases rapidly after adolescence. It should be noted that current dietary recommendations for adequate calcium intake have been increased to 500 mg for children aged 1–3 years, 800 mg for children aged 4–8 years, 1300 mg for adolescents aged 9–18 years, 1000 mg for adults aged 18–60 years and 1200 mg for adults aged 60 years and older. Unfortunately, these dietary recommendations are not being followed.

Scientific evidence suggests that consuming adequate amounts of calcium or calcium-rich foods (milk and other dairy products) promotes peak bone mass before age 30 and earlier. This slows down age-related bone loss and reduces the risk of fractures later in life.

Individualization of diet therapy

The pathogenetic principle of individualization of diet therapy at the preparatory stage of treatment is as follows:

1. Finding out the possible causes of impaired calcium absorption in the small intestine:
   malabsorption syndrome due to enteropathy (enteritis, involutional atrophy of the intestinal mucosa, chronic renal failure, etc.);
2. food supply with vitamins D, C;
3. the presence of acidic bases in food (citric, ascorbic, oxalic and some other acids);
4. analysis of the consistency of hormonal regulation of calcium metabolism (hormones that regulate Ca metabolism in the body: parathyroid hormone, calcitonin, glucocorticosteroids, thyroid hormones, growth hormone, insulin, estrogens).
5. Study of possible causes of excess calcium requirements in metabolic processes:
   arterial hypertension;
6. increased excretion of Ca from the body (with urine, bile);
7. diseases accompanied by an increased need for calcium (for example, colon tumors, hyperparathyroidism).

We should not forget that the etiopathogenetic variants of the development of osteoporosis are different. Therefore, approaches to drug therapy will also be different. This can be either hormone replacement therapy or treatment of the underlying disease. Diet therapy as an independent method of treatment is generally not used, but is used as a reliable support for drug therapy and for prevention.

Areas of diet therapy for calcium metabolism disorders:

1. Water mineralization.
2. Using foods rich in calcium.
3. Activation of calcium absorption in the body.
4. Dietary stimulation of gastric secretion, enzymatic activity of the pancreas.
5. Restoration of disturbances in the absorption function of the small intestine.
6. Prescribing diets taking into account possible enzymopathies (for example, lactase deficiency).
7. Dietary correction of food intolerance.

More about calcium

In dietary therapy for osteoporosis, the main role is played by calcium and vitamin D, the use of which can weaken the process of osteoporosis progression, although there are many nutritional factors that affect bone development (proteins, vitamins and other minerals).

Information about dietary sources of calcium and factors affecting its bioavailability is important.

Food Sources of Calcium

The population receives more than half of the amount of calcium consumed from dairy products. Other sources include some green vegetables (broccoli, cabbage), nuts, calcium-precipitated bean curd, bone meal.

Calcium-fortified foods (juices and flours) may make a significant contribution to calcium intake in some people. In food products, calcium is contained mainly in the form of sparingly soluble salts (phosphates, carbonates, oxalates, etc.). The bioavailability of calcium from a number of non-dairy sources is insufficient. The list of foods high in calcium is presented in Table 1

Food Components that Increase the Bioavailability of Calcium

Lactose increases calcium absorption. Absorption also increases after the addition of lactase, which can be explained by the fact that the most metabolized milk sugar increases calcium absorption. These data were obtained for infants. It is unclear whether lactose improves the absorption of calcium from dairy products in adults? The higher prevalence of osteoporosis in people with lactose intolerance is likely due to low dairy intake rather than to the effect of lactose on calcium absorption.

Food components that reduce the bioavailability of calcium

Dietary fiber reduces calcium absorption. Replacing white flour (22 grams of dietary fiber per day) with whole wheat flour (53 grams of dietary fiber per day) in a regular diet causes a negative calcium balance even at higher calcium intakes.

Dietary fiber from fruits and vegetables has a similar effect on calcium absorption. Several fiber constituents bind calcium. Uronic acids bind calcium strongly in vitro. This is probably why hemicellulose inhibits calcium absorption. 80% of pectin uronic acids are methylated and cannot bind calcium. Therefore, pectin does not affect calcium absorption. In theory, a typical vegetarian diet contains enough uronic acids to bind 360 mg of calcium, but most of these acids are digested in the distal intestine, so some calcium is still absorbed. A balanced diet that contains moderate amounts of various fibers does not likely affect calcium absorption.

Table 1. Food sources of calcium

*Foods rich in oxalic acid, which slows down absorption.

Phytic acid is another plant component that binds calcium. The high phytin content of wheat bran explains its adverse effects on calcium absorption. Interestingly, adding calcium to wheat dough reduces phytin degradation by 50% during fermentation and baking. Wheat bran interferes with calcium absorption to such an extent that it has been used therapeutically for hypercalciuria.

Dark green, leafy vegetables often have relatively high calcium content. But the absorption of calcium from most vegetables is prevented by oxalic acid. Spinach, beet tops, and rhubarb are rich in it. Foods low in oxalic acid (cabbage, broccoli, turnips) are good sources of calcium. For example, calcium absorption from cabbage is almost as high as from milk.

Sodium increases urinary calcium excretion, so dietary salt intake should be reduced.

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Caffeine and other drugs. Caffeine, found in coffee, tea, chocolate, cola and many over-the-counter medications, increases the amount of calcium lost in urine and feces. However, reasonable coffee consumption is a minor risk factor for osteoporosis. Up to 2 cups of black coffee per day may result in small urinary calcium excretion (up to 110 mg). This amount is easily covered by milk, which can be used with coffee, or calcium supplements.

The nicotine in tobacco reduces the body's ability to use calcium. Additionally, women who smoke tend to have lower estrogen levels and lower bone mass. It has been suggested that in smokers, estrogens are broken down more quickly in the liver and, as a result, fail to stimulate the secretion of enough calcitonin to prevent bone destruction.

Excessive alcohol consumption is a risk factor for osteoporosis and osteoporotic bone fractures. The development of osteoporosis is associated both with general metabolic disorders (malnutrition, liver cirrhosis, gastropathy, endocrine disorders) and with the direct effect of alcohol on bone tissue (a decrease in the volume of trabecular bone mass). Alcohol has been shown to have a direct toxic effect on osteocytes. Excessive alcohol consumption can also cause bone loss by impairing the absorption of calcium and vitamin D. Moderate alcohol consumption does not have a negative effect on bones.

Interaction between the absorption of calcium and other nutrients

Squirrels. The protein content in the diet of patients with osteoporosis should be at a physiological level, since protein deficiency leads to a negative nitrogen balance and a decrease in reparative processes. It is recommended to include in the diet specialized food products consisting of proteins with high biological value and digestibility (dry protein composite mixtures [GOST R 53861-2010]).

With an adequate amount of protein in the diet, about 15% of calcium is absorbed, with a low protein content - about 5%. Excessive dietary protein (especially purified amino acids) increases urinary calcium loss and causes a negative calcium balance; surprisingly, it does not result in a compensatory increase in the efficiency of intestinal calcium absorption. A pure vegetarian diet fails due to insufficient amounts of calcium and other nutrients. Adding dairy products to a vegetarian diet improves bone health in postmenopausal women.

If you have excess fat, you need to increase the calcium content in your diet. In the presence of fat malabsorption (steatorrhea), calcium precipitates with fatty acids, forming insoluble soaps in the intestinal lumen. A lack of fat in the diet can lead to a deficiency of fat-soluble vitamins, including vitamin D, which is necessary for the absorption of calcium.

Long-term, continuous dietary intake of large amounts of phosphorus leads to hyperparathyroidism and secondary bone resorption.

Since both calcium and iron are commonly recommended for women, the interactions between these supplements are interesting. In one study, calcium carbonate and hydroxyapatite supplementation reduced iron absorption by approximately 50% in postmenopausal women. In another study, milk calcium inhibited iron absorption by 30%. When taken additionally with food, calcium inhibits the absorption of iron from its preparations (ferrous sulfate), dietary non-heme and heme iron. But if calcium carbonate was taken without food, even in high doses it did not inhibit the absorption of iron from ferrous sulfate. Thus, the use of dietary calcium supplements significantly affects iron absorption. Calcium likely affects intracellular iron transfer by the enterocyte.

Essential calcium salts

In terms of content and completeness of absorption, the best sources of calcium are milk and dairy products. 100 mg of calcium is contained in 85–90 g of milk and fermented milk drinks (kefir, yogurt, etc.), 70–80 g of cottage cheese, 10–15 g of hard cheese, 20–25 g of processed cheese, 110–115 g of sour cream or cream, 70–75 g milk or cream ice cream. Thus, if the daily diet includes 0.5 liters of milk and fermented milk drinks, 50 g of cottage cheese and 10 g of hard cheese, then this provides more than half of the recommended calcium intake, and in an easily digestible form.

The calcium content in the green mass of plants is significantly lower than the content in dairy products. Therefore, dairy products are the main ones. But the daily amount of calcium is difficult to cover with food alone. In this regard, calcium salts are used for medicinal purposes. The calcium content in its various salts is presented in Table 2. According to some data, it is best to add calcium carbonate to food in small doses, according to others, it is preferable to take it in the evening or at night. Persons with achlorhydria are prescribed calcium citrate, which is better absorbed when gastric secretory activity is low.

It has been shown that additional use of calcium supplements in the diet leads to a decrease in bone loss in older women. The greatest effect was observed in those who consumed little calcium in their diet.

Calcium supplementation to women early after the onset of menopause slightly reduced bone loss at the radius and femoral neck, but not at the spine. An analysis of prospective studies of postmenopausal women found that adequate vitamin D intake reduced the risk of hip fractures associated with osteoporosis, and milk consumption and a high calcium diet did not affect the incidence of hip fractures. The authors emphasize the need for supplemental vitamin D or increased consumption of fatty fish.

Table 2. Calcium content (Ca) in its various salts (Smolyansky B.L., Liflyandsky V.G., 2004)

You can't do without vitamin D

Vitamin D deficiency in the diet or disorders of its metabolism are of great importance in the pathogenesis of many forms of osteoporosis, but especially senile osteoporosis. Vitamin D is necessary for the absorption of calcium in the intestines, as well as for its absorption by cells, including bone cells.

In medical practice, active metabolites of vitamin D3 (calcitriol, alpha-calcidol) are more often used. It is these metabolites that are widely used in the treatment of osteoporosis.

The best sources of vitamin D in the diet are fatty fish, liver, fish roe, milk fats, and eggs. Vitamin D deficiency is easily prevented by eating these foods and/or taking small doses of vitamin D supplements.

Both in the treatment of osteoporosis and for preventive purposes, all women after menopause and people of both sexes after 65 years are prescribed calcium supplements in combination with vitamin D. These recommendations are especially important for people who consume little or no dairy products due to personal tastes, diseases (lactase deficiency, food allergies, etc.), strictly vegetarian diet. These drugs are often considered as dietary supplements - nutraceuticals.

Table 3. Sample menu rich in calcium content (Bergman D., 1999)

Other vitamins for osteoporosis

In recent years, soy products have been widely used in the treatment and prevention of osteoporosis. It is known that soy proteins contain isoflavones, which have estrogen-like effects. A number of studies have shown that the inclusion of soy products in postmenopausal women leads to a reduction in the incidence of bone fractures.

Experiments on animals revealed a negative effect on bone tissue from a deficiency of a number of vitamins (C, group B) and microelements (phosphorus, magnesium, zinc, copper, manganese, boron, silicon, strontium, fluorine). But a direct connection between the development of osteoporosis and a deficiency of these elements has not been found.

It has been established that vitamin K affects osteocalcin, which, being a modulator of osteoblasts, is involved in protein synthesis in bones. Low vitamin K intake is associated with low bone mineral density and an increased risk of hip fractures in women, but not in men. Therefore, taking vitamin K for osteoporosis may be important in cases of severe deficiency in the diet.

Prevent disease

Prevention of the development of osteoporosis should be carried out before the full bone mass is formed, and treatment - from the moment bone loss begins to be detected.

Early prevention should be carried out by adequate calcium supplementation, exercise and prevention of risk factors (smoking, excessive alcohol consumption, etc.). This is especially important in adolescence, when the bone gains mass. Individuals who have developed osteoporosis usually must rely on pharmacological interventions to maintain or improve bone health. Treatment of osteoporosis currently includes taking calcium supplements with vitamin D, estrogen, and calcitonin. Treatment in any case is carried out against the background of diet therapy.

Thus, all patients with osteoporosis who are not burdened with diseases requiring special dietary therapy should receive a rational, balanced diet with a physiological protein content in the diet, but with an increased content of calcium and vitamin D, including through special nutritional supplements and medications .

D. Bergman (1999) proposed a version of such a diet that supplies more than 1000 mg of calcium per day, and also meets the needs for other important minerals (Table 3).

Table 4 provides information on the effect of certain medications on calcium metabolism in the body.

Tips for choosing

• Calcium comes in different forms.
• The powder can be diluted in water or drink. Suitable for those who do not like to swallow tablets.
• There is a release form - tablets and capsules. They need to be chewed, sucked or washed down (preferably with milk) during meals.
• The drops are perfect for young children, as well as for adults who have problems with swallowing and chewing.
• For school-age children, you can look for the drug in the form of chewing candies. As a rule, they come with various flavorings. There are also candies for adults.
• You can often see a combination of calcium and vitamin D. The fact is that they mutually enhance each other’s effects. In addition, vitamin D is not absorbed in the intestine without calcium.
• Quite often, calcium is combined with magnesium and zinc, since these three microelements are involved in the prevention of osteoporosis.

The role of diet in preventing osteoporosis

Because osteoporosis usually progresses to a clinically advanced stage before its effects become apparent, preventing bone loss is the single best way to avoid the possibility of fractures and resulting disability. Although increasing calcium in the diet is one of the strategies most often proposed, many studies have failed to show a clear relationship between dietary absorption of this mineral and bone density. Consumption of calcium and vitamin D-rich foods is likely more important during the bone-growing years before peak mass is reached rather than later in adulthood.

Dairy products contain more than 70% of the calcium in the diet of the “average” resident of our country. The calcium found in these foods is quickly absorbed because these foods contain lactose and some are fortified with vitamin D.

Vegetarians who avoid animal foods can get calcium from soy milk, tofu (soy curd) processed with calcium sulfate, grains (especially unrefined or slightly refined grains), some green leafy vegetables (cabbage, turnips), beans and nuts. Some types of currently popular mineral drinks and tap water also contain calcium, the amount of calcium varies depending on the source.

Supplement Efficacy

Due to widespread and questionable advertising linking dietary calcium to osteoporosis, this mineral has been added to many products, including orange juice, soda, and bread products.

Calcium supplements have also become popular, but their value as a source of calcium remains controversial. Supplements vary in absorption capacity, and many people take them incorrectly. For example, until recently, calcium supplements came in the form of large, difficult-to-take pills. Supplement manufacturers have reduced the size of the pills to make them easier to swallow, but they may have compressed the pills so much that they do not dissolve in the stomach and pass intact through the gastrointestinal tract.

Calcium supplements vary in the percentage of the mineral in each dose and their effect on the body. Among the most commonly used compounds are calcium carbonate (Kalmagin, Calcium D3 Nycomed, etc.) and calcium citrate (Citrical, etc.). Calcium carbonate contains up to 40% pure calcium. It reacts with hydrochloric acid in the stomach to form calcium chloride, a highly soluble and available compound.

Undesirable effects of large amounts of calcium carbonate include flatulence, nausea and constipation. Excessive use of supplements may also cause excess hydrochloric acid due to stimulation of gastric secretion; The possibility of developing kidney stones has also been reported. Calcium carbonate may reduce the absorption of medications such as aspirin, tetracycline, atenolol, and ferrous sulfate if the supplement and these medications are taken together. Antacids containing both calcium carbonate and aluminum actually block calcium absorption.

Calcium citrate contains less calcium, approximately 24%. This compound does not require hydrochloric acid to dissolve, making it more suitable for those who are deficient in this component of gastric juice. This condition, known as achlorhydria, is quite common in old age.

In addition to the evidence regarding the potential of calcium supplements to cause gastrointestinal problems, there is other evidence that casts doubt on their value. Calcium supplements alone have little beneficial effect on postmenopausal bone mineral loss. They may slow compact bone loss but are not very effective in preventing trabecular bone loss.

Additionally, medications that also contain vitamin D may cause toxic accumulation of this fat-soluble vitamin if taken in excess amounts. Bone meal and dolomite contain calcium and are relatively inexpensive, but they also contain toxins such as lead and should be avoided.

Typical mistakes in the diet of patients with osteoporosis:

• insufficient calcium in the diet;
• excessive amounts of dietary fiber, phytic and oxalic acid, which impair the absorption of calcium;
• protein deficiency in the diet, leading to a negative nitrogen balance and a decrease in reparative processes;
• too much protein in the diet, which contributes to increased excretion of calcium in the urine (for every 50 g of protein in excess of the norm, 60 mg of calcium is lost in the urine);
• excess carbohydrates in the diet, which also leads to increased loss of calcium in the urine;
• excess phosphorus in the diet, which impairs calcium absorption;
• abuse of alcohol and drinks with a high caffeine content (coffee, strong tea, cola, chocolate), which increases the loss of calcium in urine and feces;
• too much sodium, leading to loss of calcium in the urine;
• excessive (less often - insufficient) energy value of the diet;
• deficiency of vitamin D in the diet and insufficient insolation necessary for endogenous synthesis of the vitamin;
• lack of fat in the diet, which leads to impaired absorption of all fat-soluble vitamins, including vitamin D;
• underestimation of the role of dietary supplements and preparations containing calcium and vitamin D for the prevention and treatment of osteoporosis.

Best lists

Of the listed drugs, we will highlight the best in the following categories:

• the best product in the price/quality category;
• best dietary supplement.

The best product in the price/quality category

This drug is perfect if you have bone problems. Effectively heals fractures, relieves joint pain, improves heart and eye function. Chewable tablets have a lemon flavor (unlike other analogues, which taste like chalk). The manufacturer is located in Norway, which means that you can rest assured about the quality of the components, because their products undergo strict testing.

Best Dietary Supplement

This Russian supplement will be a great help for the body if you want to help your bones. The composition is enriched with a number of other useful vitamins, such as vitamin A, C, E and group B, and the price will be lower than if you had to buy all these vitamins separately. It has shown itself to be effective in healing fractures and strengthening nails and teeth.