Purpose

Calcium is essential to the body.  It is the most common mineral in the body and is needed in tiny amounts for the function of most vital organs such as heart and brain.  However, the vast majority of calcium is used by the bones and teeth.  During early childhood and adolescence, vigorous bone growth occurs.  However, bone is a living tissue and calcium leaves the bone as new bone is being created.  By the mid 30’s, a shift occurs whereby more calcium begins to leave bone than is deposited.  Bones begin to weaken.  In the earliest stages, this is called osteopenia.  As it worsens, it becomes osteoporosis.  This is when bone fractures of the hip and spine begin to occur.  It is never too late to reverse this process, though starting early in life and when young will give you the best chance of having strong bones later in life.

Risk Factors for Osteoporosis and Osteopenia

• Older age
• Non-Hispanic, Caucasian and Asian ethnicity
• Small bones – i.e. females
• Family history of osteoporosis or osteopenia
• Long-term estrogen hormone use
• Cigarette smoking
• Alcohol abuse
• Sedentary lifestyle or bedridden
• Low calcium intake
• Low vitamin D blood level
• Certain medications such as prednisone, excess thyroid, Dilantin and others

Gut Bacteria and Calcium

A remarkable new area of modern research is in the human colon.  Here, there are over 2000 species of bacteria and trillions upon trillions of bacteria.  They live and thrive in the colon and produce a large number of health benefits.  It is now known that when significant amounts of certain vegetable fibers or dietary supplements reach the colon that the very best bacteria grow vigorously.  These thriving bacteria in turn cause extra calcium to be absorbed through the colon wall. 

Soluble Prebiotic Fiber

All plant fiber arrives in the colon unchanged.  There, it is the soluble (meaning water soluble) fibers that are used by certain of the gut’s bacteria to enhance the absorption of calcium.  The two fibers that have been most studied are inulin and oligofructose.  In fact, when a group of young teenagers took this fiber supplement daily, they had a 20% increase in bone density (bone strength) after one year.

Vitamin D

Vitamin D is also essential to bone health. It encourages absorption of calcium. You get vitamin D from exposure of the skin to the sun, from a limited number of foods, and from dietary supplements. A remarkable recent finding is that there are receptors for vitamin D in many tissues other than the small intestine, where calcium from food is absorbed. These include muscles, brain, prostate, breast, colon, and immune cells. We have to believe that these vitamin D receptors serve a function since diseases in these organs have been associated with vitamin D deficiency.

Additionally, vitamin D levels have recently been found to be significantly low in many age groups. The previous recommendation of 400 IU per day is too low. The new recommendation is 800-1200 IU daily, especially for people who do not have significant skin sun exposure like the elderly or those who are inactive. Vitamin D is found in a limited number of foods such as cheese, butter, vitamin D fortified milk, oily fish and eggs.

Vitamin D and calcium are intimately connected.  You need to have a good level of vitamin D in your blood to absorb and use calcium.  In Caucasian and light-skinned people, the sun’s rays will make vitamin D in the skin.  Dark-skinned people and African-Americans need to get their vitamin D from foods and vitamin D pills.  This is important as vitamin D deficiency is very common.  For detailed information on vitamin D from the National Institutes of Health, google search: Dietary supplement Fact Sheet: Vitamin D.

Selected Foods High in Vitamin D

• Cod liver oil
• Salmon, Mackerel, Sardines, Tuna
• Vitamin D enriched milk, fruit juices, yogurt

What To Do - The Good Things

• Consume 1000-1500 mg of calcium per day in food and/or a supplement
• Active lifestyle – walking, bicycling, gym workout, etc.  You want to stress your bones.  Weight lifting by itself does not do this very well.
• Eat soluble plant fiber or take a prebiotic supplement.
• No cigarettes
• Moderate alcohol only
• Check your medications with your physicians.
• Moderate caffeine intake – coffee and sodas

Calcium Intake

By far, the most important consideration is to get enough calcium into your body every day.  A minimum of 1000 mg a day is recommended going up to 1500 mg a day when needs are high, such as in recovery from fractures, athletics and pregnancy.  The chart below provides information on calcium content in various common foods.

Calcium Content of Foods
Foods	Serving Size	mg of Calcium
Yogurt, Low Fat	1 cup	450
Cheese, Grilled Sandwich	1	371
Cheese, Ricotta	1/2 cup	337
Sardines	7	322
Yogurt, Fruit	1 cup	315
Cheese, Cheddar	1 1/2 oz	305
Milk, Skim or 2%	1 cup	300
Orange Juice with Calcium	1 cup	300
Soy Beverage with Calcium	1 cup	250-300
Cheese, Gruyere	1 cup	287
Salmon	5 oz	278
Tofu, Firm	1/2 cup	240
Cheese, Mozzarella	1 ounce	207
Tofu, with Calcium	1/2 cup	204
Macaroni and Cheese	1/2 cup	179
Waffle, Homemade	1	179
Collard Greens, Frozen/Boiled	1/2 cup	179
Ice Cream, Vanilla	1 cup	176
English Muffin, Whole Wheat	1	175
Cheese, American	1 oz	174
Rhubarb, Cooked	1/2 cup	167
Oatmeal, Instant	3/4 cup	163
Cottage Cheese, 2%	1 cup	163
Rice Beverage with Calcium	1 cup	150-300
Pudding Made with Milk	1/2 cup	147-160
Custard, Baked	1/2 cup	149
Pizza, Cheese	1 slice	111-147
Molasses, Blackstrap	1 Tbsp	137
Spinach, Cooked or Frozen	1/2 cup	122
Tofu, Regular	1/2 cup	108
Yogurt, Frozen (Fat Free/Low Fat)	1/2 cup	105
Milk, Instant (Dry/Nonfat)	2 Tbsp	105
Almonds	1/4 cup	94
Broccoli, Cooked or Fresh	1 cup	90
Kale, Cooked	1/2 cup	90
Sesame Seeds, Dried	1 Tbsp	88
Taco, Chicken	1	87
Bok Choy, Cooked or Fresh	1/2 cup	80
Mustard Greens, Cooked	1/2 cup	75
Bread, White	2 slices	70
French Toast	1 slice	65
Hot Dog, Turkey	1	58
Orange, Medium	1	52
Halibut, Baked	3 oz	51
Fig Bar Cookie	4	40
Bread, Whole Wheat	2 slices	40
Cream Cheese	2 Tbsp	23
Cream, Half and Half	1 Tbsp	16
Chicken Breast, Baked	3 oz	14
Apple, Medium	1	10
Pasta, Cooked	1 cup	10
Beef, Lean Ground	3 oz	9
Banana, Medium	1	7

Sample Menu

Breakfast	Lunch	Dinner
grapefruit,1/2 high fiber cereal (5-10 gm/serving) banana, 1/2 cup whole wheat toast, 2 slices low saturated fat spread, 2 tsp jelly or jam, 1 Tbsp skim milk, 1 cup decaffeinated coffee/tea	vegetable soup, 1 cup lean hamburger patty, 2 oz whole wheat hamburger bun sliced tomato, 2 oz lettuce with dressing, 1 Tbsp fresh fruit salad, 1/2 cup oatmeal cookie, 1 non-calorie beverage	tomato juice, 1 cup broiled chicken breast, 2 oz herbed brown rice, 1/2 cup broccoli spears, 2 cheese sauce, 1/4 cup hard dinner roll, 1 low saturated fat spread, 1 tsp carrot/raisin salad made with lite mayonnaise, 1/2 cup frozen strawberry yogurt, 1/2 cup skim milk, 1 cup

This Sample Diet Provides the Following
Calcium	1200 mg	Fat	54 gm
Calories	2120 Kcal	Carbohydrates	326 gm
Protein	84 gm	Sodium	3130 mg

Calcium Supplements

There are many different forms of calcium preparations sitting on the pharmacy shelf. How do you decide which is best for you?  If you are getting, on average, 1000-1500 mg of calcium a day in your foods, you likely do not need a supplement.  However, to get this much calcium, the diet must be rich in dairy products such as milk, yogurt, some cheeses and fish.  If you select a calcium supplement, below are some key facts to consider.

There are two main preparations of calcium:

• Calcium Carbonate
• Calcium Citrate

Calcium is also available as calcium lactate and calcium gluconate.

Elemental Calcium – This is an important term.  The label may say calcium 1000 mg, but the important term is “elemental calcium“.  This is the amount of calcium that is actually available from the preparation.  For instance:

	Weight	Elemental Calcium
Calcium Carbonate	1000 mg	400 mg (40%)
Calcium Citrate	1000 mg	210 mg (21%)

If you do not find the two words “elemental calcium” on the label, assume you must multiply the calcium weight listed by 40% for calcium carbonate and 21% for calcium citrate to get the true amount of elemental calcium.

• Expense – Calcium carbonate is the least expensive.  Calcium citrate is more expensive per pill while providing only half the elemental calcium that carbonate preparation does.
• When and how to take it – Take calcium carbonate with meals, no more than 500 mg at a time.  Twice a day is a reasonable dosing.  Calcium citrate can generally be taken with or without food.