EMAS Guideline on calcium in reducing osteoporosis risk

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The European Menopause and Andropause Society has issued a new clinical guide that summarises the evidence regarding the effects of calcium in reducing the risk of osteoporosis after the menopause.

Osteoporosis is common and affects 1 in 3 women. Calcium is vital for strong healthy bones and worldwide scientific societies have issued guidance about the daily requirements from childhood to old age. The European Menopause and Andropause Society (EMAS) has issued a new clinical guide with the aim of raising awareness of the importance of calcium in lowering the risk of osteoporosis.

The recommended daily intake of calcium after menopause varies between 700 and 1,200 mg, depending on the endorsing society. It is uncertain whether excessive intake can cause harm. Some epidemiological studies have raised concern about possible cardiovascular risk, dementia or even, paradoxically, fracture.

Calcium may be obtained from food or supplements containing calcium salts. Most people should be able to get enough calcium through healthy eating, but this is not always the case. Diets in Southern European have less dairy products than in northern countries.

Data from the NHANES database in the US showed that less than one third of women aged 9 to 71 consumed enough calcium. Supplements are poorly tolerated and therefore not usually taken long term. Another reason for concern are the rates of over prescription of supplements above the recommended upper level of 2,000 mg/day. For example, one study found that 29% of supplements were over prescribed.

EMAS confirms that calcium is an essential part of the diet from childhood to old age, and that an approximate assessment of intake should be part of routine health checks. Women need to be more calcium-aware and mindful of calcium-rich foods. But more is not better, and women should be warned that intakes above the recommended levels may be useless or, although still debated, may cause harm.

Abstract
Introduction: Postmenopausal osteoporosis is a highly prevalent disease. Prevention through lifestyle measures includes an adequate calcium intake. Despite the guidance provided by scientific societies and governmental bodies worldwide, many issues remain unresolved.
Aims: To provide evidence regarding the impact of calcium intake on the prevention of postmenopausal osteoporosis and critically appraise current guidelines.
Materials and methods: Literature review and consensus of expert opinion.
Results and conclusion: The recommended daily intake of calcium varies between 700 and 1200 mg of elemental calcium, depending on the endorsing source. Although calcium can be derived either from the diet or supplements, the former source is preferred. Intake below the recommended amount may increase fragility fracture risk; however, there is no consistent evidence that calcium supplementation at, or above, recommended levels reduces risk. The addition of vitamin D may minimally reduce fractures, mainly among institutionalised people. Excessive intake of calcium, defined as higher than 2000 mg/day, can be potentially harmful. Some studies demonstrated harm even at lower dosages. An increased risk for cardiovascular events, urolithiasis and even fractures has been found in association with excessive calcium intake, but this issue remains unresolved. In conclusion, an adequate intake of calcium is recommended for general bone health. Excessive calcium intake seems of no benefit, and could possibly be harmful.

Authors
Antonio Cano, Peter Chedraui, Dimitrios G Goulis, Patrice Lopes, Gita Mishra, Alfred Mueck, Levent M Senturk, Tommaso Simoncini, John C Stevenson, Petra Stute, Pauliina Tuomikoski, Margaret Rees, Irene Lambrinoudaki

Elsevier material
Maturitas abstract


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