The Calcium Question The Facts as my research has provided in 2004. There are no published long term studies on the Calcium Carbonate issue to support its use by gastric bypass patients. |
[I have pulled out of the NIH Statement for the purposes of WLS patients who are evaluating which supplements to take. I am not a professional in the medical field and I can only go by what I am discovering while researching when putting this information together.] 1. Absorption of calcium supplements is most efficient at individual doses of 500 mg or less and when taken between meals. Ingesting calcium supplements between meals supports calcium bioavailability, because food may contain certain compounds that reduce calcium absorption (e.g. oxalates). 2. Absorption of one form of calcium supplementation, calcium carbonate, is impaired in fasted individuals who have an absence of gastric acid. 3. Calcium supplementation in the form of calcium citrate does not require gastric acid for optimal absorption and thus could be considered in older individuals with reduced gastric acid production. 4. In individuals with adequate gastric acid production, it is preferable to ingest calcium supplements between meals. Above taken from the June 6-8, 1994 NIH Consensus Statement on Optimal Calcium Intake. NIH is the National Institute of Health. You may find this at NIH Consensus Page 19 of the document (or page 22 of the pdf file). Oxalate, which is present at high levels in some vegetables (e.g., spinach), has been found to depress absorption of the calcium present in the food ... Keep in mind that the overall recommendations on dosages are for people who have normal stomachs. If I am not mistaken the RDA is a 40 year old recommendation. FINALLY ... an abstract (page 20) that was presented at the June 2004 American Society for Bariatric Surgery meeting. A Comparison of the Absorption of Calcium Citrate and Calcium Carbonate following Roux-En-Y Gastric Bypass. Presented by: Craig G. Chang, MD; Thomas Simms, MD; Beverley Adams-Huet, MS; Khashayar Sakhaee, MD; Daniel B. Jones, MD; David A. Provost, MD; The University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA. "Results: Calcium citrate produced a greated mean increase in serum calcium from baseline than calcium carbonate (p<0.01), and a greater cumulative calcium increment from baseline than calcium carbonate in both serum (p=0.02) and urinary (p<0.001) calcium. The percent decrease in serum PTH from baseline was significantly greater after calcium citrate when compared to calcium carbonate, (p<0.01). Calcium citrate stimulated a lower nadir decrement of PTH (p<0.01), and the cumulative decrement in serum PTH was significantly greater for calcium citrate (p<0.001). Conclusion: Calcium citrate has significantly greater bioavailability than calcium carbonate following RYGB." Because calcium citrate does not require gastric acid for absorption, it is a better choice for patients with achlorhydria (i.e. limited gastric acid production). This is from: calcium article Calcium in the form of calcium citrate does not require stomach hydochloric acid for absorption. This means that it is more readily absorbed and utilized by the body and can also be taken on an empty stomach. From: Calcium Citrate Calcium, whether from the diet or supplements, is absorbed best by the body when it is taken several times a day in amounts of 500 mg or less. Calcium also interferes with iron absorption. The exception to this is when the iron supplements is taken with Vitamin C or calcium citrate. Any medication to be taken on an empty stomach should not be taken with calcium supplements. Above from: 1999 Issue of NOF's Quarterly Member Newsletter, Osteoporosis Report. From: Calcium Supplements Also: In the NIH Consensus state, page 17. Concern has been raised that increased calcium intake might interfere with absorption of other nutrients. Iron absorption can be decreased by as much as 50 percent by many forms of calcium supplements or milk ingestion but not by forms that contain citrate and ascorbic acid, which enhance iron absorption. [my note here: Calcium needs vitamin D and magnesium in a 2:1 ratio for the calcium to be absorbed properly so it would seem to me that if calcium is taken properly you would NOT take it with iron.] RDA is being replaced with DRI (dietary reference intake). To learn more about DRI go to: www.cc.nih.gov/ccc/supplements. This has a great series of pdf downloadable pages on various vitamins/minerals that we need to know about. From: www.gastricbypassfamily.com Ask AHSC Answers to Health Questions from The University of Arizona Health Sciences Center (AHSC) in Tucson, AZ. May 2001 Q: I was told to take calcium supplements daily after my gastric bypass operation. Which is better, calcium carbonate or calcium citrate? Why? And how much should I take? (I'm a 55-year-old male, 6'3", 205 lbs.) R.H. A: Calcium carbonate has more calcium per gram than calcium citrate, so it would be less volume (fewer pills or less liquid) of the calcium carbonate to provide the same amount of absorbable calcium. Because calcium carbonate requires hydochloric acid, a stomach acid, to be digested and absorbed, the type and extent of your gastric bypass will determine which calcium supplement is better for you. The recommended intake of calcium for a 55-year-old male is 1,200 milligrams daily based on the 1997 Institute of Medicine guidelines. However, you should check with the dietician who assisted you after your surgery, or check with your surgeon, for a specific, individualized recommendation. _Deborah Pesicka, R.D., registered dietician, University Medical Center, Tucson We recommend routine monitoring of vitamin D and calcium intake in all patients following obesity surgery. It is recommended that all persons should ingest 1200-1500 mg of calcium and 800 IU of vitamin D per day. this is difficult to achieve after gastric bypass without supplementation. If their dietary intake is inadequate, they should receive appropriate supplementation. If patients have extreme malabsorption, higher doses of calcium and vitamin D may be necessary to maintain normal calcium levels and prevent secondary hyperparathyroidism. We also recommend yearly screening of calcium, alkalin phosphatase, 25(OH)D and PTH. A rise in alkaline phosphatase and PTH would be the first signs of metabolic bone disease and would indicate a need to increase treatment with calcium and vitamin D and further evaluate vitamin D status. In addition, it would alert the physician that other abnormalities associated with malabsorption may also be present, such as anemia. If these tests are routinely performed postoperatively, it could greatly decrease the long-term morbidity associated with GI bypass operations. The above is from: Case Report about Severe Metabolic Bone Disease as a Long-Term Complication of Obesity Surgery. Keep in mind this particular patient appears to be a very non-compliant individual, but I particularly liked the specific recommendation that could benefit each of us. By measuring blood levels of calcium, they demonstrated that calcium citrate is 2.5 times more bioavailable (easier for your body to use) than calcium carbonate. From: http://healthlink.mcw.edu/article/964794298.html. Calcium citrate has the advantage of being absorbed when gastric acid secretion is low (very common after menopause and in those taking acid reducing medications). In addition, the citrate form is protective against the formation of calcium-rich kidney stones. From: http://jaxmed.com/articles/medications/calcium.htm BONE DENSITY IS NOT RELATED TO BLOOD CALCIUM LEVEL From: http://healthlink.mcw.edu/article/989700612.html Q: I'm a bit confused over a calcium blood test that I had done. I'm 54 and have been on both estrogen and progesterone for the last few years. Because I have a small frame and have always been concerned about osteoporosis, I've been very religious about calcium intake and have worked out with weights for about 27 years. I had my first bone density test in fall and it alrady showed some thinning even though my blood test came back showing a high calcium count. How can this be? Could you explain please? A: The level of calcium in your blod does not reflect how much calcium is in your bones or how "dense" and strong they are. On bone density tests, they compare your bones to women your age ("Z score") and to young women ("T score"). Every womanh over 50 will show bone density loss compared to 20 year-old women, so that may be the "thinning" that your test showed. You've been doing three important things for your bones: good calcium intake, exercise/weight-training, and estrogen. Even hormones are not absolute protection though. In a recent study of over 800 women, about 10% of those on hormones lost some density in their spine and hips. this is still much better than the 60% of women not taking hormones who lost bone density. HOW TO READ CALCIUM LABELS: This is an important topic to those of us who are trying to make sure that we take the correct amount of elemental calcium. Labels can be very confusing. 500 mg calcium (calcium citrate) = 500 mg elemental calcium 500 mg calcium as calcium citrate = 500 mg elemental calcium 500 mg calcium from calcium citrate = 500 mg elemental calcium 500 mg calcium citrate = approximately 105-125 mg elemental calcium depending on the manufacturer. Calcium citrate is about 21% elemental calcium. If you have a larger pill of calcium citrate (i.e. 1000 mg) just double the numbers to evaluate the amount of elemental calcium that you would be getting. If you see a bottle labeled as Calcium, but it does not tell you what type. Put it back on the shelf and continue your search for calcium citrate. It is not calcium citrate if it does not say so. Not calcium citrate brands include: Viactiv, Os-Cal, and Tums. READ YOUR LABELS!!!! Citracal is the correct form of calcium citrate and the mg listed is elemental calcium. Same with the Kirkland version of citracal. There are also many other brands of calcium citrate available. To get the amount that you desire each day you will likely be taking many capsules or tablets. Some other basic facts that will be of help to you so that you maximize your calcium intake. Do not take more than 500-600 mg of calcium at a time. We do not absorb more than that amount, seperate your calcium by a couple hours to allow your body the opportunity to absorb as much as possible. Calcium should NOT BE TAKEN with Iron. The calcium will block the iron absorption and if you are taking iron because your lab tests indicate that you need it, you will not want this happening. Vitamin D and Magnesium are good components to have in your calcium supplement. The magnesium will help with any constipating effects and the Vitamin D helps increase absorption. Magnesium is good for us in many other ways as well and most people are deficient in it. If you have kidney disease you will not want to add extra magnesium to your daily regimen without a doctor's approval. Calcium is considered safe up to 2500 mg a day. Calcium Citrate also reduces the risk of kidney stones. You will also want to have a baseline Dexa Scan (bone density test of your hips and spine) before your gastric bypass or shortly there after. You will then want to have an annual test to monitor your bone density. This should be done in the same month each year. My source for much of the above in this segment is from: Caring for the Surgical Weight Loss Patient by Gaye Andrews, Ph.D.; Diane LeMont, Ph.D.; Sally Myers, RD; Erin Nelson, RNMS; Jacquelyn Smiertka, RN. 2003. Wheat Field Publications. www.drgaye.com. Chapter Five on Nutrition. Other links of interest: Listing of citations from various authors on the topic: http://www.nlm.nih.gov/pubs/cbm/calcium.html Study: http://www.sodbrennen-welt.de/science/1989/1989_2517700.htm http://www.natlife.com/PPS/CCM.htm Calcium: http://shop.store.yahoo.com/marcella75/calcium1.html Vitamins: http://gastricbypass.netfirms.com/vitamins.htm Nutrition: http://www.nutratherapeutics.com/html/pf-sports_nutrition.html Review Bone Disease from Duodenal Exclusion: http://www.bariatricoperation.com/articles/Bone_Loss_OSG_Masonj3oju.pdf Calcium Supplements: http://lesann.tripod.com/calcium_supplements.htm Screening for Osteoporosis: http://healthlink.mcw.edu/article/950813818.html |
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