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Reviews of Calcium Preparation and Vitamin D Deficiency in Thai Elderly Women

Reviews of Calcium Preparation and Vitamin D Deficiency in Thai Elderly Women. Dr. Suppasin Soontrapa Orthopedics Department Khon Kaen University Khon Kaen Thailand. 1 Mar 09. WHAT IS OSTEOPOROSIS ?. NIH Definition of Osteoporosis 2001 ( NIH of USA).

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Reviews of Calcium Preparation and Vitamin D Deficiency in Thai Elderly Women

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  1. Reviews of Calcium Preparation and Vitamin D Deficiency in Thai Elderly Women Dr. Suppasin Soontrapa Orthopedics Department Khon Kaen University Khon Kaen Thailand 1 Mar 09

  2. WHAT IS OSTEOPOROSIS ?

  3. NIH Definition of Osteoporosis 2001 (NIH of USA) • Osteoporosis is a skeletal disorder characterized by compromisedbone strength predisposing a person to an increased risk of fracture. • Bone strength reflects the integration of bone density and bone quality • Consensus Development Conference, JAMA 2001; 285: 785-95

  4. Risk Factor of Osteoporosis

  5. Risk Factor of Osteoporosis 1. old age 2. history of maternal hip fracture 3. menopause 4. Oophorectomy 5. Low calcium and vitamin D intake 6. small body frame 7.being sedentary, no regular physical activity and exercise 8. on long term steroid medications 9. drinking excessive alcohol and smoking

  6. Risk Factor of Osteoporosis 1. old age 2. history of maternal hip fracture 3. menopause 4. Oophorectomy 5. Low calcium and vitamin D intake 6. small body frame 7.being sedentary, no regular physical activity and exercise 8. on long term steroid medications 9. drinking excessive alcohol and smoking

  7. Calcium

  8. Calcium Elemental Composition of the Human Body • Calcium is the fifth most abundant chemical element in the human body Lehninger, Biochemistry, 2nd ed., 1975

  9. Calcium • Calcium has critical roles in a variety of biochemicaland physiologic processes • 99% of calcium deposit in the bone • 1% in extracellular fluid

  10. Optimal calcium requirements recommended by the National Institutes of Health Concensus Panel (JAMA 272:1942-8;1994)

  11. Optimal calcium requirements recommended by the National Institutes of Health Concensus Panel (JAMA 272:1942-8)

  12. Women (1989)

  13. Calcium requirement estimated by balance study in elderly Japanese people (K. Uenishi, et al. Osteoporos Int 2001) • From the balance study • Daily Ca requirement was 702 mg in the men • Daily Ca requirement was 788 mg in women • RDA = 1.2x Ca requirement • RDA for Ca was 842 mg/day for men • RDA for Ca was 946 mg/day for women

  14. 842 Women 946 1000 (1989)

  15. Daily calcium intake of Thai population in Bangkok and vicinityProf. Surat Kominet al. • 400 cases of healthy population age 20-80 yrs. • Average calcium intake per day was about 361 mg. • > 65% of cases had calcium intake less than 400 mg/day • Only 2 % of cases had calcium intake > 800 mg/day

  16. Conclusion • Most of Thai population had calcium intake <400 mg/day • Thai RDA of calcium intake (1989) 800-1200 mg/day • Thai population had calcium deficit about 400-600 mg/day

  17. Calcium Supplementation and Bone Benefit

  18. Percentage of increment in BMD and BMC between groups after 1 year of 500 mg Ca supplementation in males P = .030 P = .031 P = .045 P = .007 Percentage of increments (%) Charoenkiatkul, et al. 1999

  19. Percentage of increment in BMD and BMC between groups after 1 year of 500 mg Ca supplementation in females P = .038 P = .033 Percentage of increments (%) Charoenkiatkul, et al. 1999

  20. Conclusion • The increasing in calcium intake 500 mg/day for1 yr. could significantly increase bone densityboth male and female

  21. การดูดซึมยาแคลเซียมจะมากน้อยเพียงใดขึ้นกับ 2 ปัจจัยใหญ่ๆคือ 1. การแตกตัวของเม็ดยา (disintegration) 2. การละลายตัวของยาในกระเพาะและลำไส้ (dissolotion)

  22. Standard USP procedures: • ยาควรจะแตกตัวได้หมดภายใน 30 นาทีในสารละลายที่เลียนแบบกระเพาะอาหาร • First-case USP standards: • ร้อยละ 75 ของยาจะต้องละลายตัวได้ภายใน 45 นาที

  23. The dissolution of calcium composition in differentpH % dissolution pH buffer Calcium carbonate Tricalcium phosphate Calcium lactate

  24. Stomach 1-2 Duodenum 3-4 Jejunum proximal 6 middle 7.6 Ileum >7 Calcium phosphate Calcium carbonate Calcium lactate

  25. G.I. Absorption of Calcium from Milk and Calcium Salts Objective • to compare the absorption of calcium from milk and from five calcium salts: calcium carbonate, gluconate, lactate, citrate and acetate. Subjects • eight healthy men (25-30 years) Method • to measure the net calcium absorption from milk and five calcium salts. Mudassir SS, et al. N Engl J Med 1987;317:532-6.

  26. Percent of calcium absorption (mean+S.E.) Mudassir SS, et al. N Engl J Med 1987;317:532-6. ANOVA showed no statistical significant

  27. Gastric acidity in older adults • Cross-sectional study in a volunteer sample • A total of 248 white male and female volunteers aged 65 years or older living independently Aryeh Hurwitz JAMA 1997;278:659-62

  28. Gastric acidity in older adults • More than 10% of elderly people in this study were unable to acidify gastric contents, both the basal, and stimulated state • Of those who were consistent hyposecretors of acid, most had serum markers of atrophic gastritis Achlorhydria Aryeh Hurwitz JAMA 1997;278:659-62

  29. Calcium absorption and achlorhydria • Compare absorption of calcium in patients with achlorhydria in • Carbonate form • Citrate form • 11 fasting patients with achlorhydria and 9 fasting normal subjects Robert R Recker N Engl J Med 1985; 313: 70-3

  30. Calcium absorption and achlorhydria • Mean calcium absorption(+SD) • Patients with achlorhydria • 0.452 + 0.125 for citrate • 0.042 + 0.021 for carbonate (p<0.0001) • Normal subjects • 0.243 + 0.049 for citrate • 0.225 + 0.108 for carbonate (NS) Robert R Recker N Engl J Med 1985; 313: 70-3

  31. Calcium lactate-gluconate 2.94 g (13%) = 380 mg Calcium carbonate 0.3 g (40%) =120 mg (elementary calcium 500 mg)

  32. Comparative study of the intestinal absorption of three salts of calcium in young and elderly women J.P. Praet, A. Peretz, et al. J Endocrinol. Invest. 21:263-7, 1998

  33. Objective • ต้องการเปรียบเทียบการดูดซึมแคลเซียมต่างชนิด ได้แก่ • Calcium citrate in soluble • Calcium citrate in solid • Calcium gluconolactate-carbonate

  34. กลุ่มประชากร • สตรีที่มีสุขภาพแข็งแรงอายุน้อยจำนวน 15 ราย • สตรีสูงอายุ 20 ราย

  35. methods • การศึกษานี้ใช้วิธี oral calcium loading test แบ่งกลุ่มประชากรออกเป็นสองกลุ่ม • กลุ่มแรก • เปรียบเทียบการดูดซึม 1000 mg of elementary calcium of solid calcium citrate (125 mg/tab * 8 tabs) vs. calcium gluconolactate-carbonate (500 mg/tab * 2 tabs) • ในสตรีอายุน้อยจำนวน 7 ราย (median age = 23 yr, range 22-24 yr) • และสตรีสูงอายุจำนวน 10 ราย (median age = 72 yr, range 62-85 yr)

  36. methods • การศึกษานี้ใช้วิธี oral calcium loading test แบ่งกลุ่มประชากรออกเป็นสองกลุ่ม • กลุ่มที่สอง • เปรียบเทียบการดูดซึม 1000 mg of elementary calcium of soluble calcium citrate (500 mg/tab * 2 tabs) vs. calcium gluconolactate-carbonate (500 mg/tab * 2 tabs) • สตรีอายุน้อยจำนวน 8 ราย (median age = 23 yr, range 21-46 yr) • สตรีสูงอายุจำนวน 10 ราย (median age =79 yr, range 70-91 yr)

  37. Results In preload phase • Basal calciuria เพิ่มขึ้นในสตรีสูงอายุ (p<0.01) • Basal serum calcium จะใกล้เคียงกันในทั้งสตรีอายุน้อยและสูงอายุ

  38. Results • ภายหลัง oral calcium loading • ในผู้สูงอายุ postload calciuria เพิ่มขึ้นอย่างชัดเจนในกลุ่ม soluble calcium citrate (p<0.05) และ Ca gluconolactate (p<0.05) เมื่อเทียบกับ solid calcium citrate • ในผู้มีอายุน้อยพบลักษณะเช่นเดียวกับผู้สูงอายุ แต่ไม่มีนัยสำคัญ

  39. Conclusions • การดูดซึมแคลเซียมของ Calcium gluconolactate และ soluble form of calcium citrate สูงกว่า solid form of calcium citrate

  40. Conclusions • โรคกระดูกพรุนในผู้สูงอายุต้องเสริมด้วยแคลเซียม • ผู้สูงอายุส่วนหนึ่งมีภาวะ achlorhydria และมีผลต่อการดูดซึมแคลเซียม • แคลเซียมที่เหมาะสมต่อผู้สูงอายุควรเป็นแคลเซียมชนิดที่สามารถละลายได้ในทุก pH และเป็นชนิดเม็ดฟู่เพื่อเพิ่มการดูดซึม

  41. Vitamin D

  42. Introduction • Vitamin D is an essential vitamin for maintaining a healthy skeleton throughout our lives because 1. Enhance the GI absorption of Calcium 2. Enhance mineralization of bone 3. Improve muscle function

  43. Introduction • The reduction in vitamin D is associated with • impaired calcium absorption • increasing PTH level to cause secondary hyperparathyroidism which stimulate bone resorption and bone loss especiallycortical bone and cause osteoporosis especially Femoral neck

  44. Introduction • Many elderly persons, particularly those who are confined indoors, usually have vitamin D deficiency (Gloth III FM. JAMA. 1995) • Many studies in western countries showed high prevalence of low serum vitamin D concentration (25-54 %)(Omdahl JL. Am J Clin Nutri 1982; McKenna MJ. Am J Med 1992; Goldray D. J Am Geriatr Soc 1989.)

  45. Introduction • Vitamin D deficiency is one of the risk factors of osteoporosis and osteoporotic fracture (Gloth IIIFM. J Am Geriatr Soc 1995; Meunier PJ. Am J Med 1993; Boonen S. J Endocrinol 1996; Lefoff MS. JAMA, 1999; Lips P. Am J Clin Nutr 1987) • Calcium and vitamin Dsupplementation could reduce osteoporotic hip fracture and other nonvertebral fractures among elderly women (Chapuy MC. N Eng J Med 1992; Chapuy MC. BMJ 1994)

  46. Introduction • Two main sources of vitamin D are 1. food intake ( cod liver oil, eel, salmon, milk with supplemented vitamin D, etc.) 2. photosynthesis in the skin • The skin synthesis of vitamin D is considered the most common source of vitamin D in man

  47. Introduction • Homebound elderly persons usually susceptible to vitamin D deficiency because 1. Poor nutrition(Omdahl JL. Am J Clin Nutr 1982; Delvin EE. Am J Clin Nutr 1988; Parfitt AM. Am J Clin Nutr 1982) 2. Deprivation of sunlight(Parfitt AM. Am J Clin Nutr 1982) 3. Age-related changes in skin and renal function(MacLaughlin JA. J Clin Invest 1985)

  48. Introduction • Thailand locate in the tropical zone with abundant sunlight, most people believe they have adequate sunlight exposure and should have adequate vitamin D • The Vitamin D supplementation does not necessary in Thai elderly • Do you believe this concept ?

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