Nutrition Management of Calcium Intake

Description
The medical condition and nutritional requirements of the patient influence whether the dietary intake of calcium is adequate. The amount of calcium in the diet may need to be either increased or decreased, depending on the patient’s condition.

An adequate intake of calcium has been associated with a reduced risk of osteoporosis. The Dietary Reference Intakes (DRIs) includes the amount of calcium needed to reduce the risk of osteoporosis (1). However, it is difficult for many women to consume these levels without supplementation. In addition, after gastric bypass procedures, calcium supplementation will be required to maintain serum levels and prevent metabolic bone disease.

Nutritional Adequacy
Calcium-Restricted Diet: The diet is inadequate in calcium, vitamin D, and riboflavin.

How to Order the Diet
To decrease calcium in the diet: Specify the desired level of calcium intake in milligrams. Include any other necessary restrictions. Order ______Diet, _____ mg calcium.

To increase calcium in the diet above the DRI: Specify the desired level of calcium in milligrams. The DRI for calcium for males and females is as follows (1):

Age (years)                         Calcium (mg/day)
9 to 18                                   1300
19 to 50                                 1000
³51                                         1200

Planning the Diet
To restrict calcium: Eliminate milk and all milk products.

To encourage increase in calcium intake: Refer to Table F-3: Calcium Content of Common Foods, for additional foods to encourage eating. If supplementation is required, recommend supplements with calcium carbonate, since this form contains the most available amount of elemental calcium. Refer to the supplement’s label to determine the actual amount of calcium, which usually is referred to as elemental calcium (2,3) Elemental calcium is highest in calcium carbonate (40%). Other calcium supplements contain lesser amounts of elemental calcium, eg, calcium phosphate (38%), calcium citrate (21%), calcium lactate (13%), and calcium gluconate (9%). To calculate the amount of elemental calcium in a supplement, identify the number of milligrams the supplement contains. For example: 1 pill of 650 mg of calcium carbonate [650 mg x 40%] provides 260 mg of elemental calcium (2). Approximately 4 tablets per day of calcium carbonate are needed to meet the RDI for most age-groups. Calcium supplements of 1200 to 1500 mg/day should be provided to all patients after gastric bypass surgery (Roux-en-Y and bilio-pancreatic diversion (BPD)) (4). In the cases of gastric bypass, calcium citrate with vitamin D is the preferred preparation because it is more soluble than calcium carbonate in the absence of gastric acid production (5). For patients with the BPD procedure who have clinical steatorrhea, a high dose calcium supplementation regimen (2000 mg/day) along with monthly intramuscular vitamin D is recommended to reduce the risk of metabolic bone disease (1).

Adequate intake or synthesis of vitamin D is critical to ensure adequate absorption of calcium. The DRI for vitamin D for men and women is as follows (1):

Age (years)         Vitamin D (IU)
19 to 50                 200
51 to 70                 400
³71                         600

Although vitamin D is synthesized in the skin from exposure to sunlight, studies have shown that older adults usually do not have adequate exposure to sunlight to synthesize the necessary vitamin D. This problem is compounded by increased use of sunscreens with high sun protection factors and an inefficiency of the skin to manufacture vitamin D as adults age. For adults over 50 years of age and younger adults who spend little time outside, it may be advised to take a daily multivitamin with vitamin D (which typically contains 400 IU of vitamin D) (6-8).

FOOD ITEM	SERVING SIZE	CALCIUM (mg)
Milk and Dairy Products
Cheese
American	1 oz	174
Cheddar	1 oz	204
Cottage, Creamed	1 oz	68
Mozzarella, Part Nonfat	1 oz	183
Parmesan Cheese	1 tbsp	70
Swiss	1 oz	272
Hot Cocoa	1 cup	106-300
Ice Cream	½ cup	88
Ice Milk	½ cup	102
Milk, Whole, Nonfat, Chocolate	1 cup	287-300
Pudding	½ cup	125-187
Sherbet	½ cup	52
Yogurt, Fat-Free	8 oz	314
Yogurt, Frozen	4 oz	105
Yogurt, Fruit-Flavored	8 oz	415
Yogurt, Plain	8 oz	415
Fish
Sardines, Canned With Bones	1 oz	101
Salmon, Canned With bones	1 oz	74
Vegetables
Broccoli	½ cup cooked	89
Collard Greens	½ cup cooked	178
Kale	½ cup cooked	90
Turnip Greens	½ cup cooked	125
Legumes
Great northern beans	1 cup cooked	121
Navy beans	1 cup cooked	128
Pinto beans	1 cup cooked	82
Fruits
Dried figs	5	258
Calcium-fortified orange juice	1 cup	300
Sources: USDA Handbook No. 8. Washington DC: US Dept of Agriculture; 1986. Position of The American Dietetic Association and Dietitians of Canada: vegetarian diets. J Am Diet Assoc. 003;103(6):748-765.

NUTRITION MANAGEMENT OF CALCIUM INTAKE