Alternative Choices for Calcium Supplementation
Cathy R. Kessenich, DSN, ARNP
Ingesting an adequate amount of daily calcium is important to build and maintain peak bone mass and to prevent fractures resulting from osteoporosis. Most American diets do not contain sufficient amounts of dietary calcium, and supplements are often advised to reach daily goals. For many, typical calcium supplements are large and sometimes difficult to swallow. In response to this need, several interesting alternatives have been developed to help patients meet daily requirements of calcium. Advising patients to select alternative forms of calcium supplementation may have a positive outcome in achieving daily calcium goals.
Calcium is essential for cardiac regulation, nerve conduction, stimulating hormone secretion, blood clotting, and, most importantly, attaining and maintaining of bone mass, structure, and quality. The human body cannot manufacture adequate amounts of calcium without external support. Calcium is lost daily through hair, skin, nails, sweat, urine, and feces. This lost calcium must be replaced, or the body will take calcium from the bones to perform other functions. It has been well documented that ingesting adequate calcium on a daily basis is required to offset routine losses and to prevent fractures resulting from osteoporosis.[1,2]
The recommended dietary reference intake for premenopausal and perimenopausal women (age, 31-50) years and women on hormone therapy is 1000 mg calcium/day in a combination of dietary and supplemental forms. For women aged 51 to 70 years, 1200 mg calcium/day is recommended. Women older than 65 years should ingest 1500 mg calcium/day. Adequate daily calcium intake is a key recommendation for any woman at risk of or currently being treated for osteoporosis.
Most Americans are unable to obtain the necessary amounts of calcium solely through dietary sources. Nurse practitioners commonly recommend supplements to patients to help them achieve daily calcium requirements. Calcium supplements are commonly available in combination with citrate or carbonate compounds. Calcium citrate supplements are well absorbed when taken with meals or on an empty stomach. Because it is better absorbed in less acidic environments, it may be a better choice for older adults. Calcium carbonate is better absorbed when taken with food and is typically less expensive than calcium citrate. Many manufacturers have produced various forms of calcium compound tablets to assist patients in meeting daily calcium needs. However, for many, these tablets are too large, difficult to ingest and not easily incorporated into a daily routine. Supplements in pill form often cause nausea, indigestion, constipation, and bloating. Because of gastrointestinal intolerance, calcium supplements are often left in the medicine cabinet or kitchen drawer. To meet the growing demand for calcium supplementation, many alternative forms of calcium supplements were developed. Foods, snacks, and beverages fortified with calcium are a feasible alternative source of calcium, but they should not be used at the expense of foods naturally containing calcium.[5,6] That is, practitioners should recommend a daily requirement of calcium intake met by a combination of dietary and supplemental sources. This article describes some unique options for helping patients to achieve daily calcium goals by alternative sources.
Many Americans are in the habit of consuming large volumes of bottled water on a daily basis. For many, drinking bottled water is a flavor preference over locally available tap water. To capitalize on this trend several manufacturers have highlighted the naturally occurring calcium content of their spring water or developed flavored waters with additional calcium added. For example, Cole Bros. water company bottles and distributes natural spring water that contains approximately 65.0 mg of naturally occurring calcium per 16.9-ounce serving.
A different company has developed a line of flavored waters that contains 450 mg/L. Sanfaustino calcium water comes in a pure, unflavored version. In addition, it is available in lemon, raspberry lime, lime, and orange. According to the manufacturer, Sanfaustino calcium water provides high-bioavailable calcium carbonate, without the side effects common to most other calcium sources. The absorbability of this calcium-fortified water was independently documented. Because consumers frequently sip water throughout the day, calcium-fortified waters offer a good option for obtaining divided doses of calcium on a daily basis.
Ingesting milk is probably the best way to obtain calcium by dietary sources. However, many patients need alternative beverage options because of lactose intolerance, a dislike of dairy products, or hyperlipidemia. To meet this need many manufacturers of generic and name brands of orange juice have developed calcium-fortified options. Most products provide 30% to 35% of the daily calcium requirement (300-350 mg) in an 8-ounce glass and approximately 110 calories.
Chocolate is a favorite candy choice of many Americans. Several brands of chocolate now provide calcium supplementation. Adora is a new, gourmet chocolate, made with premium, all natural milk or dark chocolate. Each bite-sized 30-calorie piece contains 500 mg of calcium carbonate. Healthy Indulgence is a line of calcium chocolate bites made with real chocolate. Each bite-sized 25-calorie piece contains 500 mg of calcium carbonate. It is available in both milk and dark chocolate varieties. Thompson Candy Company has developed a new line of calcium-fortified chocolate for children. Moobles are an all natural milk chocolate candy wrapped in black and white cow spot foil and containing 140 mg of calcium carbonate per piece. They are packaged for sale in 6-ounce paper milk cartons or 1.5-ounce mesh bags.
For consumers who prefer nonchocolate candy, calcium fortified snacks, several chewable, flavored options are available. Viactiv is chewable product that has been on the market for a number of years. The manufacturers have modified the consistency and flavors to meet consumer demand and now provide chewable caplets in flavors such as milk chocolate, strawberry cream, chocolate mint, caramel, French vanilla, or raspberry. For teenagers, they market a fudge brownie-flavored option. All of the caplets contain 500 mg of calcium carbonate and are 20 calories. Because many patients have difficulty tolerating calcium carbonate, a chewable form of calcium citrate is now available. Mission Pharmaceuticals, a company that previously manufactured only supplemental pills (Citracal) has developed a product called Creamy Bites with flavors of chocolate fudge, lemon cream, or caramel. Each serving contains 500 mg of calcium citrate and is 35 calories.
Many patients are advised to take a daily dose of aspirin to prevent heart disease and to reduce the risk of stroke and other cardiovascular events. These same patients are frequently at risk of developing osteoporosis and osteoporotic fractures. To meet the dual needs of these patients, Bayer aspirin has developed an aspirin plus calcium product. It is available in an 81-mg caplet that also contains 300 mg of calcium carbonate.
Constipation is a common complaint in patients who ingest calcium supplements. Many patients find that calcium carbonate is more constipating than calcium citrate. However, for some patients the reverse is true. The causative factors for the constipation are not well documented. To counteract the constipation frequently experienced by patients ingesting calcium supplements, manufacturers have developed products that combine calcium with fiber.
Although many breads, cereals, and cereal bars are fortified with additional calcium, patients frequently have the need to supplement dietary sources of fiber with fiber capsules. Proctor and Gamble has developed a version of fiber capsule (Metamucil plus Calcium) that contains 300 mg of calcium carbonate in each daily serving of 5 capsules. One serving (5 capsules swallowed one at time) should be taken with at least 8 ounces of water or other fluid. One serving of Metamucil plus Calcium provides 2.1 g of fiber. Fiber Choice chewable tablets contain 500 mg of calcium carbonate and 4 g of fiber in each serving of 2 tablets. They are sugar free, and flavor choices include cherry, strawberry, and wild berry. When calcium is ingested with meals that are high in fiber, its absorption is decreased. Therefore, patients may need to increase the amount of daily calcium they are ingesting if they are relying on calcium-fortified fiber as a supplement.
The alternative products noted here represent active efforts by manufacturers to address the increasing calcium needs of the general, female, and aging population. These products offer interesting alternatives to standard dietary calcium and increase the potential for most patients to achieve daily calcium requirements.
Consumers who use of a variety of calcium-fortified products and supplements may be concerned about obtaining too much calcium in their diet. Excess calcium cannot be stored; therefore, higher intakes of calcium should not be harmful. Although extremely rare, calcium toxicity can occur with long-term consumption of excessive amounts (>3000 mg/d). Symptoms range from constipation, irritability, and headache to soft tissue calcification and renal failure. It is unlikely that most patients would ever consume more than 3000 mg calcium/day. However, patients should be informed about the potential of calcium overdose. Calcium by supplement or food sources may interact with or block the absorption of some medications. For example, calcium supplements may reduce the absorption of tetracycline, iron, or thyroid medications. Typically, any medication that should be taken on an empty stomach should not be taken with calcium supplements, food, or alternative sources as noted in this article. Calcium supplementation is an important aspect of osteoporosis prevention and an adjunct to osteoporosis pharmacotherapy. Calcium in either dietary or supplement form is typically better absorbed when consumed in small amounts throughout the day.[8