Recommendations and reality Calcium intake Recommendations and reality V Bhatia Sanjay Gandhi PGIMS Lucknow

Clinical implications of calcium deficiency Impaired bone mass accrual in fetus, metabolic consequences, programming Metabolic bone disease of prematurity Childhood rickets Possible secondary vitamin D deficiency Impaired peak bone mass accrual Osteoporosis: postmenopausal, elderly

Urinary/fecal and insensible loss Urinary loss: About 140 mg/day Increased by protein (esp animal) intake (1 g = 1 mg Ca loss (complex urinary calcium and remove) Increased by sodium loss (1 gm inake = 15 mg loss)(compete for tubular reabsorption)

Protein intake in various regions Developed nations Developing nations Animal protein (gram/day) 63 13 Vegetable protein 40 47 Total per day 103 60

WHO, 2004 1200 1000 300 400 500-700 1300

WHO, 2004 ICMR, India 1200 1000 300 400 500 500-700 1300 600 No recommendn

WHO, 2004 WHO, low protein 1200 1000 300 400 750 500-700 1300 800

Vitamin D deficiency in adolescent girls and pregnant women from rural northern India Sahu M, Bhatia V, Das V, Agarwal A

Clinical and biochemical features Adolescent girls (n=121) Pregnant women(n=139) Age (yrs) 14 + 3 27 + 4 Bony deformity None Calcium intake (mg/d) 211 + 158 214 + 150 Serum calcium (mg/dl) 8.9 + 0.9 9.4 + 0.9 Serum iP (mg/dL) 4.4 + 0.9 3.6 + 0.7 Heat labile SAP (U/L) 524 + 287 246 + 126 Serum 25OHD(ng/mL) 13 + 6 15 + 8

Exposure to sun shine in rural population Summer Winter Adolescent girls %BSA exposed 15 + 6 9 + 6 Duration (hrs) 2 + 1 3 + 1 % BSA x hours 32 + 22 30 + 20 Pregnant women 14 7 Duration ( hrs) 4 + 1 35 + 16 27 + 8

Prevalence of osteomalacia and hypovitaminosis D

Effect of seasonality on 25OHD levels

Co relations of possible factors with Vitamin D status Combined group r p Serum Alkaline Phosphatase -0.2 0.006 Mean daily calcium intake 0.03 0.617 Summer sun exposure 0.3 <0.001* Winter sun exposure < 0.001*

Hypovitaminosis D: comparison between boys and girls Age (years) 14 + 3 0.56 Pubertal staging 3 + 2 4 + 1 0.08 Calcium intake (mg/day) 384 + 200 198 + 159 Summer sun exposure (h/day x % BSA) 49 + 16 31 + 21 0.001 Winter sun exp (h/day x % BSA) 33 + 6 31 + 22 0.046 25(OH)D (ng/mL) 27 + 12 13 + 5 <0.001 Prevalence of biochemical osteomalacia 11 (32%) 7 (25%) 0.6 Prevalence of hypovitaminosis D 9 (26 %) 25 (89 %)

Summary of results High prevalence of 25(OH) D deficiency in rural adolescent and pregnant females Very low calcium intake present in both groups studied Sun shine exposure positively correlates with vitamin D status Marked seasonal effect on circulating 25(OH) D levels Girls more vulnerable than boys

Conclusions Calcium deficiency has numerous implications from fetal through adult life Calcium balance studies in different age groups, in different geographical regions, are pending Scope for rationalisation of Indian guidelines exists Thank you

Absorption of dietary calcium = 35% of intake (higher at low intakes, lower at high intakes) 75% of daily needs from milk and milk products Smaller amounts from vegetable sources (not possible to maintain from veg sources without fortification) Impede absorption: Low calcium phosphate ratio Phytate, oxalate present Vitamin D deficiency Favour absorption: Infancy, adolescence, pregnancy High calcium phosphate ratio (breast vs cow milk)