1. August 2008 Nutrition and Osteoporosis Modified by the GA Agriculture Education Curriculum Office July 2002 Alice Henneman, MS, RD Lancaster County Extension Educator Linda Boeckner, PhD, RD Extension Nutrition Specialist

2. August 2008 Disclaimer The following information on the dietary aspects of osteoporosis is provided as information for general healthy eating and should not be considered a substitute for seeking dietary advice from your own healthcare provider. The calcium and vitamin D recommendations are based on those developed for the United States and Canada. They may not be appropriate for all countries due to differing dietary patterns and environmental factors.

3. August 2008 Concerns 10 million Americans have osteoporosis and 18 million have low bone mass placing them at risk of osteoporosis ( National Osteoporosis Foundation [NOF]) The “silent disease” –First sign may be a fracture –A sudden strain or bump can break a bone

4. August 2008 Concerns continued 80% of those affected are women A woman’s hip fracture risk equals her combined risk of breast, uterine and ovarian cancer 1 in 2 women and 1 in 8 men over 50 will have an osteoporosis-related fracture 24% of hip fracture patients 50 and over die during the year following their fracture

5. August 2008 The National Osteoporosis Foundation (NOF) recommends a combination of 4 steps to help prevent osteoporosis 4 Prevention Step (NOF)

6. August 2008 4 Prevention Steps (NOF) 1.Balanced diet rich in calcium & vitamin D 2.Weight-bearing exercise 3.Healthy lifestyle with no smoking or excessive alcohol use 4.Bone density testing or medications when appropriate

7. August 2008 Overview Using food and supplement labels to assess calcium intake Recommended daily calcium and vitamin D % Daily Value for calcium in common foods Additional dietary concerns Help for the lactose-intolerant person When you don’t like to “drink” milk Calcium supplements Putting it all together

8. August 2008 Nutrition Labels & Calcium FDA uses “Percent Daily Value” (% DV) to describe amount of calcium needed by general U.S. population daily 100% DV for calcium = 1,000 mg “Nutrition Facts” on food labels “Supplement Facts” on vitamin/mineral labels

9. August 2008 Sample Nutrition Facts Label Nutrition Facts Serving Size 1/2 cup (93 g) Servings Per Container 4 -------------------------------------------- Amount Per Serving Calories 25 Calories from Fat 0 -------------------------------------------- % Daily Value* Total Fat 0 g0% Saturated Fat 0 g0% Cholesterol 0 mg0% Sodium 20 mg1% Total Carbohydrate 5 g2% Dietary Fiber 3 g 12% Sugars 2 g Protein 3 g -------------------------------------------- Vitamin A 35% Vitamin C 60% Calcium 4% Iron 4% -------------------------------------------- * Percent Daily Values are based on a 2,000 calorie diet.

10. August 2008 Example of Daily Value If a food or supplement has 200 mg of calcium per serving, the "Nutrition Facts" or "Supplement Facts" panel shows: 20% DV for calcium (200/1,000 = 20%)

11. August 2008 Using Serving Size Serving size on "Nutrition Facts" panel is based on what people typically eat—it’s not a recommended amount Adjust calcium % DV if you eat a different serving size than on label –Example: If label states a half cup serving of broccoli provides 4% DV, a cup would provide 8% DV

12. August 2008 % DV recommendations Vary by Age Example: Individuals 51 years and older need to consume 1,200 mg of calcium daily Their daily goal should be 120% of the calcium DV

13. August 2008 Example of Calculating Total % DV for Calcium Food % DV Fruit yogurt 35% Oatmeal10% Nachos20% Turnip greens15% Total % DV = 80%

14. August 2008 Recommended Daily Calcium and Vitamin D Intakes Remember: –The 100% DV for calcium is based on 1,000 mg calcium –The 100% DV for vitamin D is based on 400 IU vitamin D –Some people will need more or less than the 100% DV value based on their age and reproductive status

15. August 2008 Upper limits: Calcium and Vitamin D The National Academy of Sciences (NAS), 1997, suggests a tolerable upper intake level (UL) for persons age one and up for calcium no higher than 2,500 mg daily and for vitamin D no higher than 50 micrograms or 2,000 IU (40 IU = 1 microgram) daily from foods and supplements combined.

16. August 2008 Recommended Daily Value: Calcium & Vitamin D* Birth - 6 months 210 mg calcium (21% DV) 200 IU vitamin D (50% DV) 6 months - 1 year 270 mg calcium (27% DV) 200 IU vitamin D (50% DV) * Values based on 1997 NAS recommendations

17. August 2008 Recommended Daily Value: Calcium & Vitamin D* 1 - 3 years 500 mg calcium (50% DV) 200 IU vitamin D (50% DV) 4 - 8 years 800 mg calcium (80% DV) 200 IU vitamin D (50% DV) * Values based on 1997 NAS recommendations

18. August 2008 Recommended Daily Value: Calcium & Vitamin D* 9 - 18 years 1,300 mg calcium (130% DV) 200 IU vitamin D (50% DV) 19 - 50 years 1,000 mg calcium (100% DV) 200 IU vitamin D (50% DV) * Values based on 1997 NAS recommendations

19. August 2008 Recommended Daily Value: Calcium & Vitamin D* 51 - 70 years 1,200 mg calcium (120% DV) 400 IU vitamin D (100% DV) 71 and older 1,200 mg calcium (120% DV) 600 IU vitamin D (150% DV) * Values based on 1997 NAS recommendations

20. August 2008 Recommended Daily Value: Calcium & Vitamin D* Pregnant & Lactating 14 - 18 years 1,300 mg calcium (130% DV) 200 IU vitamin D (50% DV) 19 - 50 years 1,000 mg calcium (100% DV) 200 IU vitamin D (50% DV) * Values based on 1997 NAS recommendations

21. August 2008 % DV Calcium: Grain Products Group Ready-to-eat calcium-fortified cereal –Serving size varies; check product label.

22. August 2008 % DV Calcium: Vegetable Group Broccoli with cheese; 1/2 cup = 20% DV Collards; 1/2 cup = 20% DV Turnip greens; 2/3 cup = 15% DV Kale; 2/3 cup = 10% DV Bok choy; 1/2 cup = 10% DV Broccoli; 1 stalk = 6% DV

23. August 2008 % DV Calcium: Fruit Group Orange juice, calcium- fortified –1 cup = 30% DV

24. August 2008 % DV Calcium: Milk Group Yogurt; 8 oz. = 35% DV Milk, whole, 2%, 1%, skim, Chocolate Milk 1 cup = 30% DV Cheese; 1 oz. = 20% DV Milk pudding; 1/2 cup = 10% DV Frozen yogurt; 1/2 cup = 10% DV Ice cream; 1/2 cup = 6% DV Soy milk, calcium-fortified; 1 cup = 30% DV

25. August 2008 % DV Calcium: Meat & Beans Group Tofu prepared with calcium sulfate; 3 oz. = 60% DV –check Nutrition Facts label Baked beans with sauce; 1/2 cup = 8% DV Pork & beans with sauce; 1/2 cup = 6% DV

26. August 2008 Vitamin D Dietary Sources The main dietary sources of vitamin D are fortified milk (400 IU per quart), some fortified cereals, cold saltwater fish (for example: salmon, halibut, herring, tuna, oysters and shrimp) and some calcium and vitamin/mineral supplements. Also, vitamin D can be manufactured in your skin following direct exposure to sunlight. The amount varies according to such factors as time of day, season and latitude.

27. August 2008 Concerns: Calcium Load at One Time Body can best handle about 500 mg at one time from food and/or supplements Consume calcium sources throughout day vs. all at one time

28. August 2008 Concerns: Fiber Excessive fiber can interfere with absorption –Example: sprinkling extra fiber on food at time of consuming a calcium source –Natural fiber that is part of a food is probably not a problem

29. August 2008 Concerns: Excessive caffeine Can increase urinary calcium excretion Limit to about 400 mg daily –About 100 mg/6 oz. coffee –About 40 mg/6 oz. regular brewed tea; may be less for green tea –Some soft drinks comparable to tea –Some medications have caffeine

30. August 2008 Concerns: Excessive sodium Can increase urinary calcium excretion Food and Nutrition Board recommends limit of 2,400 mg daily Sodium given on “Nutrition Facts” panel on foods

31. August 2008 Concerns: Alcohol Consuming more than 7 drinks per week is associated with greater risk of: –low bone density –falls –fractures

32. August 2008 Concerns: Oxalic acid In foods such as spinach, chard, beet greens and chocolate –Binds calcium –Doesn’t seem to affect calcium in other foods, including chocolate milk –These greens still good for you; may help calcium absorption in other ways

33. August 2008 Concerns: High protein Unbalanced, excessively high protein diets could increase urinary excretion of calcium

34. August 2008 Concerns: Soy Not all soy milk is calcium-fortified; check “Nutrition Facts” panel 4 8-oz. glasses of soy milk is usually equal to 3 8-oz. glasses of cow’s milk in availability of calcium

35. August 2008 Concerns: Fruits and Vegetables Contribute to maintenance of bone mineral density Food Guide Pyramid recommendations: –2 to 4 fruits daily –3 to 5 vegetables daily

36. August 2008 Help for the Lactose-Intolerant Person Some people lack the enzyme needed to digest lactose (milk sugar) but still may be able to obtain calcium from dairy products

37. August 2008 Help for the Lactose- Intolerant Person Start with small portions of foods such as milk and gradually increase serving size

38. August 2008 Help for the Lactose-Intolerant Person Eat dairy foods in combination with a meal or solid foods

39. August 2008 Help for the Lactose-Intolerant Person Try dairy foods other than milk –Many cheeses (Cheddar, Swiss, Parmesan) have less lactose than milk –Yogurt made with live, active bacteria

40. August 2008 Help for the Lactose-Intolerant Person It may be easier to digest lactose that is pre-digested or broken down to its simple sugar components (glucose and galactose) –Lactose-hydrolyzed milk and dairy products –Commercial lactase preparations

41. August 2008 When You Don’t Like to “Drink” Milk Make oatmeal with milk instead of water Add milk to your coffee Make soups (tomato, chowders and cream-type) with milk instead of water Add powdered milk to food (1 tablespoon = 50 mg of calcium) Make instant hot cocoa with milk

42. August 2008 When You Don’t Like to “Drink” Milk Make instant hot cocoa with milk, not water Serve milk-based desserts (puddings, tapioca, frozen yogurt, custard, ice cream) Enjoy chocolate milk –8-oz. has only 2 - 7 mg caffeine –Average glass of chocolate milk has only 60 more calories than unflavored milk

43. August 2008 When You Don’t Like to “Drink” Milk Use plain/flavored yogurt as salad dressing Top baked potatoes with yogurt Enjoy smoothies for snacks –Add 1/2 to 1 cup frozen fruit to 1 cup milk & blend. Sweeten with 1 - 2 teaspoons sugar or honey, or use an artificial sweetener. Can add about 1/4 teaspoon vanilla. Drink right away.

44. August 2008 Supplements: Calcium Carbonate vs. Citrate Calcium carbonate –Needs acid to dissolve and for absorption –Less stomach acid as we age –Often taken at meals when more stomach acid Calcium citrate –Doesn’t require stomach acid for absorption –May be taken anytime—check with your healthcare provider –May cost more

45. August 2008 Supplements: Vitamin D Vitamin D –Choose a supplement with vitamin D unless you’re getting vitamin D from other sources –Consider amount for your age group –Avoid going over a daily combined total of 50 micrograms (2,000 IU)

46. August 2008 Supplements: Time of Day If you take calcium once daily, evening may be best. Miriam Nelson (author, Strong Women, Strong Bones) advises calcium carbonate at dinner time and calcium citrate before bed. Check with your healthcare provider.

47. August 2008 Supplements: Calcium Load at One Time Limit calcium intake at one time to about 500 mg from food and supplements combined Consume food and supplements throughout the day

48. August 2008 Supplements: Absorption Absorption test: put a calcium tablet in a cup of vinegar. Stir every 5 minutes. If it doesn’t dissolve in 30 minutes, it probably won’t dissolve in your stomach either.

49. August 2008 Supplements: Increase Amount Slowly Start with 500 mg daily for about a week, gradually adding more Gas and constipation can be side effects –Increase fluids and fibrous foods –Try a different form if problems continue

50. August 2008 Supplements: Check for Interactions Check with physician or pharmacist for interactions with other prescriptions and over-the-counter drugs

51. August 2008 Supplements: Food is Still Important High calcium foods also contain other KEY nutrients that are important in the diet Try to obtain at least some of your calcium from your diet

52. August 2008 Putting it All Together 1.List foods/supplements you ate yesterday or in a typical day 2. Determine % DV of calcium/vitamin D 3.Adjust % DV if serving size was different than on label 4.Total amounts; compare score to recommended % DV for age

53. August 2008 Related Materials For more information and/or a handout about the points discussed in this presentation, refer to the article Nutrition and Osteoporosis by Alice Henneman, MS, RD and Linda Boeckner, PhD, RD at: lancaster.unl.edu/food/ftm-j01.htm Alice Henneman, MS, RD Lancaster County Extension Educator ahenneman1@unl.edu Linda Boeckner, PhD, RD Extension Nutrition Specialist lboeckner1@unl.edu University of Nebraska Cooperative Extension Institute of Agriculture and Natural Resources

54. August 2008 For More Information National Osteoporosis Foundation www.nof.org Strong Women, Strong Bones by Miriam Nelson, Ph.D.