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

2. 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

5. 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)

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

7. WHO, 2004
1200
1000
300
400
1300

8. WHO, 2004
ICMR, India
1200
1000
300
400
500
1300
600
No recommendn

9. WHO, 2004
WHO, low protein
1200
1000
300
400
750
1300
800

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

11. 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)
Serum calcium (mg/dl)
Serum iP (mg/dL)
Heat labile SAP (U/L)
Serum 25OHD(ng/mL)
13 + 6
15 + 8

12. 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
Pregnant women 14 7
Duration ( hrs)
4 + 1
27 + 8

13. Prevalence of osteomalacia and hypovitaminosis D

14. Effect of seasonality on 25OHD levels

15. 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*

16. 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)
Summer sun exposure (h/day x % BSA)
0.001
Winter sun exp (h/day x % BSA)
33 + 6
0.046
25(OH)D (ng/mL)
<0.001
Prevalence of biochemical osteomalacia
11 (32%)
7 (25%)
0.6
Prevalence of hypovitaminosis D
9 (26 %)
25 (89 %)

17. 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

18. 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

19. 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)