Calcium and Vitamin D for the Management of

Osteoporosis in Women aged 55-70 y/o

Nutritional Pharmacology- NTR30001

Swinburne University of Technology

Erin Sevilla
Abbey Kingi
Emily Wood

Sept. 20, 2017

Introduction and Background
Osteoporosis, also known as “the disease of porous bones” (Dirckx et al 2013) is a systemic
skeletal disease characterized by low bone mineral density and microarchitectural deterioration
of the bone tissue, which consequently leads to increased risk of bone fracture, limited
movement, pain, decline in quality of life and death (Grabowski 2016, Vandenbroucke et al
2017). Bone formation and sustainability consists of a delicate balance between osteoblast and
osteoclast cells working in harmony to strengthen and diminish bone. As a living tissue bone
changes based on physiological requirement, either increasing bone mass as a result of
mechanical loading or absorbing bone tissue due to immobilization and low activity. This
process can be disrupted not only by physical activity, or lack thereof, but also hormonal changes
throughout life (Dirckx 2013, Ivanova 2017). Yaşar et al (2017) suggests that bone formation
starts during foetal growth and reaches peak bone mass during adolescence. At age 26
ninety-nine precent bone mass is reached, meaning the bone mass reached at this age acts as a
“bone bank” for the remainder of life.

Osteoporosis affects over 200 million people around the world, majority of whom are elderly,
and 70% to 80% of which are women (Glibowski 2016). Women face a predisposition for
osteoporosis, as they initially start with a lower peak bone mass compared to men coupled with
the hormonal changes that occur during pregnancy and during postmenopausal years. During
pregnancy and lactation hormonal and physiological changes promote increased calcium serum
levels- relating to bone resorption- decreased bone formation and increased absorption of
calcium in the intestines (Demir et al 2008). Although many women recovered sufficient bone
mass after this period, a study done by Demir et al. (2008) found pregnancy correlated with
osteoporosis and osteopenia- which is a lower than normal bone mass density and the first step
toward osteoporosis (AIHW 2017). Commonly occurring in low socioeconomic cases, this could
be due to poor recovery time, long breast feeding periods, pregnancy before peak bone mass and
most importantly low calcium intake. Women also experience an increase of bone loss during
peri menopausal and postmenopausal years (age 40+), which is linked to a drop in oestrogen
levels (Demir 2008).
Many studies confirm that calcium and vitamin D are essential for bone health, moreover, these
micronutrients are positively correlated with bone mass and decreased risk of osteoporosis
(Yaşar et al 2017, Glibowski 2016). Calcium is needed for nerve interaction, dilation and
constriction of the blood vessels and muscle contraction (Cherbuin et al 2016). And because
most of the body's calcium is found in bones and teeth, sufficient calcium intake is required to
prevent bone mass loss (Glibowski 2016). Vitamin D works in conjugation with calcium and is
necessary for its absorption. Although vitamin D can be absorbed through the skin, many elderly
people may have trouble physically getting into the sun and therefore, fail to get adequate
vitamin D. Emphasizing the need for supplementation or fortification of calcium and vitamin D
in this demographic. Whiting et al (2016) suggest that both the calcium and protein in dairy can
provide a synergistic effect on bone sustainability. This can be especially useful for the elderly,
who tend to have a low appetite and may not meet daily dairy requirements.

Methodology
An electronic search was performed using Swinburne Online Library Database and SCOPUS
(2000-2016) over a 2 week period.
The PICO question used was “Does adequate calcium and vitamin d intake, determined by the
Australian Dietary recommendation, result in a reduction of the prevalence of osteoporosis in
women aged 55-70 years old when compared to inadequate intake?”.
Keywords used were “osteoporosis”, “bone health” “elderly women”, “calcium and vitamin d”
and “supplementation”. All study types which investigated the effect that calcium and vitamin d
intake had on the onset of osteoporosis were considered. The search was widened from
specifically osteoporosis to include terms such as bone health as an indicator of osteoporosis due
to the limited amount of information available. Dietary intake was compared with the Australian
Dietary recommendation and concluded to be either adequate or inadequate, as in the study
conducted by Meng et al (2010).
Inclusion criteria included; participants aged 50 - 75 years old, studies which included women,
studies from English speaking countries, and any form of calcium or vitamin D intake, including
supplementation or monitoring of current dietary patterns. Exclusion criteria were; participants
under 50 years old, male only studies and studies completed earlier than 2007.

Literature review
This review investigates current literature to determine the scope of information available
surrounding topics related to Osteoporosis and the impacts of dairy consumption, specifically the
micronutrients calcium and vitamin D. As the prevalence of osteoporosis in women aged over 50
is significant, with 585,000 sufferers in the 2014-2015 annual period (AIHW 2017), it is
important to identify what initiatives are successful or unsuccessful, as well as how and why they
achieve outcomes in managing calcium and vitamin D uptake, the dairy intake patterns of elderly
women, as well as supplement patterns.

The scope of preventative strategies

First and foremost, there is an abundance of literature praising the mechanisms of calcium and
vitamin D uptake in association with maintaining bone health. Higher calcium and vitamin D
uptake is virtually always associated with increased dairy consumption. In reviews conducted by
Weaver (2017) and Malavolta and Mocchegiani (2016), it was concluded that dairy products are
the richest sources of calcium and have a positive effect on bone health in the elderly. When
scoping the literature to determine the range of knowledge held by the population, results
showed a lack of understanding of the relationship between dairy consumption and calcium and
vitamin D absorption.
A study led by Curtain et al (2016), which specifically examined osteoporosis prevention in the
elderly, suggests the strategies used for prevention of osteoporosis in nursing homes in
Tasmania, Australia are not meeting the current Australian Dietary guidelines. The study aimed
to determine if residents were meeting the recommended vitamin D intake levels, measured
through supplements, dietary calcium intake and sun exposure (Curtain et al, 2016). Results
determined that “of 811 residents, 50 % received daily vitamin D supplementation of at least
1000 IU. Merely 43 % of residents obtaining osteoporosis received vitamin D supplements. The
average estimated total calcium intake of 800 ± 275 mg daily was below guideline
recommendations of 1000–1300 mg daily” (Curtain 2016). Conclusions suggested poor
compliance to relevant guidelines for the prevalence of vitamin D supplementation in nursing
home residents and a lack of understanding of the significance of behaviours associated with
bone health in elderly women (Curtain 2016).
In contrasting settings, when assessing the calcium/vitamin d uptake status of non-nursing home
residents in Western Australia, Meng et al (2010) concluded that calcium intake was inadequate,
after establishing an average dietary calcium intake of 852 ± 298 mg/day, depicted in a sample of
218 women aged over 60, which is below Australian recommendations of 1000-1300 mg/day.
Furthermore, less than 25 % of women reported taking calcium supplements and only 3%
reported taking vitamin D supplements (Meng et al 2010). This information suggests a clear lack
of initiative into osteoporosis management and prevention for elderly women.
Alternative research by Whiting et al (2016) observed the composition of dairy sources and
fortification patterns in foods in a systematic review of 24 studies. A summary was made that
“Calcium and vitamin D were the fortificants most often added to food, and in correspondence,
milk and dairy-related products were the most frequently used fortified foods (Whiting et al
2016).” Additionally, evidence suggests that in elderly women, food fortification with calcium
and vitamin D substantially improves vitamin D status (Whiting et al 2016). Thus, providing
hope for the status of bone health in elderly women.
Dairy intake patterns
Understanding the attitudes towards dairy food and the consumption behaviours of elderly
women is crucial for future osteoporosis management. The literature suggests consistent
conclusions surrounding elderly women’s eating patterns, particularly when focussing on dairy
consumption and attitudes which involve calcium and vitamin D uptake.
In a qualitative study conducted by Brownie and Coutts (2013) involving 30 women aged over
60, a general lack of awareness for nutrient intake targets for older Australians was reported.
Additionally, one of the four main themes recognised throughout the study was an overall
reduction in food consumption (kilojoules) and an attitude for less need to include animal
products such as meat and dairy into an everyday diet (Brownie and Coutts 2013). This theme
supports the statement made of the ignorance to achieve nutrient requirements (Brownie and
Coutts 2013).
A cross-sectional study by Radavelli et al (2014) revealed in depth dairy consumption patterns
and further outcomes of dairy intake. The results depicted that of 564 elderly women, the mean
dairy food intake was 1.9 ± 0.9 servings/d. There were a mere 1.6 % of participants who met
the Australian dietary guideline recommendations for dairy food intake of 4 servings/d for
women aged 50 years and older, whilst 17.4% had dairy food intake ≤1 serving/d (Radavelli et al
2014).
Supplementation
Much like most nutrients in the twenty first century, there is vast access to calcium and vitamin
D supplements, and the literature to justify supplementation is just as readily available for
assessment.
Majority of research strongly recommends adopting supplementation methods as an everyday
approach to increasing and maintaining vitamin D and calcium levels. For example, in research
conducted by Meng et al (2010), it was noted that calcium supplements on average provided 122
± 427 mg/day of calcium, which when combined with food sources, had the potential to increase
total calcium intake to 955 ± 504 mg/day. Furthermore, the results of this study depict “the
majority of elderly women failing to meet their calcium requirements from diet alone. In order to
achieve the recommended dietary calcium intake, both diet and calcium supplements appears to
be necessary” (Meng et al 2010).
Additionally, a narrative review by Vandenbroucke (2017) analyses the efficacy and safety of
supplementation for osteoporosis in old age. Vandenbroucke (2017) concludes that calcium and
vitamin D supplementation is an essential component in the management of osteoporosis, in
addition with a highly safe administration status.
There is currently little evidence to suggest that implementing calcium and vitamin D
supplements into an everyday diet is adopted by a significant amount of individuals. However, as
previously mentioned, it can be noted that supplementation is somewhat distributed in some
nursing homes, and is seen in insignificant usage in parts of Western Australia (Curtain et al
2016) (Meng et al 2010).

Conclusion
Osteoporosis is a systemic skeletal disease characterized by low bone mineral density, causing
frailty, pain, higher risk of fracture and mortality/ morbidity. Because of hormonal changes and
an initially lower peak bone mass compared to males, females over the age of 50 are at a greater
risk of developing osteoporosis (Demir 2008). An electronic search was done using the scope of
the pico question, “Does adequate calcium and vitamin D intake, determined by the Australian
Dietary recommendation, result in a reduction of the prevalence of osteoporosis in women aged
55-70 years old when compared to inadequate intake?”.
The literature responded firstly emphasizing the positive impact of dairy and more specifically
the fortified micronutrient calcium and vitamin D. Furthermore it was found that current
supplemental procedures in nursing homes in Tasmania are not meeting current dietary
guidelines for calcium and vitamin D intake (Curtain 2013) - this parallels findings from Western
Australia residence of non-nursing homes (Meng et al 2010). The literature suggest
supplementation of calcium and vitamin D “appears to be necessary” (Meng et al 2010) in
preventing and managing osteoporosis.

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