Time was, bone health was seemingly achieved with simple daily servings of milk, sunshine, and a diet rich with natural calcium. But the lifelong struggle for bone health and terror of brittle bones also spawned an industry of calcium supplements and calcium-fortified foods. Alas, bones are losing the battle. Today, half of all American citizens older than 50 are at risk of osteoporosis and low bone mass.

Unfortunately, calcium deficiency is common. Many do not get enough calcium from their daily diets. For those with chronic dietary deficiencies, the use of both calcium supplements and vitamin D has been the standard recommendation for meeting requirements. And for a while, the commerce of calcium supplementation enjoyed the boost of incidental benefits – calcium supplementation, besides reducing fractures and osteoporosis, also showed benefits in lowering blood pressure and reducing colon cancer risks.

The past few years, alas, studies have raised doubts on the benefits of calcium supplementation, and further, raised concerns on increased cardiovascular events, myocardial infarction and strokes, including the adverse effect of "abrupt increases" of calcium within hours of supplementation.

Calcium is in the YesNoYesNo category.

Many are not aware of the on-going debates and concerns, and physicians, still mired in debate and disagreement, are unable to provide a consensus advice to patients. Many patients continue cobwebbed advice on vitamins and supplements, religious in their doses of calcium for the bones, and vitamins and supplements for what they can replenish and for the maladies they can prevent.

As the debate goes on.

General Info
Calcium
• Calcium is the most abundant mineral in the human body, accounting for about 1.5% of body weight, more than 99% of it is stored in the bones and teeth where it provides support and structure; and the other 1% is in the blood, muscle, and intercellular fluids involved in the intricate systems of enzymes, hormones, neurologic functions, cardiac rhythm and muscle contraction.
• Calcium is found in some foods, added to some (calcium-fortified), present in some medicines (antacids) and available as dietary supplements.
• Unfortunately, calcium deficiency is common. Many do not get enough from the food they eat. When intake is low or ingested calcium is poorly absorbed, the body makes up by bone breakdown, mobilizing stored calcium for essential biological functions. For chronic deficiency of intake, meeting requirements require the use of supplements.
• The 99% stored in bones and teeth is in a dynamic state of remodeling, with constant resorption (loss, reabsorption, removal) and deposition (addition, formation) into new bone. This balance changes with age: In children and adolescents, bone formation exceeds resorption; in early and middle adulthood, the processes are relatively equal; and in aging adults, especially postmenopausal women, bone breakdown and loss exceeds formation, an imbalance that increase the risk for osteopenia (low bone mass) and osteoporosis (bone porosity and fragility) over time.
• In the U.S., there is an estimated 1.5 million fractures a year attributed to osteoporosis. calcium is critical in the prevention and treatment of osteoporosis and in lowering the risk of fractures over the age of 65.
• Excess of calcium: Hypercalcemia (elevated calcium) rarely results from dietary or supplemental intake; it is most often associated with primary hyperparathyroidism or malignancy. However, excessive intake or supplementation may influence the absorption of other minerals such as iron and magnesium; cause flatulence and habitual constipation; and long term, it may cause renal stones.
• Calcium supplements constitute the largest component of U.S. dietary supplements, with a 2001 value of $846.1 million, an increase of 4.4% from the previous year. In 2002, calcium supplements were about $875 M in the U.S., accounting for about 60% of mineral sales.

Vitamin D
• Vitamin D is a fat-soluble vitamin naturally present in very few foods, added to others, and available as a dietary supplement. Sun exposure is essential for maintenance of vitamin D requirements. It is produced endogenously when sunlight's ultraviolet rays strike the skin and trigger vitamin D synthesis. Vitamin D from food, sun exposure, and supplements is biologically inert and must undergo two hydroxylations in the body for activation–first, in the liver, converting to calcidiol (25-hydroxyvitamin D[25(OH)2D]; and second, in the kidney, forming calcitriol,1,25-dihydroxyvitamin D[1,25(OH)2D].
• It promotes calcium absorption in the gut and helps maintain adequate calcium and phosphate balance required for normal mineralization of the bone and to prevent hypocalcemic tetany. It is also essential for bone growth and bone remodeling by osteoblasts and osteoclasts. It is essential in the prevention of rickets in children and osteomalacia in adults. With calcium, it helps protect from osteoporosis.
• Vitamin D is also essential in modulation of cell growth, neuromuscular and immune function, and reduction of inflammation.
• Vitamin D deficiency is an unrecognized epidemic among both children and adults in the U.S. Besides causing rickets in children and osteomalacia in adults, it also precipitates and worsens osteoporosis in adults. Deficiency also increases risks for cancers, cardiovascular diseases, multiple sclerosis, rheumatoid arthritis and type 1 DM.
• Excessive sun exposure does not result in vitamin D toxicity. Sustained heat on the skin is thought to photodegrade provitamin D3 and vitamin D3 as it is formed. Vitamin D from food is an unlikely cause of toxicity. Toxicity is more likely to occur from high intakes of dietary supplements containing vitamin D.
• Most reports suggest a toxicity threshold for vitamin D of 10,000 to 40,000 IU/day and a serum 25(OH)D levels if 500-600 nmol/L (200-240 ng/mL). Symptoms are unlikely at intakes of 10,000 IU/day.

So, what to do?
The debate within the scientific community is ongoing. Physicians are divided and continuing to advise patients according to their chosen viewpoint. While alternative gurus and naturopaths espouse their natural methods of supplementation, the nutritional supplement industry, with its more than $20 billion sales, of which calcium is a major component, would love to continue to fortify your bones through the commerce of vitamins and minerals. Trying to decide what to do is not an easy task.

My take. . . until the cloud settles and a consensus if formed:
No, for supplemental calcium.
Yes, for dietary sources of calcium.

• Alas, easier said than done. Despite the wars waged against osteoporosis – dietary and nutritional education, calcium and vitamin D awareness, the calcium fortification of the food industry, osteoporosis is still winning the war. Calcium deficiency continues to be common.
• In his report, Surgeon General Richard Carmona warned that half of all American citizens older than 50 will be at risk for fractures from osteoporosis and low bone mass if no immediate action is taken. About 10 million Americans over age 50 already have osteoporosis, with an additional 34 million more at risk.
• With the views shifting against calcium supplementation, the list of options for achieving adequate calcium balance has become shorter.
DIET
• Unfortunately, in the U.S. as many as 50% to 75% of people do not get enough calcium in their diets, nor enough of vitamin D. Many are unaware of the varied choices of calcium rich foods; many are drawn to "high calcium, fortified" foodstuffs, alas, some too high in calories. But there is easy sources of natural calcium out there.
• Calcium is high in tofu, low fat milk, cheese, milkshakes, eggnog, sardines with bones, salmon with bones, sesame seeds. Figs are a good low-calorie source of calcium: 4 figs giving 506 mg of calcium in 130 calories.
• Some vegetables are higher in calcium than others: soybeans, okra, almonds, collard greens, oranges, spinach, kelp, broccoli, blackstrap molasses, sesame seeds, Brazil nut and celery.
• Another list of10 vegetables highest in calcium: collard greens, raw kale, turnip greens, garlic, arugula, rabe broccoli, mustard greens, sun-dried tomatoes, rach spinach, and okra.

Philippine Medicinal Plants / Calcium Sources
• The poor in rural Philippines might not always have affordable access to the usual sources of calcium (milk and calcium fortified foodstuff), but certain kinds of fish, especially sardines, are common food fare; and for some, there is the serendipity of calcium rich sources in their surrounding flora.
• Plants listed as excellent sources of calcium: Alambangbang (leaves); alugbati (shoots and stems); ampalaya (twice the calcium content of spinach), apoi-apoian (tender shoots and young leaves); endiba, gulasiman (leaves), katurai (flowers); kintsay; lubi-lubi (large fruit variety), malunggay (96 mg/100 g/ 1 cup cooked), mustasa, pasaw-na-haba (young shoots), pili (119 mg/ 100g), siling labuyo, spinach.
• Plants considered good sources of calcium are: bignay, bubo (young leaves), calabash (shoots, flowers, roots), kamote (leaves and roots), labanos (young leaves), okra, pasau (young shoots), patola, sigarilyas, sinkamas, tiesa (100g fruit/ 26.5 mg), upo, utong (fruit), watercress.

VITAMIN D and SUNLIGHT
And of course, bone health is more than just trying to maintain adequate calcium intake. Vitamin D, regular exercise, and regular doses of sunlight are essential components of bone health.
• Vitamin D
• Most people get their vitamin D from sunlight, an easy source in high latitudes. However, if you're housebound, sun-screened, sun-averse or avoiding the sun because of skin cancer risks, food and supplements are the other options for vitamin D. However, food is not an easy source of vitamin D. Although present in oil fish (tuna and sardines) and eggs yolks, these are not usual daily food items. Vitamin D supplements remain the good alternative.
• The optimal daily dose is uncertain, but it is safe for anyone older than 1 year to take up to 2,000 IU a day. Recommendations for adults are from 400 to 1,000 IUs a day. And all vitamin D are not the same. Studies have shown vitamin D3 to be better than D2. Vitamin D3 was 56% to 87% more potent than vitamin D2 in raising serum 25(OH)D. Given its potency and lower cost, D3 should be the preferred treatment for correcting vitamin D deficiency or as D supplement.
• Sunlight
•Sun exposure is essential for maintaining the balance of vitamin D and calcium. One regimen of sensible sun exposure consists of 5 to 10 minutes of exposure of the arms and legs or the hands, arms, and face, 2 to 3 times a week. Regular doses of good sunlight will benefit in the maintenance and balance of vitamin D and calcium.