Too Much Calcium?

Doc:  How much calcium should I take to protect my bones? 

A:  The amount recommended for daily calcium supplementation seems to have just become a little more confusing. 

Or maybe I should say as "clear as milk". 

The National Institutes of Health (NIH) states that women over 40 lose 0.5% to 1.0% of bone density per year.  Calcium and vitamin D3 supplementation are given to many postmenopausal women to reduce the risk of osteoporosis (bone thinning) in an effort to reduce the risk of bone fracture in later years.

The NIH recommended dietary allowance for vitamin D3 is 600 to 800 IU/day, and the recommended dietary allowance for calcium is 1200 mg/day.  

The question has been raised, though, whether this is too much daily intake.  Is there a risk taking this much calcium beyond the common side effect of constipation? 

There has been a concern that too much calcium supplementation causes hypercalcemia (too much calcium in the blood) and hypercalciuria (too much calcium in the urine). Too much calcium in the urine has been shown to increase the risk of nephrolithiasis, or kidney stones, as most people call them.  

(This is the point where every reader who has ever had a kidney stone pauses, reflects on the agonizing pain kidney stones inflict, and does a personal assessment of "what am I doing today to avoid ever having that unbelievable agony again?")

Without exception, every female patient I have known who has had a kidney stone and also childbirth states that kidney stone pain is much worse.  No exception. 

There is a strong suggestion that current recommendation might be too much according to a recent study released on June 16 by John Christopher Gallagher, MD, from the Bone Metabolism Unit, Creighton University, Omaha, Nebraska, in the medical journal 'Menopause' (my 'Sports Illustrated' was mainly covering World Cup Soccer and 'Menopause' was far more interesting). 

In a well controlled study of 163 white women aged 57 to 90 confirmed to be deficit in vitamin D, different levels of vitamin D were given to the women according to their group and a controlled amount of calcium citrate, adjusted for diet, between 1200 and 1400 mg/day was also given.  

Some women were given a placebo instead of vitamin D.  All of them received calcium.   

Every 3 months these ladies had their blood levels checked, and, amazingly, collected a 24 hour urine sample.  For anyone who has done a 24 hour urine sample, it isn't easy, and, obviously, especially for women. 

The researchers found that 8.8% experienced elevated calcium in the blood, and 31% experienced elevated calcium in the urine.  Most interestingly, they found no relationship between hypercalcemia or hypercalciuria and vitamin D dose, and hypercalciuria was equally frequent in the placebo group.

Essentially, 31% of women had a noticeably elevated presence of calcium in the urine regardless of vitamin D intake.  Further analysis noted some women had up to 20 times greater risk of calcium in the urine.  

That is a significantly increased risk of kidney stones, and to this point, is something that has not routinely been measured in modern medicine. 

So what is a patient to do who is concerned about their calcium intake? The researchers stated that even 500 mg/day might be too much for some women and they "recommend measuring blood and urine calcium levels before beginning calcium and vitamin D supplementation and repeating the measurements within 3 months."

Every 3 months a blood test and a 24 hour urine collection for every woman taking calcium and vitamin D supplementation?  Right. The researchers did not comment on how the women felt about collecting a 24 hour urine every three months but I believe I could guess how that conversation went.  And then recommend it be done indefinitely? They provided no clarity on this point. 

Clearly there is a concern here for too much calcium and it was also suggested that women carefully evaluate their diets for how much calcium they intake and to not go over the NIH recommended amount.  One study of 163 patients will not be enough to convince NIH to change its policy, however, it is worth paying attention to in future research. 

I am not a researcher, but my real world clinical experience tells me a 24 hour urine collection for every woman on calcium supplementation would be a challenge in the world of real medicine. 

There are risks and benefits with anything in life, including medicine and supplements.  The risk of bone fractures weighed against the risk of kidney stones and elevated calcium in the blood is another example of this fact.  Reading new research is only one part of maintaining a healthy lifestyle and should include a conversation with a physician prior to making a change in medicine. 

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His new office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.

VAtergate

A very recent conversation with a veteran about his major cardiovascular surgery at a Veteran's Hospital here in Tennessee was enlightening, and not a surprise.  

"It was great.  They treated me very well and I feel better now than I have in years." 

That is consistent with many of the experiences shared with me from veterans I have known and also from my experience in training in the VA system.  There is a lot of good care that is provided the majority of the time. 

But, of course, not all of the time.  

The recent whistle blower case in Phoenix has brought a lot of attention to the failures of the VA medical system, especially the outpatient services.  Some have suggested that this is a failure of the current administration and there may be some blame to be shouldered there, but the inherent weakness here is one that any large government entity or corporation knows all too well. 

To quote a line from one of my favorite movies, "What we have here, is failure -  to communicate." 

Every veteran listened to the recruiter, or draft board, when they had their first encounter with the military.  They then listened, or they better have, to the sergeant in basic training.  Then they had to listen to the officer who gave the orders of where to move to and what to do there.  Listen, listen, listen, then do what you are told.  That's what the military does.

But when the veteran is discharged, it becomes the government's turn to listen. 

And that is where the problem begins.  

Failure of communication in listening to the projections of the number of service men and women who would need medical care as a result of military duty.  Failure to listen to the service men and women who complained about wait times.  Failure of the government as a whole to anticipate the number of physicians needed in order to provide basic access to medical care in both the Veterans Administration and the public as a whole.  

My training at the Memphis Veteran's Hospital was an experience not easily forgotten.  One of the things that really stood out to me was the patience of the veterans as they knew they were helping medical students learn and how willing they were to be a part of that process.  Our team consisted of an attending physician who had few words but a lot of intimidation, a fourth or fifth year resident, a second year resident, and intern who did all the work, and two or three medical students.  

As medical students we were viewed much like the kids at the card table at Thanksgiving: give them something to do to learn where they won't get in trouble.  The basics of taking a history and physical was the main emphasis and if you didn't spend two or three hours sitting with a patient as a medical student, you were sent back in.  

The vast majority of the vets enjoyed it, and actually were more that patient with the fumblings of a third year medical student learning his craft.  I will not forget the WWI vet I took care of, or the one who was in charge of giving lie detectors for the military - he had a way of looking through your skull as you talked to him. All of them had a story. All of them understood things didn't move quickly, but all of them wanted to be heard and cared for.  

There were extraordinarily dedicated physicians and nurses in the Memphis facility.  Yet they worked in an institution known for inefficiencies.  It was a given that if you wanted a chest x-ray on a patient, not only did you order it, but you found the wheelchair, loaded up the patient, carried him to radiology, waited on the films, and returned to the floor with the vet, wheelchair, chest x-ray and you better not make the attending wait, either. 

That will be the challenge for the Veteran's Administration: listen to the needs of the veterans and find a way to efficiently provide them.  It is a lessen for anyone who thinks that big government is the best source of medical care. 

It will take an massive effort of leadership to improve the communication, streamline the coordination, and utilize creative thinking to tackle this enormous problem.  

I would watch the simultaneous launch of two FedEx jets every minute, on the minute, beginning at 4 AM every morning as I jogged on the track at UT Memphis. It is an amazing thing to watch. It struck me as very ironic that in the same city where a transporter for a patient cannot be found in a government hospital, a major international company could deliver a package anywhere in the world with mind boggling efficiency. 

It can be done. 

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His new office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.