Calcium nutrition and bone health in the elderly

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Abstract
The average elderly person is in negative calcium balance and accordingly is losing bone mass. While factors such as decreased mechanical loading of the skeleton undoubtedly figure in this age-related loss, a growing body of evidence suggests that inadequate calcium intake may contribute to this loss. On any given day men and women in the US 65 yr or older ingest about 600 and 480 mg calcium, respectively. Calcium intake in the elderly is less than in the young, and reduced absorption efficiency further lowers effective intake. Additionally, other nutrients such as protein and fiber, taken in excess, effectively increase the calcium requirement. Estrogen withdrawal at menopause leads to a decrease in intestinal calcium absorption efficiency and in renal calcium conservation, both effects equivalent to an effective increase in calcium intake requirement. Thus it is not surprising that all studies of mean requirements for zero balance performed in elderly subjects have yielded values above the current RDA for the US. The available evidence thus suggests that the RDA for adults should surely not be lowered below its current level (800 mg), but that, instead, it ought to be raised. It is not possible to say with certainty to exactly what level, but available evidence is compatible with allowances of at least 1200 to 1500 mg/day. Further, the evidence indicates that the mean requirement ought to be thought of as a complex function of age, sex, absorption efficiency, intake of protein, fiber, and probably other nutrients, estrogen status, and mechanical loading. Extensive experience with calcium supplements indicates that daily intakes up to at least 2.5 g of elemental calcium are quite safe in all persons except for certain subsets of the population uncommon among the elderly (eg, those with sarcoidosis, active tuberculosis, or other absorptive hypercalciuric syndromes). At the same time it must be said that osteoporosis is a complex, multifactorial disorder, and that factors unrelated to calcium nutrition undoubtedly play important, even dominant roles in many—perhaps most—osteoporotics. The available evidence, taken together, does not indicate that raising calcium intake will abolish the problem of osteoporosis. It does indicate, however, that calcium nutrition is considerably more important in the genesis of osteoporosis than has been commonly thought for the past 35 yr. As our listing of “important issues” indicates, the full extent of that importance, in both pathogenesis and prophylaxis, remains to be elucidated.