Alice Henneman, MS, RD, Extension Educator & Dietitian
Linda Boeckner, PHD, RD, Extension Nutrition Specialist

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         - "It's snowing outside and my newspaper was tossed on the bottom of the steps -- do I dare go after it?"

          - "I've lost six inches in height and none of my clothes fit me anymore. Plus, it's hard to get clothes that look nice when my back is so hunched over."

         - "This medication is so darned expensive. But if I want to maintain my independence, I can't afford to let my condition get worse either."

         - "It seemed like it took forever for my bone to heal when it broke. I don't want that to happen again. It's so frustrating always worrying about falling."

      - "If somebody had told me sooner what I know now about osteoporosis, none of this might be happening to me!"

Ten million Americans have osteoporosis and another 18 million have low bone mass, placing them at increased risk of osteoporosis, according to the National Osteoporosis Foundation (NOF). Osteoporosis often is called the "silent disease" because bone loss occurs without symptoms. The first sign of osteoporosis may be a fracture that occurs as a result of a weakened bone. A sudden strain or bump may be all it takes to break a bone.

Eighty percent of those affected by osteoporosis are women. A woman’s risk of an osteoporosis-related hip fracture equals her combined risk of breast, uterine and ovarian cancer. Overall, one in two women and one in eight men over 50 will have an osteoporosis-related fracture. On average, 24 percent of hip fracture patients 50 and over die during the year following their fracture, according to NOF.

A Gallup poll of women with osteoporosis showed few took preventive action, and 9-out-of-10 wish they had known how to take preventive measures (source: NOF news release, May 2000).

Though there are treatments for osteoporosis, there is currently no cure. That's why prevention is so very important. The National Osteoporosis Foundation recommends a combination of these four steps to help prevent osteoporosis:

1. a balanced diet rich in calcium and vitamin D;
2. weight-bearing exercise;
3. a healthy lifestyle with no smoking or excessive alcohol use; and
4. bone density testing and medications when appropriate.

While osteoporosis occurs most frequently in older persons, it's important to start building healthy bones while young. Eating a healthy diet and leading a healthy lifestyle throughout life is important for BOTH women and men.

The following information on the dietary aspects of osteoporosis is provided as information for general healthy eating and should not be considered a substitute for seeking dietary advice from your own health care provider. Topics covered in this article include:

1. Using food and supplement labels to assess calcium intake;
2. Percent Daily Value for calcium in common foods;
3. Additional dietary concerns;
4. Help for the lactose-intolerant person;
5. When you don't like to "drink" milk;
6. Considerations when taking calcium supplements;
7. Putting it all together.

Using Food and Supplement Labels to Assess Calcium Intake

Calcium, the major component of bones, is one of the dietary factors most frequently mentioned in relation to osteoporosis. We can use the product label to learn how much calcium is in packaged foods and in vitamin/mineral supplements. The Food and Drug Administration (FDA) uses the term "Percent Daily Value" (% DV) to describe the amount of calcium a food or supplement provides in relation to the general U.S. population's daily needs.

NOTE: The calcium and vitamin D recommendations in this article are based on those developed for the United States and Canada. They may not be appropriate for all countries due to differing dietary patterns and environmental factors.

The 100% DV level for calcium equals 1,000 mg. The % DV on the "Nutrition Facts" panel of a food label or the "Supplement Facts" section of a vitamin/mineral supplement tells how much calcium one serving provides in relation to 1,000 mg. For example: If a food or supplement provides 200 mg of calcium per serving, the label would show a 20% DV for calcium (200/1,000 = 20%).

The serving size on the "Nutrition Facts" panel of foods is based on what people typically eat -- it is not a recommended amount. The serving size is given at the top of the panel.

To determine your calcium intake from a specific food or supplement, identify the serving size and the % DV on the label. For example, suppose the serving size listed on a package of frozen chopped broccoli is 1/2 cup and this amount provides 4% of the calcium DV. If you eat TWICE this amount (1 cup), you will consume 8% of your daily calcium need.

By adding up the % DV for calcium in all your foods and supplements, you can learn whether you reach your goal each day. Also, it's easy to compare the calcium content of different products by looking at the % DV.

Depending on your age and such factors as whether you're pregnant or lactating, you may need MORE or LESS than the 100% DV level of 1,000 mg of calcium daily. For example: If the calcium recommendation for your age grouping 1,200 mg of calcium, your daily goal should be 120% of the calcium DV.

The following chart gives the recommended daily calcium and vitamin D intakes for various ages. Calcium is an important component of bones, and vitamin D is essential for optimum calcium absorption. These amounts are based on the 1997 recommendations of the National Academy of Sciences (NAS). Depending on your situation, your physician may recommend slightly more than these levels. Remember: The 100% DV for calcium is based on 1,000 mg calcium. For vitamin D, the 100% DV is based on 400 IU vitamin D.

Recommended Daily Calcium and Vitamin D Intakes
NOTE: The NAS (1997) suggests a tolerable upper intake level (UL) for persons age one and up for calcium no higher than 2,500 mg daily and for vitamin D no higher than 50 micrograms or 2,000 IU (40 IU = 1 microgram) daily from foods and supplements combined. UL's have not been established for individuals below one year of age. However, unless your physician advises otherwise, the following recommendations from NAS for the various ages should be sufficient.
Birth - 6 months 210 mg calcium (21% DV) 200 IU vitamin D (50% DV)	9 - 18 years 1,300 mg calcium (130% DV) 200 IU vitamin D (50% DV)
6 months - 1 year 270 mg calcium (27% DV) 200 IU vitamin D (50% DV)	19 - 50 years 1,000 mg calcium (100% DV) 200 IU vitamin D (50% DV)
1 - 3 years 500 mg calcium (50% DV) 200 IU vitamin D (50% DV)	51 - 70 years 1,200 mg calcium (120% DV) 400 IU vitamin D (100% DV)
4 - 8 years 800 mg calcium (80% DV) 200 IU vitamin D (50% DV)	71 and older 1,200 mg calcium (120% DV) 600 IU vitamin D (150% DV)
Pregnant & Lactating
14 - 18 years 1,300 mg calcium (130% DV) 200 IU vitamin D (50% DV)	19 - 50 years 1,000 mg calcium (100% DV) 200 IU vitamin D (50% DV)

Percent Daily Value For Calcium In Common Foods

To start you thinking about your dietary calcium intake, here's the approximate % DV for some common foods. Check actual food labels for a more exact amount. These amounts are based, in part, on information provided in: "Calcium! Do You Get It?," by the U.S. Food and Drug Administration/Center for Food Safety and Applied Nutrition at::
http://vm.cfsan.fda.gov/~dms/ca-toc.html

Grain Products Group

• Ready-to-eat cereal, calcium, fortified. Serving size varies; check product label.

• Broccoli with cheese; 1/2 cup = 20% DV
• Collards; 1/2 cup = 20% DV
• Turnip greens; 2/3 cup = 15% DV
• Kale; 2/3 cup = 10% DV
• Bok choy; 1/2 cup = 10% DV
• Broccoli; 1 stalk = 6% DV

• Orange juice, calcium-fortified; 1 cup = 30% DV

• Yogurt; 8 oz. = 35%
• Milk, whole, 2%, 1%, skim, chocolate; 1 cup = 30% DV
• Cheese; 1 oz. = 20% DV
• Milk pudding; 1/2 cup = 10% DV
• Frozen yogurt; 1/2 cup = 10% DV
• Ice cream; 1/2 cup = 6% DV
• Soy milk, calcium-fortified; 1 cup = 30% DV

• Tofu prepared with calcium sulfate; 3 oz. = 60% DV
• Baked beans with sauce; 1/2 cup = 8% DV
• Pork & beans with sauce; 1/2 cup = 6% DV

Additional Dietary Concerns

While dietary calcium and vitamin D are important in helping prevent or treat osteoporosis, the following dietary concerns also come into play.

1. Food is best calcium source. Most experts agree food is the best source of calcium as there may be other factors found in calcium food sources that also affect use by the body.

2. Total calcium load at one time. Your body can best handle about 500 mg of calcium at one time, whether from food or supplements. Consume your calcium foods/supplements throughout the day rather than all at one time.

3. Fiber. Excessive fiber can interfere with calcium absorption. Dr. Miriam Nelson (author, Strong Women, Strong Bones) advises that the fiber occurring in food is probably not a problem. But, if you're sprinkling extra fiber on food, such as bran on cereal, that might affect calcium absorption.

4. Caffeine. Nelson advises consuming under 400 milligrams of caffeine daily. Excessive caffeine can increase urinary excretion of calcium. A 6 oz. cup of coffee has about 100 milligrams caffeine -- the actual amount would depend on brewing time, etc. Tea, soft drinks and various medications also can contain caffeine. There are about 40 milligrams of caffeine in 6 oz. of regular brewed tea; green tea may contain less caffeine. Some soft drinks are comparable to tea in caffeine content. To check the amount of caffeine in foods, search the USDA Nutrient Database (caffeine is the last entry at the end of each nutrient report): www.nal.usda.gov/fnic/foodcomp/index.html

5. Excessive sodium. Excessive sodium can increase urinary calcium excretion. Go easy on the salt shaker; taste before you salt. Limit the number of high salt foods. The Food and Nutrition Board recommends sodium be limited to 2,400 mg daily. The Nutrition Facts panel on foods gives the sodium content of a food.

6. Alcohol. Consuming more than seven alcoholic drinks per week is associated with an increased risk of low bone density and of falls and fractures, according to Nelson. Obviously, you shouldn't drink seven drinks all in the same day.

7. Oxalic acid. This acid, present in certain foods, such as spinach, chard and beet greens, binds up the calcium in these foods. However, it doesn't seem to affect the calcium in foods served with them. These greens are still good for you and may actually help improve calcium status in other ways. Also, though chocolate is a source of oxalic acid, it doesn't seem to tie up the calcium in milk if you drink chocolate milk.

8. Soft drinks. When soft drinks replace milk as a beverage, individuals are drastically reducing the calcium content of their diets.

9. Protein. Unbalanced, excessively high protein diets could increase urinary excretion of calcium.

10. Soy. While soy is a nutritious food, not all soy is a source of calcium -- check the "Nutrition Facts" panel on the label for calcium content.

    Some recent research found calcium from calcium-fortified soy milk was absorbed at only 75% the efficiency of calcium from cow's milk. There may be some brands not studied that offer a greater absorption rate; however, at the time of the study, researchers felt their sample was representative of most of the calcium-fortified soy milk currently available. (Source: Heaney, RP, et al. Bioavailability of the calcium in fortified soy imitation milk, with some observations on method. Am J Clin Nutr 2000; 71: 1166-9.)

    These researchers suggest to get the same amount of usable calcium from soy milk as you would get from three 8-ounce glasses of cow’s milk, you will need to drink four 8-ounce glasses of soy milk.

11. Fruits and vegetables. Research by Tucker and colleagues found a diet high in fruits and vegetables contributed to the maintenance of bone mineral density. The study found whole grains also helped contribute to potassium and magnesium. (Source: Tucker, KL, Potassium, magnesium, and fruit and vegetable intakes are associated with greater bone mineral density in elderly men and women. Am J Clin Nutr 1999; 69: 727-36.)

    The Food Guide Pyramid recommends 2 to 4 daily servings of fruits and 3 to 5 daily servings of vegetables. Choose from a variety of fruits and vegetables daily. Try many colors and many kinds.

If you lack the enzyme needed to digest lactose (milk sugar), you still may be able to obtain calcium from dairy products. (Source: Suarez, FL, et al. Lactose maldigestion is not an impediment to the intake of 1,500 mg calcium daily as dairy products. Am J Clin Nutr 1998; 68: 1118-1122.)

These suggestions might work for you:

1. Eat small portions of dairy foods. Start by eating small portions of lactose-containing foods such as milk and gradually increase the serving size.

2. Combine dairy foods with other foods. Eat dairy foods in combination with a meal or solid foods.

3. Try non-milk dairy foods. Consider dairy foods other than milk. Many cheeses (e.g. Cheddar, Swiss, Parmesan) contain less lactose than milk. Aged cheeses generally have negligible amounts of lactose. Also, many cultured dairy foods such as yogurt made with live, active bacteria are generally well tolerated.

4. Pre-digest lactose. When lactose is broken down to its simple sugar components, glucose and galactose, it may be easier for someone who is lactose intolerant to use. Consume lactose-hydrolyzed milk and other dairy foods or consider commercial lactase preparations (capsules, chewable tablets, solutions).

Dairy products are one of nature's most concentrated dietary sources of calcium. But you may not like to drink milk. Here are 10 easy tips for including more milk products in your diet without ever drinking a glass of milk. (Source: Dairy Council of Nebraska.)

1. Make oatmeal with milk.

2. Add milk to your coffee. (But watch how much caffeinated coffee you drink!)

3. Make soups such as tomato, chowders and cream-type soups with milk instead of water.

4. Add powdered milk to foods. One tablespoon is equal to 50 milligrams of calcium.

5. Make instant hot cocoa with milk instead of water. Or, when using packets of hot chocolate, add 1/3 cup of powdered milk which is equivalent to a cup of milk.

6. Serve milk-based desserts such as puddings, tapioca, frozen yogurt, custard and ice cream frequently.

7. Enjoy a cup of hot chocolate instead of coffee. An 8-ounce serving of chocolate milk has only 2 to 7 milligrams of caffeine. Six ounces of coffee has about 100 milligrams of caffeine. Also, chocolate milk provides, on average, only about 60 calories more per serving than unflavored milk.

8. Use plain or flavored yogurt as a dressing for fruit salads. For example: Try Key lime yogurt as a dressing over fruit. Lemon yogurt works with waldorf salads (typically made with apples and such ingredients as raisins or grapes, celery and walnuts).

9. Top baked potatoes with yogurt. For added flavor, mix in some snipped fresh chives or dried chives.

10. Enjoy smoothies for snacks. TIP: blend small frozen fruit pieces (berries work especially well) with milk or yogurt. Use about a cup of milk or yogurt; then add 1/2 to 1 cup frozen fruit and blend until smooth and of desired consistency. Yogurt gives a tangier taste than milk. Or, use a combination of milk and yogurt. Sweeten to taste with a teaspoon or two of sugar, honey or jelly; or, use an artificial sweetener. If desired, add about 1/4 teaspoon vanilla. Drink right away.

    You also can freeze small pieces of fresh or canned fruit until solid. Freeze for a few hours or overnight on a cookie sheet or in shallow metal pans -- place fruit in a single layer. Chop larger fruits like bananas, apricots, etc. into smaller chunks -- about 1/2 to 1 inch. Transfer frozen fruit to freezer bags for later use or enjoy in a smoothie right away!

If you're unable to obtain the recommended amount of calcium from your diet, the following tips will help you achieve the most benefit from calcium supplements. Always read the directions carefully. NOTE: Some supplements may require more than one tablet to achieve the amount of calcium listed in the serving size.

1. Calcium carbonate. This supplement requires acid to dissolve and for efficient absorption. As we age, we may not produce as much stomach acid between meals. It's usually recommended a person take calcium carbonate at mealtime when the stomach produces more acid.

2. Calcium citrate. This supplement tends to be more expensive than calcium carbonate but doesn't require stomach acid for absorption. It may be taken any time; however, your health care provider may recommend a specific time for you.

3. Vitamin D. Choose a calcium supplement with vitamin D unless you're already getting vitamin D from other sources. Consider the recommended Daily Value for vitamin D for your age group. Avoid going over a combined total of 50 micrograms (2,000 IU) from all calcium supplements, vitamin/mineral supplements and foods during the day.

4. Total calcium load at one time. Your body can best handle about 500 mg of calcium at one time, whether from food or supplements. Consume your calcium supplements and calcium foods throughout the day rather than all at one time.

5. Time of day. If you take just one supplement, it's probably best to take it in the evening, according to Nelson. Miriam Nelson recommends taking calcium carbonate at dinner time and calcium citrate before bed. This may enhance absorption and utilization.

6. Absorption. If your brand doesn't say it has met USP (United States Pharmacopoeia) standards, you may want to give it the vinegar test. (NOTE: Applying for this symbol is voluntary at this time, so there may be many good products that don't carry it.) Put a tablet in a cup of vinegar and stir every 5 minutes. It should dissolve in 30 minutes. If it doesn't, the calcium tablet probably won't dissolve in your stomach, either.

   Chewable and liquid forms should dissolve well as they're already broken down.

7. Increase amount slowly. NOF recommends you increase the amount of calcium supplements slowly, starting with 500 mg a day for a week and then gradually adding more. Some types can cause side effects such as gas or constipation for some people. Increasing fluids and fibrous foods (fruits, vegetables, whole grains) may help. If you still have problems, switch to another form of supplement.

8. Check for interactions. NOF advises checking with your physician or pharmacist about possible interactions with other prescriptions and over-the-counter drugs you're taking. For example, calcium supplements may reduce the absorption of the antibiotic tetracycline. If you take a medicine on an empty stomach, you probably shouldn't take it with a calcium supplement because it could affect the absorption.

9. Food is still important. Nelson advises high calcium foods also contain other nutrients that are important in the diet. She recommends you don't obtain all your calcium from calcium-fortified orange juice and candies.

To apply this information on calcium and vitamin D:

1. List the foods/supplements and the serving sizes you ate yesterday or in a typical day.

2. Determine the % DV of calcium and vitamin D they provided, based on the label.

3. Adjust the % DV if you consumed a serving size of food that was different from the amount listed on the label.

4. Total your amounts and compare your score to the recommended % DV for your age group.

A quote in Dr. Miriam Nelson's book (Strong Women, Strong Bones), taken from the Massachusetts Osteoporosis Awareness Program, sums it all up: "Support your bones. They support you."

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ABOUT FOOD REFLECTIONS Food Reflections is a FREE monthly e-mail newsletter from the University of Nebraska Cooperative Extension and also is archived at lancaster.unl.edu/food/archives.htm. It provides a "how-to" message on food, nutrition, or food safety for health professionals, educators, and consumers. Author: Alice Henneman, MS, RD, Extension Educator. Permission to Copy: You may reproduce for educational but not sales purposes. Please credit: Food Reflections Newsletter, University of Nebraska Cooperative Extension in Lancaster County (lancaster.unl.edu/food/foodtalk.htm) E-Mail Subscription to Food Reflection: Sign up at lancaster.unl.edu/food/foodtalk.htm Endorsement Policy: Use of commercial and trade names does not imply approval or constitute endorsement by the University of Nebraska Cooperative Extension in Lancaster County. Nor is criticism implied of products not mentioned. Contacting Us: Send your comments and suggestions to: ahenneman1@unl.edu For More Information: For personalized answers to food, nutrition and food safety questions, contact your local Cooperative Extension office. Find your Extension office at: lancaster.unl.edu/office/locate.htm

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