Falls are every provider’s responsibility to prevent in every venue of practice. One out of every three older persons fall every year. Continue reading →

Physicians in primary care are inundated with patient demands for services including preventive care, chronic disease management, and acute care Continue reading →

Patients walk through your doors every day with active infections, carriage of infections or susceptibility to infections. Continue reading →

Primary care physicians order a lot of tests – to diagnose complaints, to monitor chronic diseases, to check medication levels, to screen for health risks and early disease. Continue reading →

Two out of every three office visits results in a prescription. Each year over 1.3 billion drugs are prescribed Continue reading →

What can go wrong in the office? Isn’t patient safety something that hospitals, and to a lesser extent, nursing homes should be worrying about? Continue reading →

With the holidays just around the corner, we look forward to spending time with our families.  Children returning home from college or parents visiting from out of town make this time even more precious than ever.  The season is a time to be together, catch up with friends and other family, and to give thanks.  Continue reading →

The Hygiene Hypothesis is a theory that suggests a young child’s environment can be “too clean” to effectively stimulate the developing immune system to respond to various “threats” such as allergens Continue reading →

Colorectal cancer (CRC) is the second leading cause of cancer related deaths in the United States. Continue reading →

Back in February, 2013 this blog looked at the positive association between calcium intake and the risk of all cause death rates and cardiovascular disease in women.  Older people have historically been encouraged to obtain their calcium from dietary sources instead of supplements.  A recent systematic review of randomized controlled trials as well as observational studies by Mark Bolland et al. concluded that there is no association with dietary intake of calcium and risk of fracture. Moreover, these authors found that the association between calcium supplements and fracture risk is similarly weak.

Interestingly, there are only two randomized controlled studies of dietary calcium intake and fractures. Contrary to RCT evidence, there are 50 reports from 44 cohort studies on the relationship.  In adults older than 50, for most studies (> 75%) , no relationship between dietary calcium intake, including milk or dairy sources, and fractures of the hip, spine or forearm could be confirmed.

In randomized studies, the degree of total fracture reduction associated with supplemental calcium was statistically significant with an 11% reduction (95% CI, 0.81, 0.96). However, the clinical importance of this reduction is uncertain.  When examining this relationship with specific fracture types (hip or forearm fractures), a statistically significant reduction could  not be demonstrated.  One trial¹ in frail elderly women in residential care with low dietary calcium and low Vitamin D levels, did show decreased fracture risk (but 6 other similar trials that did not.)

So, most of the studies were observational and suffer from the inherent risk of bias.  It seems to me, the blogger, that there should be some level of calcium intake that is necessary.  Where too much is unhealthy, zero intake would seem to be unhealthy as well (reductio ad absurdum).  Nonetheless, we clinicians are caught calcium carbonate and a hard place again.

What’s a doctor to do?  Well, it starts with our pediatrician and family physician colleagues.  Put the calcium in during growth.  Even after they stop growing taller kids continue to make more bone than they lose.   Bone mass peaks somewhere between 18 and 25.  Seek to dispel parental concerns (and self-diagnoses)  of lactose intolerance in those less at risk (more common in the elderly, Blacks, Asians, Hispanic, and Native Americans but much less common in Northern Europeans).   Being products of the Kool-Aid generation, we missed out on this little piece of advice and are paying for it now.

1. Chapuy MC, Pamphile R, Paris E, et.al Combined calcium and vitamin D3 supplementation in elderly women: Confirmation of reversal of secondary hyperparathyroidsism and hip fracture risk :  The Decalyos II study.  Osteroporosis Int 2002;13:257-64.