Calcium and Vitamin D position Statement 2017
Updated Calcium and D statement December 2018
ESA/ANZBMS/MSA/COSA Position Statement: "Optimising bone health in women with breast cancer on endocrine therapy" now published in Clin Endo
Benefits of Dietary Calcium
The Australian and New Zealand Bone and Mineral Society, Osteoporosis Australia and Endocrine Society of Australia collectively reject the suggestion of Mr Pete Evans (reported in the Sydney Morning Herald1, ABC2and recently on the programme Sunday Night3, 26th March 2017) that “calcium from dairy can remove the calcium from your bones" or that calcium obtained from dairy foods can cause or contribute to osteoporosis.
Ensuring sufficient calcium intake is an important component for bone health across the entire lifespan. Dairy foods are an important and inexpensive source of calcium for many individuals, and most Australians obtain the majority of their calcium intake from dairy sources. Dairy foods also represent an important source of protein and calories for many frail older people.
Men and women with osteopaenia or osteoporosis should be reassured and confident that a good dairy intake does not have adverse effects upon skeletal health.
Calcium and Bone Health
The final version of the "Calcium and Bone Health" position paper was accepted in 2007 and is endorsed by ANZBMS, Osteoporosis Australia (OA) and the Endocrine Society of Australia (ESA).
Vitamin D and adult bone health in Australia and New Zealand
A position statement by a working group of the ANZBMS, ESA and OA.
Published MJA 2005; 182: 281–285.
A significant number of Australians are deficient in vitamin D. Indeed, it is a fallacy that Australians receive adequate vitamin D from casual exposure to sunlight. Here, we outline the causes and outcomes of vitamin D deficiency, the people who are at risk, and recommendations for management of deficiency.
Exercise and Osteoporosis
Download the position statement on Exercise and Osteoporosis.
Jaw osteonecrosis with bisphosphonates
The adverse event of jaw osteonecrosis has been reported most commonly with the use of intravenous bisphosphonates (zoledronate and pamidronate) in cancer patients, but has also been reported with the use of oral bisphosphonates in osteoporosis and Paget’s patients. There have been 78 cases associated with alendronate therapy in 20 million patient years of exposure (Fosamax, Merck & Co) and there have also been a number of cases associated with risedronate (Actonel, Procter & Gamble).
What is it?: A number of conditions including “dry sockets” are currently grouped under the name of “jaw osteonecrosis’. In the worst case, individuals develop a deformity around or at a tooth socket. A painful and gaping hole may occur in the jaw. The deforming area around dead bone may fail to heal which may result in chronic dental problems.
Why does it occur? Why is the jaw affected?: The cause is not understood, nor is it clear why some patients get the more severe condition. However bone normally undergoes renewal on a continuous basis. This remodelling process involves osteoclasts resorbing old, possibly damaged bone and osteoblasts building new bone. Jaw osteonecrosis may stem from the mechanism of action of bisphosphonates. These drugs work by preventing the resorption of old bone, since bisphosphonates are toxic to the osteoclasts. This leads to a reduction in bone turnover that may be more critical in the jaw.
Bone in the jaw has a faster turnover than bone elsewhere in the body, both because it is subjected to constant stress from activities such as talking and chewing and also because of the presence of teeth, which mandates daily bone remodeling at the periodontal ligament. Also the jaw can often be damaged during dental surgery such as extractions. The potential concentration of these drugs in the jaw bones, when coupled with chronic invasive dental diseases/treatments and the thin mucosa over the bone, may predispose to the condition being manifest in the jaw.
Who is at risk?: Jaw osteonecrosis has usually been observed after patients have been taking therapy for five or more years. However it has been reported to occur earlier in the presence of certain risk factors. For example, of the 78 cases with alendronate, most developed after an invasive dental procedure, such as a tooth extraction. Other risk factors include oral infections, use of steroid therapy and radiotherapy.
How common is this problem?: Jaw osteonecrosis is rare, occurring in perhaps one out of 1,000 to 10,000 patients. At the US Federal Drug Administration hearing on this subject in March 2005, Novartis reported 875 possible cases of jaw osteonecrosis associated with the two intravenous products, zoledronate and pamidronate. The majority of these cases occurred in patients with cancer treated with doses ranging up to 20 times higher than used in osteoporosis. As of June 2005, Merck had received 78 reports of jaw osteonecrosis associated with alendronate. However, the company saw no cases of jaw osteonecrosis during preclinical studies, in which alendronate was used at far higher doses than are approved for osteoporosis, and also no cases were seen in controlled clinical trials, which involved more than 17,000 patients. Alendronate has been on the market for 10 years now, during which time total exposure to the drug is estimated at around 20 million patient-years. Moreover these case reports have not all been carefully evaluated and some may represent relatively mild problems, such as dry socket that have been reported long before bisphosphonates were in use.
Prevention is better than cure: Despite its rarity, physicians who prescribe bisphosphonates should be aware of this side effect and should discuss it with patients. It is important to ask about dental hygiene before starting therapy. The best strategy is prevention, as most cases appear to follow a dental procedure. If the patient’s dental fitness is in doubt, it may be prudent to send them for these procedures before they start on a course of bisphosphonate therapy and to encourage thorough dental hygiene at all times. Once on the drug, patients should be advised to let their dentist know they are taking such medication and, in general, invasive dental procedures should be avoided. It may be prudent to temporarily withdraw bisphosphonate therapy before such procedures although it is recognised that these drugs remain in bone long term – for example, alendronate has a half-life of about 10 years.
Osteoporosis New Zealand publishes Fracture Liaison Service Resource Pack
Osteoporosis New Zealand has published a Fracture Liaison Services (FLS) Resource Pack, which was endorsed by the Health Quality & Safety Commission New Zealand:
Fragility Fracture Network launches new website
The Fragility Fracture Network’s mission is to promote globally the optimal multidisciplinary management of the patients with a fragility fracture, including secondary prevention. FFN is a fast growing organisation with global reach and a multidisciplinary membership, which is particularly well represented in Australia and New Zealand. Professor David Marsh (orthopaedics) from the UK is the current FFN President and Professor Maria Crotty (Rehabilitation Physician) from Adelaide is President-Elect.
The FFN is focused on 6 themes:
- Peri-operative care: Improving the peri-operative care of fragility fracture sufferers has, and will continue to be a major focus for FFN members and a theme of FFN Congresses.
- Surgical treatment: A key challenge facing surgeons is how to obtain secure fixation of an implant to osteoporotic bone.
- Rehabilitation: Provision of effective rehabilitation is a vital component of any system of care for fragility fracture sufferers.
- Secondary prevention: Effective secondary prevention must urgently be established as a standard part of post-fracture care throughout the world.
- Research and education: FFN Special Interest Groups are active in establishing a minimum dataset for hip fracture audit, developing evidence-based pathways for vertebral fracture patients and defining key questions in rehabilitation research.
- Changing healthcare policy: Driving policy change that will raise fragility fracture care up the healthcare agenda across the world is a major aim of the FFN.
The new website can be visited at www.fragilityfracturenetwork.org. Please take a look, and if you find the site useful, share it with colleagues who are also interested in the care of fragility fracture sufferers.
Osteoporosis Australia Medical and Scientific Advisory Committee Position statements:
- Building Healthy Bones throughout life - an evidence-informed strategy to prevent osteoporosis in Australia’ MJA OPEN - full paper
- Calcium Supplementation Statement (reviewed 06/2015)
- Vitamin D Position Statement (10/2013)
- Vitamin D and health in adults in Australia & New Zealand: A position statement. MJA (June 18, 2012)
- Clinical guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men(RACGP, 2010)
- Hormone replacement therapy and osteoporosis(August, 2012)
New Osteoporosis National Action Plan 2016
A new Osteoporosis National Action Plan, the result of a 12 month collaboration among a national alliance of stakeholder groups, launched on 20 October 2016 - World Osteoporosis Day. The plan presents a joint vision to address this major health issue as a matter of urgency.
Australian and New Zealand Bone and Mineral Society releases widely endorsed Position Paper on Secondary Fracture Prevention: A Call to Action.
On 11 May 2015, the Australian and New Zealand Bone and Mineral Society (ANZBMS) launched its pivotal Position Paper on Secondary Fracture Prevention, calling for radical change in how people who have suffered a fragility fracture are being managed.
Know Your Bones
Osteoporosis Australia and Garvan Institute of Medical Research launched Know Your Bones on Thursday 16 June. An Australian-first bone health self-assessment tool designed to help consumers understand their bone fracture risk, is now available to all adults, including the 7.5 million Australians living with brittle bones.
The Know Your Bones online tool helps adults assess their likelihood of fractures, including those diagnosed with osteopenia and osteoporosis – two common bone conditions that, together with fractures, will cost the nation more than $3 billion this year.
Further information: http://www.osteoporosis.org.au/experts-launch-know-your-bones
Information about the launch event: http://www.osteoporosis.org.au/minister-ley-attends-launch
Calcium Supplements and Vascular Disease
Updated: 10 September 2010
A recent publication by Bolland et al published in the British Medical Journal suggests that calcium supplements may increase the relative risk of ischaemic heart disease by 30%.1
While it is important to investigate possible harm caused by dietary supplements, it is difficult to know how much weight to put on this meta-analysis for several reasons. Firstly, a similar study – i.e. a pooled analysis of several randomized controlled trials where calcium supplements were given, funded by the American Heart Association did not detect any statistically significant increased risk of cardiovascular disease or other negative effects of calcium supplements.2 Secondly, none of the individual randomized trials analysed reported a statistically significant increased risk of ischaemic heart disease. Thirdly, new data from Lewis et al also reported no increase in atherosclerotic vascular disease related events in elderly women receiving calcium supplements (1200mg per day) followed for a total of 9.5 years (5 years on calcium supplements and a further 4.5 years). Importantly, records in this study, but not in most others, were validated through hospital admission data linkage although data for myocardial infarction events were not reported separately3. Fourthly, previous observational studies examining data from very large numbers of people have shown no adverse effect of high calcium intakes. As pointed out by Bolland et al, the effect of high dietary calcium intakes from diet were not studied in their recent meta-analysis.
While these studies were negative, it is important to recognise that methodological issues in the individual trials would have resulted in lack of power to detect a deleterious effect of calcium supplementation if there really was one present. For example, compliance in most, if not all the large trials, was around 50% so that a deleterious effect of calcium might have been missed. In post hoc analysis, the reduction in sample size when only compliers are examined, reduces the power of the study. Furthermore, none of the trials with calcium supplements were designed to investigate vascular events, so that randomization may have produced an uneven distribution of risk factors for cardiovascular disease, which could produce spurious results in either direction. In most of the studies, the subjects were not dietary calcium deficient, so supplements were given to people who already had adequate calcium intakes from dietary sources. In some studies, total calcium intakes were above 2000mg/day.
Given these uncertainties, ANZBMS recommends achieving a total calcium intake of 1000-1300mg, depending on age and sex, where possible through dietary intake of calcium rich foods. Similar recommendations come from the National Health and Medical Research Council. If dietary intake is not feasible and the treating doctor believes calcium supplements are needed for fracture risk reduction, then calcium supplements in doses of 500-600mg can be considered after a discussion of their benefits vs risks.
1. Bolland MJ, Avenell A, Baron JA, Grey A, MacLennan GS, Gamble GD, Reid IR. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ 2010; 341:c3691.
2. Wang L, Manson JE, Song Y, Sesso HD. Systematic review: Vitamin D and calcium supplementation in prevention of cardiovascular events. Ann Intern Med. 2010 Mar 2;152(5):315-23.
3. Lewis JR, Calver J, Zhu K, Flicker L, Prince RL. Calcium supplementation and the risks of atherosclerotic vascular disease in older women: results of a 5-year RCT and a 4.5-year follow-up. J Bone Miner Res. 2010 Jul 7. [Epub ahead of print].