Академический Документы
Профессиональный Документы
Культура Документы
INTRODUCTION
Address reprint requests to: Robert P. Heaney, M.D., Creighton University, 601 N. 30th St., Suite 4841, Omaha, NE 68131. Email: rheaney@creighton.edu
Work supported in part by contracts with GlaxoSmithKline.
Journal of the American College of Nutrition, Vol. 22, No. 2, 142146 (2003)
Published by the American College of Nutrition
142
METHODS
Protocol
Two studies were conducted in Omaha, Nebraska at 41.3
N. latitude, approximately one year apart, in the spring of the
year at the time of the seasonal nadir for serum 25OHD. Each
was a randomized, cross-over study, designed to test the relative absorbabilities of two calcium supplement sources, ingested at single, 500 mg loads taken as part of a standard low
calcium breakfast. Results from the first study, comparing the
two calcium sources, have been published previously [7]. The
protocol for the first study included pre-dosing with 25OHD
(Calderol, Organon, West Orange, NJ), at a dose of 20 g
given on alternate days for an average of three weeks prior to
the absorption measurements, a stratagem designed to bring all
participants rapidly into a state of vitamin D sufficiency. By
contrast, in the second study, there was no pretreatment with
vitamin D or 25OHD. The test substances in both studies were
commercially marketed preparations of Os-Cal and Citracal
in doses providing 500 mg of calcium (as calcium carbonate for
Os-Cal) and 515 mg of calcium (as calcium citrate for Citracal).
Both sources also provided 200 IU of vitamin D, which the
participants received one time only, on the day of the test.
Subjects were fed a low calcium lunch five hours after the test
breakfast.
In both studies the two marketed products tested were found
to be bioequivalent, with nearly identical (and nonsignificantly
different) indices of absorption. Hence, for purposes of this
analysis, within-subject averages of calcemia for the two calcium sources in each study were taken as the best estimates of
each participants absorptive performance under the then prevailing vitamin D status.
Participants
Participants were 34 postmenopausal women, 14 of whom
took part in both studies. Average age at time of study was
56 7 years in the first study and 64 9 years in the second.
Body mass index (kg/m2) was 29.2 5.2 for the study with
25OHD supplementation and 28.8 3.8 for the study without.
Twelve of the 24 women in the first study were receiving
estrogen replacement therapy, and 10 in the second study.
Individuals with digestive disorders, antibiotic use within five
days or unstable medical conditions of any sort were excluded.
The study was approved by the Creighton University Institutional Review Board, and each subject gave written consent.
Absorption Measurement
Relative absorption was estimated from the area under the
curve over intervals ranging from 9 to 12 hours after dosing
(AUCt). Blood was drawn immediately prior to the test breakfast (time zero) and at frequent intervals thereafter out to 24
hours in the first study and to 12 hours in the second. AUC was
calculated for 9, 10 and 12 hours by the trapezoidal method
using the increment above each individuals baseline serum
calcium value, and the individual participant AUCt values were
aggregated across each study. Comparative absorption was
expressed as the ratio of the means of the two AUCt values.
Since the timing of the blood samples was not identical for the
two studies, AUCt was calculated for each using values confected at 9 or 10 hours (as the case may be) by linear interpolation between measurements on either side of the desired time
point. As the values were close to baseline by nine hours, this
assumption of linearity can have introduced at most only a
trivial error. Because AUC9 has been shown elsewhere [8] to be
better correlated with true absorption than AUC values at
earlier or later times, the primary comparisons we report will be
based on AUCt calculated over nine hours. Fractional absorption was calculated from the AUC9 values using the following
formula [8]:
Analytical Methods
Serum calcium was measured by atomic absorption spectrophotometry (AAnalyst 100, Perkin-Elmer, Norwalk, CT).
Serum 25OHD was measured once at baseline on each subject
in each study (Nichols Institute Diagnostics, Catalog No. 402135, San Juan Capistrano, CA). Serum immunoreactive parathyroid hormone (iPTH) was measured as the intact molecule
by IRMA (Nichols, San Juan Capistrano, CA).
Statistical Analyses
Data were analyzed in two ways. Since approximately half
of the subjects in each group were not common to the two
studies, the two sets of values were analyzed as independent
samples, using ANOVA and testing for period and treatment
effects. For the 14 women common to each study, a repeated
measures ANOVA was performed, also testing for treatment
and period effects. In both instances we used SAS (SAS Institute, Cary, North Carolina), as well as the various descriptive
statistics provided by Excel (Microsoft, Redmond, WA).
RESULTS
Table 1 sets forth the numerical values for the principal
findings in this study. Serum 25OHD at baseline was 36
nmol/L higher in the study in which participants had been
143
N
Serum 25(OH)D (nmol/L)
Baseline serum Ca (mg/dL)
Incremental AUC9 Ca (mg hr/dL)
Baseline serum PTH (pg/mL)
Incremental AUC10 PTH (pg hr/mL)
With 25OHD
Without 25OHD
24
86.5 24.0
9.64 0.33
3.63 1.15
36.9 13.7
116.0 79.5
24
50.2 15.7
9.31 0.34
2.20 1.18
43.0 13.3
103.1 79.9
0.001
0.002
0.001
NS
NS
144
the reference normal range (8.8 to 10.2 mg/dL), were significantly higher in the D participants (by 0.33 mg/dL; P
0.002). While basal serum PTH was higher in the D group,
the difference was not statistically significant, largely because,
unlike calcium, which is tightly regulated, PTH values exhibited broad dispersion with a coefficient of variation more than
10 greater. Similarly, the AUC for PTH showed less of a drop
in the study without supplemental vitamin D, but the difference
was not statistically significant. Finally, there was no difference
in AUC9 in either study between those receiving estrogen
replacement therapy and those not so treated (data not shown).
Even within each of the two treatment groups there was a
broad range of 25OHD values; in fact, 25OHD values were
continuously distributed across both groups. Hence we pooled
the two studies and regressed AUC9 on 25OHD concentration
(Fig. 3). As expected there was a significant positive association (P 0.05). The coefficient of correlation improved substantially if the regression were confined to 25OHD values
below 90 nmol/L (above which level the correlation was effectively zero).
Subjects in the second study, without supplemental 25OHD,
were significantly older than those in the first study. Because of
this age difference and the possibility that some or all of the
absorptive difference was due to age rather than to vitamin D
status, we separately evaluated the within-individual differences in AUC9 in the 14 participants common to both studies.
DISCUSSION
Many nutrients exhibit what has been termed threshold
behavior, that is, the values for the physiological response
change directly with intake up to some threshold value, above
which the response does not change with further increases in
intake. Calcium, iron and ascorbic acid are well recognized
examples. Vitamin D is usually considered to exhibit similar
behavior, and the limited evidence available is consistent with
that interpretation. Threshold behavior in this instance would
mean that, in a state of vitamin D sufficiency, variations in
vitamin D intake within the physiological range would not alter
calcium absorption efficiency, while absorption would vary
with intake at subthreshold values for vitamin D status.
As noted earlier, the Food and Nutrition Board in its 1997
recommendations [1] was not able to specify the serum 25OHD
value at which vitamin D status reaches the response threshold.
Mortensen and Charles [9] had shown an improvement in
absorption in healthy Danish subjects given short-term pretreatment with vitamin D, but unfortunately their study provides no
data on serum 25OHD concentrations. Scotti et al. [11] more
recently have shown very similar results in Italian male subjects, in this case with accompanying serum 25OHD values.
Specifically, the index of calcium absorption used was higher at
145
4.
5.
6.
8.
9.
10.
11.
REFERENCES
1. Food and Nutrition Board, Institute of Medicine: Dietary Reference Intakes for Calcium, Magnesium, Phosphorus, Vitamin D,
and Fluoride. Washington, DC: National Academy Press, 1997.
2. Chapuy M-C, Preziosi P, Maamer M, Arnaud S, Galan P, Hercberg
S, Meunier PJ: Prevalence of vitamin D insufficiency in an adult
normal population. Osteoporos Int 7:439443, 1997.
3. Thomas MK, Lloyd-Jones DM, Thadhani RI, Shaw AC, Deraska
146
12.
DJ, Kitch BT, Vamvakas EC, Dick IM, Prince RL, Finkelstein JS:
Hypovitaminosis D in medical inpatients. N Engl J Med 338:777
783, 1998.
Dawson-Hughes B, Harris SS, Dallal GE: Plasma calcidiol, season,
and serum parathyroid hormone concentrations in healthy elderly
men and women. Am J Clin Nutr 65:6771, 1997.
Burckhardt P: Calcium and vitamin D in osteoporosis: supplementation or treatment? Calcif Tissue Int 70:7477, 2002.
Heaney RP: The importance of calcium intake for lifelong skeletal
health. Calcif Tissue Int 70:7073, 2002.
Heaney RP, Dowell MS, Bierman J, Hale CA, Bendich A: Absorbability and cost effectiveness in calcium supplementation.
J Am Coll Nutr 20:239246, 2001.
Heaney RP: Measuring calcium absorption by pharmacokinetic
methods [Abstract]. J Am Coll Nutr 2:478, 2002.
Mortensen L, Charles P: Bioavailability of calcium supplements
and the effect of vitamin D: comparisons between milk, calcium
carbonate, and calcium carbonate plus vitamin D. Am J Clin Nutr
63:354357, 1996.
Barger-Lux MJ, Heaney RP: Effects of above average summer sun
exposure on serum 25-hydroxyvitamin D and calcium absorption
fraction. J Clin Endocrinol Metab 87:49524956, 2002.
Scotti A, Bianchini C, Gianalfredo A, Marzo A: Absorption of
calcium administered alone or in fixed combination with vitamin D
to healthy volunteers. Arzneim-Forsch/Drug Res 51:493500,
2001.
Trivedi DP, Doll R, Khaw KT: Effect of four monthly oral vitamin
D3 (cholecalciferol) supplementation on fractures and mortality in
men and women living in the community: randomised double blind
controlled trial. BMJ 326:469474, 2003.