Calcium and Vitamin D After 60: Doses, Food and Sun

Why they matter

Calcium is the main mineral in bones and teeth, and is needed for muscle contraction, nerve signals and the heartbeat. When dietary calcium is low, the body takes it from bone. Vitamin D helps the gut absorb calcium and supports bone and muscle function and probably immune function. Together they help reduce bone loss, and, with other treatments, the risk of fractures in people at risk; see osteoporosis at home: preventing fractures and living well. After about fifty, bone loss accelerates, especially in women after menopause, and falls and fractures become a major threat; see hip fracture recovery at home.

How much is needed

Recommendations differ slightly between bodies. As a general guide:

• Calcium: Indian recommendations for adults are about 1,000 mg per day from all sources (food plus supplements). Many international guidelines suggest about 1,000 to 1,200 mg per day for older adults. The total upper limit is generally about 2,000 to 2,500 mg per day.
• Vitamin D: Indian and international guidance commonly suggest about 600 IU (15 micrograms) per day for adults under seventy and about 800 IU (20 micrograms) for those over seventy, from all sources including sunlight and supplements. The commonly accepted upper limit for long-term daily intake is about 4,000 IU (100 micrograms) per day. Doctors sometimes prescribe higher, short-term "loading" doses, often weekly, for confirmed deficiency; follow the prescription exactly and do not repeat or extend without testing and advice.

Vitamin D units: 40 IU equals 1 microgram. Labels may use either; see how to read a supplement label.

Calcium from food first

Food sources supply calcium in a form the body uses well and bring other nutrients. A glass of milk (about 250 ml) gives roughly 250 to 300 mg. Good Indian sources include:

• Milk, curd, buttermilk, paneer and cheese.
• Ragi (finger millet), one of the richest plant sources, in rotis, dosa, idli, porridge or malt.
• Sesame seeds (til): in chutneys, laddoos and sprinkled over dishes, and gingelly oil dishes.
• Green leafy vegetables: amaranth (chaulai), drumstick leaves (moringa), curry leaves, fenugreek (methi), colocasia leaves and mustard greens; note that spinach calcium is poorly absorbed because of oxalates.
• Small fish eaten with bones, such as sardines and anchovies.
• Almonds, figs (anjeer) and dried fruits.
• Soya products, tofu set with calcium, and calcium-fortified foods.
• Pulses and legumes in smaller amounts.
• Jaggery gives small amounts.

See 10 food sources of calcium for your bones and are you consuming an adequate amount of calcium.

Estimating intake: a rough tally of milk, curd, paneer, ragi and greens can show whether the diet supplies about 600 to 800 mg; the shortfall is what a supplement may fill, if any. A dietician can calculate.

Absorption tips: spread calcium across the day, since the body absorbs about 500 mg or less at a time. Vitamin D, lactose and some proteins help absorption; oxalates in spinach, phytates in some grains and high salt reduce it. Excess caffeine, alcohol, smoking and very high protein or salt intakes increase calcium loss.

Vitamin D: sunlight and food

Sunlight. The skin makes vitamin D when exposed to ultraviolet B rays. In India, midday sun (roughly late morning to early afternoon) has the strongest rays, but many older adults spend most of their time indoors, cover their skin, use sunscreen, have darker skin (which makes less vitamin D) or live in polluted cities, so deficiency is very common; see vitamin D deficiency in India. A commonly suggested pattern is about 10 to 30 minutes of midday sun on uncovered arms and face (and legs where acceptable), several times a week, without sunscreen for that short period, but the right amount depends on skin tone, season, location, age and health; avoid sunburn, heat exposure and long periods in strong sun, particularly with skin cancer risk, certain medicines that increase sun sensitivity or heart and kidney conditions. Glass windows block the useful rays. Ask the doctor what is safe.

Food. Few foods contain much vitamin D: oily fish (sardines, mackerel, salmon), egg yolk, liver, mushrooms exposed to sunlight, and fortified products such as fortified milk and oil. It is difficult to reach recommended intake from food alone.

Supplements

Vitamin D. Available as D3 (cholecalciferol, usually preferred) or D2, in tablets, capsules, drops, sachets or weekly doses. Take with a meal containing some fat for better absorption. Doses as above. A doctor may check a blood test (25-hydroxy vitamin D) to confirm deficiency. In general, levels below about 12 ng/mL (30 nmol/L) are considered deficient and levels of about 20 ng/mL (50 nmol/L) or more adequate, though laboratories and guidelines vary; the doctor interprets results.

Calcium. Common forms: - Calcium carbonate: high elemental calcium, cheap, best absorbed with food since it needs stomach acid. May cause bloating and constipation. - Calcium citrate: absorbed with or without food, better for those with low stomach acid or on acid-reducing medicines; lower elemental calcium per tablet, so more tablets may be needed. - Other forms such as calcium gluconate, lactate or from coral or algae; check elemental calcium.

Elemental calcium is what matters: a tablet labelled "calcium carbonate 1,250 mg" provides about 500 mg of elemental calcium. Read the label for the elemental amount; see how to read a supplement label.

How to take: split doses, no more than about 500 mg of elemental calcium at one time, with meals if carbonate. Many combination tablets contain calcium with D3; see multivitamins for older adults, which often contain little calcium. Count calcium from all sources so the total does not exceed the upper limit; a supplement of about 500 mg a day is common when diet falls short.

Do not exceed label doses, and do not take both a calcium and D supplement, multivitamin and antacid containing calcium without counting the totals.

Who should be careful or ask first

• Kidney disease or a history of kidney stones: calcium and vitamin D can raise blood calcium and the risk of stones, and in advanced kidney disease the body handles vitamin D differently. The nephrologist may prescribe specific forms; see eating with chronic kidney disease: a family guide and chronic kidney disease: a home care guide.
• High blood calcium, parathyroid disease, sarcoidosis, some cancers or lymphoma.
• Heart disease: some studies have raised questions about very high calcium supplement doses and heart risk; discuss with the doctor and favour food sources.
• Digestive conditions such as coeliac disease, inflammatory bowel disease, after stomach surgery.
• Osteoporosis treatment: medicines such as bisphosphonates need adequate calcium and vitamin D, and some must be taken separately; follow the doctor's instructions.

Interactions: common medicines

Always tell the doctor and pharmacist about all supplements; see supplements and medicine interactions: a safety guide.

• Levothyroxine: calcium reduces absorption; take at least four hours apart.
• Iron tablets: calcium and iron compete; separate by a few hours; see iron and anaemia in older adults.
• Some antibiotics (tetracyclines, quinolones): calcium binds them; separate as the pharmacist advises.
• Bisphosphonates (for osteoporosis): take with plain water on an empty stomach, and keep calcium several hours apart as instructed.
• Thiazide water tablets: can raise blood calcium, so combined with calcium and D supplements needs monitoring.
• Digoxin and some heart medicines: high calcium can be dangerous.
• Acid reducers (PPIs, H2 blockers): reduce carbonate absorption; citrate may be preferred.
• Steroids increase bone loss and calcium needs.
• Anticonvulsants and some other medicines can lower vitamin D.
• Orlistat, cholestyramine reduce fat-soluble vitamin absorption.

Do not stop any prescribed medicine to fit supplements; ask the pharmacist about timing.

Side effects and warning signs

• Constipation, bloating, gas (more with carbonate); increase fluids and fibre, or try citrate; see constipation in older adults: fibre, fluids and movement.
• Too much calcium or vitamin D can cause nausea, vomiting, loss of appetite, thirst, frequent urination, constipation, weakness, confusion, kidney stones and abnormal heart rhythm. Seek urgent help for confusion, severe vomiting, severe abdominal or flank pain, or palpitations; call 112 if severe.

Monitoring

• Blood tests for calcium, kidney function and 25-hydroxy vitamin D, as the doctor advises, particularly before high-dose treatment and after a few months.
• Bone density scan for osteoporosis risk; see osteoporosis at home: preventing fractures and living well.
• Height and weight, and fractures history.
• Regular review of the supplement plan; do not continue high-dose vitamin D indefinitely without checking.

Practical tips for Indian homes

Store supplements in a cool, dry place in the original pack, take calcium with lunch or dinner, use a pill organiser to avoid double dosing (see pill organiser guide), and use ragi and sesame in everyday cooking. Falls prevention matters as much as bones; see falls risk assessment at home.

When to ask a professional

Ask the doctor to check vitamin D and calcium levels, kidney function and bone health, and to prescribe doses. Ask a dietician to estimate dietary calcium. Ask a pharmacist about interactions and timing. Seek urgent help for confusion, severe vomiting, severe pain, palpitations or a fall with suspected fracture; call 112 for severe symptoms.