Modern India and Dietary Calcium Deficiency-Half a Century Nutrition Data-Retrospect-Introspect and the Road Ahead.

Calcium and vitamin D are inseparable nutrients required for bone health. In the past half a century, the dietary calcium intake of rural, tribal, and urban India has declined. Though India is the largest producer of milk and cereals, the major source of calcium in India is through non-dairy products. The highest intake of cereals and lowest intake of milk & milk products was observed in rural and tribal subjects whereas, the intake of cereals, milk & milk products were similar in both urban and metropolitan subjects. One of the reasons for lower calcium intake was the proportion of calcium derived from dairy sources. Over the past half a century, the average 30-day consumption of cereals in the rural and urban population has declined by 30%. The Per Capita Cereal Consumption (PCCC)has declined despite sustained raise in Monthly Per capita Consumption Expenditure (MPCE) in both rural and urban households. The cereal consumption was the highest in the lowest income group, despite spending smaller portion of their income, as cereals were supplied through public distribution system (PDS). About 85% of the Indian population are vitamin D deficient despite abundant sunlight. Dietary calcium deficiency can cause secondary vitamin D deficiency. Though India as a nation is the largest producer of milk, there is profound shortage of calcium intake in the diet with all negative consequences on bone health. There is a decline in dietary calcium in the background of upward revision of RDI/RDA. There is a gap in the production-consumption-supply chain with respect to dietary calcium. To achieve a strong bone health across India, it is imperative to have population based strategies addressing different segments including supplementing dietary/supplemental calcium in ICDS, mid-day-meals scheme, public distribution system, educational strategies. Other measures like mass food fortification, biofortification, bioaddition, leveraging digital technologies, investments from corporate sector are some measures which can address this problem. India is a vast country with diverse social, cultural and dietary habits. No single measure can address this problem and requires a multi-pronged strategic approach to tackle the dietary calcium deficiency to achieve strong bone health while solving the problem of nutritional deficiency.

Efecto de un preparado lácteo con isoflavonas de la soja sobre la calidad de vida y el metabolismo óseo en mujeres posmenopáusicas: estudio aleatorizado / Effect of milk product with soy isoflavones on quality of life and bone metabolism in postmenopausal Spanish women: randomized trial

Fundamento y objetivo: Analizar los efectos de la intervención nutricional con un producto lácteo enriquecido con isoflavonas de soja sobre la calidad de vida y el metabolismo óseo en mujeres posmenopáusicas españolas. Pacientes y método: Estudio aleatorizado, controlado y doble ciego. Un total de 99 mujeres posmenopáusicas fueron distribuidas en el grupo S (n=48) con consumo de un producto lácteo enriquecido con isoflavonas de soja (50mg/día) y en el grupo C (n=51) con consumo de un producto lácteo control durante 12 meses. Se evaluaron parámetros de calidad de vida (escala Cervantes), marcadores de metabolismo óseo y masa ósea estimada mediante ultrasonografía de calcáneo (QUS).Resultados: En conjunto, hubo una mejoría en los dominios menopausia (p=0,015) y sintomatología vasomotora (p<0,001). En el grupo S destacó la valoración de la sintomatología vasomotora (p=0,001) y se diferenció positivamente respecto al grupo C en salud (p=0,019), sexo (p=0,021) y pareja (p=0,002). Se produjo un descenso de fosfatasa ácida tartrato resistente (p<0,001) y osteoprotegerina (p=0,007) y un aumento de los valores de 25-OH-vitamina D (p<0,001), sin diferencias entre grupos. En la evaluación del QUS, se observó un incremento de la densidad mineral ósea estimada en el grupo S (p=0,040), mientras que en el grupo C no se observaron diferencias significativas. Conclusiones: El consumo diario de estos productos lácteos aumenta los niveles de 25-OH-vitamina D y supone un descenso de algunos marcadores del metabolismo óseo. La suplementación adicional con isoflavonas de soja parece mejorar la calidad de vida y la masa ósea en mujeres posmenopáusicas españolas (AU)

Background and objective: To analyze the effects of nutritional intervention with a milk product enriched with soy isoflavones on quality of life and bone metabolism in postmenopausal Spanish women.Patients and method: We performed a double-blind controlled randomized trial in ninety-nine postmenopausal women. Group S women (n=48) were randomized to consume milk product enriched with soy isoflavone (50mg/day) while group C (n=51) consumed product control for 12 months. Parameters of quality of life (Cervantes scale), markers of bone metabolism and bone mass estimated by ultrasound of the calcaneus (QUS) were evaluated. Results: Overall, there was an improvement in the domains menopause (P=.015) and vasomotor symptoms (P<.001). S group emphasized the assessment of vasomotor symptoms (P=.001) and differed positively from group C in health (P=.019), sex (P=.021) and partner (P=.002). Serum levels TRAP (P<.001) and OPG (P=.007) decreased and concentrations of 25-OH-vitamin D increased (P<.001) without differences between groups. In the assessment of QUS, there was an increase in estimated bone mineral density in group S (P=.040), whereas in group C there were no significant differences. Conclusions: Daily consumption of these milk products increases levels of 25-OH-vitamin D and decreases bone metabolism markers. Additional supplementation with soy isoflavones seems to improve quality of life and bone mass in Spanish postmenopausal women

Efecto del consumo de soja sobre la masa ósea en mujeres menopáusicas / Effect of soy consumption on bone mass in menopausal females

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Results of medical treatment and metabolic risk factors in children with urolithiasis.

Data on conservative treatment in children with urolithiasis are limited. The aim of the study was to determine the metabolic etiology and results of conservative treatment in children with urolithiasis. We evaluated the clinical presentation and metabolic features of 112 children with urolithiasis. The mean age at diagnosis of urolithiasis was 3.9 (range 0.1-18) years, and follow-up duration was 16.7 (range 1-36) months. The most common presenting symptoms were flank or abdominal pain and restlessness (25%). Urine analysis revealed metabolic abnormalities in 92% of cases, including hypocitraturia (42%), hyperoxaluria (32.1%), hypercalcuria (25%), hyperuricosuria (9.8%), and cystinuria (2.7%). Patients who had metabolic risk factors were treated according to underlying metabolic abnormalities. About half of these patients were stone free or stones were diminished in size. These results showed that early recognition and treatment of urinary metabolic abnormalities will reduce the number of invasive procedures and renal damage in children with urolithiasis.

[Altered calcium-phosphorus metabolism and low-protein diet]. / Alterazione del metabolismo calcio-fosforo e dieta ipoproteica.

Many metabolic disorders associated with uremia can affect the long-term survival of patients with chronic kidney disease. Such disorders can be defined as: hypocalcemia, increased levels of phosphorus, reduced synthesis of 1,25-dihydroxyvitamin D and serum calcitriol, and reduced expression of vitamin D receptors on parathyroid cells with increased parathyroid hormone levels and secondary hyperparathyroidism. Phosphorus, which plays a crucial role in the progression of progressive renal disease, has been shown to be an independent risk factor for death in hemodialysis patients. Thus, reducing the phosphorus intake by decreasing dietary proteins may slow the progression of renal disease. Hypocalcemia is typically associated with chronic kidney disease. It is due to the reduced intestinal absorption of calcium and the spontaneously reduced protein intake that occur in patients with progressive renal disorders. Activated vitamin D and calcium supplements should be administered to patients who are following low-protein diets to prevent secondary hyperparathyroidism; the doses should be correlated with actual renal function and protein intake.

Hipercalciuria idiopática en la infancia / Childhood idiopathic hypercalciuria

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Hipercalciuria idiopática en pediatría / Idiopathic hypercalciuria in pediatrics

Hace 50 años se observó que pacientes portadores de litiasis renal presentaban una excreción aumentada de calcio en orina. Posteriormente Albrigth y Henneman describieron un grupo de pacientes adultos con litiasis renal que presentaban hipercalciuria en ausencia de hipercalcemia, hiperfosfemia, alteraciones óseas, ingesta de vitamina D, ingesta de calcio, tumores, acidosis renal tubular, endocrinopatías o situaiones de rápida reabsorción ósea como inmovilización o enfermedad de Paget. En ese momento fue acuñado el término de hipercalciuria idiopática (HI) para describir este grupo de enfermos

Tumoral calcinosis. Case report with treatment failure.

Periarticular calcifications are the hallmark of a rare entity: tumoral calcinosis. We have followed for 90 months a nine-year-old black girl with involvement of both shoulders. Seven initial local excisions of the mass on the right shoulder were attempted without complete removal and prompt recurrence after each attempt. The entire lesion on the right side, including a cutaneous ulceration, was managed by en masse surgical excision. Preoperative inpatient medical management in the form of low calcium and low phosphorus diet was unsuccessful. Postoperatively, she has remained free of ulceration; however, after two and a half years, the right mass has again increased in size with compression of the brachial plexus. This recurrence occurred despite strict dietary control starting immediately postoperatively. Although there are many advocates of surgical excision of these lesions and, more recently, several cases reported of successful medical management, we find that often a combination approach is necessary to effectively treat tumoral calcinosis and reduce the rate of recurrence.

[Phosphorus-calcium metabolism and dietetic correction of its disorders in chronic kidney diseases in children]. / Sostoianie fosforno-kal'tsievogo obmena i dieticheskaia korrektsiia ego narushenii pri khronicheskikh bolezniakh pochek u detei.

Ninety children with varying renal diseases were under observation. The investigations conducted have shown that disorders in phosphoric-calcium metabolism depend on the type, activity of chronic glomerulonephritis (CGN) and etiology of chronic renal insufficiency (CRI). Significant disorders in phosphoric-calcium metabolism were detected in patients with nephrotic and mixed types of CGN. Most manifest clinical and x-ray changes of the osseous system were observed in patients with CRI that developed as a result of the tubulointerstitial pathologic process. Low-phosphate diets with preset amounts of Ca and P were developed, composed of products with relatively low content of P, and of new dietetic products rich in Ca. The diets were used for correction of hyperphosphatemia in children with CGN and in those with CRI, simultaneously with drug therapy, to prevent or diminish disorders in phosphoric-calcium metabolism, and to reduce the risk of invalidism among children with chronic renal diseases.

Effect of thiazide on urinary calcium excretion and hematuria in children with postglomerular hematuria.

The effect of short term hydrochlorothiazide therapy on urinary calcium excretion was compared to that of low calcium and a combined low calcium and low sodium diet in 30 children with postglomerular hematuria. On basal conditions 9 children were normocalciuric, 11 had absorptive, 10 renal hypercalciuria. The effect of thiazide treatment on the haematuria was also evaluated. Thiazide revealed to be more effective in reducing calcium excretion than low calcium diet alone in all groups (p less than 0.001 in normocalciuria; p less than 0.01 in both hypercalciuric groups). Combined low calcium--low sodium diet and thiazide treatment were equally effective in reducing calcium excretion in the hypercalciuric groups. On the first 3 days of thiazide treatment a slight increase of hematuria was observed; in the following period a significant decrease in the occurrence (p less than 0.01 in both hypercalciuric groups) and degree (p less than 0.01 in absorptive; p less than 0.02 in renal hypercalciuria) of hematuria was noted. These data furnish further evidence on the relation of hypercalciuria and post-glomerular hematuria.

Tratamento da hiperabsorçäo intestinal de cálcio com farelo de arroz / Treatment of excessive intestinal calcium absorption with unprocessed bran

Foi avaliado o efeito do farelo de arroz a nível intestinal em sete crianças com hiperabsorçäo intestinal de cálcio. Este diagnóstico foi estabelecido através da prova de sobrecarga oral de cálcio. A idade dos pacientes variou de cinco a 13 anos, sendo quatro do sexo masculino e três do feminino. O farelo de arroz foi administrado oralmente, na dose de 10 a 20g/dia, durante dois meses. Observamos reduçäo significativa de 50% na excreçäo urinária de cálcio urinário após a administraçäo do farelo. Näo houve alteraçäo nos níveis plasmáticos de cálcio, magnésio ou creatinina. Näo foram observados efeitos colaterais importantes. O presente trabalho sugere que o farelo de arroz diminui a obsorçäo excessiva de cálcio a nível intestinal, reduzindo sua excreçäo urinária e, portanto, constitui alternativa no tratamento da hipercalciúria por hiperabsorçäo intestinal de cálcio

Critical role of oxalate restriction in association with calcium restriction to decrease the probability of being a stone former: insufficient effect in idiopathic hypercalciuria.

The probability of being a stone former (PSF) was calculated in 3 groups of idiopathic calcium stone formers [with normocalciuria (NC), dietary hypercalciuria (DH) and idiopathic hypercalciuria (IH)] in 4 conditions: while on a free diet; on a calcium- and oxalate-restricted diet during 4 days; after an oxalate load, while on a 1.5-gram calcium diet, and after an oxalate load while on a calcium-restricted diet. Combined calcium and oxalate restriction significantly decreased PSF only in NC and DH whereas the decrease was not significant in IH because of a concomitant significant increase in oxalate excretion. Increase of PSF with the oxalate load was significantly greater during a calcium-restricted diet than during the 1.5-gram calcium diet in all groups of patients (4, 6 and 12 times greater in NC, DH and IH, respectively). These data show the critical role of oxalate restriction when calcium is restricted in order to decrease the PSF. This combined restriction is however not sufficient in idiopathic hypercalciuric patients to decrease their PSF.

Idiopathic hypercalciuria: its control with unprocessed bran.

Eighty-four patients with idiopathic hypercalciuria were entered into a study of the effects of treatment with unprocessed bran. Of 72 patients with complete data available for analysis 62 (86%) had a significant reduction in urinary calcium excretion during bran treatment and 28 (39%) returned their calcium excretion to within the normal range. Unprocessed bran is therefore an effective means of reducing urinary calcium excretion in patients with idiopathic hypercalciuria.

[Idiopathic hypercalciuria: effects of acute phosphorus deficiency (author's transl)]. / Hypercalciurie idiopathique: effet d'une carence aiguë en phosphore.

Eleven patients with kidney stone disease and idiopathic hypercalciuria (urinary calcium above 4 mg/kg/j), without phosphorus renal leak and 6 control subjects have been put for 3 days on a diet containing 1 g calcium and 1 phosphorus daily (period A), and then for 4 days on a diet containing 1 g calcium, 450 mg phosphorus and 3 g aluminium hydroxyde daily (period B). During period A, no significant difference in blood calcium, phosphorus and magnesium, not in phosphaturia, rate of phosphorus reabsorption (RPR) and ratio maximum RPR/creatinine clearance was found between the two groups. After 2 days on a low phosphate diet (period B) the blood phosphorus decreased significantly in the hypercalciuric patients but not in the control subjects, thus revealing among the forme a latent abnormality in the retention of phosphates. This abnormality could play an important role in the pathogenesis of hypercalciuria.