Monograph: Calcium

 

 
 

Based on a systemic review of scientific literature edited and peer-reviewed by contributors to the Natural Standard Research Collaboration.

Calcium is the most abundant mineral in the human body and has several important functions. More than 99 percent of total body calcium is stored in the bones and teeth where it supports the structure. The remaining one percent is found throughout the body in blood, muscle and the intracellular fluid. Calcium is needed for muscle contraction, blood vessel constriction and relaxation, the secretion of hormones and enzymes and nervous system signaling. A constant level of calcium is maintained in body fluid and tissues so that these vital body processes function efficiently.

The body gets the calcium it needs in two ways. One method is dietary intake of calcium-rich foods including dairy products, which have the highest concentration per serving of highly absorbable calcium, and dark, leafy greens or dried beans, which have varying amounts of absorbable calcium. Calcium is an essential nutrient required in substantial amounts, but many diets are deficient in calcium.

The other way the body obtains calcium is by extracting it from bones. This happens when blood levels of calcium drop too low and dietary calcium is not sufficient. Ideally, the calcium that is taken from the bones will be replaced when calcium levels are replenished. However, simply eating more calcium-rich foods does not necessarily replace lost bone calcium, which leads to weakened bone structure.

Hypocalcemia is defined as a low level of calcium in the blood. Symptoms of this condition include sensations of tingling, numbness and muscle twitches. In severe cases, tetany (muscle spasms) may occur. Hypocalcemia is more likely to be due to a hormonal imbalance, which regulates calcium levels, rather than a dietary deficiency. Excess calcium in the blood may cause nausea, vomiting and calcium deposition in the heart and kidneys. This usually results from excessive doses of vitamin D and may be fatal in infants.

The Surgeon General’s 2004 report “Bone Health and Osteoporosis” stated that calcium has been singled out as a major public health concern today because it is critically important to bone health, and the average American consumes levels of calcium that are far below the amount suggested. Vitamin D is important for good bone health because it aids in the absorption and utilization of calcium. There is a high prevalence of vitamin D insufficiency in nursing home residents, hospitalized patients and adults with hip fractures.

Calcium supplements are widely used to reduce bone resorption in osteoporosis, and many studies support this use. Calcium supplementation is also used as an antacid, for building bone mineral density, for hyperphosphatemia, hypocalcemia, renal failure, magnesium toxicity, black widow spider bite, fracture prevention, gastrointestinal (GI) tract and colorectal cancer prevention, hypercalcemia, hypertension, lead toxicity, osteomalacia (bone softening)/rickets, postsurgical side effects (rectal epithelial hyperproliferation), preeclampsia, premenstrual syndrome (PMS), seizures, arrhythmias, bone diseases, breast cancer prevention, cardiovascular risk reduction, cystic fibrosis, endometrial cancer prevention, fall prevention, growth, childbirth (preterm birth prevention), circulation, hyperparathyroidism, mortality, muscle strength, myocardial infarction, osteoporosis (druginduced), ovarian cancer prevention, postnatal depression, type 2 diabetes, weight loss, cardiopulmonary resuscitation (CPR), and vaginal disorders. Calcium’s use for calcium channel blocker overdose is investigational.

Tradition/Theory

Bone density improvement (lactating women), cancer (carcinoma), cardiac arrest, dental hygiene, diarrhea, disease diagnosis (Zollinger-Ellison), female urinary incontinence, high cholesterol, intestinal disorders, ischemic stroke (prevention), leg cramps (pregnancy), medullary thyroid cancer (diagnosis), multiple sclerosis, neuromuscular blockade (antagonize), poisoning (yellow oleander), psoriasis, reducing fluoride levels (children), tumors (astrocytic glioma).

Dosing 

Adults (18 years and older) 

A good food source of calcium contains a substantial amount of calcium in relation to its calorie content and contributes at least 10 percent of the U.S. Recommended Dietary Allowance (RDA) for calcium in a selected serving size. The RDA for elemental calcium is 1,000 mg daily for adults (except pregnant or lactating women) and children over four years of age. Adequate intake (AI) recommendations published in August 1997 were set at 1,000 mg for men and women aged 19-50, and 1,200 mg for individuals older than age 70 and in postmenopausal women.

The dose, frequency, and duration of calcium used for any indication are dependent on individual requirements. The following amounts have been suggested for daily elemental calcium intake: 1,000 mg (19-50 years), 1,000 mg (51-70 years), and 1,200 mg (postmenopausal women or 71- plus years). In human study, oral calcium doses typically range from 200-3,500 mg daily. Many forms are available. Different conditions may require unique dosing and should be discussed with a qualified health care provider.

The dose, frequency, and duration of calcium gluconate used for any indication are dependent on individual requirements. According to the National Institutes of Health (NIH), the usual adult dose of calcium gluconate ranges from 5-20 ml given intravenously either directly or by infusion. Oral calcium phosphate has been used for oral mucositis (mouth ulcers/irritation).

Children (under 18 years old) 

The dose, frequency, and duration of calcium gluconate used for any indication is dependent on individual requirements. The following amounts have been suggested for daily calcium intake: 200 mg (0-6 months), 260 mg (7-12 months), 700 mg (1-3 years), 1,000 mg (4-8 years), 1,300 mg (9-13 years) and 1,300 mg (14-18 years). Special dosing may be suggested by a qualified healthcare provider for certain indications. In very low birth weight infants, high calcium diets may require greater phosphorus intake, with an optimal calcium: phosphorus mass ratio of 1.6:1 to 1.8:1. 

The daily tolerable upper intake level (UL) by age is 0-6 months, 1,000 mg; 6-12 months, 1,500 mg; 1-3 years, 2,500 mg; 9- 18 years, 3,000 mg; 19-50 years, 2,500 mg; 51-plus years, 2,000 mg.

The dose, frequency, and duration of calcium gluconate used for any indication is dependent on individual requirements. According to NIH, the usual dose of calcium gluconate in children ranges from 2-5 ml given intravenously either directly or by infusion. For infants, the dose is not to exceed 2 ml.

Safety 

Allergies 

Avoid in individuals with a known allergy/ hypersensitivity to calcium supplements or any of their ingredients. Dairy products contain lactose and dairy products are a common food source of calcium, but some people are lactose intolerant. Lactose intolerance may cause cramping, bloating, gas, and diarrhea. Lactose intolerance affects the population in varying degrees.

Avoid calcium supplementation in those who are very sensitive to any component of a calcium-containing supplement, or who have hypercalcemia (high levels of calcium in the blood). Conditions causing hypercalcemia include sarcoidosis (inflammation in the lymph nodes and other organs), hyperparathyroidism (high levels of parathyroid hormone), and hypervitaminosis D (high levels of vitamin D).

Side Effects and Warnings 

Calcium supplementation is likely safe when used orally and intravenously, as suggested by a qualified healthcare professional. It is also likely safe when used orally and appropriately in pregnancy and lactation, as suggested by a qualified healthcare professional. Routine dietary intake and supplementation in suggested doses are not associated with significant adverse effects.

Excretion of abnormally large amounts of calcium in the urine is a well-established side effect of administration.

Low levels of calcium in the blood and tissues may cause sensations of tingling, numbness, muscle twitches and muscle spasms (tetany). This condition is more likely to be due to a hormonal imbalance in the regulation of calcium rather than a dietary deficiency.

Excess calcium in the blood may be without symptoms or it may cause loss of appetite, nausea, vomiting, constipation, abdominal pain, dry mouth, thirst, frequent urination and calcium deposition in the heart and kidneys. More severe hypercalcemia may result in confusion, delirium, coma, and if not treated, death. Hypercalcemia has been reported only with the consumption of large quantities of calcium supplements usually in combination with antacids, particularly in the past when peptic ulcers were treated with large quantities of milk, calcium carbonate (antacid) and sodium bicarbonate (absorbable alkali).

Use cautiously in those with achlorhydria (absence of hydrochloric acid or Hcl in gastric juices) as low levels of gastric acid during digestion reduces urinary phosphate and calcium excretion. It may be advisable to take calcium carbonate with food to stimulate gastric acid production. Consult a qualified healthcare provider.

Use cautiously if taking large amounts of vitamin D. Excess calcium in the blood (hypercalcemia) may cause nausea, vomiting, and calcium deposition in the heart and kidneys. This usually results from excessive doses of vitamin D and may be fatal in infants. Consult a qualified healthcare provider.

Use cautiously when used with antiarrhythmics, antidiabetics, antihypertensives, antilipemics, bisphosphonates, calcium channel blockers, calcipotriene, Dovonex, tetracycline, fluoroquinolones, gentamicin, quinolones, diuretics, gadoversetamide, H2 antagonists, magnesium, inositol hexaphosphate, phytic acid, iron salts, lithium, Orlistat, Xenical, oxalic acid, parathyroid agents, cinacalcet, potassium, sodium alginate, zinc, calcium carbonate and tribasic calcium phosphate tablets, large amounts of vitamin D, anticonvulsants, with aluminum and magnesium-containing antacids, and in those with hypothyroidism or taking thyroxine, in postmenopausal women due to an increased possibility of cardiovascular side effects, and in those prone to the formation of calcium-containing kidney stones, and in patients with hyperphosphatemia or hypophosphatemia.

Use cautiously in individuals with heart arrhythmias and ventricular fibrillation (irregular heart beating). Large fluctuations in free calcium during intravenous calcium infusion may cause the heart to slow down or beat too rapidly. Although calcium appears to have benefits on bone density and osteoporosis, calcium should be used cautiously in postmenopausal women due to an increased possibility of cardiovascular side effects. Consult a qualified healthcare provider.

Avoid calcium supplements made from dolomite, oyster shells, or bone meal, because such compounds may contain unacceptable levels of lead.

Avoid high doses of calcium without food in those who are prone to the formation of calcium-containing kidney stones, as calcium supplementation in the absence of food may be associated with an increased risk of calcium oxalate stone formation. Consult a qualified health care professional if you are prone to kidney stones before using calcium supplements.

Avoid cigarette smoking, as this decreases intestinal calcium absorption and may lead to decreased bone mineral density.

Avoid in excess: the daily tolerable UL by age is 0-6 months, 1,000 mg; 6-12 months, 1,500 mg; 1-3 years, 2,500 mg; 9- 18 years, 3,000 mg; 19-50 years, 2,500 mg; 51-plus years, 2,000 mg. In patients using sodium polystyrene sulfonate; with digoxin (i.e., digitalis) toxicity or using digoxin. With hypercalcemia, hypercalciuria, hyperparathyroidism, bone tumors, and sarcoidosis; in chronic renal failure patients, especially in those taking aluminum-containing agents. In patients using ceftriaxone. Calcium supplements made from dolomite, oyster shells, or bone meal due to possible lead toxicity.

Pregnancy & Breast Feeding

The Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food, and Nutrition Board suggests that current calcium recommendations for non-pregnant women are also sufficient for pregnant women, because intestinal calcium absorption increases during pregnancy.

Pregnant women are especially vulnerable to accelerated bone turnover due to the physiologic stress of pregnancy and lactation. Studies indicate that pregnant women should take calcium supplements to prevent bone density loss. The National Academy of Sciences suggests that women who are pregnant or breastfeeding consume calcium each day. For pregnant teens, the suggested intake is higher.

Consult a qualified healthcare professional to determine dosing during pregnancy and breastfeeding.

Interactions 

Interactions with Drugs 

Intestinal aluminum absorption is increased in healthy and kidney failure patients taking even small amounts of calcium citrate. As a result, all citrate-containing preparations are contraindicated in chronic renal failure patients taking aluminum- containing compounds.

Seizure medications may decrease calcium absorption by increasing the metabolism of vitamin D. Taking seizure medications may lead to hypocalcemia (low blood calcium) and softening of the bones (osteomalacia).

Intake of a bisphosphonate and calcium may decrease the absorption of the bisphosphonate. Patients should take bisphosphonates at least 30 minutes before calcium. Optimally, the two would be consumed at different times of the day.

Caffeine may increase urinary calcium excretion and has been implicated in osteoporosis; however, research is still conflicting. Caffeine has a small effect on calcium absorption.

Calcitriol is a form of vitamin D that is used to treat and prevent low levels of calcium in the blood of patients whose kidneys or parathyroid glands (glands in the neck that release natural substances to control the amount of calcium in the blood) are not working normally.

When given intravenously, calcium may reverse the effects of calcium channel blockers (commonly used for high blood pressure). Calcium channel blockers include: nifedipine (Adalat, Procardia), verapamil (Calan, Isopin, Verelan), diltiazem (Cardizem), isradipine (DynaCirc), felodipine (Plendil) and amlodipine (Norvasc).

Cholestyramine (commonly used for high cholesterol) may reduce the absorption of vitamin D, which, in turn, reduces the absorption of calcium.

Corticosteroids (commonly used for inflammation) may cause significant bone loss (osteoporosis) if the suggested level of calcium and vitamin D intake is not met.

Calcium levels should be monitored if taking the heart rhythm medication digoxin due to the potential for interaction with high blood levels of calcium and the need for adequate blood levels of calcium. Patients taking digoxin should consult with a qualified healthcare professional before using calcium supplements.

Alcohol may affect calcium status by reducing the intestinal absorption of calcium. It may also inhibit enzymes in the liver that help convert vitamin D to its active form, which in turn reduces calcium absorption. However, the amount of alcohol required to affect calcium absorption is unknown. Evidence is currently conflicting on whether moderate alcohol consumption is helpful or harmful to bone.

Fluroquinolone antibiotics form complexes with calcium in the Gl tract, which may lead to reduced absorption of both if taken at the same time.

Use of histamine-2 (H2) blockers (like ranitidine commonly used to treat acid reflux) at the same time as calcium carbonate or calcium phosphate may interfere with the absorption of these calcium salts.

Hormone replacement therapy (HRT) alone may be associated with a fall in calcium absorption efficiency. However, the bone-preserving effects of estrogen treatment are increased by calcium supplementation. Estrogen increases supplemental calcium absorption in postmenopausal women.

Use of inositol hexaphosphate (phytic acid) and calcium may decrease the absorption of calcium.

Mineral oil or stimulant laxatives (cascara, senna, and bisacodyl), when used for prolonged periods, may reduce dietary calcium and vitamin D absorption often causing osteomalacia (bone softening).

Intake of levothyroxine (synthroid, levothroid, levoxyl) at the same time as calcium carbonate has been found to reduce levothyroxine absorption and to increase serum thyrotropin levels. Levothyroxine may adsorb (stick) to calcium carbonate in an acidic environment, which may block its absorption.

Loop diuretics, including furosemide (Lasix), bumetanide (Bumex), ethacrynic acid (Edecrin), and torsemide (Demadex), at high doses, may reduce serum calcium levels because they increase urinary calcium excretion.

Orlistat (Xenical, Alli) has been shown to induce a relative increase in bone turnover (increased resorption or bone loss), which may be due to the malabsorption of vitamin D and/or calcium.

The effect of dietary phosphorus on calcium is minimal. Some researchers speculate that the detrimental effects of consuming foods high in phosphate such as carbonated soft drinks is due to the replacement of milk with soda rather than the phosphate level itself. Calcium may decrease the absorption of phosphate supplements.

Increasing dietary potassium intake in the presence of a low sodium diet may help decrease calcium excretion particularly in postmenopausal women.

Use of proton pump inhibitors (like esomeprazole used to treat ulcers) and calcium carbonate or calcium phosphate at the same time may cause decreased absorption of these calcium salts.

Typically, dietary sodium and protein increase calcium excretion as their intake is increased. However, if a high protein, high sodium food also contains calcium, this may help counteract the loss of calcium.

Calcium may form complexes with sotalol (a beta-blocker drug used to treat irregular heartbeats), reducing its absorption. A physician should be contacted in order to determine optimal timing of doses. Patients taking sotalol should consult a qualified health care professional before using calcium supplements.

Intake of a tetracycline antibiotic and calcium may decrease the absorption of the tetracycline, including doxycycline, minocycline, and tetracycline. Two to four hours between tetracyclines and calcium supplements should be allowed.

Thiazides are diuretics that reduce calcium excretion by the kidneys. These diuretics include: chlorothiazide (Diuril), hydrochlorothiazide (HydroDIURIL, Esidrix), indapamide (Lozol), metolazone (Zaroxolyn), and chlorthalidone (Hygroton).

Other agents with which calcium may interact: alendronate, antacids, anticoagulants, antidiabetics, antidotes, antihypertensives, calcium salts, ceftriaxone, dovonex, fluoride, gadoversetamide, gentamicin, heart rate-regulating agents, heavy metal antagonists/chelating agents, iron salts, lithium, magnesium, orlistat, oxalic acid, parathyroid agents, potassium salts, propionate, quinolones, and uronic acid.

Interactions with Herbs and Dietary Supplements 

Calcium carbonate and aluminum hydroxide taken together have produced a significant rise in serum and urine aluminum levels.

Combined use of inositol hexaphosphate (phytic acid) and calcium may decrease the absorption of calcium.

Stimulant laxatives (cascara, senna, and bisacodyl) when used for prolonged periods may reduce dietary calcium and vitamin D absorption often causing osteomalacia (bone softening).

Combining calcium salts may increase absorption or alter efficacy.

Large doses of magnesium salts may cause hypocalcemia (low levels of blood calcium). Oral magnesium supplements do not affect calcium absorption.

Caffeine may increase urinary calcium excretion and has been implicated in osteoporosis; however, research is still conflicting. Caffeine has a small effect on calcium absorption.

Herbs with diuretic properties may reduce serum calcium levels by increasing urinary calcium excretion.

Herbs with estrogenic properties may increase supplemental calcium absorption in postmenopausal women.

Increasing dietary potassium intake in the presence of a low sodium diet may help decrease calcium excretion particularly in postmenopausal women.

Typically, dietary sodium and protein increase calcium excretion as their intake is increased. However, if a high protein, high sodium food also contains calcium, this may help counteract the loss of calcium.

Combined use of iron and calcium may not inhibit the absorption of iron over long periods of time. Combined use of fluoride, magnesium, or zinc and calcium may decrease the absorption of these minerals. However, these possible mineral interactions have not been shown to be of clinical significance.

Mineral oil may interfere with calcium utilization and retention by reducing the absorption of calcium and vitamin D. 

Combined use of nondigestible fructooligosaccharides or inulin and calcium may increase the absorption of calcium in the colon.

Calcium taken orally may bind with phosphate in the gut, preventing its absorption and reducing the hyperphosphatemia (high levels of phosphate in the blood) associated with renal failure. Calcium carbonate or calcium acetate is used for this purpose, whereas calcium citrate is not suggested, because it increases aluminum absorption.

While the effects of high phosphorus intakes on calcium balance and bone health are presently unclear, the substitution of large quantities of soft drinks for milk or other sources of dietary calcium is cause for concern with respect to bone health in adolescents and adults. The effect of dietary phosphorus on calcium is minimal.

Reports show that increased sodium intake results in increased loss of calcium in the urine suggesting that an effect of reducing bone loss by increasing calcium supplementation may also be achieved by halving daily sodium excretion. Intake of sodium alginate and calcium may decrease the absorption of calcium.

Excessive vitamin A use has also been found to alter bone turnover. Too much preformed vitamin A may promote fractures. Avoid vitamin supplements that have large amounts of vitamin A as preformed vitamin A, unless prescribed by a doctor. Vitamin A in the form of beta-carotene does not appear to increase one’s fracture risk.

Use of vitamin D and calcium increases the absorption of calcium. Vitamin D is important and suggested for optimal calcium absorption.

Use cautiously with alcohol, antacids, antiarrhythmics, anticoagulants, anticonvulsants, antilipemics, digoxin, drynol cibotin, hypoglycemics, hypotensives, laxatives, oxalic acid, probiotics, soy, or uronic acid.

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1164. Bijlsma, J. W., Raymakers, J. A., Mosch, C., Hoekstra, A., Derksen, R. H., Baart, de la Faille, and Duursma, S. A. Effect of oral calcium and vitamin D on glucocorticoid-induced osteopenia. Clin Exp.Rheumatol. 1988;6(2):113-119. View Abstract
1165. Bijlsma, J. W., Raymakers, J. A., Mosch, C., Hoekstra, A., Derksen, R. H., Baart, de la Faille, and Duursma, S. A. Effect of oral calcium and vitamin D on glucocorticoid-induced osteopenia. Clin Exp.Rheumatol. 1988;6(2):113-119.
1166. Emkey R, Shen V, Lyssy J, and et al. A prospective, randomized study of vitamin D and calcium in the treatment of steroid induced osteoporosis in patients with rheumatoid arthritis [abstract]. Arthritis Rheum 1994;37(9):S183.
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1168. Reginster, J. Y., Kuntz, D., Verdickt, W., Wouters, M., Guillevin, L., Menkes, C. J., and Nielsen, K. Prophylactic use of alfacalcidol in corticosteroid-induced osteoporosis. Osteoporos.Int 1999;9(1):75-81. View Abstract
1169. Healey, J. H., Paget, S. A., Williams-Russo, P., Szatrowski, T. P., Schneider, R., Spiera, H., Mitnick, H., Ales, K., and Schwartzberg, P. A randomized controlled trial of salmon calcitonin to prevent bone loss in corticosteroid-treated temporal arteritis and polymyalgia rheumatica. Calcif Tissue Int 1996;58(2):73-80. View Abstract
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1174. Reid, I. R., King, A. R., Alexander, C. J., and Ibbertson, H. K. Prevention of steroid-induced osteoporosis with (3-amino-1-hydroxypropylidene)-1,1-bisphosphonate (APD). Lancet 1-23-1988;1(8578):143-146. View Abstract
1175. Rizzato, G., Tosi, G., Schiraldi, G., Montemurro, L., Zanni, D., and Sisti, S. Bone protection with salmon calcitonin (sCT) in the long-term steroid therapy of chronic sarcoidosis. Sarcoidosis. 1988;5(2):99-103. View Abstract
1176. Guaydier-Souquieres, G., Kotzki, P. O., Sabatier, J. P., Basse-Cathalinat, B., and Loeb, G. In corticosteroid-treated respiratory diseases, monofluorophosphate increases lumbar bone density: a double-masked randomized study. Osteoporos.Int 1996;6(2):171-177. View Abstract
1177. Rizzoli, R., Chevalley, T., Slosman, D. O., and Bonjour, J. P. Sodium monofluorophosphate increases vertebral bone mineral density in patients with corticosteroid-induced osteoporosis. Osteoporos.Int 1995;5(1):39-46. View Abstract
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1179. Garcia-Delgado, I., Prieto, S., Gil-Fraguas, L., Robles, E., Rufilanchas, J. J., and Hawkins, F. Calcitonin, etidronate, and calcidiol treatment in bone loss after cardiac transplantation. Calcif Tissue Int 1997;60(2):155-159. View Abstract
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1182. Kotaniemi, A., Piirainen, H., Paimela, L., Leirisalo-Repo, M., Uoti-Reilama, K., Lahdentausta, P., Ruotsalainen, P., Kataja, M., Vaisanen, E., and Kurki, P. Is continuous intranasal salmon calcitonin effective in treating axial bone loss in patients with active rheumatoid arthritis receiving low dose glucocorticoid therapy? J Rheumatol. 1996;23(11):1875-1879. View Abstract
1183. Adachi, J. D., Bensen, W. G., Bell, M. J., Bianchi, F. A., Cividino, A. A., Craig, G. L., Sturtridge, W. C., Sebaldt, R. J., Steele, M., Gordon, M., Themeles, E., Tugwell, P., Roberts, R., and Gent, M. Salmon calcitonin nasal spray in the prevention of corticosteroid-induced osteoporosis. Br.J Rheumatol. 1997;36(2):255-259. View Abstract
1184. Jenkins, E. A., Walker-Bone, K. E., Wood, A., McCrae, F. C., Cooper, C., and Cawley, M. I. The prevention of corticosteroid-induced bone loss with intermittent cyclical etidronate. Scand.J Rheumatol. 1999;28(3):152-156. View Abstract
1185. Adachi, J. D., Bensen, W. G., Brown, J., Hanley, D., Hodsman, A., Josse, R., Kendler, D. L., Lentle, B., Olszynski, W., Ste-Marie, L. G., Tenenhouse, A., and Chines, A. A. Intermittent etidronate therapy to prevent corticosteroid-induced osteoporosis. N.Engl.J Med. 8-7-1997;337(6):382-387. View Abstract
1186. Saag, K. G., Emkey, R., Schnitzer, T. J., Brown, J. P., Hawkins, F., Goemaere, S., Thamsborg, G., Liberman, U. A., Delmas, P. D., Malice, M. P., Czachur, M., and Daifotis, A. G. Alendronate for the prevention and treatment of glucocorticoid-induced osteoporosis. Glucocorticoid-Induced Osteoporosis Intervention Study Group. N.Engl.J Med. 7-30-1998;339(5):292-299. View Abstract
1187. Saag, K. G., Emkey, R., Schnitzer, T. J., Brown, J. P., Hawkins, F., Goemaere, S., Thamsborg, G., Liberman, U. A., Delmas, P. D., Malice, M. P., Czachur, M., and Daifotis, A. G. Alendronate for the prevention and treatment of glucocorticoid-induced osteoporosis. Glucocorticoid-Induced Osteoporosis Intervention Study Group. N.Engl.J Med. 7-30-1998;339(5):292-299.
1188. Wolfhagen, F. H., van Buuren, H. R., den Ouden, J. W., Hop, W. C., van Leeuwen, J. P., Schalm, S. W., and Pols, H. A. Cyclical etidronate in the prevention of bone loss in corticosteroid-treated primary biliary cirrhosis. A prospective, controlled pilot study. J Hepatol. 1997;26(2):325-330. View Abstract
1189. Boutsen, Y., Jamart, J., Esselinckx, W., Stoffel, M., and Devogelaer, J. P. Primary prevention of glucocorticoid-induced osteoporosis with intermittent intravenous pamidronate: a randomized trial. Calcif Tissue Int 1997;61(4):266-271. View Abstract
1190. Geusens, P., Dequeker, J., Vanhoof, J., Stalmans, R., Boonen, S., Joly, J., Nijs, J., and Raus, J. Cyclical etidronate increases bone density in the spine and hip of postmenopausal women receiving long term corticosteroid treatment. A double blind, randomised placebo controlled study. Ann.Rheum Dis. 1998;57(12):724-727. View Abstract
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1199. Henderson, K., Eisman, J., Keogh, A., MacDonald, P., Glanville, A., Spratt, P., and Sambrook, P. Protective effect of short-tem calcitriol or cyclical etidronate on bone loss after cardiac or lung transplantation. J Bone Miner Res 2001;16(3):565-571. View Abstract
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1224. Welberg, J. W., Monkelbaan, J. F., De Vries, E. G., Muskiet, F. A., Cats, A., Oremus, E. T., Boersma-van, Ek W., van, Rijsbergen H., Van der Meer, R., Mulder, N. H., and . Effects of supplemental dietary calcium on quantitative and qualitative fecal fat excretion in man. Ann.Nutr.Metab 1994;38(4):185-191. View Abstract
1225. Jacobsen, R., Lorenzen, J. K., Toubro, S., Krog-Mikkelsen, I., and Astrup, A. Effect of short-term high dietary calcium intake on 24-h energy expenditure, fat oxidation, and fecal fat excretion. Int.J Obes.(Lond.) 2005;29(3):292-301. View Abstract
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1234. Bowen, J., Noakes, M., and Clifton, P. M. A high dairy protein, high-calcium diet minimizes bone turnover in overweight adults during weight loss. J Nutr. 2004;134(3):568-573. View Abstract
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1237. Neumar, R. W., Otto, C. W., Link, M. S., Kronick, S. L., Shuster, M., Callaway, C. W., Kudenchuk, P. J., Ornato, J. P., McNally, B., Silvers, S. M., Passman, R. S., White, R. D., Hess, E. P., Tang, W., Davis, D., Sinz, E., and Morrison, L. J. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 11-2-2010;122(18 Suppl 3):S729-S767. View Abstract
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1246. Checa, M. A., Garrido, A., Prat, M., Conangla, M., Rueda, C., and Carreras, R. A comparison of raloxifene and calcium plus vitamin D on vaginal atrophy after discontinuation of long-standing postmenopausal hormone therapy in osteoporotic women. A randomized, masked-evaluator, one-year, prospective study. Maturitas 9-16-2005;52(1):70-77. View Abstract
1247. Mize, C. E., Uauy, R., Waidelich, D., Neylan, M. J., and Jacobs, J. Effect of phosphorus supply on mineral balance at high calcium intakes in very low birth weight infants. Am J Clin Nutr 1995;62(2):385-391. View Abstract

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