THE CORRELATION BETWEEN OSTEOPOROSIS AND CALCIUM INTAKE

AMONG 50 YEARS OLD WOMEN IN WEST JAKARTA IN 2008

UNIVERSITY OF TRISAKTI, JAKARTA

NAME : MOHD ASHAF BIN AMAT KHAINAN NIM : 03007299

PREFACE AND ACKNOWLEDGMENT

Alhamdulillah. Thanks to God, that has given me a chance to finish my work. Maybe its not the first time I need to make my own paper about any topic. So,this is a good time to learn something from the topics,about osteoporosis and calsium intake ans also its relationship between each other. In the aother hand, thia task make me understand to learn from any source around me and my effort to finish the task. First of all, I would like to thanks especially Mr. Husni nd Mdm. Fatmi that have given me this kind of opportunity to make my own paper. Also, to all my friends, for their support and encouragement that they have provided. In creating this kind of paper, it is important to achieve a happy medium between complexity and simplication. I need to come out everything I know about the topics and need to search every source especially through the internet, the main source for seeking the information. Finally, I hope that everyone will find all the information that I have gathered in this paper and I do wonder what their comments might have been abut this paper. So, I hope you will enjoy reading my paper and understand the important of knwoledge. Thank you.

Mohd Ashaf Bin Amat Khainan.

CONTENTS
Preface and acknwoledgement i. ii. iii. Introduction Background Problems Limitations of problems Objective Methode of writing Frame of writing Part 1 : Osteoporosis Definitions Etiology Epidemiology Symptoms Factors Complications Diagnosis Treatment and medication Preventions Part 3 : Calcium Intake Calcium : what it is? What is the recommended intake for calcium? What Are the Important Cofactors for Achieving Optimal Calcium Intake? iv. v. vi. What foods provide calcium? Part 4: Correlation between osteoporosis and calcium intake Part 5: Conclusion Bibliography 21-22 22-24 25-28 29 30 19 19-21 8 9 10-11 11 12 13 13 14-15 16-18 4-7

PART 1 : Introduction
1) Background.

Bones are rigid organs that form part of the endoskeleton of vertebrates. They function to move, support, and protect the various organs of the body, produce red and white blood cells and store minerals. Because bones come in a variety of shapes and have a complex internal and external structure, they are lightweight, yet strong and hard, in addition to fulfilling their many other functions. One of the types of tissues that makes up bone is the mineralized osseous tissue, also called bone tissue, that gives it rigidity and honeycomb-like three-dimensional internal structure. Other types of tissue found in bones include marrow, endosteum and periosteum, nerves, blood vessels and cartilage. There are 206 bones in the adult human body. The primary tissue of bone, osseous tissue, is a relatively hard and lightweight composite material, formed mostly of calcium phosphate in the chemical arrangement termed calcium hydroxylapatite (this is the osseous tissue that gives bones their rigidity). It has relatively high compressive strength but poor tensile strength, meaning it resists pushing forces well, but not pulling forces. While bone is essentially brittle, it does have a significant degree of elasticity, contributed chiefly by collagen. All bones consist of living cells embedded in the mineralized organic matrix that makes up the osseous tissue. For the calcium, You have more calcium in your body than any other mineral. Calcium has many important jobs. The body stores more than 99 percent of its calcium in the bones and teeth to help make and keep them strong. The rest is throughout the body in blood, muscle and the fluid between cells. Your body needs calcium to help muscles and blood vessels contract and expand, to secrete hormones and enzymes and to send messages through the nervous system. It is important to get plenty of calcium in the foods you eat. Foods rich in calcium include diary products such as milk, cheese and yogurt, and leafy, green vegetables. The exact amount of calcium you need depends on your age and other factors. Growing children and teenagers need more calcium than young adults. Older women need plenty of calcium to prevent osteoporosis. People who do not eat enough high-calcium foods should take a calcium supplement.

2) Problems. Your bones help you move, give you shape and support your body. They are living tissues that rebuild constantly throughout your life. During childhood and your teens, your body adds new bone faster than it removes old bone. After about age 20, you can lose bone faster than you make bone. To have strong bones when you are young, and to prevent bone loss when you are older, you need to get enough calcium, vitamin D and exercise. There are many kinds of bone problems: Osteoporosis makes your bones weak and more likely to break Osteogenesis imperfecta makes your bones brittle Paget's disease of bone makes them weak Bone disease can make bones easy to break Bones can also develop cancer Other bone diseases are caused by poor nutrition, genetic factors or problems with the rate of bone growth or rebuilding So, the structure of the bones somehow are connected with the calcium intake. Futhermore, it related to one of the bones disease, osteoporosis. For this paper, the bones disease that will be discuss are about osteoporosis and its correlatin with calcium intake among 50 years old women in West Jakarta in 2008 3) Limitation of problems. In this paper , I will be discuss the topics according to a few aspects: I. II. III. IV. V. VI. VII. VIII. IX. What is the definition? What is the etiology? What is the epidemiology? What are the symptoms? What are the factors? What are the complications? How to diagnose? What are the treatments and medications? What are the preventions?

4) Objective. The main objective is to reveal the correlation and relationship between osteoporosis and calcium intake. Furthemore, the other objectives are to know facts about osteoporosis, one of the silent disease especially among women after menapouse and the effects of calcium intake towards the disease. So that, people will more understand the real situation about the disease and how to protect themselves from being infected.

5) Method of writing. The method that being used in this paper are searched and gathered all the information from the internet, rewrite and choose the best informations that related to the topics. The informations that have been choosed will be put according its subtopics and the paper structures.

6) Frame of writing Preface and acknolegment Part 1 : Introduction Background Problems Limitation of problems Objective Methode of writing Frame of writing

Part 2: Osteoporosis Definition Etiology Epidemiology Symptoms Factors Diagnosis Treatment and medication preventions

Part 3 : Calcium Intake Part 4 : Correlations Between Osteoporosis and Calcium Intake Part 5 : Conclusion

PART 2 : OSTEOPOROSIS

a. Definition

A disease in which bones become fragile and more likely to break. If not prevented or if left untreated, osteoporosis can progress painlessly until a bone breaks. These broken bones, also known as fractures, occur typically in the hip, spine, and wrist.

A condition characterized by the loss of the normal density of bone, resulting in fragile bone. Osteoporosis leads to literally abnormally porous bone that is more compressible like a sponge, than dense like a brick. This disorder of the skeleton weakens the bone causing an increase in the risk for breaking bones (bone fracture).

Normal bone is composed of protein, collagen, and calcium all of which give bone its strength. Bones that are affected by osteoporosis can break (fracture) with relatively minor injury that normally would not cause a bone fracture. The fracture can be either in the form of cracking (as in a hip fracture), or collapsing (as in a compression fracture of the vertebrae of the spine). The spine, hips, and wrists are common areas of bone fractures from osteoporosis, although osteoporosis-related fractures can also occur in almost any skeletal bone.

b. Etiology

The accepted etiology of osteoporosis is related to sex hormone deficiency in menopause and andropause, suboptimal calcium and vitamin D nutrition, and lack of exercise. However, in spite of massive efforts over several decades, osteoporosis continues to remain an enormous clinical problem. The mechanisms through which hormone deficiency facilitates bone osteoporosis remain controversial.

According to Dr. Susan Brown of the Osteoporosis Education Project, osteoporosis can be seen as a consequence of chronic metabolic acidosis, which robs us of our mineral reserves and impairs efforts to rebuild the bone matrix. She holds that the excess acid load promoting metabolic acidosis is acquired by: dietary choices (excess protein, fat, phosphate/phosphoric acid and sulfate/sulfuric acid); maladaptation to stress (distress-induced excess cortisol and adrenaline); immune hypersensitivity (delayed allergy) reactions

Osteoporosis occurs in women and men because of decreased formation of bone and decreased renal production of 1,25(OH)2 D3 occurring late in life. The consequence is a loss of cortical and trabecular bone and increased risk for fractures of the hip, long bones, and vertebrae.

Osteoporosis occurs secondary to medications, especially glucocorticoids, or other conditions that cause increased bone loss by various mechanisms.

c. Epidemiology

In the United States, more than 28 million people are affected. The major clinical consequence of osteoporosis is a greatly increased risk of fracture. Osteoporosis predisposes the population to 1.5 million fractures yearly (including 700,000 vertebral fractures; 250,000 hip fractures; and 250,000 wrist fractures [Riggs and Melton, 1995])

NHANES III was a 6-year study (1988-1994) divided into two phases: Phase 1 (1988-1991) and Phase 2 (1991-1994). Bone mineral measurements were performed on 14,646 men and women ages 20 and older in the full survey over the 6-year period. The population of men and women was categorized into three ethnic groups: nonhispanic white (NHW), nonhispanic black (NHB), and Mexican American (MA).

Estimates of the number of older men and women (ages 50 and older) in the United States with low bone density at the hip (osteopenia and osteoporosis) were made using dual energy X-ray absorptiometry (DXA) measurements gathered in both Phases 1 and 2 of NHANES III.

Using data from Phase 1 of NHANES III, the National Osteoporosis Foundation (NOF) estimated that about 8 million women and 2 million men have osteoporosis. Moreover, nearly 16 million women and 3 million men have osteopenia and are at increased risk for developing osteoporosis and osteoporotic fracture.

Using data from Phases 1 and 2 of NHANES III, the NOF published in the Physicians Guide to Prevention and Treatment of Osteoporosis that 13-18% (4-6 million) of postmenopausal American women have osteoporosis and an additional 37-50% (13-17 million) of women have low bone density at the hip.

Another analysis of NHANES III Phase 1 data, using a different cutoff for the definition of osteoporosis, provided estimates of the number of women ages 50 and older with osteoporosis (BMD more than 2 SD below the young adult mean). Using this cutoff, 14 million women in the United States have osteoporosis and an additional 12 million have low bone mass.

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In the United States, osteoporosis causes a predisposition to more than 250,000 hip fractures yearly [Ray et al., 1997]. It is estimated that a 50-year-old white woman has a 17.5% lifetime risk of fracture of the proximal femur [Melton et al., 1992]. The incidence of hip fractures increases each decade from the sixth through the ninth for both women and men for all populations. The highest incidence is found among those men and women ages 80 or older [Melton et al., 1992].

d. Symptoms The osteoporosis condition can be present without any symptoms for decades, because osteoporosis doesn't cause symptoms unless bone fractures. Some osteoporosis fractures may escape detection until years later.Therefore, patients may not be aware of their osteoporosis until they suffer a painful fracture. Then the symptoms are related to the location of the fractures. But once bones have been weakened by osteoporosis, you may have osteoporosis symptoms that include: Back pain, which can be severe if you have a fractured or collapsed vertebra Loss of height over time, with an accompanying stooped posture Fracture of the vertebrae, wrists, hips or other bones

Up to 30% of patients suffering a hip fracture will require long term nursing home care. Elderly patients can further develop pneumonia and blood clots in the leg veins that can travel to the lungs (pulmonary embolism) due to prolonged bed rest after a hip fracture.

Some 20% of women with a hip fracture will die in the subsequent year as an indirect result of the fracture. In addition, once a person has experienced a spine fracture due to osteoporosis, he or she is at very high risk of suffering another such fracture in the near future (next few years).

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e. Factors

Osteoporosis makes your bones weak and more likely to break. Anyone can develop osteoporosis, but it is common in older women. As many as half of all women and a quarter of men older than 50 will break a bone due to osteoporosis.

Risk factors include : Getting older -The older you get, the higher your risk of osteoporosis. Your bones become weaker as you age. Being small and thin -Men and women who are exceptionally thin or have small body frames tend to have higher risk because they may have less bone mass to draw from as they age. Having a family history of osteoporosis-Osteoporosis runs in families. For that reason, having a parent or sibling with osteoporosis puts you at greater risk, especially if you also have a family history of fractures. Taking certain medicines-Long-term use of the blood-thinning medication heparin, the cancer treatment drug methotrexate, some anti-seizure medications, diuretics and aluminum-containing antacids also can cause bone loss. Being a white or Asian woman-You're at greatest risk of osteoporosis if you're white or of Southeast Asian descent. Black and Hispanic men and women have a lower, but still significant, risk. Having osteopenia, which is low bone mass Eating disorders- Women and men with anorexia nervosa or bulimia are at higher risk of lower bone density in their lower backs and hips.
Low calcium intake-A lifelong lack of calcium plays a major role in the development of osteoporosis. Low calcium intake contributes to poor bone density, early bone loss and an increased risk of fractures.

Breast cancer- Postmenopausal women who have had breast cancer are at increased risk of osteoporosis, especially if they were treated with chemotherapy or aromatase inhibitors such as anastrozole and letrozole, which suppress estrogen. This isn't true for women treated with tamoxifen, which may reduce the risk of fractures.

Osteoporosis is a silent disease. You might not know you have it until you break a bone. A bone mineral density test is the best way to check your bone health. To keep bones strong,
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eat a diet rich in calcium and vitamin D, exercise and do not smoke. If needed, medicines can also help. (National Institute of Arthritis and Musculoskeletal and Skin Diseases)

f. Complication Fractures are the most frequent and serious complication of osteoporosis. They often occur in your spine or hips bones that directly support your weight. Hip fractures usually result from a fall. Although most people do relatively well with modern surgical treatment, hip fractures can result in disability and even death from postoperative complications, especially in older adults. Wrist fractures from falls also are common. In some cases, spinal fractures can occur without any fall or injury simply because the bones in your back (vertebrae) become so weakened that they begin to compress. Compression fractures can cause severe pain and require a long recovery. If you have many such fractures, you can lose several inches of height as your posture becomes stooped.

g. Diagnosis A routine x-ray can reveal osteoporosis of the bone, which appears much thinner and lighter than normal bones. Unfortunately, by the time x-rays can detect osteoporosis, at least 30% of the bone has already been lost. In addition, x-rays are not accurate indicators of bone density. The appearance of the bone on x-ray is often affected by variations in the degree of exposure of the x-ray film. The National Osteoporosis Foundation, the American Medical Association, and other major medical organizations are recommending a dual energy x-ray absorptiometry scan (DXA, formerly known as DEXA) for diagnosing osteoporosis. DXA measures bone density in the hip and the spine. The test takes only 5 to 15 minutes to perform, uses very little radiation (less than one tenth to one hundredth the amount used on a standard chest x-ray), and is quite precise.

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The bone density of the patient is then compared to the average peak bone density of young adults of same sex and race. This score is called the "T score," and it expresses the bone density in terms of the number of standard deviations (SD) below peak young adult bone mass. Osteoporosis is defined as bone density T score of 2.5 SD or below. Osteopenia (between normal and osteoporosis) is defined as bone density T score between 1 and 2.5 SD.

The National Osteoporosis Foundation guidelines state that bone density testing does not need to be performed if a person has a known osteoporotic fracture because the condition will be treated with or without bone density results. In addition, bone density testing is not appropriate if the person undergoing the test is not willing to take any treatment based on the results. Therefore, if bone density testing is done, it should be performed on people willing to take some specific action based on the results.

h. Treatment And Medication

The goal of osteoporosis treatment is the prevention of bone fractures by stopping bone loss and by increasing bone density and strength. Although early detection and timely treatment of osteoporosis can substantially decrease the risk of future fracture, none of the available treatments for osteoporosis are complete cures.

In other words, it is difficult to completely rebuild bone that has been weakened by osteoporosis. Therefore, prevention of osteoporosis is as important as treatment. Osteoporosis treatment and prevention measures are:
Medications that stop bone loss and increase bone strength, such as alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista), ibandronate (Boniva), calcitonin (Calcimar), and zoledronate (Reclast);

Hormone therapy (HT) was once the mainstay of treatment for osteoporosis. But because of

concerns about its safety and because other treatments are available, the role of hormone therapy in managing osteoporosis is changing. Most problems have been linked to certain oral types of HT, either taken in combination with progestin or
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alone. If you're interested in hormone therapy, other forms are available, including patches, creams and the vaginal ring. A new physical therapy program has been shown to significantly reduce back pain, improve posture and reduce the risk of falls in women with osteoporosis who also have curvature of the spine. The program combines the use of a device called a spinal weighted kypho-orthosis (WKO) a harness with a light weight attached and specific back extension exercises. The WKO is worn daily for 30 minutes in the morning and 30 minutes in the afternoon and while performing 10 repetitions of back extension exercises. Life style changes including quitting cigarette smoking, curtailing alcohol intake, exercising regularly, and consuming a balanced diet with adequate calcium and vitamin D;

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i. Prevention

National Osteoporosis Foundation's Five Steps to Bone Health and Osteoporosis Prevention: Get your daily recommended amounts of calcium and vitamin D Engage in regular weight-bearing exercise Avoid smoking and excessive alcohol Talk to your healthcare provider about bone health When appropriate, have a bone density test and take medicine.

Other tips for prevention These measures also may help you prevent bone loss: Exercise. Exercise can help you build strong bones and slow bone loss. Exercise will benefit your bones no matter when you start, but you'll gain the most benefits if you start exercising regularly when you're young and continue to exercise throughout your life. Combine strength training exercises with weight-bearing exercises. Strength training helps strengthen muscles and bones in your arms and upper spine, and weight-bearing exercises such as walking, jogging, running, stair climbing, skipping rope, skiing and impact-producing sports mainly affect the bones in your legs, hips and lower spine. Swimming, cycling and machines such as elliptical trainers can provide a good cardiovascular workout, but because they're low impact, they're not as helpful for improving bone health as weight-bearing exercises are. Add soy to your diet. The plant estrogens found in soy help maintain bone density and may reduce the risk of fractures. Don't smoke. Smoking increases bone loss, perhaps by decreasing the amount of estrogen a woman's body makes and by reducing the absorption of calcium in your intestine. The effects on bone of secondhand smoke aren't yet known. Consider hormone therapy. Hormone therapy can reduce a woman's risk of osteoporosis during and after menopause. But because of the risk of side effects, discuss the options with your doctor and decide what's best for you. Testosterone replacement therapy works only for men with osteoporosis caused by low testosterone levels. Taking it when you have normal testosterone levels won't increase bone mass.
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Avoid excessive alcohol. Consuming more than two alcoholic drinks a day may decrease bone formation and reduce your body's ability to absorb calcium. There's no clear link between moderate alcohol intake and osteoporosis.

Limit caffeine. Moderate caffeine consumption about two to three cups of coffee a day won't harm you as long as your diet contains adequate calcium. Maintain good posture. Good posture which involves keeping your head held high, chin in, shoulders back, upper back flat and lower spine arched helps you avoid stress on your spine. When you sit or drive, place a rolled towel in the small of your back. Don't lean over while reading or doing handwork. When lifting, bend at your knees, not your waist, and lift with your legs, keeping your upper back straight.

Prevent falls. Wear low-heeled shoes with nonslip soles and check your house for electrical cords, area rugs and slippery surfaces that might cause you to trip or fall. Keep rooms brightly lit, install grab bars just inside and outside your shower door, and make sure you can get in and out of your bed easily.

Manage pain. Discuss pain management strategies with your doctor. Don't ignore chronic pain. Left untreated, it can limit your mobility and cause even more pain.

Other therapy : Soy, a plant in the pea family, has been common in Asian diets for thousands of years. It is found in modern American diets as a food or food additive. Soybeans, the high-protein seeds of the soy plant, contain isoflavones-compounds similar to the female hormone estrogen. The following information highlights what is known about soy when used by adults for health purposes. People use soy products to prevent or treat a variety of health conditions, including high cholesterol levels, menopausal symptoms such as hot flashes, osteoporosis, memory problems, high blood pressure, breast cancer, and prostate cancer. Like peas and beans, red clover belongs to the family of plants called legumes. Red clover contains phytoestrogenscompounds similar to the female hormone estrogen. Current uses of red clover are for menopausal symptoms, breast pain associated with menstrual cycles, high cholesterol, osteoporosis, and symptoms of prostate enlargement.

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PART 3 : CALCIUM INTAKE

A. Calcium: What is it?

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Calcium, the most abundant mineral in the human body, has several important functions. More than 99% of total body calcium is stored in the bones and teeth where it functions to support their structure . The remaining 1% is found throughout the body in blood, muscle, and the fluid between cells. Calcium is needed for muscle contraction, blood vessel contraction and expansion, the secretion of hormones and enzymes, and sending messages through the nervous system . A constant level of calcium is maintained in body fluid and tissues so that these vital body processes function efficiently.

Bone undergoes continuous remodeling, with constant resorption (breakdown of bone) and deposition of calcium into newly deposited bone (bone formation) . The balance between bone resorption and deposition changes as people age. During childhood there is a higher amount of bone formation and less breakdown. In early and middle adulthood, these processes are relatively equal. In aging adults, particularly among postmenopausal women, bone breakdown exceeds its formation, resulting in bone loss, which increases the risk for osteoporosis (a disorder characterized by porous, weak bones)].

B. What is the recommended intake for calcium? Recommendations for calcium are provided in the Dietary Reference Intakes (DRIs) developed by the Institute of Medicine (IOM) of the National Academy of Sciences. Dietary Reference Intake (DRI) is the general term for a set of reference values used for planning and assessing nutrient intakes of healthy people. Three important types of reference values included in the DRIs are Recommended Dietary Allowances (RDA), Adequate Intakes (AI), and Tolerable Upper Intake Levels (UL). The RDA recommends the average daily intake that is sufficient to meet the nutrient requirements of nearly all (97-98%) healthy individuals in each age and gender group. An AI is set when there is insufficient scientific data available to establish a RDA. AIs meet or exceed the amount needed to maintain a nutritional state of adequacy in nearly all members
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of a specific age and gender group. The UL, on the other hand, is the maximum daily intake unlikely to result in adverse effects. It is listed in the section "Is there health risk of too much calcium?" of this fact sheet. For calcium, the recommended intake is listed as an Adequate Intake (AI), which is a recommended average intake level based on observed or experimentally determined levels. Table 1 contains the current recommendations for calcium for infants, children and adults. Table 1: Recommended Adequate Intake by the IOM for Calcium Male and Female Age 0 to 6 months 7 to 12 months 1 to 3 years 4 to 8 years 9 to 13 years 14 to 18 years 19 to 50 years 51+ years 210 270 500 800 1300 1300 1000 1200 Calcium (mg/day) N/A N/A N/A N/A N/A 1300 1000 N/A Pregnancy & Lactation

*mg=milligrams

There is a widespread concern that Americans are not meeting the recommended intake for calcium. According to the Continuing Survey of Food Intakes of Individuals (CSFII 1994-96), the following percentage of Americans are not meeting their recommended intake for calcium : 44% boys and 58% girls ages 6-11 64% boys and 87% girls ages 12-19 55% men and 78% of women ages 20+

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C. What Are the Important Cofactors for Achieving Optimal Calcium Intake?
Several cofactors modify calcium balance and influence bone mass. These include dietary constituents, hormones, drugs, and the level of physical activity. Unique host characteristics may also modify the effects of dietary calcium on bone health. These include the individual's age and ethnic and genetic background, the presence of gastrointestinal disorders such as malabsorption and the postgastrectomy syndrome, and the presence of liver and renal disease. Interactions among these diverse cofactors may affect calcium balance in either a positive or negative manner and thus alter the optimal levels of calcium intake. Vitamin D metabolites enhance calcium absorption. 1,25-Dihydroxy vitamin D, the major metabolite, stimulates active transport of calcium in the small intestine and colon. Deficiency of 1,25-dihydroxy vitamin D, caused by inadequate dietary vitamin D, inadequate exposure to sunlight, impaired activation of vitamin D, or acquired resistance to vitamin D, results in reduced calcium absorption. In the absence of 1,25-dihydroxy vitamin D, less than 10 percent of dietary calcium may be absorbed. Vitamin D deficiency is associated with an increased risk of fractures. Elderly patients are at particular risk for vitamin D deficiency because of insufficient vitamin D intake from their diet, impaired renal synthesis of 1,25-dihydroxy vitamin D, and inadequate sunlight exposure, which is normally the major stimulus for endogenous vitamin D synthesis. This is especially evident in homebound or institutionalized individuals. Supplementation of vitamin D intake to provide 600-800 IU/day has been shown to improve calcium balance and reduce fracture risk in these individuals. Sufficient vitamin D should be ensured for all individuals, especially the elderly who are at greater risk for development of a deficiency. Sources of vitamin D, besides supplements, include sunlight, vitamin D-fortified liquid dairy products, cod liver oil, and fatty fish. Calcium and vitamin D need not be taken together to be effective. Excessive doses of vitamin D may introduce risks such as hypercalciuria and hypercalcemia and should be avoided. Anticonvulsant medications may alter both vitamin D and bone mineral metabolism, particularly in certain disorders, in the institutionalized, and in the elderly.

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Although symptomatic skeletal disease is uncommon in noninstitutionalized settings, optimal calcium intake is advised for persons using anticonvulsants. Sex hormone deficiency is associated with excessive bone resorption in women and men. Low calcium intake can exacerbate the deleterious consequences of sex hormone deficiency. One study suggested that calcium supplementation can decrease the minimum estrogen dosage required to maintain bone mass in postmenopausal women. However, oral calcium alone does not prevent the postmenopausal bone loss resulting from estrogen deficiency. In addition to estrogen, other endogenous cofactors that could enhance net calcium absorption include growth hormone, insulin-like growth factor-I, and parathyroid hormone. An interrelationship between physical activity and calcium balance has not been established conclusively. In a single study, increased physical activity enhanced the beneficial effect of oral calcium supplementation on bone mass in young adults. Thus far, studies of elderly individuals and perimenopausal women have failed to establish a positive interaction between calcium intake and exercise to increase bone mass. Therefore, the positive effects of exercise on skeletal health are not likely to be related to calcium intake. D. What foods provide calcium? - In the United States (U.S.), milk, yogurt and cheese are the major contributors of calcium in the typical diet [4]. The inadequate intake of dairy foods may explain why some Americans are deficient in calcium since dairy foods are the major source of calcium in the diet [4]. The U.S. Department of Agriculture's Food Guide Pyramid recommends that individuals two years and older eat 2-3 servings of dairy products per day. A serving is equal to: - 1 cup (8 fl oz) of milk - 8 oz of yogurt - 1.5 oz of natural cheese (such as Cheddar) - 2.0 oz of processed cheese (such as American)

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Figure 1: Calcium Content of 8 fl oz of Milk Compared to Other Food Sources of Calcium

Source: [5] Table 2: Selected Food Sources of Calcium [6-8] Food Yogurt, plain, low fat, 8 oz. Yogurt, fruit, low fat, 8 oz. Sardines, canned in oil, with bones, 3 oz. Cheddar cheese, 1 oz shredded Milk, non-fat, 8 fl oz. Milk, reduced fat (2% milk fat), no solids, 8 fl oz. Milk, whole (3.25% milk fat), 8 fl oz Milk, buttermilk, 8 fl oz. Milk, lactose reduced, 8 fl oz.** Mozzarella, part skim 1 oz. Tofu, firm, made w/calcium sulfate, cup*** Orange juice, calcium fortified, 6 fl oz. Salmon, pink, canned, solids with bone, 3 oz. Pudding, chocolate, instant, made w/ 2% milk, cup Cottage cheese, 1% milk fat, 1 cup unpacked Tofu, soft, made w/calcium sulfate, cup*** Spinach, cooked, cup Instant breakfast drink, various flavors and brands, powder prepared with water, 8 fl oz. Frozen yogurt, vanilla, soft serve, cup Ready to eat cereal, calcium fortified, 1 cup Calcium (mg) 415 245-384 324 306 302 297 291 285 285-302 275 204 200-260 181 153 138 138 120 105-250 103 100-1000 % DV* 42% 25%-38% 32% 31% 30% 30% 29% 29% 29-30% 28% 20% 20-26% 18% 15% 14% 14% 12% 10-25% 10% 10%23

100% Turnip greens, boiled, cup Kale, cooked, 1 cup Kale, raw, 1 cup Ice cream, vanilla, cup Soy beverage, calcium fortified, 8 fl oz. Chinese cabbage, raw, 1 cup Tortilla, corn, ready to bake/fry, 1 medium Tortilla, flour, ready to bake/fry, one 6" diameter Sour cream, reduced fat, cultured, 2 Tbsp Bread, white, 1 oz Broccoli, raw, cup Bread, whole wheat, 1 slice Cheese, cream, regular, 1 Tbsp *DV=Daily Value **Content varies slightly according to fat content; average =300 mg calcium *** Calcium values are only for tofu processed with a calcium salt. Tofu processed with a non-calcium salt will not contain significant amounts of calcium. Daily Values (DV) were developed to help consumers determine if a typical serving of a food contains a lot or a little of a specific nutrient. The DV for calcium is based on 1000 mg. The percent DV (% DV) listed on the Nutrition Facts panel of food labels tells you what percentages of the DV are provided in one serving. For instance, if you consumed a food that contained 300 mg of calcium, the DV would be 30% for calcium on the food label. 99 94 90 85 80-500 74 42 37 32 31 21 20 12 10% 9% 9% 8.5% 8-50% 7% 4% 4% 3% 3% 2% 2% 1%

A food providing 5% of the DV or less is a low source while a food that provides 10-19% of the DV is a good source and a food that provides 20% of the DV or more is an excellent source for a nutrient. For foods not listed in this table, please refer to the U.S. Department of Agriculture's Nutrient.

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PART 4 : CORRELATION BETWEEN OSTEOPOROSIS AND CALCIUM INTAKE

Calcium and bone health Your bones are living tissues and continue to change throughout life. During childhood and adolescence, bones increase in size and mass. Bones continue to add more mass until around age 30, when peak bone mass is reached. Peak bone mass is the point when the maximum amount of bone is achieved. Because bone loss, like bone growth, is a gradual process, the stronger your bones are at age 30, the more your bone loss will be delayed as you age. Therefore, it is particularly important to consume adequate calcium and vitamin D throughout infancy, childhood, and adolescence. It is also important to engage in weight-bearing exercise to maximize bone strength and bone density (amount of bone tissue in a certain volume of bone) to help prevent osteoporosis later in life. Weight bearing exercise is the type of exercise that causes your bones and muscles to work against gravity while they bear your weight. Resistance exercises such as weight training are also important because they help to improve muscle mass and bone strength. Examples of weight bearing exercise walking running dancing aerobics Examples of NON-weight bearing exercise swimming bicycling water aerobics skating

Osteoporosis is a disorder characterized by porous, fragile bones. It is a serious public health problem for more than 10 million Americans, 80% of whom are women. Another 34 million Americans have osteopenia, or low bone mass, which precedes osteoporosis. Osteoporosis is a concern because of its association with fractures of the hip, vertebrae, wrist, pelvis, ribs, and other bones . Each year, Americans suffer from 1.5 million fractures because of osteoporosis .

Osteoporosis and osteopenia can result from dietary factors such as : chronically low calcium intake low vitamin D intake poor calcium absorption excess calcium excretion

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When calcium intake is low or calcium is poorly absorbed, bone breakdown occurs because the body must use the calcium stored in bones to maintain normal biological functions such as nerve and muscle function. Bone loss also occurs as a part of the aging process.

A prime example is the loss of bone mass observed in post-menopausal women because of decreased amounts of the hormone estrogen. Researchers have identified many factors that increase the risk for developing osteoporosis.

These factors include being female, thin, inactive, of advanced age, cigarette smoking, excessive intake of alcohol, and having a family history of osteoporosis .

In 1993 the FDA authorized a health claim for food labels on calcium and osteoporosis in response to scientific evidence that an inadequate calcium intake is one factor that can lead to low peak bone mass and is considered a risk factor for osteoporosis .

The claim states that "adequate calcium intake throughout life is linked to reduced risk of osteoporosis through the mechanism of optimizing peak bone mass during adolescence and early adulthood and decreasing bone loss later in life".

Various bone mineral density (BMD) tests, including those that measure your hip, spine, wrist, finger, shin bone, and heel, can help determine bone mass. These tests provide a Tscore which is a measure of bone mineral density that compares an individual's BMD to an optimal BMD of a 30 year old healthy adult.

See Figure 2 below. A T-Score of -1.0 and above indicates normal bone density. A T-score of -1.0 to -2.5 indicates that a person is considered to have low bone mass (osteopenia). A score below -2.5 indicates osteoporosis.

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Figure 2: Interpreting Bone Mineral Density Scores

Although osteoporosis affects people of different races, genders and ethnicities, women are at highest risk because their skeletons are smaller to start with and because of the accelerated bone loss that accompanies menopause. Adequate calcium and vitamin D intakes, as well as weight bearing exercise are critical to the development and maintenance of healthy bone throughout the lifecycle. Older adults should strive to maintain recommended daily calcium intakes as well as an adequate vitamin D intake.

Richard Panjaitan, one of the health minister's advisers, said that as the first symptoms of the disease usually did not appear until the advanced stages, it was important to detect it as early as possible.

Recent research from the Health Ministry found that one in three Indonesian women aged
50 years and above are prone to osteoporosis due to insufficient calcium intake during

their childhood. The research also showed that Indonesian women in West Jakarta consume 244 grams of calcium per day on average, well below the minimum intake (for women) of 1,000 grams.

Indonesian men are also susceptible to brittle bones as they consume only 300 grams of calcium per day on average. Calcium is found in dairy products such as milk, eggs,and cheese as well as vegetables and fruits. Most people have heard of osteoporosis but mistakenly associate it exclusively with elderly women.

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TABLE 4 : Calsium and other minerals intake among 50 years old women in Weat jakarta in 2008

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PART 5 : CONCLUSION - Summary of osteoporosis

Osteoporosis is a common problem that can respond to treatment and prevention. Exercise, healthy diet, and adequate calcium and vitamin D are important steps that everybody can take to improve their bone strength. Osteoporosis affects men, too. Preventing new fractures is the basic goal of osteoporosis treatment. The bone density findings provide valuable clues but the real reason for treatment is to prevent fractures. Estrogen deficiency is the most common cause of osteoporosis.

Osteoporosis is an epidemic problem that can be stopped if you just start to work on it today. Realize that every year you work on building bone density, you improve your bodys response to the aging process.

Osteoporosis is not a debilitating disease if one starts on the prevention protocol quickly, as early as age 35, the time when bone loss starts to become significant. From a diet perspective, one that is high in alkaline and base is preferred to an acidic body causes minerals to be bleached out of the bones in most cases.

The best strategy for maintaining healthy bones would appear to be adequate calcium consumption from the diet and supplements taken at mealtime if necessary.

Calcium carbonate achieves maximum absorption when taken with meals, and therefore is an excellent choice as a supplement. It is also the most widely used supplement, contains the highest amount of elemental calcium of all supplements and is moderately priced.

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BIBLIOGRAPHY
1 Osteoporosis. Available at : http://www.medicinenet.com. Accessed on June 16, 2008. 2 Osteoporosis. Available at : http://www.nlm.nih.gov/medlineplus. Accessed on June 16, 2008. 3 National Osteoporosis Foundation. Available at : http://www.nof.org/. Accessed on June 17, 2008. 4 Osteoporosis. Available at : http://www.emidicine.com/. Accessed on June 17, 2008. 5 Dietary Supplement Fact Sheet. Available at : http://ods.od.nih.gov/. Accessed on June 18, 2008. 6 Optimal Calcium Intake. Available at : http://consensus.nih.gov/. Accessed on June 18, 2008. 7 Free Scans Take Aim at Osteoporosis. Available at : http://old.thejakartapost.com. Accessed on June 20, 2008. 8 Osteoporosis. Available at : http://www.mayoclinic.com. Accessed on June 20, 2008. 9 Osteoporosis. Available at : http://nihseniorhealth.gov/. Accessed on June 23, 2008. 10 Etiology of Osteoporosis: Bones of Contention. Available at : http://www.bnet.com/. Accessed on June 23, 2008.

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