Date: {{$ActivityAssignDate}}

Dear Dr. {{ $doctorName }},

Subject : Participation in survey “To understand the usage pattern of calcium and vitamin D supplements in clinical practice”

Calcium and vitamin D play an important role in bone and muscle health. They are also required for various other functions in the body like excitability of nerves and muscles, cell transport, immunity, etc. In India, a survey of general population showed that the dietary calcium intake was 429 mg/day, and the status of vitamin D levels were 10-19.6 ng/ml. In a meta-analysis study, the pooled prevalence of vitamin D deficiency was reported to be 61 % across various age groups. The prevalence of osteopenia and osteoporosis is 49.9 and 18.3% respectively. This data highlights the need to address this state of deficiency of dietary calcium and vitamin D in India.

Calcium is available in many dietary supplements, including multivitamin/mineral products and supplements containing calcium only or calcium plus vitamin D. The dose of calcium in supplements vary widely; multivitamin/mineral supplements commonly contain about 200 to 300 mg, and common amounts in calcium or calcium plus vitamin D supplements are 500 or 600 mg. The two most common forms of calcium in supplements are calcium carbonate and calcium citrate. Other calcium forms in supplements include calcium sulphate, ascorbate, microcrystalline hydroxyapatite, gluconate, lactate, and phosphate. Vitamin D is available as calciferol (D2) and cholecalciferol (D3) in supplements commonly. Diet does not provide adequate vitamin D, therefore sun exposure and supplementation become necessary.

Vitamin D deficiency is a global public health issue. Decreased dietary intake and sun exposure are common causes of deficiency. Vitamin D deficiency results in osteomalacia and further leading to osteoporosis. Muscle weakness, particularly of large proximal muscles, is typical and may reflect both hypophosphatemia and inadequate vitamin D action on muscle. Guidelines for management of osteoporosis, in regards to calcium and vitamin D supplementation, advise for total calcium intake of at least 1000mg/day along with vitamin D supplementation, typically required at a dose of 1000 to 2000 IU daily maintenance therapy.

Estrogen lowers the sensitivity of bone mass to parathyroid hormone, thus reducing bone resorption. It increases the production of calcitonin and accelerates calcium resorption by the intestine. Also, it reduces the calcium excretion from the kidney. At menopause the normal bone turnover cycle is impaired by estrogen deficiency. The osteoclastic resorption activity increases while the osteoblastic activity decreases. As a result, the amount of bone resorbed exceeds the amount deposited, which leads to a net loss of bone. To address this net loss of bone in menopausal women, guidelines advise to offer calcium and/or vitamin D supplementation as an adjunct to anti-osteoporosis drug treatment.

Poor maternal and new-born health and nutrition remain significant contributors to the burden of disease and mortality. Calcium supplementation has the potential to reduce adverse gestational outcomes, in particular, by decreasing the risk of developing hypertensive disorders during pregnancy, which are associated with a significant number of maternal deaths and considerable risk of preterm birth, the leading cause of early neonatal and infant mortality. The national guidelines for calcium supplementation during pregnancy and lactation, India advises that all pregnant and lactating women should be counselled about intake of calcium rich foods. Oral swallowable calcium tablets should be taken twice a day (total 1g calcium/day) starting from 14 weeks of pregnancy up to six months post-partum. In recent years, the awareness for the use of multivitamins and multimineral supplements with botanicals like ginseng has increased in treatment of fatigue, diabetes, PCOS and menopausal symptoms. There is limited data available on the preference and rationale for selection of different vitamins and minerals and available botanicals. Therefore, this multicentric survey is designed to understand the use of multivitamin multimineral supplements with ginseng in management of such patients in India.