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Program Considerations for Calcium Supplementation

Dr Tahmeed Ahmed
Director, Centre for Nutrition & Food Security, ICDDR,B Professor, Public Health Nutrition James P. Grant School of Public Health, BRAC University

PE affects 7-10% pregnancies, rates higher in


Malnutrition, inadequate dietary intakes?

Villar J, et al. Int J Gynae Obstet, 2004

Bioavailability of Calcium from Different Foods is a Key Factor

Food Serving size (g) Calcium content (mg) Fractional absorption % Estimated absorbable calcium/ serving(mg) Servings needed to equal to 1 cup of milk

Milk or 1 cup yogurt or 1.5 oz cheese Beans, dried









Spinach Tofu, Calcium set

90 126

122 258

5 31

6 80

16 1

Adapted from Weaver, CM, et al., AJCN 70:543S-8S.,1999

300 250 200

Consumption of Milk Products


Consumption of Milk Products (Kg/Capita/year)

159 150 100 50 0 88.1 68.7 61.8 40.9 28.7 16

Bhatia 2008, He Y 2007, Darwish 2009, Islam MZ 2003, Wang Y 2008

Calcium intake in Countries

1200 1000 Calcium Intake (mean intake in mg/day) 800 600 962 879

200 0 United States Egypt

400 211 200




Bhatia 2008, He Y 2007, Darwish 2009, Islam MZ 2003, Wang Y 2008



Daily Calcium Intake of Women in Pirgacha and Trishal, Bangladesh

Age (years) Pirgacha

Daily calcium intake (mg) 157 (103, 227)

26.2 6.7 29.6 8.8


144 (97, 226)

Islam M, Ahmed T, et al. Unpublished

The Lancet Series on Maternal and Child Undernutrition

Interventions with Sufficient Evidence to Implement in All Countries

Maternal and Birth Outcomes Iron folate supplementation Maternal supplements of multiple micronutrients Maternal iodine through iodization of salt Maternal calcium supplementation Interventions to reduce tobacco consumption or indoor air pollution Newborn Babies
Promotion of

Infants and Children

Promotion of

breastfeeding (individual and group counseling)

breastfeeding (individual and group counseling) Behavior change communication for improved complementary feeding Zinc supplementation Zinc in management of diarrhea Vitamin A fortification or supplementation Universal salt iodization Hand washing or hygiene interventions

13 trials involving 15,730 women

Randomized trials comparing at least 1 g daily

of calcium with placebo

Hofmyer GJ, et al. Cochrane Collab 2011

Risk of hypertension reduced with Ca, RR 0.65


Risk of PE reduced, RR 0.45 (0.31-0.65)

Among low Ca consumers, RR 0.36 (0.2-0.65) Pre-term birth reduced, RR 0.76 (0.6-0.97)

Hofmyer GJ, et al. Cochrane Collab 2011

Poor Calcium intake

Reduced serum Ca

Parathormone & renin

Vascular Intracellular Ca in smooth muscle

Vascular resistance & vasoconstriction

Belizan JM, Villar J. Am J Obs Gynecol 1988

What is the way forward for introduction and implementation of calcium supplementation?

Calcium Supplementation: Early Introduction

Policy &

SBCC strategy


Preservice/inservice training

Clinical coverage

Local evidence

Guidance on Calcium from Exercise: Early Introduction

Advocate with policy makers using global evidence Separate national policy or streamline into clinical guidelines Develop advocacy plan/ strategy to reduce PE/E Cost deliver calcium in a cheap way; work with manufacturers to reduce cost Training of volunteers and health workers Logistics part of essential and national drug list, supported by USAID, UNICEF, WHO

Guidance on Calcium from Exercise: Early Introduction

Raise awareness of community health workers
Develop IEC materials (benefits to child, lower risk of PE/E) Carry out social marketing for calcium Address misperceptions of health workers about calcium Product compliance, feasibility

Guidance on Calcium from Exercise: Early Introduction

Inform prior to pregnancy the benefits of Ca supplementation (adolescents, newly weds) Generate country-specific information on Ca deficiency and intake Track through monitoring and evaluation Develop public/private partnerships

Guidance on Calcium from Exercise: Research

Conduct formative research on practices and understanding of PE/E; BCC strategy

Develop different formulations of calcium through research Research interactions between calcium and iron, currently testing pill with both calcium and iron Research on optimal dose of calcium (500 mg?)

Next Steps
Fill out country-level maps in your country MCHIP to follow-up in 3 months on calcium introduction maps