Medicine For People!

March 2005: Calcium, Leukemia Survivor, Save Money on Pharmaceuticals

This Month in the Newsletter

Patients are always asking me how much calcium to take. Last year we wrote about related topics -- osteoporosis in August 2004 and Vitamin D in February and March 2004. This month we round out the picture by tackling the calcium question. If you just want to know how much to take and don't care about the whys and wherefores, scroll down to "Recommendation." Then go on to read an insightful reader letter about the pharmaceutical industry followed by a practical guide to saving money on prescriptions.

Calcium - How Much is Enough?

You already know that calcium is important for bone strength. You may also know that it acts as a messenger inside the cells and is required for the proper function of most body proteins and enzymes. Combined with Vitamin D, it reduces the risk of colon cancer Truly, this mineral is important for your strength and health.

You may still be confused, however, about how to get enough calcium. How many calcium pills should you take? The answer is... that depends. Each person is unique and cookie-cutter medical advice doesn't always work. In this article, we will try to explain how you can figure out your individual needs. (Jump down to "Recommendations" for the telegram version.)

Here are the Numbers

There is so much variation between individuals, including genetic makeup, diet, and lifestyle, that it is impossible to set a number that is right for an average person. Nonetheless, we estimate that men and women over the age of 50 should consume about 1200 milligrams per day for good health, and 1500 milligrams per day if they have low bone density. (Information about bone density.) Individuals need to look at their digestion and diet to calculate what these estimates mean to them.

Calcium is more available from some foods than from others

The average person absorbs only 10 to 20 percent of the calcium in the food they eat. An average person over fifty eating a typical diet absorbs about 200 mg of calcium. If you take 1500 milligrams of calcium (total of food and supplements) and your digestion is good, you absorb about 300 mgs. That is enough to keep you healthy. However, calcium absorption varies greatly between individuals, and also by type of food. That may explain why a Cornell Medical School study found that the Chinese consume less calcium than we do yet suffer less from osteoporosis.

Your first step is to know which foods are rich in calcium.

  • Tofu is generally made with calcium, and calcium is as well absorbed from tofu as it is from milk.
  • Foods of the brassica family (cabbage, broccoli, cauliflower, kale, etc.) provide much more calcium than other vegetables.
  • Calcium from dairy sources is about 30% absorbed, that from spinach about 5%

Here is a list of foods with amounts of calcium typically absorbed. Look at ordinary tables and you'll see that these foods contain much more calcium than you see here. This table just tells you how much calcium you'll obtain from each food. Remember, you're only aiming at 300 milligrams per day actually absorbed:

Food Serving Size Calcium absorbed
Milk or yogurt 8 oz 100 mg
Cheese 1 oz 100 mg
Tofu with calcium 4 oz 80 mg
Cabbage 3 oz 40 mg
Calcium pill * 1 tablet 40 mg
Kale 2 oz 30 mg
Broccoli 2 oz 22 mg
Dried beans 6 oz 8 mg
Spinach 3 oz 6 mg

*calcium citrate-malate (CCM) 100 milligrams

Calcium: the Ins and Outs

  • Some foods increase calcium loss in the urine
  • Consumption of table salt, sweets, and coffee increase calcium losses in the urine, and so also increases our daily requirement. Although moderate use of alcohol seems to strengthen bones, excessive use, as in alcoholism, leads to osteoporosis. Foods such as red meat, which are high in phosphorous, pull calcium out of the bones.

  • Poor digestion can decrease calcium absorption
  • As we age, it is more likely that we fail to make adequate stomach acid to digest our food. The most common symptoms of this are that food seems to sit in our stomach, or regurgitate back up into the esophagus, or that we have constipation. In this case, we will absorb less calcium from the food we eat.

  • Nutritional deficiency can impair calcium status
  • If we are low in vitamin D or magnesium, we can ingest adequate calcium but it will not strengthen our bones.

    Which Calcium Supplement is best?

    Pure calcium is a metal. Combine a metal with another substance and you obtain a salt. Different salts of calcium have widely varying degrees of absorption. The best available is calcium citrate malate (CCM) which is about 40 percent absorbed when it is taken with apple juice and somewhat less when mixed with orange juice or other foods. Since the calcium in milk is about 30 percent absorbed, this makes this product significantly more bio available then the calcium in milk. Tums500 is another choice, containing 500 milligrams of calcium total, of which about 30% (150 mg) is absorbed when taken with a meal.


    I recommend that you look at your diet and health conditions and work with your health care provider to come up with a good number. If you'd like a ball park estimate, for a woman who eats the typical American diet, five tablets 160 milligrams each of calcium citrate-malate (CCM) or two tablets of Tums500 should be sufficient to provide adequate calcium for bone rebuilding. If she has a healthier diet, she can take less calcium, down to two tablets CCM a day or one Tums500. Calcium is best absorbed when taken with a meal. And remember, other nutrients, including vitamin D, and exercise are absolutely required to get that calcium from the bloodstream into the bones.

    For more on natural treatment and optimal evaluation of osteoporosis, click here.

    A Leukemia Survivor Joins the Pharmaceutical Industry Debate

    We don't have space to print the many letters we received in response to our request for feedback. The consensus is that you appreciate the newsletter. Thank you. To round out our discussion of the pharmaceutical industry and government medicine, we include this letter from a savvy patient who has been around the block a time or two. We have shortened the letter a bit.

    Dr. Rienstra:
    In my role as a stress management and crisis intervention consultant, I have traveled to, been treated in and have friends in several countries where universal health care -- that is health care overseen by the state--is in practice. I want to inject a few observations into this debate.

    First, many of my clients are big drug companies. They exist, as do all social and business entities, on several levels. The lab techs and researchers are some of the most devoted people I have ever met. Their search for cures and treatments, however, are driven by two engines: a personal desire to make a difference in the treatment of illness, and a reward system designed by management to push development of products that will make money and attract stock holders. . . . These two drives are contrary, and create a great deal of stress at the research level. To keep their jobs, scientists are often forced to go against professional or intuitive actions in order to satisfy the second goal.

    On an upper management level I have found little or no concern, beyond a desire to maintain a positive public image, for the health and welfare of clients. As we have seen recently, this drive for profit pushes drugs to market before they are fully proven or the side-effects are truly known. Hence, the flood of lawsuits. The attorneys in this scenario are not, in my experience, morally debased, profit driven dogs, although many of them fall into that category. The other half are motivated by true concern for clients and their families who have been seriously injured, incapacitated or even killed by the drugs that were prescribed.

    In countries where universal health care is the norm, [there are] problems of equal severity. First, the "guaranteed safety net" is made of gossamer. Patients are not allowed to seek legal recourse against a physician for cutting off the wrong leg, nor is the physician compelled to go up for review until after three such mistakes. Drug companies are not held accountable in any fashion, and there is no recourse for patients who suffer due to misdiagnosis, negative drug reactions or even death due to known drug causes. Even after a drug has been pulled from the market because of proven defects, patients affected by such medication receive little or no compensation.

    In every country I have visited which employs universal health care, anyone who can afford it has secondary insurance, which they pay for. Statistically, such individuals are the first to be seen by physicians, the first to receive organ donations, and the first into the operating room for complex procedures.

    Both systems are flawed by a common, human weakness, and that weakness is greed. A solution lies not in the reformation of either system, but a reformation in the morals and ethics of modern societies. I do not expect to live long enough to see the latter come about. Until then, I will take charge of informing myself by studying the physicians, drugs and treatments offered to me. Having survived two major brain surgeries, and an ongoing battle with chronic leukemia, I have found such information invaluable.

    When I fell ill in Sweden, I was put on a waiting list for an appendectomy, and hospitalized. Although it was a matter of days before the problem would poison my system and lead to incapacitation or death, I was heavily drugged and still placed on a waiting list. Had it not been for the intervention of my client, I have no idea if I would have received treatment in time to avert severe consequences.

    In the United States, despite excellent, personal health care insurance, I was pushed over the edge of financial ruin . . . and nearly died from the side effects while undergoing a year-long hospitalization for treatment of adult leukemia. Grateful to be alive, I chose not to initiate suit. I simply did not have the resources or energy to do so, although I did sign up with a class action suit which has yet to be resolved.

    Medicine is not confined to the practice of treating patients; it is incumbent upon physicians to remain informed and to support their patients with the best knowledge they have available. If, in doing so, Dr. Rienstra feels it necessary to put forth his opinion on anything from Vitamin E to pharmaceutical misinformation, I welcome it.

    With Hope,
    Charles W.

    How to Save Money on Pharmaceuticals

    1. Improve your lifestyle - Better diet, more exercise, plenty of sleep starting from 9:00 or 10:00 in the evening will improve your health and may allow you to reduce medications for the many illnesses made worse by stress. Stress-related illnesses include headache, colitis, high blood pressure, diabetes, asthma,and heart disease.

    2. Use natural methods to treat illness. Congestive heart failure, migraine headache, hypertension, and many other illnesses often respond well to non-pharmaceutical remedies.

    3. Substitute off-patent generic drugs for brand names. Nexium® reduces gastric acid nicely, at $4.20 per day; omeprazole, a generic, has the same proton-pump inhibition effect for 70 cents a day. Examples are legion.

    4. Split tablets. Brand name Tenormin®, at 50 milligrams per day, runs about $500 per year. Buy a six-month supply of generic atenolol (same active drug) in the 100 milligram size, cut them in half, and you'll get the same pharmaceutical effect for under $40 per year.

    5. Seek out pharmacies that deal only in cash. Reduced paperwork allows them to provide medications for less. At you can price your prescriptions online. (Call them at 888.932.4779 if their computer doesn't give you a price: it doesn't list every drug they carry) Based in Minnesota, they can provide medication by mail. Most of their offerings are generic, but prices are far less than overseas pharmacies. As an example, an albuterol inhaler that runs $25 or so from an insurance-company-billing pharmacy is under $7 at FairCare Rx. Other cash-only pharmacies are opening around the country.

    CJK February 1, 2006



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    Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.