What are the recommended calcium (1,000–1,200 mg/day) and vitamin D (800–1,000 IU/day) supplementation guidelines for post‑menopausal women and men aged 60 years or older, including dosing, dietary sources, and contraindications such as hypercalcemia, kidney stones, chronic kidney disease, and sarcoidosis?

Calcium and Vitamin D Supplementation Guidelines

Recommended Daily Dosing

For postmenopausal women and men aged 60 years or older, the recommended daily intake is 1,200 mg of calcium (from all sources including diet and supplements) and 800 IU of vitamin D. 1, 2

Age-Specific Recommendations

• Women aged 19-50 years: 1,000 mg calcium daily and 600 IU vitamin D daily 1, 2
• Women over 50 years: 1,200 mg calcium daily and 800 IU vitamin D daily 1, 2, 3
• Men aged 19-70 years: 1,000 mg calcium daily and 600 IU vitamin D daily 1
• Men over 70 years: 1,200 mg calcium daily and 800 IU vitamin D daily 1, 2

Upper Safety Limits

• Maximum calcium intake should not exceed 2,000 mg/day for adults over 50 years to minimize risk of kidney stones and potential adverse effects 1, 3
• Vitamin D upper safe limit is generally 2,000-4,000 IU daily 2

Dietary Sources vs. Supplements

Dietary calcium from food sources is strongly preferred over supplements because it carries lower risk of kidney stones and does not increase cardiovascular concerns 1, 3

Calcium-Rich Food Sources

• Dairy products provide approximately 300 mg calcium per serving (milk, yogurt, cheese) 1
• Non-dairy sources include fortified foods, leafy greens, and calcium-fortified beverages 1
• Calculate total dietary calcium intake before adding supplements to avoid exceeding recommended amounts 1, 2

When to Use Supplements

• Supplements should be considered only when dietary intake is inadequate to meet the 1,000-1,200 mg/day target 1
• If dietary intake provides 600-800 mg/day, supplement with only 400-600 mg/day to reach the total goal 1

Supplement Formulations and Absorption

Calcium Carbonate

• Contains 40% elemental calcium (highest concentration) 1
• Must be taken with meals because gastric acid is required for optimal absorption 1, 2
• Most cost-effective option 1
• Common side effects include constipation and bloating 1

Calcium Citrate

• Contains 21% elemental calcium 1
• Can be taken without food and is preferred for patients on proton pump inhibitors or with achlorhydria 2
• Better tolerated if gastrointestinal side effects occur with calcium carbonate 2

Optimizing Absorption

• Divide calcium doses into no more than 500-600 mg per dose for optimal intestinal absorption 2, 3
• If taking 1,200 mg supplemental calcium, split into two 600 mg doses or three 400 mg doses throughout the day 2

Vitamin D Supplementation Details

Target Serum Levels

• Minimum adequate serum 25(OH)D level is 20 ng/mL (50 nmol/L) for bone health 2, 4
• Optimal levels are 30 ng/mL (75 nmol/L) or higher for fracture prevention 2

Correcting Vitamin D Deficiency

• For documented deficiency (<20 ng/mL): 50,000 IU vitamin D2 weekly for 8 weeks as initial correction 2
• Maintenance therapy: 800-1,000 IU daily after correction 2
• Vitamin D3 (cholecalciferol) is preferred over vitamin D2 (ergocalciferol) for long-term supplementation 2

Monitoring

• Measure serum 25(OH)D levels after 3 months of starting supplementation to confirm adequacy 2, 3
• Recheck every 1-2 years thereafter 2

Clinical Efficacy Evidence

High-dose vitamin D (≥800 IU/day) reduces hip fracture risk by 30% and non-vertebral fracture risk by 14% in adults 65 years and older 2

• Combined calcium and vitamin D supplementation reduces hip fracture risk by 16% and overall fracture risk by 5% 2
• Doses of 400 IU or less vitamin D with 1,000 mg or less calcium show no net benefit for fracture prevention 1, 2
• The U.S. Preventive Services Task Force found that low-dose supplementation (≤400 IU vitamin D, ≤1,000 mg calcium) has no net benefit in community-dwelling postmenopausal women 1

Absolute Contraindications

Hypercalcemia

• Do not supplement if serum calcium is elevated above normal range 1
• However, normal serum calcium does not reflect total body calcium stores, and patients with documented osteoporosis still require supplementation 2

Active Kidney Stones (Nephrolithiasis)

• Calcium supplementation modestly increases kidney stone risk: 1 additional case per 273 women supplemented over 7 years 1, 2, 3
• Dietary calcium does NOT increase stone risk and may actually be protective 1, 3
• If supplementation is necessary despite stone history, monitor 24-hour urinary calcium 2

Sarcoidosis

• Patients with sarcoidosis should not receive calcium or vitamin D supplementation due to risk of hypercalcemia from dysregulated vitamin D metabolism 2
• This is the only condition where calcium supplementation carries significant hypercalcemia risk 2

Chronic Kidney Disease

• Use caution and individualize dosing based on stage of CKD, serum calcium, phosphorus, and parathyroid hormone levels 1
• Standard supplementation may not be appropriate in advanced CKD (stages 4-5) without nephrology guidance 1

Special Populations Requiring Supplementation

Glucocorticoid Therapy

• Patients on ≥2.5 mg/day prednisone (or equivalent) for >3 months require 800-1,000 mg calcium and 800 IU vitamin D daily 2
• Supplementation should begin immediately upon starting steroid therapy 2, 3

Institutionalized Elderly

• All institutionalized elderly should receive 800 IU/day vitamin D or equivalent intermittent dosing 2
• This population has high risk of deficiency due to limited sun exposure 2

Chronic Liver Disease

• Patients with chronic liver disease require 800 IU vitamin D and 1,000 mg calcium daily 2
• No increased risk of hypercalcemia except in those with concurrent sarcoidosis 2

Dark-Skinned or Veiled Individuals

• May require supplementation without baseline measurement due to increased risk of vitamin D deficiency from limited sun exposure 2

Important Safety Considerations and Monitoring

Hypercalciuria Risk

• Hypercalciuria (>300 mg/day) occurs in approximately 30% of women taking calcium and vitamin D supplements 5
• Episodes are transient in half of cases and recurrent in the other half 5
• The relationship between hypercalciuria and vitamin D dose is unclear; it occurs equally in placebo groups 5

Cardiovascular Concerns

• The National Osteoporosis Foundation concluded with moderate-quality evidence that calcium with or without vitamin D has no relationship to cardiovascular disease, cerebrovascular disease, or all-cause mortality in generally healthy adults 2
• Earlier studies raised concerns about increased cardiovascular risk with calcium supplements, but findings were inconsistent and inconclusive 1
• Dietary calcium carries no cardiovascular risk 1, 3

Monitoring Requirements

• No routine serum calcium monitoring is needed for healthy adults taking recommended doses 3
• Measure serum 25(OH)D after 3 months of supplementation, then every 1-2 years 2, 3
• Consider 24-hour urinary calcium in patients with history of kidney stones 2
• For patients on long-term supplementation, check serum calcium and phosphorus at least every 3 months 2

Common Pitfalls to Avoid

• Do not supplement without first calculating dietary calcium intake – many patients already consume adequate calcium from diet and risk over-supplementation 1, 2
• Do not prescribe calcium carbonate without instructing patients to take it with meals – absorption is significantly reduced on an empty stomach 1, 2
• Do not use low doses (≤400 IU vitamin D, ≤1,000 mg calcium) expecting fracture prevention benefit – these doses are ineffective 1, 2
• Do not exceed 2,000 mg/day total calcium intake in adults over 50 years 1, 3
• Do not give single large bolus doses of vitamin D (300,000-500,000 IU) – these may increase fall and fracture risk 2

Duration of Supplementation

• Minimum of 5 years of supplementation is recommended for osteoporosis management 2
• Bone densitometry (DXA) should be performed after 2 years of treatment and at the end of treatment 2
• For patients on glucocorticoids, continue supplementation for the entire duration of steroid therapy 2