International Journal of Nutrition and Food Sciences

2020; 9(2): 54-62

http://www.sciencepublishinggroup.com/j/ijnfs
doi: 10.11648/j.ijnfs.20200902.13
ISSN: 2327-2694 (Print); ISSN: 2327-2716 (Online)

Relevance of Calcium and Vitamin D in Supporting Bone

Health: An Expert Panel Recommendation in Indonesia
Saptawati Bardosono1, *, Andon Hestiantoro2, Andri Maruli Tua Lubis3, Siti Setiati4,
Ani Retno Prijanti5, Purwantyastuti6, Luciana Sutanto7, Maria Regina Rachmawati8, Sheryl Tan9
1
Department of Nutrition, Faculty of Medicine, University of Indonesia / Cipto Mangunkusumo Hospital, Jakarta, Indonesia
2
Department of Obstetrics & Gynecology, University of Indonesia / Cipto Mangunkusumo Hospital, Jakarta, Indonesia
3
Department of Orthopaedic Faculty of Medicine, Universitas Indonesia / Cipto Mangunkusumo Hospital, Jakarta, Indonesia
4
Department of Internal Medicine Faculty of Medicine, Universitas Indonesia / Cipto Mangunkusumo Hospital, Jakarta, Indonesia
5
Department Biochemistry and Molecular Biology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
6
Department of Pharmacology, Faculty of Medicine, Universitas Indonesia / Cipto Mangunkusumo Hospital, Jakarta, Indonesia
7
Department of Nutrition, Universitas Kristen Kr, Jakarta, Indonesia
8
Faculty of Medicine, Universitas Gunadarma / Pasar Minggu Municipal Hospital, Jakarta, Indonesia
9
Medical & Clinical Development, Bayer Consumer Care, Singapore

Email address:

*
Corresponding author

To cite this article:

Saptawati Bardosono, Andon Hestiantoro, Andri Maruli Tua Lubis, Siti Setiati, Ani Retno Prijanti, Purwantyastuti, Luciana Sutanto, Maria
Regina Rachmawati, Sheryl Tan. Relevance of Calcium and Vitamin D in Supporting Bone Health: An Expert Panel Recommendation in
Indonesia. International Journal of Nutrition and Food Sciences. Vol. 9, No. 2, 2020, pp. 54-62. doi: 10.11648/j.ijnfs.20200902.13

Received: August 22, 2019; Accepted: April 23, 2020; Published: May 14, 2020

Abstract: Osteoporosis is a bone health related condition that weakens the bones, making individuals fragile and prone to
breaks. Nutrients such as calcium and vitamin D are essential for bone health. Calcium helps in building and maintaining bone
mass while vitamin D aids in the absorption and utilization of calcium. According to WHO, 28.8% men and 32.3% women in
Indonesia have osteoporosis, and this is inspite of the international recommendations for the daily intake of calcium and
vitamin D intake. This could be attributed to low community awareness on how to prevent and care for osteoporosis. Several
high-risk population groups have been identified such as those with osteopenia, undergoing rehabilitation and
pregnancy/lactation periods. Therefore, in this review, an expert panel comprising of specialties of dietetics, rehabilitation
medicine, orthopaedic, obstetrics & gynaecology, pharmacology, and geriatrics, convened to provide an evidence-based
guidance on the prevention and care for osteoporosis. The recommendations are as follows: (i) It is important to know that
calcium and vitamin D work synergistically to maintain bone health. (ii) The intake of calcium and vitamin D must start early.
(iii) We should be aware that our diet and lifestyle today does not allow us to meet the recommended daily intake of calcium
and vitamin D required for optimal bone health. (iv) Supplementation can compensate for the deficits in both calcium and
vitamin D intake, thereby strengthening bone health. This study could guide the primary health care team, who plays a critical
role in community care, to encourage early bone health awareness and care in Indonesia.
Keywords: Calcium, Vitamin D, Indonesia, Supplement, Osteoporosis, Pregnancy

tissues, and is important in protecting our organs and

1. Introduction muscles, supporting the production of new blood cells,
The skeletal system comprises of bones and connective and regulating calcium homeostasis [1]. Bone health is
 International Journal of Nutrition and Food Sciences 2020; 9(2): 54-62 55

increasingly important with age, as older adults 3. Recommendations from the Expert
experience bone loss, which increases the risk of bone
fractures [2]. One condition that weakens the bones, Panel
making them fragile and prone to breaks is osteoporosis. 3.1. Calcium and Vitamin D Work Synergistically to
This condition builds up over a period gradually, not Maintain Bone Health
visible until the individual experiences a fall or sudden
impact. Causes of osteoporosis is primarily due to loss of Calcium is one of the most important elements in the
bone density with age and occurs at different rates based human body, wherein, 99% of calcium is stored in the
on multifactorial reasons. Examples include gender, long- skeleton as hydroxyapatite which provides skeletal (bone)
term use of certain medication such as steroids, co- strength, and around 1% of calcium is in the blood, soft
morbidities, genetics, lifestyle and diet [3]. Besides tissues and extracellular fluid. It is a vital component of bone
osteoporosis, pregnancy and breastfeeding periods also architecture and is required for deposition of bone mineral
put extra demand on women’s bone health. During throughout life [9]. Some of the natural sources of food items
pregnancy, the fetus depends on the maternal calcium rich in calcium includes milk, yogurt, cheese, soymilk, tofu,
store to develop its skeleton, especially so in the last kale etc [10]. Notably, intracellular calcium is also an
trimester. Subsequently, during breastfeeding, the baby important second messenger that is involved in a wide range
continues to draw calcium from the mother’s bones. Bone of physiological roles such as muscle contraction, cellular
loss during pregnancy and breastfeeding is usually motility, fertilization, cell growth or proliferation,
recovered after the period ends. However, the incidence of neurogenesis, synaptic plasticity as well as learning and
osteoporosis during pregnancy/breastfeeding is possible memory [11]–[13]. Also, during pregnancy, calcium plays a
[4]. Related to the prevention and management of vital role. The main period of skeletal mineralization of the
osteoporosis, rehabilitation periods are also critical [5]. fetus starts during the third trimester of pregnancy. In this
Rehabilitation refers to the restoration of health post period, the increased fetal demand for calcium is met by
injury or illness and is required to restore muscle and bone maternal calcium stores [14, 15]. This results in a reduction
strength. Success of rehabilitation in osteoporotic and in total calcium concentration in pregnant women, which
fractured individuals have improved their overall quality could possibly increase the risk of pregnancy-induced onset
of life [6]. of osteoporosis [16, 17].
In Asia, osteoporosis is one of the most prevalent and Vitamin D is a fat-soluble vitamin which is converted to
costly health problems, where socio-economic advancements calcidiol [25 (OH) D; vitamin D2] in the liver, and then
are coupled with a rapidly ageing population [7]. Taking converted to calcitriol (1,25- dihydroxycholecalciferol;
Indonesia as a key example, the Indonesia Osteoporosis vitamin D3) which is the biologically active form of vitamin
Society (PEROSI) estimates that about 41.8% of Indonesian D involved in the absorption of calcium in the small intestine
men and 90% of Indonesian women were osteopenic [9, 18]. Some of the natural sources of food items containing
(lowered bone mineral density), whereas 28.8% of men and vitamin D include; oily fish, fortified milk, egg yolk, cheese
32.3% of women had osteoporosis according to WHO etc. Vitamin D, in concert with peptide hormones such as
criteria. The Indonesian Ministry of Health has parathyroid hormone (PTH) and calcitonin, mediates calcium
acknowledged osteoporosis as a major health problem since and phosphorous metabolism at target tissues, including bone,
2006 [8]. To support this endeavor, this article aims to review intestine and kidney [19]. Other roles of vitamin D includes
the role of nutrition in bone health and provide optimization and maintenance of bone mineral density (BMD)
recommendations to improve awareness on building bone [20, 21] and improvement of muscle strength [22]. Without
health in Indonesia. sufficient intake of vitamin D, there could be dearth of
calcitriol, ergo, insufficient absorption of calcium [23, 24].
2. Methods The respective biological roles of calcium and vitamin D
in our body suggests that both nutrients work together to
An expert panel group consisted of a multidisciplinary protect the bones - calcium helps build and maintain bones
consortium of seven experts across specialties including and vitamin D helps in effective absorption of calcium. This
obstetrician-gynecologist, medical rehabilitation specialist, synergy has been demonstrated to reduce the risk of
internist, orthopedic & traumatologist, clinical nutritionist, osteoporosis [25].
pharmacologist as well as biomedical & molecular The American Food and Nutrition Board (FNB)
biologist from Indonesia. An advisory board meeting was established recommended dietary allowances (RDA) for
convened in Indonesia in March 2019 to deliberate on calcium and vitamin D for bone health, subcategorized by
evidence-based recommendations pertaining to the role of age, gender or for pregnant, or lactating women [10, 26].
calcium and vitamin D in bone health. The panel also Table 1 consolidates information on the RDA of calcium and
shared their clinical experiences specific to the Indonesian vitamin D as per the International Osteoporosis foundation
population. All information was gathered and summarized (IOF) benchmarked against FNB. The daily intakes
in this publication. The views here do not represent the recommended by the Indonesian Healthy Bone Foundation
opinion of any national or international societies. (PERWATUSI) [27] refers to IOF and as shown in table 1,
56 Saptawati Bardosono et al.: Relevance of Calcium and Vitamin D in Supporting Bone Health: An
Expert Panel Recommendation in Indonesia

both FNB and IOF guidelines are similar, demonstrating the mg for men respectively. Recommendations for vitamin D
consistency in the need for both calcium and Vitamin D intake also increases with age for both men and women,
intake across all age groups and conditions. It is similar to that of calcium intake. As described by their
recommended that intake of calcium increases with age for biological roles and recommended daily intakes by
both men and women. Also, for women aged 51-70 years old, international guidelines, both calcium and vitamin D are
there is a higher recommended intake of calcium compared critical and synergistic in building bone health, eventually
to men of the same age i.e. 1200 mg for women versus 1000 preventing osteoporosis in later life.
Table 1. Calcium and vitamin D nutrition adequacy rate as per international recommendations.

FNB [10, 26] IOF [28, 29]

Infancy to adolescence
0-6 months 200 mg -
7- 12 months 260 mg -
1-3 years 700 mg 700 mg
4-8 years 1,000 mg 1,000 mg
9 -13 years 1,300 mg 1,300 mg
Calcium 14- 18 years 1,300 mg 1,300 mg
(mg/day) Adults
Male Female Male Female
19- 50 years 1,000 mg 1,000 mg 1,000 mg 1,000 mg
51-70 years 1,000 mg 1,200 mg 1,000 mg 1,200 mg
Pregnant/lactation 14-18 years old 1,300 mg 1,300 mg
Pregnant/lactation 19-50 years old 1,000 mg 1,000 mg
71+ years 1,200 mg 1,200 mg 1,200 mg 1,200 mg
Male Female Male Female
Vitamin D 0-12 months 400 IU (10 mcg) 400 IU (10 mcg) 400 IU (10 mcg) 400 IU (10 mcg)
(IU/day) 1-70 years 600 IU (15 mcg) 600 IU (15 mcg) 600 IU * (15 mcg) 600 IU* (15 mcg)
>70 years 800 IU (20 mcg) 800 IU (20 mcg) 800 IU (20 mcg) 800 IU (20 mcg)

* IOF recommendations for adults aged 60 years and over are 800 to 1000 IU/day for falls and fracture protection

3.2. Intake of Calcium and Vitamin D Must Start Early prevalence of low levels of vitamin D in comparison to WHO
standards among pre-school and school-aged children in
Establishing the vital roles of calcium and vitamin D in Indonesia [36]. Another study showed similar results; high
bone health, the authors also recommended an early intake of prevalence of vitamin D insufficiency in healthy children
these nutrients. Current literature has demonstrated the aged 7-12 years in Indonesia [37]. Vitamin D insufficiency is
prevalence of low levels of calcium and vitamin D among a health problem among Indonesian children, wherein the
Indonesians today [36-43]. Deficiency of calcium at level of vitamin D in teenagers was found at the minimum
infancy/childhood not only increases the risk of skeletal level of 15 ng/dL [38]. According to the National Institute of
problems in the future, but could also lead to nutritional Health standards, the vitamin D level in blood should be at
rickets or osteomalacia among children, the consequences of least 20 ng/mL [26].
which could be lethal or persist into adulthood [30]–[32]. Aside from adequate intake of calcium and vitamin D at
During puberty and adolescence, the calcium requirement early stages of life (puberty & adolescence), pregnancy and
is higher, due to accelerated muscular, skeletal and endocrine lactation also require high calcium intake. A recent review on
development. About 95% of young women’s peak bone mass nutritional uptake in pregnant women reported low average
is present by age 20 and overall gain continues often until intake of calcium among women in Indonesia [39]. This
age 30. Adequate intake of calcium and vitamin D during this corresponded to another research by IOF that found low
period of life helps to achieve peak bone density [33, 34]. A dietary calcium intake among the general population in Asian
study in Indonesia showed that 40.6% of Indonesian women countries including Indonesia [40]. There is also a higher
aged 20-29 years had a low peak bone mass, indicating that a prevalence of vitamin D deficiency and insufficiency among
higher proportion of women could face the risk of fractures pregnant women compared to non-pregnant counterparts in
in the next 20 years when they reach menopause, which is the Indonesia [41]. A study which assessed the rate of bone
typical onset of decreased bone mass and an increased risk of health decline and incidence rate of osteoporosis in several
osteoporosis. This study also showed that lower levels of Asian countries demonstrated that the T-mean score of
calcium intake during childhood or adolescence, calculated women decreased dramatically with ageing and was the
using the historical calcium index (HCI), could potentially lowest for Indonesia, indicating that osteoporosis could be a
influence the peak bone mass of women. This demonstrates major problem in the near future [42].
that lower consumption of calcium in childhood and early The current literature above has suggested there is low
adulthood is one of the key determinants of low peak bone intake of both calcium and vitamin D among Indonesians
mass [35]. today. This low intake may occur in childhood or during
With regards to vitamin D, a SEANUT study showed pregnancy and persist in later life, manifesting as
 International Journal of Nutrition and Food Sciences 2020; 9(2): 54-62 57

osteoporosis-related problems. Therefore, early intake of the body mass index (BMI). Studies have shown that with a
both calcium and vitamin D are essential to prevent the higher level of body fat, the serum level of calcidiol will be
buildup of related medical conditions, which are irreversible. lower. Since vitamin D is deposited in the adipocyte cells and
is difficult to transport for circulation, the serum levels of
3.3. Diet and Lifestyle May Hinder Meeting the Daily calcidiol is low [47]. This was also observed in a South-east
Recommended Intake of Calcium and Vitamin D Asian study, whereby, in Indonesians, higher BMI was
The intake of calcium and vitamin D is negatively associated with a lower calcidiol levels [58].
impacted by diet and/or lifestyle-related factors such as Overall, we have collated evidence pertaining to the
reduced exposure to sun, lack of physical activity and obesity impact of lifestyle, physical activity and obesity on calcium
[43, 44]. Based on the international standards i.e. FNB or IOF, and vitamin D intake, all pointing to the direction that our
the recommended daily allowances of calcium ranges diet and lifestyle today may not allow us to meet the daily
between 1000-1200 mg/day for adults [45]. A study in 2010 recommended intake of calcium and vitamin D. These critical
revealed that the average calcium intake of the Indonesian factors in the Indonesian cohort need to be further addressed
people reached only 254 mg/day. One of the possible reasons with relevant country-wide initiatives.
cited was the lower consumption of calcium rich foods or 3.4. Supplementation can Compensate for Deficits in the
cooking methods which resulted in significant loss of nutrient Daily Recommended Intake of Calcium and Vitamin D
intake [46].
There is an established association of vitamin D deficiency With the possible avenues leading to deficits in the
with lifestyle, for example, women who spent significant recommended dietary intake of calcium and vitamin D, one
time indoors, avoiding sun rays, sunblock application, and may opt for supplementation to fill the gaps [25]. There has
low physical activity have a higher likelihood of vitamin D been increasing evidences over the years on how
deficiency [48-50]. These lifestyle factors are common supplementation in adequate proportion supports health
among Indonesian women [47]. A study on Indonesian outcomes [59]. For example, calcium supplementation
women of childbearing age working as female garment reduces bone turnover by 20% and was associated with a
workers, revealed that those women who wore veil had a reduction in postmenopausal bone loss [60]. A study in
higher risk of vitamin D deficiency compared to workers Thailand has also showed a decrease in bone turnover and
who did not wear veil [49]. Consequently, a study in North prevention of bone loss among elderly women who were
Sumatra, Indonesia, showed that the mean vitamin D level in supplemented with calcium [61]. Interestingly, there was also
women was 17.1 ng/mL, which was far below the normal prevention of clinical fractures among elderly who were
serum level for a country with sufficient sun exposure [48]. compliant on calcium supplementation relative to those with
There is also a positive association between higher poor compliance [62]. With respect to pregnancy, studies also
physical activity outdoors and vitamin D levels [50]. A showed that maternal skeletal remodeling could be reduced
Spanish study showed that 82% of Spanish indoor athletes by means of calcium supplementation [63, 64]. A randomized
had suboptimal levels of plasma vitamin D concentration, crossover trial of calcium supplementation on bone
suggesting that outdoor physical activities increases plasma resorption among pregnant women by Vanitha et al. showed
vitamin D concentration [51, 52]. A US study conducted by that 1200 mg of calcium supplementation during third
Sragg and Camargo using the US National Health and trimester of pregnancy reduces maternal bone skeletal
Nutrition Examination Survey (NHANES III) found that the turnover [63]. Additionally, a Cochrane review of 13 trials
association between physical activity and vitamin D was reported that the average risk of pre-eclampsia was reduced
stronger in outdoor compared to indoor environments [53]. among those receiving calcium supplementation [64].
Additionally, a Dutch longitudinal cross-sectional study Vitamin D supplementation prevents hip fractures among
showed that serum 25-hydroxyvitamin D (25-OHD) below elderly persons [65]. A meta-analysis of randomized
20 ng/ml was associated with poor physical performance controlled trials on prevention of fractures with vitamin D
among older men and women [54]. supplementation showed that vitamin D supplementation in
Dionyssiotis et al. also showed that physical activity and the range of 700-800 IU reduced the risk of hip fractures and
adequate dietary calcium intake was indicated as means to any non-vertebral fractures among the elderly [66]. Studies
maximize bone status benefits for women [55]. Additionally, also showed benefits of vitamin D supplementation on fall
there have been studies demonstrating association between prevention among older individuals [22, 67]. A systematic
physical activity (regardless of sunlight exposure) and BMD. review and meta-analysis study further revealed an additive
For example, a cochrane review indicated a protective effect effect of physical exercise and vitamin D3 supplementation
of exercise on bone density in post-menopausal women in on the improvement of muscle strength among older adults
comparison with control groups [56]. A Canadian study also [68]. Additionally, prenatal multivitamin supplementation
demonstrated that a step increase in the amount of daily helped to raise the serum 25 (OH) D (calcidiol; vitamin D2)
activity, using simple, daily performed tasks, can help level among childbearing age women with high prevalence of
prevent BMD decrease in post-menopausal women [57]. vitamin D insufficiency [69].
High level of fat in adipose tissue which affects health is Supplementation of combined calcium plus vitamin D
defined as obesity. Obesity can be calculated by measuring supports the prevention of osteoporosis and subsequent
58 Saptawati Bardosono et al.: Relevance of Calcium and Vitamin D in Supporting Bone Health: An
Expert Panel Recommendation in Indonesia

fractures among the older population [70]–[74]. Daily intake to build and maintain bones and vitamin D helping in the
of calcium and vitamin D supplementation was found to have effective absorption of calcium. This synergy has been
a positive effect on the skeleton of ambulatory demonstrated to reduce the risk of osteoporosis [25]. In
postmenopausal women [75]. Chapuy et al. showed that Indonesia, this could be emphasized and potentially
supplementation with vitamin D3 and calcium reduces the introduced to all healthcare practitioners, particularly in the
risk of hip fractures among elderly women [76]. Decalyos-II, primary care community. One way to achieve this could be to
a double-masked, placebo-controlled trial showed that provide a consensus guidance document, initiated by
calcium (1200 mg) and vitamin D3 (800 IU) in combination professional organizations such as Ikatan Dokter Indonesia
reduced both hip bone loss and the risk of hip fracture among (IDI), with the endorsement of ministry of health (MOH) for
elderly women [RR 1.69 (95% CI=0.96,3.0)] compared to implementation to the general population.
the placebo group. Besides this, other studies such as With emphasis on the study that highlights 40.6% of
Decalyos-I and the Dawson-Hughes et al. study have also Indonesian women aged 20-29 years had a low peak bone
established effects of combined calcium and vitamin D3 mass, indicates that these women could face the risk of
supplementation on the prevention of fracture risk [77]. fractures in the next 20 years when they reach menopause,
Overall, current literature have clearly demonstrated the which is the typical onset of decreased bone mass and an
benefits of calcium, vitamin D and combined calcium- increased risk of osteoporosis. This relatively high
vitamin D supplementation in meeting gaps in daily percentage of Indonesian women with low peak bone mass
requirement, more so in (i) preventing pre-eclampsia during could be attributed to low calcium consumption during late
pregnancy, and (ii) osteoporosis prevention among elderly childhood and early adulthood. With reference to the
[64, 70]–[72]. More research is warranted to further define SEANUT study, there is also low levels of vitamin D in
the benefits of calcium and vitamin D supplementation for comparison to WHO standards among pre-school and school-
pregnancy care and osteoporosis prevention. aged children in Indonesia. Exposure to morning sunlight is
Nevertheless, despite evidence emphasizing the benefits of the common practice amongst parents of newborn until
supplementation, there are a couple of watch-outs prior to around 2-4 years of age. However, this practice stops as soon
intake. Firstly, it is important to note the lower and upper as children reach pre-school age (4 years and above), largely
tolerable intake limits of each nutrient. Over intake of due to the environment. Parents try to keep children indoors
calcium and/or vitamin D could have negative consequences to minimize exposure to air pollution and drastic temperature
as these are fat-soluble nutrients, reinforcing the importance changes, thereby limiting their daily exposure to sunlight.
of guideline recommendations of tolerable limit. For example, Dietary habits such as the intake of processed food also
inconclusive evidence have suggested high calcium intake contributes to low vitamin D level. Vitamin D levels in our
may increase the risk of prostate cancer [78]. Preliminary body can be met with sufficient exposure to morning sunlight,
studies have also suggested an association of high calcium accompanied by adequate outdoor exercises. Efforts need to
levels with elevated risk of kidney stones [79]. Similarly for be put in the future, to increase this awareness in parents.
vitamin D, a study showed that intake of high doses of Supplementation in adequate proportion can support
vitamin D (cholecalciferol 500,000 IU) in older women was positive outcomes in bone health [59]. Current literature have
associated with more falls and fractures [80]. Also, the source clearly demonstrated the benefits of calcium, vitamin D and
and amount of calcium per intake needs to be considered too. combined calcium-vitamin D supplementation in meeting
Most calcium supplements provide calcium via either one of gaps in daily requirement [64, 70]–[72]. In Indonesia,
the two sources of elemental calcium: calcium carbonate or calcium supplementation has always been regarded mainly
calcium citrate. Calcium carbonate is absorbed best when for young children, pregnant women and elderly. The
taken with food, while calcium citrate is absorbed well on an purpose of consuming calcium supplements relates to helping
empty or a full stomach. Notably, calcium absorption is best children grow strong teeth and achieve heights, and for
when a person consumes no more than 500mg at a time. So a elderly to prevent osteoporosis. Overall, the awareness to
person who takes 1000 mg/day of calcium from supplements build up calcium repository from childhood up until
is advised to split the dose rather than take it all at once [10]. adulthood is low. There is a potential gap here that could be
All in all, prior to taking calcium and vitamin D supplements, addressed with continued efforts to educate the community
we need to take extra consideration on total amount taken, via healthcare professionals.
source of calcium and the amount per intake. Lastly, in this review, we focused on healthy individuals
going through various life stages such as childhood,
4. Conclusion adulthood, pregnancy and old age, however, some limitations
could be noted. More discussion and research is potentially
Overall, the literature on the FNB and IOF guidelines required for individuals with existing and/or underlying
demonstrated the importance of both calcium and vitamin D health conditions such as hypertension and diabetes. In these
in protecting and maintaining bone health, by recommending individuals, care for their bone health needs to be further
increased intake of both nutrients with age. This is tailored by their healthcare professionals, taking into account
scientifically well supported by the known synergistic roles their lifestyle and environment. Additionally, there is also a
of calcium and vitamin D in our bodies, with calcium helping need for an increased understanding of the benefits and
 International Journal of Nutrition and Food Sciences 2020; 9(2): 54-62 59

watch-outs of supplementation, with more discussion and be important guiding lights to assess nutrient deficiencies and
research relevant towards Indonesian population. associated risks. In the future, interventions could be best
In conclusion, early and adequate intake of calcium and initiated within the primary care communities, which has
vitamin D, alongside lifestyle modifications and appropriate frequent touchpoints with the general population.
supplementation could contribute towards strong bone health Table 2 summarizes the key recommendations and
in Indonesia. In this journey, healthcare professionals could accompanying literature to support.
Table 2. Key recommendations.

Recommendations Available evidences

1) Ilich JZ et al. Eur J Clin Nutr. 2003. 57 (4): 554-65.
2) Chen LR et al. International Journal of Gerontology. 2014. 8: 183-188
Calcium and vitamin D work synergistically to
3) Von Domarus et al. Clin Orthop Relat Res. 2011. 469 (11): 3127–3133
maintain bone health
4) Kyoung M K et al. J Clin Endocrinol Metab. 2014. 99 (7): 2409-2417
5) Beaudart C et al. J Clin Endocrinol Metab. 2014. 99 (11): 4336-45
1) Setiarsih D et al. Makara J. Health Res. 2016. 20 (3): 63-68
2) Sugianto R et al. Jurnal Gizi Klinik Indonesia 2014.11 (2): 78-84
Intake of calcium and vitamin D must start early 3) M. C. Kruger et al. Nutrients. 2016. 8 (6): 376
4) C. F. Munns et al. J Clin Endocrinol Metab. 2016.101: 394–415
5) Uday, S. & Högler, W. et al. Curr Osteoporos Rep.201.15: 293
1) Scragg R et al. Am J Epidemiol. 2008.168 (6): 577-86
2) Dionyssiotis et al. BMC Women's Health. 2010. 10: 12
Our diet and lifestyle today may not allow us to meet 3) Howe TE et al. Cochrane Database Syst Rev. 2011. (7): CD000333
the daily recommended intake of calcium and vitamin 4) Wicherts IS, et al. J Clin Endocrinol Metab. 2007. 92: 2058–65
D 5) Valtueña J et al. Nutr Hosp. 2014. 30 (1): 124-31
6) Wanner M et al. Cancer Causes Control. 2015. 26 (6): 881-91.
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