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PARENT STRATEGIES FOR PARENTS, BY PARENTS

EPSOM SALTS (and calcium) AND YOUR CHILD WITH ASD (expanded version)

A Note To Our Readers: Welcome to our BBB Guides, a series of documents by and for parents on various topics. When searching the web, I could find little in the way practical solutions to issues like handling Halloween and large family gatherings. Our message board, however always contains such fantastic tips offered by our experts: parents of children with ASD. These are parents of various stages, their children are affected with various severities and they are all different ages. About half of our contributors have more than one child on the spectrum.

I hope you enjoy this guide and the upcoming series; and that they are helpful to you. If you would like to contribute to or have ideas for future guides, please email me at mailto:bbbautism@deaknet.com.

Thanks to all our great parent-contributors. It couldn’t be done it without you!

Note: Our children are referred to as first initials only and we don’t include last names. We never publish these comments without permission from the contributor.

BBB Autism Online Support Network: http://www.bbbautism.com/club_front_page.htm - club_new_front_page

I was telling someone about this recipe I read, (in BBB Autism). It was an ointment with Epsom salts for those of our kids who respond to getting their Magnesium this way. I remember reading that it was a bit like making Mayonnaise? Does anyone else remember this? I went back to the old club site and have spent hours reading through old posts with no luck, so I was hoping someone here might recall what it was and maybe even have it.

I have heard that some kids with autism have big improvements using Epsom salts. In what way are they being used? Does anyone know why they help?

THE REPLIES

Read one family’s experience here: http://www.afrikanalouisiana.com/epsom_salts_baths__candace_start.htm

“Sulfation also plays an important part in detoxifying the body, according to Paul Shattock. These children do not absorb sulfur-based substances well. He recommended giving children baths in Epsom salts two or three times a week to help sulfur be absorbed through the skin. Although baths are best, he also suggested that bottle with a sponge tip (such as those used for dish detergent) could be used as an applicator to wet the skin with a mixture of Epsom salts and water. “ From the Biology of Autism conference: http://autismcoach.com/page2.html

EPSOM SALTS CREAM FROM KIRKMANS’

Hi Sue,

Do you want to use the Epsom Salt as a cream for sulphation purposes? We use a magnesium sulphate cream for that. We got it from our local pharmacy, but I know you can get it from Kirkmans (you don't need a prescription). This magnesium sulphate cream is just like mayonnaise, and we rub a teeny amount on L. as he sleeps.

Hi Sue,
OK I have my books out here for you...Let's see what they say about magnesium...

MAGNESIUM
Sue you wondered if this was related to leaky gut. Don't know about that, but since it is an "anti-stress" mineral, perhaps it helps out. Magnesium is needed for calcium & vitamin C metabolism. Essential for nerve & muscle functioning & to convert blood sugar into energy. Combined with calcium can work as a natural tranquilizer.

A person under stress tends to lose excess magnesium. A deficiency then creates the setting for less resistance to stress. (My interpretation - autistic children are under stress, they lose magnesium, becoming less resistance to stress... therefore magnesium is calming because it helps reduce stress). I know there is a ratio for calcium-magnesium (I think it's 3:1)

EPSOM SALTS
I don't have anything written in front of me about this, but here's my interpretation... Epsom Salts help sulphation. That's the process where enzymes transform chemicals in our bodies (I think!). In other words, it's the body's ability to detoxify itself. It's believed that autistic people don't have this ability (most likely showing a PST deficiency - one of the enzymes needed to do this sulphation). Two things you can do about this - reduce the intake of things that need detoxification such as reducing artificial colouring, preservatives, and food additives. And Epsom salts work in the bath, by absorbing into the skin... or what we use is magnesium sulfate cream (doctor needs to recommend this). As for the leaky gut and how this is all intertwined... The proteins lining the gut are normally sulfated and form a protective layer over the surface of the gut wall. If sulphation is deficient, gaps occur in the gut wall (says my book).

DIRECTIONS FOR EPSOM SALTS IN THE BATH…

Bath Tub Soaking
By placing 1 cup per every 60 lbs. of body weight (it is not necessary to exceed 4 cups) in a warm* bathtub of water. The water temperature should be as comfortable. Rub skin all over with a washcloth to open up the pores for absorption of the Epsom salts. If some areas are sore rub them a little longer. If you are treating an injury you should rub both the area of the involved site on one extremity and the same area on the other extremity (bilateral stimulation reflex). In rubbing both extremities you yield a little extra stimulation to the injured site. Don't rinse off before getting out of the bathtub. Just dry off and retire for the evening.

Special Notation:
1.You may want to have some water for drinking near the tub. Hot baths can make you light headed and thirsty.

2. If you want to take a soap bath - do it first, because soap does not work in a salt bath.

Bath Procedure
Epsom salt baths are taken routinely, just before going to bed, the night before a major competitive event or race and just after. It also helps with combating jet. The bath will allow a more productive and restful sleep as well as produce an energy charging up effect on your body for the next day’s performance. According to nutritional researchers it improves the rate by 33.333%. This means that not only will you body heal faster but also sleep productivity will increase. That is to say, if you sleep eight hours, following the Epsom salts bath, the body productivity would be 8 hrs times 33.333% increase or 10.666 hrs of productivity. The body's performance is that of 10.66 hours of rest and repair.

Epsom salts and water are very therapeutic and help to prevent problems as well as help to solve them. Epsom salt baths may be taken daily, one, twice, or even more to provide the necessary energy levels needed to both recover from injury or illness and charge up extra energy going into high stress levels of mental and/or physical activity. Routine Epsom salt baths are often recommended as a form of prevention.

* Use common sense when adjusting temperature for your child. A hot bath can be dangerous. To dissolve the salts, mix in with some hot water to start and add the cold to make the bath nice and warm. Never put your child in a hot bath!

A TREASURE CHEST OF EPSOM SALTS INFORMATION

Epsom Salts are simply hydrated Magnesium Sulfate, (MgSO4), and can be used as an alternative source of magnesium, beyond their use as a sulfate, since the magnesium can also be absorbed through the skin.

This has been found useful in persons who have Leaky Gut Syndrome, and thus have difficulty in absorbing certain essential minerals through the skin.

Interestingly enough, Epsom salts, taken orally, used to be the treatment of choice for chelation of heavy metals, such as lead. (This is back around the beginning of this century). Often this is called Methylation or Sulfination. Other things, like Zinc, should be used to prevent reabsorbtion of mercury or lead.

Magnesium Sulfate is also used to treat Pre-eclampsia, pre-term labor, asthma, Magnesium Sulfate Class CNS Depressant

Description Magnesium sulfate reduces striated muscle contractions and blocks peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural junction. In emergency care, magnesium sulfate is used in the management of seizures associated with toxemia of pregnancy. Other uses of magnesium sulfate include uterine relaxation (to inhibit

***Note in post above that it is also used in treating Alzheimer's/Dementia. I do know one woman whose father does much better with Epsom salts in his sponge bath water. He does calm down. His memory does not improve but his deterioration stabilized then later, when a new aide was bathing him and forgot the Epsom salts, he did become agitated and deteriorated further before they discovered that he had not been getting his Epsom salt baths daily. After starting them again he was calmer after two days.

Phenolsulphertransferase (PST) deficiency—theory that some with autism are low on sulphate or an enzyme that uses this, called phenol-sulphotransferase-P. This means that they will be unable to get rid of amines and phenolic compounds once they no longer have any use for them. These then stay in their body and may cause adverse effects, even in the brain. Treatment is dietary as well as Epsom salts baths.

Forms of Magnesium:
After looking into magnesium for months, what I came away with is that magnesium comes in two types: soluble forms/organic (aspartate, malate, glycinate, citrate and succinate etc.) and insoluble forms/inorganic salts (chloride, carbonate, oxide). Overall, the chelated magnesium and magnesium glycinate are often referred to as being very absorbable.

The soluble ones are pretty equally absorbed and as a group are much better absorbed than the insoluble group. Of the insoluble group, the oxide is the best absorbed. The insoluble group is far more likely to cause loose stools/diarrhea than the other group. If magnesium nutrition is what you want, go for the soluble group. If constipation is the issue, then some insoluble forms are okay. The loose stool effect (if not wanted) can be minimized by taking the magnesium with food.

Most of the products I saw on the shelves at the store were a mixture of magnesium types. Sometimes I would see a bottle of a specific type of magnesium, such as Magnesium Citrate. But the ones marked just Magnesium were usually a mixture. And some had as many as 4-5 different types in the mixture.

Although I have spent some time looking at magnesium sources, there seems to be varied opinions. Here is a reputable source from a book on nutrition:

"Magnesium chelated with amino acids is probably the most absorbable form. Less absorbable forms include magnesium bicarbonate, magnesium oxide, and magnesium carbonate. Magnesium oxide is probably somewhat better than magnesium carbonate (dolomite). The newly available salts of magnesium aspartate or citrate, both known as mineral transporters, have a better percentage of absorption."

http://www.healthy.net/asp/templates/article.asp?PageType=article&ID=2060

What Chelate Form Means:

"Magnesium Chelate (Amino Acid): A chemically reacted magnesium ion, bound to 1 or more amino acids, thus allowing the magnesium to enter through the intestinal wall via the amino acid pathway rather than active magnesium diffusion. A true reacted chelate differs from simply mixing the amino acids and minerals which is often referred to as "chelated"."

http://www.nutraceuticals.com/reactedmagnesium.htm

You need to balance out how absorbable a product is versus the quantity of the mineral that is in it versus the price.
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Magnesium in the Body:

Many times the chelated forms of anything are very absorbable and this explains why. Next is a link to a short summary of magnesium and its role in the body:

http://www.auravita.com/secure_check.asp?prodpage=http://www.auravita.com/healthnotesonline/ukinet50/Supp/Magnesium.asp

An even shorter summary:
http://health.yahoo.com/health/Diseases_and_Conditions/Disease_Feed_Data/Magnesium_in_diet

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Recommended Dosing:

RDAs:
350 mg/day for adult males over age 18
280 mg for females over age 18
320 mg for adult females - pregnant
355 mg for females lactating 0-6 months
340 mg for females lactating 6 months+
400 mg for males ages 15-18
300 mg for females ages 15-18
270 mg for males ages 11-14
280 mg for females ages 11-14
170 mg for children ages 7-10
120 mg for children ages 4-6
80 mg for children ages 1-3
60 mg for infants ages 0.5-1.0
40 mg for infants ages 0-0.5

These amounts are for healthy people. A person in an unwell or deficient state would need more. Most places recommend 2:1 calcium: magnesium ratio for regular function, not including a deficient state. When I was researching this, I looked up the amounts in a reference book in the HFS. The average recommended amount was generally 1000 mg/day for ADHD, anxiety disorder, migraines, sleep disorders, autism and some of the autoimmune disorders. These are probably for an adult and so a child should have 1/2 or 1/3. This puts it around 300-500 mg/day. I haven't found an upper limit to magnesium, and have read several places there is no known toxicity.

Also, we saw again and again that there was not a toxicity problem because the body does not store magnesium as it does calcium. The body excretes what is not used. Your upper limit will be when you notice continuous loose stools.

Here is a link to children's doses for vitamins, minerals and herbs. You may need to piece the URL together since it is so long:

http://www.alternativeparenting.com/health/natural_remedies/herbal_dos

NOTE: Excessive magnesium inhibits calcium and excessive calcium inhibits magnesium - although I didn't seen any amount as given as "excessive" for magnesium. Calcium had the number of 2500 mg/day most likely for an adult - from the Encyclopedia of Nutritional Supplements at the HFS. It is a balancing act.

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Symptoms of Magnesium Deficiency
Magnesium deficiency is associated with fibromyalgia, chronic fatigue, migraines, and a bunch of other ailments. Supplementing with magnesium has helped many of these conditions in clinical studies.

The symptoms of magnesium deficiency are irritability, tantrums, seizures, insomnia, muscle cramps/twitching, hyperactivity and poor digestion among others. Magnesium is needed for proper electrolyte function, over 300 enzyme functions, and calcium absorption.

I also found it very interested to read that one of the primary sources of dietary magnesium is whole grains and cereals. If one goes 100% gluten free, you would be loosing a main source of magnesium, and could go deficient especially if you are also supplementing with extra calcium to make up for the casein free part.

Higher amount of magnesium may cause a laxative effect (milk of magnesium, Epsom salts).
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References:
I am currently using Natural Calm. It is a very absorbable magnesium citrate powder that you dissolve in water and drink. I like heating it and drinking it like tea - it has a very mild citrus/orange taste. There is a web site http://www.naturalcalm.com/ and you can get it at your health food store.

Here is the site for Natural Calm magnesium: http://www.naturalcalm.net/home.shtml

Even if you aren't interested in this product, it has LOADS of information on magnesium, how is affects different conditions, how calcium and/or magnesium deficiencies are created AND you can ask for a free sample to be sent. I got a free sample in the HFS and, if it is the same sample, it contains 3 full teaspoons, which is 1 serving. Although for a child you would give at least half and start lower. The price on the web site is the same as it is at my HFS.

Magnesium is supposed to help with pain, migraines, chronic fatigue, fibro and other conditions. This is supposed to be quickly absorbed. The literature says it can work "in minutes" and so I made some as soon as I got home. About 20 minutes later, my headache was significantly better. It is used by doctors and clinics according to the literature.

The Brainchild Night-Cal supplement contains the following, each 2 Teaspoon Dose of NightCal:

Calcium from Kreb's Chelates450 mg
Magnesium from Kreb's Chelates50 mg
Potassium Alpha Ketoglutarate100 mg
Selenium from Selenomethionine100 mcg
Vitamin D-3 as Cholecalciferol100 IU

The direct link with description is: http://www.brainchildnutritionals.com/Night_Calx.html

Here is a link to a pretty thorough, but easy to follow, description of magnesium from HealthWorld Online.

http://www.healthy.net/asp/templates/article.asp?PageType=article&ID=2060

"Magnesium chelated with amino acids is probably the most absorbable form. Less absorbable forms include magnesium bicarbonate, magnesium oxide, and magnesium carbonate. Magnesium oxide is probably somewhat better than magnesium carbonate (dolomite). The newly available salts of magnesium aspartate or citrate, both known as mineral transporters have a better percentage of absorption."

It also says that calcium and magnesium should be taken in between meals, on an empty stomach for best absorption.

"The many enzyme systems that require magnesium help restore normal energy levels. Because of this function and its nerve and muscle support, magnesium may also be helpful for nervousness, anxiety, insomnia, depression, and muscle cramps. Magnesium is also given as part of a treatment for autism or hyperactivity in kids, usually along with vitamin B6."

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Epsom Salts
by Karen DeFelice and notes from Susan Owens
http://groups.yahoo.com/group/enzymesandautism

What are Epsom salts?
Epsom salts are magnesium sulfate. Salts are just molecules that come together based on having a positive and negative charge. Magnesium has a positive charge. Sulfate has a negative charge, and they dissociate (or go their separate ways) in solution. Sulfate is a sulfur atom surrounded by four oxygen atoms and it has a negative charge. It has all sorts of unique biological functions. Epsom salts can be very beneficial for individuals with neurological conditions including autism spectrum, sensory integration disorder, and ADD/ADHD.

How do they work? Why do they work?

Dr. Rosemary Waring has found that most autistic spectrum kids, and lots of others with neurological conditions, are very low in sulfate. They may be as low as 15% of neurologically typical people. Sulfate is needed for a pathway in the body that processes salicylates, phenols, chemicals of all kinds (including food colors, artificial flavoring, and preservatives), and other things the body sees as toxins. This can include heavy metals. The body may have more toxins to process than it can because of a lack of sulfur. To alleviate the unpleasant reactions such as hyperness, aggression, tantrums, sleep problems, night sweats, irritability, eczema, other skin conditions, etc. you can unclog this "bottleneck" by 1) getting rid of the amount of toxins that enter the body, or 2) supplying more sulfur to increase the amount of toxins that can be processed from the body. Epsom salts (magnesium sulfate) supplies the needed sulfur. The body takes in more sulfur, more toxins are processed and you don't see the nasty behaviors and effects.

Many people on a typical American diet are very deficient in magnesium as well. Epsom salts also supplies magnesium. A main effect
of insufficient magnesium is hyperness, irritability, anxiety and muscle twitching or spasms. So the salts provide two-way assistance.
Sulfur can also be added to the body by supplementing with MSM.

Some people may think Epsom salts work by pulling the toxins out of the body and into the water. Certainly you can sweat out certain toxins like you would in a sauna, but the role of sulfate in the water for that process is questionable. The way sulfate in the water is most likely to be working is by being absorbed into the body through the skin where it can become part of the biological process of detoxification.

Once in the blood, sulfate does not stay there for long. In fact, some studies have suggested that it does what it does and then ends up in the urine four to nine hours later. The Epsom salts left on the skin may continue to be absorbed as long as it is still on the skin, offering something sort of like "timed release" into the blood stream. For that reason, leaving the Epsom salts on the skin to dry may be beneficial for stretching out the effectiveness of this intervention, like medications that are administered through skin patches. None of this process of skin absorption has ever been quantified (as far as I know).

Here is a link to a VERY LONG description (may "thorough" is a better description) of this detox pathway and sulfur.
http://groups.yahoo.com/group/enzymesandautism/files/Related Topics/PST

Here is a link to a quick description on phenols and salicylates.
http://autismawakeninginia.bizland.com/autismawakeningdietintervention/id10.html

If you do a search for PST or phenyl sulfotransferase system, you will find many, many references on this.

How to Give Epsom Salts:
There are several methods parents have used.

1. Epsom salt baths. Most people use about 1-2 cups per tub. Dissolve the salts in hot water first and then fill the tub to about waist deep, as warm as possible. The amount of salts that you may find works best will depend on the individual tolerance, the temperature of the water, and the size of the tub. The warmer the water and larger the tub, the more salts will dissolve. You may need to start slowly using as little as one tablespoon of salts and working up gradually. Some people have been deficient for so long that the full quantity is too much a shock, and you will see negative reactions. In the beginning, a person may react with hyperactivity, irritability or moodiness. However, at the right amount, most people find the salts very calming and relaxing. This works well before bedtime. Soak in the bath a good 20 minutes. It is okay to let the salts dry on the skin. They may leave a dry clear- white powder. If it is too itchy or irritating, just rinse them off. If the skin feels too dry, use lotion or oils to moisturize. Don't drink the bath water because it could cause diarrhea.

2. Epsom salt oil. I have been experimenting a bit with the Epsom salts. It would leave a salty film on the skin, which my two boys and I didn't like (itchy). Lately, I have been mixing some coconut oil in with the salts and water. Actually it is more oil than water. 3 tablespoons water + 4 tablespoons salts + 12 tablespoon coconut oil. The coconut oil is good for the skin anyway and it seems to counter the drying effect of the salts. I found that just mixing the salts and oil did not dissolve the salts, so I needed to add just some water. I apply this liberally on the skin and it soaks in plus leaves the skin smooth and soft.

3. Mix 1 part salts to 2 parts water (or more so the salts dissolve) and let the person soak their feet in it. My boys would soak their feet about 30 minutes while they did reading or homework.

4. Mix 1 part salts and 1 part water (add more water if the salts are not dissolved) and put in a spray-squirt bottle. Mist the child's chest and/or back and let it dry on. Works well in the summer.

5. Use one of those plastic squeeze bottles with a sponge on top that are used for dampening postal stamps, and fill it with the Epsom salts and water. A solution of 1 part salts to 4 parts water works well. This can be applied to the arms or leg or tummy or whatever is easily accessible.

6. There are some new Epsom salt creams available.

7. You can mix a salt and some kind of acceptable lotion into a paste. Put this paste on a large band-aid and apply to the skin. The salts will soak in.

As you can see, there is no exact ratio…just what seems to get the salts dissolved and on the skin. MSM powder or creams (many of these on the market) can help with the sulfur. However, some recent research shows that oral sulfur is not as well absorbed. Also, this won't supply magnesium.

Sulfate has an influence over almost every cellular function. Sulfate attaches to phenols and makes them less harmful, and sets them up for being excreted from your kidneys. A lot of these potentially toxic molecules are in foods, and since this is a capacity-limited system, those who are low in sulfate do well to eliminate exposures to foods and environmental things, which might put extra stress on this chemistry. That strategy is the focus of the Feingold diet, which restricts phenols from the diet. Your body also makes many different chemicals of this type, and they need to be cleared from the system before they get harmful.

If growth factors were bankers, sulfate would be their money. Growth factors use sulfate to do their business. That is why it is known that if you become VERY deficient in sulfate you will stop growing if you are a child, or you will start to break down (catabolize) your own muscle to make up for this deficiency. That means if your child has not been growing, and has very flimsy muscles, you should be concerned that his sulfate chemistry may be hurting. When this happens in very sick adults, it puts them into a state called cachexia, a wasting process that happens in Alzheimer's disease, AIDS, cancer, and an autism spectrum disorder called Rett Syndrome.

Sulfate is used to regulate the performance of many other molecules. Many systems in the body will not function well in a low-sulfate environment. One of the things is influences is the hormone that helps humans recognize faces and "socialize". Increasing sulfur in the body can improve socialization and related issues. Sulfur is so critical to life that the body will apparently borrow protein from the muscles to keep from running too low.

The autism community is learning that activating the immune system can put significant demands on this chemistry, and if that happens during infancy often enough and at critical stages, it may change or slow development. The body can start to waste sulfate into the urine: sulfate that it needs critically. If this happens, it could lead to the situation where the dietary sources of sulfur cannot be adequate to keep up with this drain. Dr. Rosemary Waring has found that autistic children tend to be dumping needed sulfate and related sulfur compounds into the urine. She has also found that the enzymes that make sulfate out of protein appear to be inhibited by one of the chemicals that is turned on by an activated immune system

Blood tests are not really adequate for measuring this, because the blood is a delivery system, and can be a compensatory system. Blood levels of sulfur-related compounds will actually go UP in the blood when the cells are starving, because the liver is trying to help out the rest of the body by exporting these materials.

Epsom Salt Ointment

(Please note: I got this recipe from a message board, and that person had got it from a list...you get the idea. I have not tried this myself, so it's not a personal endorsement)

>>I am sure that a handy person can come up with a cream/ ointment in the same way I did but here is the formula I have been using for about a year now. We use it after a bath before bed and as a hand and foot lotion during PT and to soothe. It absorbs fine and leaves only a little powder type residue.

1 cup Epsom salts
2 t non-aluminum baking soda
1/2 cup boiling distilled water
2 T glycerin
1/4 cup almond, olive, or sunflower oil
1/2 cup favorite natural lotion or cream from HFS OR 1/2 cup coconut butter

optional
a few drops lavender or other essential oils
a T flaxseed oil
a T evening primrose oil
a T of MSM powder to boost sulfate levels

This is like making real mayonnaise, you need to blend at high speed and add ingredients a little at a time.

Boil water and add to Epsom salts and baking soda in blender, pulse till dissolved and not grainy (must be boiling).

Add glycerin, then slowly add oils while blending to emulsify.

Still blending add lotion, cream, or coconut butter a little at a time.

Pour into a clean container, preferably ceramic or glass (I use a wide mouth mason jar that I can sterilize).

If this separates into layers when cool, rewarm and add 2T guar gum dissolved into a bit of hot water, reblend and cool.
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Mine separates almost immediately and I can't find any guar gum ANYWHERE. If anyone knows what could be used to stop the separation, please post a solution.
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It should not get grainy and should smooth on well and be rubbed into warm open pores. If you like it more or less oily change that part of the recipe, I make mine kind of thin like a light massage oil rather than a cream.<<(thanks to Dana!)

See following information about the benefits of Epsom salts contributed recently to OAARSN by Minna Mettinen of Whitefish in Northern Ontario. If you post this information, please could you credit her for all the research?

I would agree from our experience with our adult son who has been taking Epsom salts in solution through his nightly bath before bedtime for the past 5 years--he soaks for 30 minutes each night in a solution oft least half a kilo of salts per tub. There are the added benefits of the relaxing soak promoting good sleep.

It is also said that soaking in an Epsom salt solution removes toxins from the body.

As to passing on the advice, I think that's OK. I think it wise always to include a small disclaimer that this is experience on the front lines and people should consult/inform their health professionals. Epsom salts are unlikely to do any harm.

Epsom salts are magnesium sulfate. Salts are just molecules that come together based on having a positive and negative charge. Magnesium has a positive charge. Sulfate has a negative charge, and they dissociate (or go their separate ways) in solution. Sulfate is a sulfur atom surrounded by four oxygen atoms and it has a negative charge. It has all sorts of unique biological functions. Epsom salts can be very beneficial for individuals with neurological conditions including autism spectrum, sensory integration disorder, and ADD/ADHD.

Mild calcium deficiency can cause nerve sensitivity, muscle twitching, brittle nails, irritability, palpitations and insomnia. Signs of severe deficiency include abnormal heartbeat, muscle pains and cramps, numbness, stiffness and tingling of the hands and feet, and depression. Calcium deficiency in severe forms also can be characterized by excessive sweating of the head; insomnia; bone deformities; and growth retardation. In adults, deficiency can lead to osteomalacia with symptoms of bone pain, muscle weakness and delayed healing of fractures. Those at risk of calcium deficiency also includes people who are on high protein or high fiber diets. High dietary levels of phosphorus cause calcium to be removed from bone and excreted. Phosphorus is found in many common foods such as meat, cheese, processed foods and soda drinks, and people who consume large amount of these foods are at increased risk of calcium deficiency. Insoluble fiber, such as that found in wheat bran, reduces calcium absorption; but soluble fiber, such as that found in psyllium and fruit pectins, does not seem to affect absorption.

Although there are some variations between recommendations issued by different groups, the official Canadian recommendations for daily intake of elemental calcium are as follows:

Calcium needs to be balanced with magnesium. Most sources say the calcium: magnesium ratio should be 2:1 for most healthy people. Other sources recommend 1:1 for those trying to correct a magnesium deficiency and/or for overall health. Other nutrients are also needed for good calcium uptake, such as vitamin D and K and potassium, but these usually do not need to be supplemented in addition to a regular diet. Sometimes not having enough magnesium will cause calcium to be deficient because there is not enough magnesium for the body to adequately use all the calcium available.

Supplementing with calcium is often necessary in addition to food intake. There are several issues involved here which complicate the matter. There is no 100% consensus on any part of calcium supplementation and so the consumer needs to be very informed in order to find a product that meets their needs, and educated in knowing how to interpret the large volumes of literature available.

Selling mineral supplements has become a large, thriving business. This link goes to an article on the marketing of minerals – a nice description of the tactics and considerations involved in selling mineral supplements including calcium. Generally, a company will sell on price, source of calcium form, quality, performance, or service - trying to convince you any of these is the most important thing. http://www.nutraceuticalsworld.com/janfeb001.htm

In the area of calcium, you can find at least a few studies to support whatever position you want to take. Did find a Pubmed journal article saying that with low stomach acid they found no calcium carbonate absorption but good calcium citrate absorption. This was right by another Pubmed journal article saying that with low stomach acid, both carbonate and citrate were absorbed the same. There were studies saying to take calcium with food and without food. Studies saying to take calcium at a different time than magnesium and others saying to take calcium with magnesium. Studies saying it is best taken in the morning and others at night. Studies saying that carbonate is just as absorbable as other forms and dozens saying it wasn’t. So whatever someone’s particular point of view is, they can find a scientific published study – or perhaps a couple dozen - to support that. The information presented here reflects what the majority of the references have found state, and some of the counter arguments as well.

These are several issues that determine which products will ultimately be beneficial to the body.

- Solubility means the ability of a product to go into solution. The body can only use elemental calcium and so the compound must break up into the individual parts. A product must dissolve first before it can be absorbed.

A supplement should disintegrate in your stomach in an adequate amount of time for it to be useful to your body. To see if your calcium supplement disintegrates easily, place it in a bowl or glass in about 6 oz of vinegar or warm water. Stir occasionally for 30 minutes. It should be completely dissolved. If not, it is likely that this is how it will remain in your body and you should look for a different supplement. Many of the brands containing calcium carbonate in tablet or caplet form will have a note on the bottle saying it dissolved completely within 30 minutes. This test us only appropriate for the actual calcium salt, not multi-vitamins. Most water-soluble forms of calcium dissolve readily in the gut, just make sure it is not in tablet form, which could inhibit this reaction. The powdered products usually dissolve quickly, and the liquid supplements already have the compound in solution.

- Absorption means the ability of the elemental calcium in the product to be taken into the body in an acceptable form. Many manufacturers claim their minerals are easily absorbed. There can be two different interpretations of this:

Absorbed into the system - Anything that is one micron or smaller will pass through the stomach wall and go into the blood stream. One could say the product has been "absorbed". Most absorption occurs in the small intestine.

Absorbed into the cells - Just because something passes through the stomach wall into the blood does not necessarily mean it is useable. To be used by the body the minerals must be able to enter individual cells. Micron-sized minerals are too large. The mineral needs to be angstrom size. An angstrom is one million times smaller than a micron. Ionic forms are readily available. Other forms may or may not reach this size. http://www.healthcatchers.com/compare.html

6. Adequate or higher stomach acid - the acid environment of the stomach makes calcium salts more soluble, and therefore easier to absorb

These nutrients assist in the assimilation of calcium so it can work to help stop bone loss and improve electrolyte balance.

2. Compounds known as phytates (in dietary fiber) and oxalates (in leafy greens)

4. Smoking, high refined sugar intake, caffeine, alcohol and excess salt promote calcium excretion

5. High protein diets increase calcium excretion, particularly if the protein comes from meat.

Bioavailability refers to how well the elemental calcium is used by the body in a desirable way, not just taken into the blood stream and floating around. Even if a particle is small enough to be absorbed into the blood stream, it may not be small enough, or in the right form to be used at the cell level; therefore it cannot meet the body's requirement for calcium. When calcium intake is inadequate to maintain blood levels and other functions, calcium is removed from storage sites in bone. Osteoporosis may develop. It is also possible to have toxicity from too much unusable calcium in the body. At the same time the body may have a calcium deficiency because there is not enough calcium that is in usable form.

Some large mineral forms will simply move through the digestive tract and exit the body. Nothing is gained and nothing is lost except the cost of purchase. At other times the consequences are much more serious. Certain minerals, including calcium, tend to build up in the body and become toxic. When the calcium supplied through dietary intake is too large to go into the cells, some of it gets lodged between cells. That leads to calcium deposits associated with certain types of arthritis. Sometimes it shows up as kidney stones. Other large calcium molecules float around in the blood ready to become plaque inside the arteries. Unusable calcium is also responsible for a number of other disease conditions.

Some examples of metallic calcium are eggshell, oyster shell, calcium carbonate, dolomite, calcium salts and certain antacids such as Rolaids and Tums. The bioavailability (usability) of metallic minerals is approximately 8-12% in young people. After the age of 35-40 years, usability of the forms of calcium within the human body drops to 3-5%.

Bioavailability - Chelated Minerals During the chelation process an enzyme, protein or amino acid gets wrapped

around a mineral. When a cell is in need of one of those nutrients, the mineral wrapped in that nutrient is taken into the cell. The outer coating gets digested and guess what! There was a mineral hidden in the center! The body was tricked but our goal was achieved; the mineral was taken into the cell. Chelation sometimes increases the bioavailability to 30 or 40%. The usable portion still remains a small percentage of the total intake. When taking calcium in a usable form, the first thing that happens is the calcium goes for immediate use where it is most needed at the moment. That probably means it will be used by the cells. After the cells have been satisfied, then the extra calcium goes into bone storage.

Low bone density starts increasing. When there is not enough calcium to satisfy the cell need, calcium is taken from the bone.

The law says the amount of the element needs to be listed of the label by weight. The form that the calcium comes in is listed in parenthesis beside the weight. So if the label says Calcium 600 mg (as calcium malate), then you know that in each serving you are getting 600 mg of elemental calcium from the compound calcium malate. The weight of the compound form is irrelevant here and maybe much more. You are only interested in the weight of the elemental calcium because that is what your body needs and uses.

If the label does not use this format (then they are in violation of the guidelines for one thing) and just uses the form of calcium and then the weight, such as Calcium Carbonate 1000 mg, then the weight listed is the weight of the entire compound and not the weight of just elemental calcium. In this example, you would need to multiple the weight by the percent of calcium in the compound, so 1000 x 40% = 400 mg of elemental calcium is the elemental calcium you would really be getting.

If one bottle says each serving contains Calcium 250 mg (calcium carbonate), and another bottle says each serving contains Calcium 250 mg (calcium citrate), you are getting 250 mg of elemental calcium from either bottle. At this point, look at the form of the calcium and whether it is tablet, capsule, powder or liquid, if this makes a difference to you. The carbonate form, in general, is not very absorbable and some sources put it between 4 and 20%. The citrate form is more absorbable and some sources say from 20-66% more than the carbonate. A chelated or ionic form would also be highly absorbable. See the section on Which Form of Calcium is Best. Look for supplements that say "purified" or have the USP (U.S. Pharmacopoeia) symbol. The USP symbol, which is voluntary among vitamin and minerals manufacturers, means that the supplement meets certain criteria for quality, strength, and purity.

The calcium supplements on the market come with and without a vitamin D supplement. The reason that vitamin D is often put in calcium supplements is because vitamin D is needed for absorption of calcium from the intestine. What you need to consider in deciding whether you need a vitamin D supplement with your calcium supplement is if you get enough vitamin D from other sources. Humans can get vitamin D from 2 sources - the action of sunlight on skin, and milk, cereals, and other foods fortified with vitamin D. Daily exposure of skin (on hands, arms and face) to sunlight as little as 15 minutes per day provides sufficient vitamin D to prevent the bone disease rickets. Supplementation with vitamin D is probably not necessary except for people chronically shielded from sunlight and those who do not drink milk daily. However, the amount of the vitamin D supplement in most calcium supplements is at a safe level.

Possible side effects of calcium supplements include gas, bloating, constipation, and headache. Excess calcium not used at the cell level can contribute to kidney stones, gallstones, and calcium deposits on joins (arthritis). Taking magnesium will reverse these last problems. Magnesium will dissolve any excess calcium from the body, while helping any needed calcium to assimilate. Citrate does not produce the side effects that carbonate does. Also, taking calcium in smaller doses, less than 500 mg at a time, has been shown to reduce side effects. http://www.findarticles.com/m3225/8_62/65864208/p1/article.jhtml

There is a fair amount of conflicting information in the area of calcium sources. Most of the studies, literature and references indicated the ionic, chelated or water-soluble forms such as citrate were far more bioavailable and better to use whenever possible (about 85% of sources). Some other studies and sources say that there is no difference in the

availability of any form as long as they were pure and refined (about 15%) and even if there is, the carbonate form gives you more for your money. No sources were found that said carbonate was more available than other forms of calcium.

"Although calcium carbonate has the highest concentration of calcium by weight, this form of calcium is relatively insoluble, especially at a neutral pH. In contrast, calcium citrate, although containing about half as much calcium by weight, is a more soluble form of calcium." http://www.oznet.ksu.edu/ext_f&n/_timely/calcium.htm

Just as with magnesium and most other minerals, most sources all highly recommended an ionic or chelate form such as citrate, malate, fumarate, succinate, or lactate among others. A few studies showed carbonate may be equally absorbable, but not more absorbable. Three sources said under certain conditions of a person being in very good health, no malabsorption, no gastritis or other stomach conditions and having a lot of stomach acid (which is not the norm) then the carbonate may be equally absorbable. Most agreed that carbonate was a benefit over taking nothing, but that other sources were much better. Several of these studies are cited in the reference section. Completely avoid calcium supplements that are made from bone meal, dolomite, or unrefined oyster shell. These sources may be contaminated with of lead, aluminum, arsenic, mercury, and cadmium. Every source agreed that calcium carbonate is the lowest cost source of calcium, in general. However, this may be more from the manufacturers point of view than the consumers. Have gone to 2 health food stores, 3 pharmacies and 1 grocery-drug store doing cost comparisons on brand after brand of calcium supplements (November 2001). Studied at least 20 bottles in each place. Did not find any trend in cost based on the form of calcium. The carbonate containing products were just as expensive or just as cheap as the citrate and other forms. Some brands used just one form calcium and others used a mixture of forms. Costs ranged from $8-15 for a months supply to over $35 for a months supply. In fact, the cheapest source found was a brand of pure calcium citrate. Most online supplement sources also sold calcium citrate, or other water-soluble forms, as inexpensively as calcium carbonate containing products.

More adverse reactions and side effects are seen with the carbonate form calcium (constipation, nausea, irritability, headaches, etc.). Calcium citrate and others are far better tolerated and rarely are side effects noted with these forms.

Most manufacturers use carbonate because it is an older form of calcium, widely available, cheaper for the manufacturer, and reduces bulk. Because carbonate is 40% Ca, products can contain a higher concentration of elemental Ca in the carbonate form (40%). So you may be able to take 2 tablets of calcium to get 600 mg using carbonate, but need to take 4 or more tablets to get 600 mg of Ca using other forms. Several sources noted that although the carbonate is not as available, it may be easier to get someone to take fewer capsules containing carbonate rather than more capsules containing another form that may be less problematic. However, you could also take fewer capsules of the more bioavailable form and still get the same amount of usable calcium.

Because of the large amount of inconsistent information, have decided to divide the sources into groups to see if any trends or consistencies emerged. This is how it played out.

Each commercial company that sold supplements, whether it was carbonate, citrate, ionic, any other form or a blend, adamantly stood by their product as being fully supported by clinical studies, excellent quality ingredients and product, high quality manufacturing practices, and good value for the price.

Those in support of calcium carbonate as a good source referenced these advantages:

1. Cheaper to make (although this was not apparent for the consumer in my observations, see above)

2. Less bulk – this means that someone can take less amount of a product, either fewer pills or less powder, in order to get the same amount of elemental calcium from the source. Whether this elemental calcium becomes available for use by the body is debated.

3. Widely available – most calcium supplements on the market are in carbonate form.

4. Product quality – most manufacturers said THEIR brand of carbonate was very pure in quality and highly available and that the studies showing carbonate was not available used other companies inferior products.

5. Studies – most companies referenced studies supporting their view that carbonate is just as available as other forms and said that contrary studies were old, not conducted fairly, or did not measure absorption properly.

Those in support of citrate of other soluble forms as a good source referenced these advantages:

1. Cheaper to use – although the carbonate form was less expensive for the manufacturer, they pointed out the body could not use most of it in that form so the consumer was wasting money on it. So other forms were much cheaper in the long run as a way to get usable calcium in the body 2. More bulk – considered not as relevant because the quantity of a liquid was not that much more to drink, the quantity of a powder was not much more to mix, and most people who swallow pills did not care if they needed to take more. And if your body wasn’t going to use the calcium form anyway, why bother taking it at all.

3. Widely available – although not the most common source, these forms of calcium can be found practically anywhere calcium supplements as sold.

4. Product quality – most manufacturers said THEIR brand of calcium was very pure in quality and highly available and that the contrary studies showing carbonate was just as available used other companies inferior products.

5. Studies – most referenced studies supporting their view that the carbonate form is not as or not very available and said that other contrary studies were old, not conducted fairly, or did not measure absorption properly.

Those in support of a blend of calcium forms or who sold more than one form noted these advantages:

have looked up calcium in these reference books available at the health food stores and pharmacies:

1. If you are going to take a calcium supplement for over a couple of months, you need to balance other minerals with them. Taking a multi-vitamin/mineral supplement is sufficient to do this.

4. Calcium is better absorbed in small amounts, so taking smaller doses enhances total calcium uptake.

5. When considering supplements, make sure you correctly note how many pills or capsules need to be taken to achieve one serving, or will be needed to get the amount of elemental calcium you want.

6. Calcium carbonate is one of the least expensive forms, but causes constipation and bloating. It is not well absorbed by people with low or reduced stomach acid. Taking with meals improves absorption.

7. Chelated calcium citrate, citrate malate, lactate, gluconate, aspartate, or orotate are water-soluble and well-tolerated forms, although they may be bulkier. These are better for building bone and correcting osteoporosis.

10. Soybeans, cocoa, kale, spinach, cashews, almonds contain phytic/oxalic acid, which can bind with calcium in the intestines and inhibit absorption.

Although some sources of calcium are absorbed better than others, inadequate information exists to compare them all and determine if one is always best. Calcium carbonate is a good source of calcium as long as adequate stomach acid or acid foods are present. Most people absorb calcium better from calcium citrate than from carbonate because it is soluble in water. The citrate form is also considered safer from side effects and better tolerated.

Many references can be found on the internet or in Pubmed by searching for calcium, calcium supplements, and calcium absorption. Just a few are given below.

2. Citracal - A lot of calcium information here: http://www.missionpharmacal.com/citracal/delivers.htm

3. Kansas State Research and Extension: http://www.oznet.ksu.edu/ext_f&n/_timely/calcium.htm

4. General information on calcium supplements: http://www.musclephotos.com/supplemt.html

5. The Natural Pharmacist – online nutrition reference: http://www.tnp.com/encyclopedia

7. Excerpt from lecture by Dr. Steven Whiting, Director, Institute of Nutritional Science Reproduced with permission: http://www.webdeb.com/bio-calcium.htm

8. Table comparing calcium citrate and carbonate, and vitamin D: http://www.kumc.edu/SAH/dietetics/research/calcium/inform/calcsupp.html

11. Calcium Availability from Food: http://www.nutritionnewsfocus.com/archive/a1/CalcBioAvl.html

Fourteen normal subjects took 1000 mg calcium orally as calcium citrate or calcium carbonate. The amount of calcium absorbed was estimated from the rise in urinary calcium. The urinary calcium following calcium citrate load significantly higher (by 20-66%), whether expressed as the total amount or as the increment above basal (fasting) excretion. Thus, calcium citrate provides a more optimum calcium bioavailability than calcium carbonate.

J Clin Endocrinol Metab 1985 Aug;61(2):391-3 Related Articles, Books Nicar MJ, Pak CY. PMID: 4008614 [PubMed - indexed for MEDLINE]

13. Pharmacokinetics of calcium absorption from two commercial calcium supplements. Heller HJ, Stewart A, Haynes S, Pak CY.

14. Dose dependency of calcium absorption: a comparison of calcium carbonate and calcium citrate. Harvey JA, Zobitz MM, Pak CY.

These results confirm the superior calcium bioavailability from calcium citrate as compared with calcium carbonate.

15. Pharmacokinetic and pharmacodynamic comparison of two calcium supplements in postmenopausal women. Heller HJ, Greer LG, Haynes SD, Poindexter JR, Pak CY.

Compared with calcium carbonate, calcium citrate provided a 46% greater peak-basal variation and 94% higher change in area under the curve for serum calcium and a 41% greater increment in urinary calcium. Moreover, the decrement in serum parathyroid hormone concentration from baseline was greater after calcium citrate. In conclusion, calcium citrate is more bioavailable than calcium carbonate when given with a meal.

Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas 75390-8885, USA.

16. Absorbability and cost effectiveness in calcium supplementation. Heaney RP, Dowell SD, Bierman J, Hale CA, Bendich A.

BACKGROUND: Cost-effectiveness of calcium supplementation depends not only on the cost of the product but on the efficiency of its absorption. Published cost-benefit analyses assume equal bioavailability for all calcium sources. Some published studies have suggested that there are differences in both the bioavailability and cost of the major calcium supplements. RESULTS: All three calcium sources (marketed calcium carbonate, encapsulated calcium carbonate and marketed calcium citrate) produced identical 24-hour time courses for the increment in total serum calcium. Thus, these were equally absorbed and had equivalent bioavailability. Urine calcium rose slightly more with the citrate than with the carbonate preparations. but the difference was not significant. Serum iPTH showed the expected depression accompanying the rise in serum calcium, and there were no significant differences between products. CONCLUSION: Given the equivalent bioavailability of the two-marketed products, the cost benefit analysis favors the less expensive carbonate product.

17. Bo-Linn, G.W. et al., "An Evaluation of the Importance of Gastric Acid Secretion in the Absorption of Dietary Calcium," Journal of Clinical Investigation, 73:640-647, 1984.

Study measuring gastrointestinal absorption of calcium following a single meal. A large dose of the H2 antagonist cimetidine, which significantly reduces stomach acid, had no effect on calcium absorption in both normal subjects and in one patient with diagnosed achlorhydria (absence of stomach acid).

18. Relation between gastric secretion of acid and urinary excretion of calcium after oral supplements of calcium. Hunt JN, Johnson C.

The object of this study was to determine in 12 healthy subjects the relation between gastric secretion of acid and absorption of calcium from two different preparations of calcium, as judged from increased outputs of calcium in the urine. The increase in urinary output of calcium after solid calcium carbonate was greater in the subjects with the most gastric secretion of acid. The absorption of calcium after a solution of monocalcium citrate was independent of gastric secretion of acid. In the four subjects with the least gastric secretion of acid, there was no absorption of calcium after calcium carbonate, but the absorption after monocalcium citrate was as great as that for those who secreted greater amounts of acid.

19. A study in the New England Journal of Medicine by Dr. Robert Recker has shown that calcium absorption from calcium carbonate was lower in patients with achlorhydria (low or no stomach acid) than in normal subjects. Yet when calcium carbonate was taken with a meal, calcium absorption was normal even in patients with no stomach acid.

Recker, R.R., "Calcium Absorption and Achlorhydria," New England Journal of Medicine, 313:70-73, 1985.

Levenson, DI and R.S. Bockman, "A Review of Calcium Preparations," Nutrition Reviews, 50: 221-232, 1994.

Those studies that measure actual systemic calcium absorption show that calcium from most sources is well absorbed in healthy individuals. They also show that little acidity is necessary for calcium absorption, and that no basal gastric acidity seems to be necessary if calcium is taken with meals.

21. Stomach acid IS necessary for carbonate absorption (and other general information) NIH Concensus Panel

22. Sheikh, M.S., et al., "Gastrointestinal Absorption of Calcium from Milk and Calcium Salts," New England Journal of Medicine, 317:532-536,1987.

This study found no difference in the amount of calcium absorbed from equivalent amounts of various sources, including milk and several calcium salts, in fasting, healthy, young volunteers. This was true regardless of the solubility of the various forms of calcium.

23. Meta-analysis of calcium bioavailability: a comparison of calcium citrate with calcium carbonate.

RESULTS: Calcium absorption from calcium citrate was consistently significantly higher than that from calcium carbonate by 20.0% in the whole set, by 24.0% in Category A, by 27.2% on an empty stomach, and by 21.6% with meals. CONCLUSION: Calcium citrate is better absorbed than calcium carbonate by approximately 22% to 27%, either on an empty stomach or co-administered with meals.

Am J Ther 1999 Nov;6(6):313-21 Related Articles, Books University of Texas Southwestern Medical School, Center for Mineral Metabolism and Clinical Research, Dallas, TX 75235-8891, USA. Publication Types: Meta-Analysis PMID: 11329115 [PubMed - indexed for MEDLINE]

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