Exercise and Calcium Supplementation:

Effects on Calcium Homeostasis in

CLINICAL SCIENCES
Sportswomen
BERDINE R. MARTIN, SHELLY DAVIS, WAYNE W. CAMPBELL, and CONNIE M. WEAVER
Department of Foods and Nutrition, Purdue University, West Lafayette, IN

ABSTRACT
MARTIN, B. R., S. DAVIS, W. W. CAMPBELL, and C. M. WEAVER. Exercise and Calcium Supplementation: Effects on Calcium
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Homeostasis in Sportswomen. Med. Sci. Sports Exerc., Vol. 39, No. 9, pp. 1481–1486, 2007. Purpose: Exercise-induced sweat calcium
losses have been reported as substantial in male athletes. The first aim of the study was to quantify the increase in 24-h total dermal
calcium losses and the net changes in calcium retention in active sportswomen after a 1-h strenuous exercise session. A second aim was
to determine the effectiveness of calcium supplementation to offset any calcium loss. Methods: Twenty-six premenopausal
sportswomen completed three 8-d intervention phases in a randomized-order, crossover design. The three phases were placebo + no
exercise (control), placebo + exercise, and 400 mg of calcium as calcium carbonate (TUMS Ultra) twice daily + exercise. The
supervised exercise was 1 hIdj1 cycling at 65–70% of heart rate reserve. A controlled diet of approximately 450 mgIdj1 of calcium and
24-h pooled urine and fecal collections allowed determination of calcium balance on days 5–8 of each phase. Twenty-four-hour dermal
collections were made at the end of each phase using a whole-body washdown procedure. Results: Exercise increased (P G 0.05)
dermal calcium losses (means T SD, 92 T 49 vs 79 T 31 mgIdj1 in the nonexercise intervention period), which was no longer significant
(P = 0.14) when calcium supplementation was provided (83 T 49 mgIdj1). Higher (P G 0.01) urinary calcium excretion during calcium
supplementation is suggestive of higher net calcium absorption. Exercise did not affect urinary calcium excretion indicating lack of
compensation for dermal losses. Net calcium retention was positive only during the exercise + calcium supplementation intervention
period. Conclusions: Calcium supplementation can correct for negative calcium balance attributable to low calcium dietary intake and
additional dermal losses from exercise. Key Words: CALCIUM BALANCE, PHYSICAL ACTIVITY, WOMEN, TOTAL-BODY
SWEAT LOSS, SWEAT CALCIUM

ence between whole-body 47Ca retention and 47Ca excretion

N
et deposition of calcium into bone requires that
calcium intake is greater than obligatory calcium
losses, which can occur in urine, feces, and the
whole-body dermis. Women are at risk for calcium
insufficiency, mainly because of inadequate intake (11).
Although serum calcium concentration is tightly regulated
through a vitamin D and parathyroid hormone–mediated
homeostatic regulatory system, this mechanism is unable to
fully compensate for low calcium intakes or high calcium
losses. Obligatory losses of calcium in urine and endoge-
nous excretion are substantial (9 200 mgIdj1). Sweat
calcium loss in adults has been estimated from the differ-
Address for correspondence: Wayne W. Campbell, Ph.D., Associate
Professor, Department of Foods and Nutrition, Purdue University, 700
W. State Street, West Lafayette, IN 47907-2059; E-mail: campbeww@
purdue.edu.
Submitted for publication January 2007.
Accepted for publication April 2007.
0195-9131/07/3909-1481/0
MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ
Copyright Ó 2007 by the American College of Sports Medicine
DOI: 10.1249/mss.0b013e318074ccc7
as an average of 63 mgIdj1 (6).
A few studies in men have reported much higher calcium
losses during periods of vigorous physical activity. Sweat
samples collected during practice from cotton T-shirts of
basketball players during 3 d of two practices per day lasting
two or more hours averaged a calcium loss of 247 mg, which
was sufficient to translate to a skeletal loss of calcium (12).
In 42 males undergoing fire-fighting training, sweat calcium
loss averaged 107 mg per session (18). These studies in
men undergoing strenuous activity do not predict calcium
losses that might occur in women participating in strenuous
exercise programs. These studies also did not measure total
calcium balance and looked only at dermal losses from a
small proportion of the total skin surface.
Several studies have included measurements of calcium
losses during exercise under short-term, controlled con-
ditions or have measured 24-h calcium losses without
studying the effects of exercise on calcium losses. Arm
bags were used to measure sweat calcium losses of men in
environmental chambers of various temperatures for 7.5 h
that included 100 minIdj1 of exercise (9). Sweat calcium
losses averaged 8.1 mgIhj1 at 21-C. In a second experiment,

1481

Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 three men participating in moderate exercise for 30 min at
23.9-C lost an average of 3 mgIhj1 calcium in sweat (9).
Whole-body dermal calcium losses during 40 min of intense
CLINICAL SCIENCES
exercise in 16 young men ranged from 18 to 31 mg (8). We
have previously reported whole-body 24-h dermal calcium
losses of 103 T 22 mgIdj1 (~4.3 mgIhj1) in six young
women not participating in an exercise intervention (19).
The lower calcium losses in this study compared with the
studies involving exercise could be an exercise effect on
dermal calcium loss, overestimates from partial body
measurements compared with whole-body measurements,
or a gender difference in dermal calcium loss.
The aims of the present study were to assess the effects of
moderate-intensity exercise on dermal calcium losses dur-
ing abstinence from exercise versus strenuous exercise in
the context of overall daily calcium retention, and to
determine the role of calcium supplementation on calcium
homeostasis in premenopausal physically active sports-
women. We hypothesized that calcium supplementation
could correct exercise-induced calcium losses.
METHODS
Subjects. Healthy, premenopausal women (N = 26,
20–40 yr) who had regular menstrual cycles (21–35 d)
were recruited through flyers posted at local exercising
facilities. Aerobically trained women were included as
assessed during screening who participated in more than
three exercise sessions per week and who had maximal O2
uptake capacities (V̇O2peak) of 9 36.7 mLIkgj1Iminj1. Each
woman`s V̇O 2peak was estimated using the YMCA
multistage cycle ergometry protocol and a Monark
Ergomedic bike, Model 818E. Women were included with
a BMI between 18.5 and 29.9 kgImj2. General health was
assessed by a clinical chemistry profile and a screening
instrument. Exclusion criteria included pregnancy, lactation,
amenorrhea, unwillingness to stop dietary supplements, use
of medications affecting calcium metabolism, use of
prescription products for osteoporosis, known intolerance
to study materials, history of renal or hepatic disease or
eating disorders, or clinical laboratory values greater than or
less than 10% of normal ranges.
Weight in light clothing was measured with a calibrated
electronic scale and height, without shoes, was measured
with a wall-mounted stadiometer. Prestudy dietary intake
was determined by a 3-d diet record following instructions
given by study personnel. The study protocol was approved
by the Purdue University institutional review board, and all
subjects provided written, informed consent.
Sample size was determined by power calculations. Power
calculations were made with a univariate, one-way repeated-
measures ANOVA with constant correlation design with a
significance of 0.95, three treatment periods, and an assump-
tion of correlation of 0.75 between periods for each end point.
For dermal calcium loss, assuming a within-treatment stand-
ard deviation of 22.3 mgIdj1 (19) and a between-treatment
1482 Official Journal of the American College of Sports Medicine
Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
standard deviation of 37.5 mgIdj1, a sample size of 21 was
determined to have 9 90% power to detect a difference of 15
mgIdj1 between two treatments. For calcium retention,
assuming a within-treatment standard deviation of 104
mgIdj1 (22) and a between-treatment standard deviation of
506 mg, a sample size of 21 had 85% power to detect a
50-mgIdj1 difference between two treatments.
Protocol. For at least 2 wk before the beginning of the
intervention, subjects consumed one Geritol Complete daily
containing 148 mg of Ca and 400 IU of vitamin D; they
continued this throughout the complete study. Subjects
participated in three 8-d intervention phases in a
randomized-order, crossover design. The three intervention
phases were 1) placebo/no exercise (control), 2) placebo/
exercise, and 3) calcium supplementation/exercise. Each
phase was separated by a 7- to 30-d washout period. During
each intervention period, subjects consumed a controlled
diet provided by the research staff. The diet consisted of a
3-d cycle menu, which provided 2400–2500 kcal, 60–65 g
of protein, 25–30% kcal as fat, 400 g of carbohydrate, and
450–500 mg of calcium (including Geritol calcium). Our
targeted daily calcium intake was 600 mgIdj1, but the
software program`s analysis of diet estimated the calcium
content to be about 150 mg higher than was found when the
food was analyzed. Uneaten food was returned for
determination of actual calcium intake.
Calcium supplementation was provided as calcium
carbonate (TUMS Ultra); each tablet contained 400 mg of
elemental calcium and two tablets were taken daily with
meals for a total daily supplementation of 800 mg of
elemental calcium. Calcium supplements and matching
placebos were provided by Glaxo Smith Kline Consumer
Health Care (Parsippany, NJ). Unused tablets were returned
to assess compliance. During the supplemented phase of the
study, total calcium consumption was equal to approxi-
mately 1250–1350 mgIdj1.
The exercise intervention consisted of daily supervised 1-h
sessions of cycling in a temperature (67–69-F) and humidity
(~30%)-controlled facility on a cycle ergometer at 65–70%
of heart rate reserve. This level of exercise intensity was
chosen as it is within the 55–90% range of V̇O2max
recommended by the American College of Sports Medicine
to promote cardiorespiratory fitness in healthy adults, and
1 h was chosen because it is the upper limit recommended
for cardiorespiratory health promotion (2). Intensity was
monitored by heart rate using a watch dial heart rate
monitor (Heart Meter Impulse, Sports Beat, Inc.) at 5-min
intervals for 15 min then at 10-min intervals for 45 min.
During the no-exercise phase, subjects participated in 1 h of
supervised rest in the same facility. The remainder of the
24-hIdj1 period was not supervised. Subjects recorded
hours and intensity of all daily exercise outside of the
monitored session. During the no-exercise phase, partici-
pants were instructed to eliminate all exercise. If they could
not comply with that guideline, they were to reduce both
time and intensity of exercise as much as possible.
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TABLE 1. Subject characteristics (N = 26). Analysis. Duplicate composites of each cycle menu,
Mean T SD Min–Max urine, and stools were processed and analyzed for calcium
Age (yr) 25 T 5 20–40b by inductively coupled plasma spectrophotometry (Optical

Height (cm) 167 T 6
Weight (kg) 62 T 8
BMI (kgImj2) 22.1 T 2.2
Habitual calcium intake (mgIdj1) 926 T 463
V̇O2peak (mLIkgj1Iminj1) 43 T 6
Serum 25-hydroxyvitamin D (ngImLj1) 46 T 22
Serum 1,25-dihydroxyvitamin D (pgImLj1) 49.8 T 12.2
Serum parathyroid hormone (pgImLj1) 43.1 T 12.9
Serum calcium 9.4 T 0.3
a
Day 1 of first phase.
b
Determined during screening procedure.
c
Excludes one person who used a tanning bed weekly with a serum 25-hydroxyvitamin
D level of 233 ngImLj1 .
Twenty-four-hour urine and fecal collections were taken
throughout the intervention phase, which ended with rising
collections on day 9. The first 4 d were considered the
adjustment period, and the next 4 d were used to determine
calcium balance.
On day 7 of each 8-d phase, 24-h whole-body dermal
calcium losses were determined as previously described
(19). After the supervised exercise or rest period on day 7,
subjects had a whole-body scrubdown to remove sweat,
dirt, and exfoliated skin. They dressed in pretreated cotton
pajamas and an external paper suiting, which covered the
whole body except the head and hands. After the supervised
exercise or rest period on day 8, which corresponded to
24 h in the cotton pajamas, the pajamas and rinses from a
second whole-body scrubdown were collected for extraction
and determination of calcium losses. This procedure
includes sweat plus any dermal losses from exfoliated skin
during the 24-h period from the whole body minus hands
and head.
Fasting blood was drawn on days 1 and 7 for determi-
nation of serum calcium, 25-hydroxyvitamin D, 1, 25-
hydroxyvitamin D, and parathyroid hormone.
Safety of the treatments was ensured by using both verbal
and written query reports of adverse events. Nonpregnant
status was verified at the beginning of each phase (Quick
Vue T One Step hCG Combo test, Pacific Biotech, Inc).
Resting blood pressure and heart rate were measured at the
beginning of each exercise session. Subjects were not
allowed to exercise if blood pressure was outside of
normally accepted values (90–140/50–90 mm Hg) after
three consecutive measures.
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156–181b
51–86b
Emission Spectrometer, Optima 4300 DV, Perkin Elmer,
19–27b Shelton, CT) as previously described (4). Uneaten food that
375–2523b was returned was weighed, and the calcium content was
37–58b
14–112a,c calculated using Food Processor v. 7.4 (ESHA Research,
28–71a Salem, OR). Resulting milligrams of calcium not consumed
25–73a
8.5–9.8a
were subtracted from known dietary calcium content.
Calcium retention was determined through mass balance
as intake minus (dermal + fecal + creatinine adjusted
urinary losses). Balance for each subject was calculated
from 4 d of urine and fecal collections, but only 1 d of sweat
collection during each period. All serum biochemical assays
were conducted by a certified lab (Quest Diagnostics,
Clinical Trials, Van Nuys, CA).
Statistical analysis. The 95% confidence intervals
were computed for the differences in dermal calcium loss
through sweat and calcium retention between each pair of
regimens. Least squares means and their variances were
used to compute the confidence intervals. The means were
obtained from a general linear model that regressed critical
end-point variables on treatment, sequence, subject nested
in sequence, study period, and carryover effect (SAS
Institute, Inc., v. 9, Cary, NC).
RESULTS
Subject characteristics are shown in Table 1. The average
V̇O2peak represents the 75th percentile for women between
the ages of 20 and 29 yr (2). Habitual calcium intakes
averaged almost 1000 mgIdj1.
Eighty-three women were screened for participation in
this study. Thirty women met the screening criteria and
began the first phase of the study. Subsequently, four
subjects withdrew from the study because of lack of time to
complete the protocol. Compliance with calcium supple-
mentation was 100% according to pill count. Compliance
with the supervised 1-hIdj1 exercise intervention was
100%. Although subjects were requested to avoid physical
activity during the no-exercise period, activity logs indi-
cated that there were no significant differences in reported
activity (in METS) among the three intervention periods
outside the 1-hIdj1 supervised exercise or no-exercise
intervention. During days of sweat collection, subjects
remained mostly sedentary while wearing the sweat

TABLE 2. Effect of exercise and dietary calcium on calcium loss and retention in physically active, premenopausal women (N = 26).
Placebo/No Exercise (mgIdj1) Placebo/Exercise (mgIdj1) Calcium Supplements/Exercise (mgIdj1)
Calcium intake 464 T 39 477 T 43 1276 T 59
Calcium dermal loss 79 T 31 92 T 49* 83 T 49
Urinary calcium loss 92 T 48 84 T 39 108 T 53**
Fecal calcium loss 447 T 250 430 T 161 928 T 349***
Net calcium retention j139 T 234 j100 T 168 204 T 283***
Values are mean T SD.
* Significantly different from placebo/no exercise at P = 0.035; ** significantly different from placebo/exercise at P = 0.0013; *** significantly different from placebo/exercise at
P G 0.001.

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 collection suits, except during the 1 h of supervised exercise
intervention. Diet intake compliance was adjusted by
analysis of collected uneaten food. Incomplete or missed
CLINICAL SCIENCES
fecal or urine collections were reported, but were G 5% or
G 2.5%, respectively, of total collections. No significant
adverse events from the treatment were observed.
The effect of treatment on calcium losses and retention is
given in Table 2. Exercise had a modest effect on whole-
body 24-h dermal calcium loss. Urinary and fecal calcium
excretion increased with calcium supplementation, but there
was no effect of exercise on these losses. Net calcium
retention was negative on low-calcium diets, but it was
quite positive during the period of calcium supplementation.
The increase in calcium retention with supplementation was
304 T 225 mgIdj1.
There were no significant differences in serum PTH,
25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, or cal-
cium concentrations among the three intervention periods or
change from day 1 to day 7 within each phase.
DISCUSSION
This study demonstrated that healthy, exercising premen-
opausal sportswomen who exercise strenuously for 1 hIdj1
have a small but significant increase in dermal calcium loss.
The 13-mg additional dermal calcium loss with exercise
would require consumption of an additional 40 mgIdj1 of
calcium to make up for these dermal losses. The effect of
this loss of calcium on bone is dependent on the calcium
status of the woman. If her daily calcium intake is below the
total calcium loss, then she will be in negative calcium
balance and calcium will be released from bone to maintain
normal serum calcium levels. In this study, participants
consumed prepared diets that contained about 450 mgIdj1
of calcium, and we found that even without partaking in the
exercise program, the women were in negative calcium
balance. In contrast, supplementation with 800 mgIdj1 of
calcium ensured sufficient calcium so that the additional
loss in sweat resulting from the 1 h of exercise in addition
to low calcium intakes did not put these women in negative
calcium balance.
The modest dermal loss of calcium seen in our population
is very similar to the less than 20 mgIdj1 reported by Lentner
et al. (14), even though their population included post-
menopausal women with osteoporosis who consumed about
900 mgIdj1 of calcium. Our data are similar to the findings
of Rianon et al. (20), who found that dermal calcium losses
were very similar for individuals when they were either at
rest or exercising, with dermal losses of approximately 35
mgIdj1. The effect of exercise on dermal calcium loss in
our study was less than expected on the basis of the much
greater losses (9 100 mg per session) reported in men
participating in rigorous exercise—that is, professional
basketball practice and firefighting training (12,18). The
losses were more in line with those reported in men
participating in moderate exercise (8,9) at room temper-
1484 Official Journal of the American College of Sports Medicine
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ature. The difference may be partly attributable to environ-
ment, because calcium losses in sweat increase with heat
(9,21). Calcium losses through sweat increased from 111
mgIdj1 at 21-C to 201 mgIdj1 at 37.8-C, as estimated by
arm-bag collections during 7.5-h periods that included 100
min of exercise (9). Differences in estimates of exercise-
induced dermal loss may also relate to the error associated
with projections using surface-area extrapolations from
regional sweat collections through arm bags or patches to
whole-body losses. For example, projections from arm and
leg patches overestimated whole-body calcium dermal
losses by three- and fourfold from patches on the upper
back (19). When eight patches were used to provide a more
representative sample of whole-body surface area, the error
in projecting to whole-body dermal calcium losses reduced
to 1.6-fold.
The effect of 1-h strenuous exercise on dermal calcium
losses was too small to be reflected in the daily net calcium
retention, which is largely influenced by fecal excretion.
The variability in calcium retention is three to four times
that of dermal loss, which greatly reduces power to observe
differences. Urinary calcium excretion was not affected by
exercise in our study, indicating lack of compensation for
dermal losses. Urinary calcium excretion is little affected by
exercise or heat (5,9).
Calcium supplementation improved calcium retention by
threefold. Although urinary and fecal calcium losses
increased with calcium supplementation, net calcium
retention was dramatically improved. The effect of calcium
supplementation on dermal calcium loss cannot be deter-
mined independently from exercise from our study design.
Calcium intake from the basal diet in the groups receiving
placebo was low, just under half of the adequate intake of
1000 mgIdj1 recommended for this age group by the
Institute of Medicine (11). This is below the mean of U.S.
intakes for women of similar age from the 1994 USDA CFS
II of 647 mgIdj1 (17) and by the 1999–2000 NHANES III
of 797 mgIdj1 (25). However, it is comparable with mean
intake of women in many populations (15) and for 25% of
U.S. women (17). The low level of calcium intake put the
women in our study in negative calcium balance. When
total intake was approximately 1300 mgIdj1, the women
were in positive calcium balance, even with 1 h of moderate
exercise. The average usual calcium intake in this group of
women was near the adequate intake, but the range was
broad; one fourth of the subjects consumed G 600 mgIdj1.
We have previously reported positive calcium balance in
young women aged 18–31 yr of 73 T 107 mgIdj1 on
calcium intakes similar to those achieved with calcium
supplementation in the present study (22). Fecal calcium
losses were similar at 1061 T 142 mgIdj1, but urinary
calcium excretion was more than twice as high in that study
(204 T 73 mgIdj1). Dermal calcium losses were not
measured. In that study, the subjects were not sportswomen.
Sportswomen may be better able to use calcium in the diet
when it is adequate. Clinical and laboratory animal studies
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have shown that exercise is associated with higher bone
mass (16) and higher calcium absorption (13) and retention
(13,26) in rats. Calcium and vitamin D supplementation
decreased stress fractures by 27% relative to a placebo
control group in female military recruits during basic
training (Lappe, personal communication, 2006).
In this study, if we assume that the sportswomen had
average total-body calcium levels of 1000 g (11), and if this
relative decrement in calcium retention was sustained, it
would translate into a skeletal calcium difference between
the period of supplementation versus the loss seen when
they were on low calcium diets of 11.7% per year. It is
possible that this difference will not likely be sustained for
one year as it is expected that the low calcium intakes will
result in increases in calcium absorption efficiency and
decreased urinary losses (23). However, full adaptation is
unlikely, because calcium homeostasis does not efficiently
adapt to low calcium intakes even during puberty when
bone is rapidly growing (1). Calcium from supplements and
calcium enriched milk have been shown to benefit bone in
postmenopausal women who have usual calcium intakes of
450–750 mgIdj1 (7,10), but not in premenopausal women
aged 23.1 T 2.7 yr (3). The authors argue that failure to see
a benefit of calcium supplementation on bone in their study
of premenopausal women was likely attributable to the
increase in calcium intake in the placebo group to 824 T 213
mg over the course of the study, use of a calcium
supplement with half the expected bioavailability, and lack
of power due to attrition.
Strengths of our study include the use of a crossover
design to reduce subject to subject variation (and thus, the
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Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
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CLINICAL SCIENCES
meals during the intervention and analysis of calcium
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