MBD: Metabolic Bone Disease

NMBD or MBD)

Nutritional Metabolic Bone Disease

What causes NMBD?

NMBD is caused by an improper ratio of calcium, phosphorous, and Vit D in the diet.

RATIOS ARE IMPORTANT!

The optimum diet you can provide for your possums is one that contains a ratio of 2 to 1, in other words, a diet that is twice as high in calcium as it is in phosphorous.

Don't get me wrong, calcium needs the presence of phosphorous in order to do its job. Next to calcium, phosphorous is the most abundant mineral in the body. These 2 important nutrients work closely together to build strong bones and teeth. About 85% of the body's phosphorous is on the bones and teeth. But, having too much phosphorous in the body is actually more worrisome than having too little. The adverse effects of a diet too high in phosphorous include reduced calcium absorption and calcification of tissues (particularly the kidneys), metabolic bone disease, and some studies show it can also cause heart disease.

In addition to Vitamin D, Vitamin C, Vitamin E, Vitamin K, magnesium and boron also assist in absorbing calcium and also with increasing bone mass.

FOODS HIGH IN PHOSPHOROUS:

Unfortunately, the vast majority of foods are loaded with phosphorous, there is no need to give supplements, or go looking for foods high in this. The list below is by no means complete, but these are a few of the highest phosphorous-containing foods:

Cheese,
Salmon
Tuna
Nuts/seeds
Meat
Dairy products
Soy/tofu
Beans (legumes)
Mushrooms
Zucchini
Watercress
Pumpkin
Whole grains/cereals, and other bakes goods

WHAT FOODS HAVE A GOOD CALCIUM TO PHOSPHOROUS RATIO?

***This is where you need to do your research. You not only want to use foods high in calcium, but also foods that have at least close to twice as much calcium in them as phosphorous.

Providing meals that have this 2:1 ratio can be daunting, especially in the beginning. The lists I have prepared below will help you with some of this.

The following is a short list of foods that have a good 2:1 ratio or at least are close to that, some even exceed it. The first number indicates the percentage of calcium and the second indicates the percentage of phosphorous:

Oranges 2.86:1
Papaya 4.80:1
Beet Greens 2.85:1
Chinese Cabbage 2.84:1
Chicory 29:13.6
Collards 14.50:1
Dandelion Greens 2.83:1
Turnip Greens 4.42:1
Kale 2.41:1
Spinach 2.02:1
Mustard Greens 2.40:1

As you can see, a few of these have very large percentages of calcium, (in particular collards and also papaya) so you could use them to offset a meal that may have some high phosphorous components to it.

CALCIUM/PHOSPHOROUS RATIOS: (To learn more):

http://www.health-science-spirit.com/calcium.html

Dairy:

Dairy has long been touted as the end-all, be-all for NMBD possums. I am here to tell you this is far from the truth. While most dairy products do contain calcium and Vit D, they are also VERY high in phosphorous! If you are counting on dairy to provide ample calcium, you are not doing that animal any favors because the amount of phosphorous negates the smaller amount of calcium it contains. That’s not to say they can’t have it; you just cannot rely on it to fulfill their dietary calcium needs so that meal better also contain some calcium right greens to make up for it.

I hear it all the time:” But, my possum LOVES his cheese”. Just because something tastes good, does not necessarily mean it’s good for you. Much of it is loaded with unhealthy, artery clogging fat, sugars, and sodium. All things in moderation, please.

Dairy also contains an array of unhealthy possibilities such as all or some of the following: antibiotics, hormones and other medications and pus. (Just Google it, if you don't believe me). Yes, you read that right, dairy contains pus. Dairy is not the healthiest of foods for any of us to consume, let alone an animal with such a short life span.

What are some alternative food choices that provide Vitamin D?

Mushrooms
Sockeye salmon
Trout
Sardines
Mackerel
Herring
Sunshine!!!

What can block the body's ability to utilize calcium?

Many things can prevent the body from properly absorbing calcium, to name a few:

Medications such as prednisone (steroids)
Excessive dietary protein (ring a bell anyone?) So many people feed their opossums way too much protein!
An abundance of foods high in oxalates.

High Oxalate Foods Include:

Legumes (beans)
Beets
Berries
Cranberries
Dark leafy greens (some)
Nuts
Oranges
Rhubarb
Soy/tofu
Spinach
Sweet potatoes
Grain products

Not to say that your possums cannot eat any of the above items, you just have to find a healthy medium......do not feed anything one thing excessively.

Clinical Signs of Nutritional Metabolic Bone Disease (NMBD):

Clinical Signs of Nutritional Metabolic Bone Disease (NMBD): The easiest way I can explain one component of what NMBD does to a body is to compare it to arthritis. For those of you who are too young to know what this feels like, I can tell you that arthritis is painful! The animal may experience anything from mild to moderate to severe pain, depending on the severity of the NMBD. Not all possums will display all of the following symptoms:

• Bones become thin and brittle. If the NMBD is severe enough, a leg may break from the animal simply putting their weight on it and attempting to walk.

• Bones can also soften, causing them to bend and become deformed.

• It may be very difficult or impossible for them to chew their food so they may require a liquid diet. The jaw bone, instead of being hard becomes soft, more like rubbery cartilage. The lower jaw itself may look under developed, where it doesn't grow out far enough and the upper jaw sticks out much farther in comparison. In some possums, the entire snout may be stunted. • One or both eyes may appear to bulge.

• Rounded skull.

• Hyperparathyroidism; low levels of of calcium in the blood leads to increased production of parathyroid hormone, which removes calcium from the bone.

• Legs, paws and fingers take on an abnormal appearance, either from broken bones, or bones that become malformed. The animal may not be able to grasp onto anything at all, or their grasp is weakened.

• Tails may drag limply and are unable to curl around and hold onto objects.

• Curvature of the spine.

• Lethargy, muscle tremors, lack of appetite.

• Fur may become sparse or brittle.

In the early stages of NMBD, you might notice that the possum is losing its ability to grip with its tail and or feet. Sometimes tremors are noted or a sort of uncoordinated gait. The animal will become more lethargic, sleeping more, and losing interest in food. As the disease progresses many possums have difficulty walking and climbing. It may take short, faltering steps or they may even drag their legs or revert to crawling. You may notice a bowing of the legs and a “frog-like” appearance and or they may appear to be "chubby". The back may appear hunched. Other skeletal deformities may be noted. The bones at this stage are extremely fragile, leading to fractures. Jerky movements and tremors may become more pronounced. Pain management is needed. As NMBD progresses even further, the opossum may lose the ability to eat and drink. Bone structure changes in the skull may occur resulting in an inability to use the mouth and may also cause the tongue to protrude. Internal organ systems may also be effected, leading to organ failure and death.

Feeding an NMBD Possum:

The most important thing to remember is that this animal must be on the appropriate diet for the rest of its life. NMBD can be manageable, but the animal can worsen if not fed correctly.

HERE IS WHAT I RECOMMEND: The vegetables you choose to use for the Peter's Food recipe should primarily be a combination of any of the following:

Turnip greens, Kale, Beet Greens, Collard greens, Mustard Greens, Endive, Broccoli stems, (not the tops) Green or yellow wax beans, Chinese cabbage, (AKA: Napa Cabbage) Sprouts, (alfalfa etc add a lot of wonderful micro-nutrients to their diet. I make my own here at home.

You may then add small amounts of squash, or other vegetables but make the bulk of the recipe with the ones listed above so that your getting a good amount of calcium in the food.

Use the following fruit: I use primarily Papaya, blueberry, figs and cranberry, and sometimes berries, apple, banana etc.

After everything is mixed together, I put it all in a blender, using a little extra formula to make it thinner if necessary. Picky possums will often eat it this way.

This diet will ensure your NMBD possum is getting plenty of dietary calcium, which is absolutely necessary for their condition. I also use certain supplements with NMBD possums.

Given Daily: Glucosamine, Chondroitin, MSM (supports bone/joint health) Omega 3 oil supplement (anti-inflammatory) Recipe can be found below.

Golden paste or golden milk powder (recipe is farther down the page) (excellent antiinflammatory and immune support as a maintenance dose). Very small dose once daily.

CoQ-10: CoQ10 has the potential to vastly improve health. It can help combat fatigue, for example, as well as obesity, and a weak immune system (particularly for those with HIV, other viruses, and yeast infections). It also prevents toxin overload, and swollen gums (those with periodontal disease tend to have low levels of CoQ10 in their gums). The American Chemical Society's most prestigious honor, the Priestley Medal, was awarded to Karl Folkers, Ph.D., for his landmark Coenzyme Q10 (CoQ10) research. That’s because Folkers found that in addition to the benefits listed above, CoQ10’s most valuable role may lie in fighting heart disease.....which is so prevalent in our male possums. SEE RECIPE BELOW...

L-Carnitine and Taurine: A must for your possum! L-carnitine and taurine has been shown to help protect against damage to the heart muscle and the circulatory system. Healthy heart function is critically dependent on adequate levels of L-carnitine. Changes in the properties of cell membranes throughout the heart are thought to contribute to impaired heart muscle contraction and increased susceptibility to irregular beats, and to the eventual death of heart tissue. Supplementing the diet with L-carnitine increases levels within the heart tissue, and helps to prevent heart damage. L-carnitine supplements also boost antioxidant enzyme levels, helping to protect cells from unstable molecules called free radicals. In addition to helping with angina, these cell-protective effects make L-carnitine beneficial in recovery from: heart attack, deterioration of the heart muscle, irregular heart rhythm, and congestive heart failure. SEE RECIPE BELOW....

Omega Oil Supplement recipe: My Vet concocted a supplement recipe that incorporates heart health and immune support. I give it to the animals here every day. Doses depend on the size of the animal. Note that only Omega 3 is used, and the reason for this is Omega 6 and 9 tend to be inflammatory, while omega 3 is antiinflammatory. You can use krill oil for omega 3 or something plant based like flax oil. Just be aware that your choice on what kind of oil you use should be based on the animal your giving it to. Generally, omnivores can use either form of Omega 3, but carnivores (like cats) should be given only fish or krill omega 3 oils as their bodies cannot utilize a plant based omega 3.

1 oz Omega 3 oil (You can use organic Flax oil or Krill) (not omega 3-6-9)

1000 mg L-carnitine 1000 mg taurine

1000 iu vitamin E 400 mg

CoQ10 500 mg hawthorn( optional)

500 mg dandelion root (make sure its the powdered root only)

Golden Milk: (Natural anti-inflammatory) I am going to cover 2 ways to give your possum the benefit of this amazing mix. If your NMBD possum is on formula, you can mix the following product right into it. This makes it easier as you just sprinkle in 1/8th of a tsp into 1 batch of formula. It’s important to know that Golden Turmeric products work best when eaten with fat, as it helps the body absorb its properties. Formula has plenty of fat already in it so for NMBD possums, it can easily be used this way. It is a powerful anti-inflammatory. Apart from antioxidant, anti-inflammatory, and anticarcinogenic properties, the curcumin in golden paste has proven to offer positive cardiovascular effects. Animal studies have shown that regular consumption of turmeric helps protect the heart from serious conditions like an enlarged heart or even heart failure.

Golden paste: For possums who are no longer on formula, I make what is called Golden paste. To prepare Golden Paste: Ingredients: 1/2 cup Ayurvedic Organic Golden Milk Powder

1-2 cups water (use half the total amount to begin with and have the other half ready if needed)

1/3 cup cup olive oil

Directions: Combine the turmeric and water in a small saucepan and bring to a boil. Reduce the heat to keep the mixture at a simmer, and cook for 7-10 minutes. Stir frequently to keep from sticking, and add more water as need to keep it to a paste consistency. The exact thickness isn't important--you can adjust that to your preference. Remove it from the heat and allow it to cool until the pan is just warm to the touch. Add the oil, and stir thoroughly until they are completely mixed in. Store in a clean jar in the refrigerator. It should keep for about 10 days. I freeze it in small portions so none of it goes to waste. Dose: Small animals should start with no more than a small dollop about the size of a BB, so you need to adjust the dose accordingly spending on the size of your possum.....this gives you a basic guideline to go by, obviously there is no data on how to dose possums. An adult possum would get only appx 1/8th tsp a day.

Laura’s Green Powder: A lot of folks have problems getting their possums to eat their greens and other vegetables. There are several tricks you can try and one of them is to mix some of this into their food. There are products like this on the market with varying ingredients, but none of them contain as many different plants as I use (at least none that I have seen yet). And this will cost you almost nothing but your time. We grow so many edible plants on our property and I always put some aside to dry out and store for winter feedings for the turtles, rabbits and other animals in our care. One day I decided to pulverize some of it into a powder and use it for the animals that will not readily eat dried plants. I have a basic recipe that I use, based on what we have in our yard or where I know I can pick it where there are no chemicals used, and far away from major roads so the exhaust from cars doesn't pollute it. If I am going to use probiotics, I sprinkle that on separately:

Orchard and timothy hay

Collards

Kale

Hibiscus leaves and flowers

Rose; flowers and the hips

Violets and pansies

Marigold

Alyssum

Nasturtium

Blossoms off the squash, peas, and other vegetables that we grow

Sage blossoms

Bee balm

Chamomile

Clover

Echinacea

Dandelion

Plantain

Wheat grass

Chickweed

Raspberry leaf

Spirulina (store bought) Appx 1 tsp

Chlorella (store bought) Appx 1 tsp All you do is gather the plants throughout the growing season, let them thoroughly air dry and seal in an air tight container.

Once you have enough on hand, simply put it all into your blender and let it run until everything is ground into a fine powder (you might want to wear a mask because it creates a lot of dust). Once it’s all ground up, I add the last 2 ingredients, blend it for a few seconds more and then I fill up a salt shaker with some of it and store the rest of it in a Ziploc bag. You can sprinkle it on their food or mix it in. Works great in smoothies as well.

Pain Management: A possum with NMBD is going to be experiencing discomfort, that can be anywhere from mild to severe. Pain management is important until you get the condition under control. An animal in pain is not going to want to eat well, if at all. Historically, Metacam/Meloxicam has been used for inflammation as it is good for generalized inflammation, but it’s not good to use long term as it can affect the kidneys. A better choice is probably Gabapentin. It's used for neuropathic pain, and that includes pain caused by NMBD. You could use both gabapentin and golden paste and leave Metacam/Meloxicam out of the equation. Adding in Golden paste to their food helps with inflammation, I have given this is to many different species.

Sunshine and Vitamin D: Our exposure to natural sunlight provides our bodies with one of the most powerful sources of Vitamin D there is. The UV the sun provides enables our bodies (as human beings) to manufacture this vitamin all on its own. I suspect that animals who are nocturnal have their own method of getting the D they need. THAT being said, even though opossums are primarily nocturnal, and you are not likely to find them sunbathing, I encourage you to give an animal with NMBD a good 20 minutes of exposure to natural dappled sunlight every day that its nice outside. If nothing else, the fresh air is good for them and will certainly cause no harm. DO NOT place them in the hot sun where they cannot move out of it and into the shade.

To date, Vit D levels in opossums have not been studied, so we do not know what their needs are or what is considered to be a "normal" level. Blood tests would need to be performed on multiple wild caught adults to see what their levels are and then those would need to be compared to captive opossums. I would be particular curious to see what the levels are in MBD possums as well.

Here is Lucy soaking up some natural UV in dappled sunlight. This bassinette sure came in handy with her as it enabled me to roll her around with ease. Lucy could not walk or climb so she was perfectly safe.
Make sure to never leave your possum unattended in the sun! They should always be in dappled sun so that they do not overheat if the temps are high. The sun changes positions so even if you leave them in partial shade, you might come back outside to find them in full sun so sit and relax awhile with them and keep them safe.

Vitamin D and other Supplements: The one thing I warn people against is loading up a possum with D supplements and too much calcium. Both can have negative and even dangerous health consequences. You have to remember that what might what might work for a human being does not always transfer to what will work for animals. DO NOT give D supplements to your opossum. On the same note, once a possum is off formula, there is no need (except in rare cases) to add in any calcium supplements. They should get all their body needs from their diet.

*** Putting an animal in front of a closed window or even an open but screened window, WILL NOT provide that animal with UV. Glass and screen will filter almost all of it out.

What do I do if it’s too cold to go outside? Again, since opossum’s requirements for Vit D is unknown, we also do not know how necessary natural sunlight or UV lights would be for them. But what I do know, is exposure to either one is not going to cause them any harm, unlike bombarding them with supplements can. If you want to try lights during the cold months of each year, I recommend the use of a UV lamp when you cannot take the animal outside for natural sunshine. The only safe UV light to use over a mammal are those florescent tube lights as they provide UV, a low level of brightness and very little heat......which means you can safely put them within the therapeutic range of the animal. It is crucial that the lamp itself be appx 12-14 inches above the animal (read the directions for your particular bulb). If it is too far away, it will not provide UV to that animal. You will need to gauge what the depth of your container is so that the lamp will hang at the proper distance above your animal. Place the animal in a large Sterilite container and cover the top with chicken wire. What I do is I cut out the center of the lid that came with my Sterilite or Rubbermaid container, leaving a 2 inch or so rim around the edges so that the lid will still clamp down onto the container. I attach chicken wire to the center area that's been cut away and secure it well with wire or zip ties all along the edges. Places your chicken wire on the top side of your lid as it will have sharp edges that you do not want your possum inuring himself on. The spaces in chicken wire will not hinder the UV rays from getting thru, unlike other screening materials will.

UV bin set up: I cut the center of the lid out and replaced it with chicken wire. make sure its attached securely.

Leave the lamp on for about 15- 20 minutes, once a day.....DO NOT leave that animal alone while the lamp is in use! It’s also important that they cannot hide under anything or else they will not be benefiting from the UV.

These are the style reptile light bulbs I am referring to. DO NOT use mercury vapor lamps, or those coiled reptile bulbs or anything other than these pictured. The others are either way too bright and or too hot to use on a possum and they can cause damage to their eyes. The lights pictured do not emit much heat and the brightness of the bulbs are minimal......while providing a good source of UV. The 5.0 strength of this bulb is more than enough for a possum...do not go to a higher strength of UV.

Swollen Extremities: The MBD babies that have been brought to us with swollen legs/feet were all found to have stress fractures or breaks. Stress fractures are tiny cracks in a bone — most commonly, in the weight-bearing bones of the lower leg and foot. It takes 6 to 8 weeks for a stress fracture to heal. More serious stress fractures can take longer. Chronic stress fractures or stress fractures in bone with less blood supply can take longer to heal. When a person breaks or fractures a bone, a doctor sets it, maybe you have to wear a cast to mobilize the area for a period of time so that it heals properly. But when these breaks go untreated, it starts to heal in whatever position it’s in. And while all of this is in progress, you have an animal that is moving around on unstable bones, which only increases the damage and lengthens the healing process. In addition to this, the animal may also have bones that have been deformed by NMBD. Imagine the pain this animal is in! The swelling you see around those areas is partly caused by inflammation, but it is also the bodies way of building up a sort of natural cushion to protect that area. Animals effected like this will surely develop arthritis at some point and the legs will always have some deformity. It’s very important to support these animals throughout their lifetimes with various supplements and proper diet to support the bones and joints and to keep pain and inflammation at a minimum. A proper diet is absolutely crucial to prevent NMBD from worsening. The condition was caused by an incorrect diet, the progression can likely be halted by making corrections, but it cannot be cured once the damage has been done.

Physical Therapy: One of the best forms of physical therapy for these little ones is water therapy. Fill a bath tub or a deep kitchen sink with nice warm water....make it deep enough so that their legs cannot touch the bottom. Fully support the body from underneath while allowing all 4 legs to move freely, and let them "swim" for a while. Be careful not to let their faces dip below the water as that will cause them to panic and possibly inhale water into their lungs. You can also make a sling out of any kind of material. Cut a rectangle large enough to accommodate your possum, leaving several more inches on either side. You are going to want to cut holes in it for each leg to slip through, while also leaving enough for their chin to rest on. Once you have your possum in this, fold each side up (think of this like a hot dog in a hotdog bun sort of look. The excess material will be your handle so you can support them while in the water. If necessary, you can use a little extra piece of rolled up material under the chin to keep their face out of the water.

***If being in water is too stressful for your animal, please don’t force it on them.

Housing: NMBD possums should be kept in a habitat where there is no opportunity for them to climb. Falls are common and bones break easily! This simple habitat was made with an x-pen. The front was clear plexiglass attached to the inside and the inner sides were made with plastic coroplast sign material which is easily cut to fit (hardware stores sell this in large sheets). The potty tray should have a very low edge to make it easy for the possum to walk on and off of. I now use these nifty cafeteria trays sold on Amazon. I line them with damp (not sopping wet) paper towels as possums are drawn to potty where its damp. They only cost around $5.00 each.

Just a simply, inexpensive cafeteria tray make a perfect potty tray for any opossum.

NMBD Pictorial:

Kizzie arrived here with severe deformities

All 4 of Lucy's legs were deformed and splayed out to the sides.

Note the abnormal facial bones

Lucy, the day she arrived.

Severe fur loss from NMBD

Abnormal fur coloration

Look how twisted poor Lucy's legs and paws were.

Tessa being examined at the Vets with my friend Cathy and Dr. B

Tessa's abnormal jaw

This was the swelling around one of Tessa's fractures. This is how the body responds to help protect the injured area.

X-ray of some of Tessa's fractures.

thumbnail_Lucy Mowrey Legs 8-1-1700001 copy.jpg

More x-rays, more fractures....

Before and After:

Look at the vast difference in Lucy's appearance after only 5 days! She arrived in horrible condition; dehydrated, emaciated, her fur was coarse and brittle and she had a case of ringtail. It's amazing how quickly hydration fluids, good nutrition, humidity, getting cleaned up, and a lot of love can turn an animal around. X-rays revealed Lucy had 9 stress fractures severely deformed leg/feet bones on all 4 extremities. She was never able to walk or feed herself without some assistance but she was a sweet, gentle girl and boy could she get around scooting on that little belly of hers! Lucy lived to be 4 years of age.....truly a little miracle girl!

lucy and tessa Aug 7 2017 (12 of 36).jpg

This was Tessa. She arrived with 7 stress fractures and she was unable to grip with her paws or tail. She only got to be 3 lbs fully grown and only ever developed 3 teeth so her little tongue hung out of the side of her mouth sometimes. Her jaw was malformed as well and at times her eyes would bulge out.. Everyone was so in love with Tessa, she was such a sweet, sweet gentle little girl. Despite all her health issues, Tessa lived to be 4 1/2 years old.....practically unheard of given how she started out in life.

Links: Here are links to the potty trays, to purchase golden paste ingredients and for the items that need to be added into the formula recipe.

Cafeteria Trays: https://www.amazon.com/gp/product/B00FRIBG9Y/ref=ppx_yo_dt_b_asin_title_o07_s00?ie=U TF8&psc=1&fbclid=IwAR0qx6JQNZabTJrpNtTD1LDyb7YH4hpbus445QaeGyPd3wR4o5BA Bp5yH8E

FeelGood Organic Turmeric Powder:

https://www.amazon.com/Premium-Organic-Fortified-Turmeric-Powder/dp/B07JLR6SCP/ref=sr_1_5?crid=1UGWE4XGP9GN3&keywords=golden+paste+powder+with+black+pepper&qid=1696448357&s=hpc&sprefix=golden+paste+powder+with+black+peppe%2Chpc%2C142&sr=1-5

Barleans Organic Flax oil:
https://www.amazon.com/Barleans-Organic-Lignan-Flax-16- oz/dp/B002VLZ81M/ref=sr_1_6_f3_0g_wf?crid=32VC4UGR381KE&keywords=barleans+orga nic+flax&qid=1659131299&s=grocery&sprefix=barleans+organic+flax%2Cgrocery%2C123&sr =1-6

Brewer’s Yeast 7.5 grain tablets:

https://www.amazon.com/Amazing-Nutrition-Brewers-YeastTablets/dp/B00VU9EU2O/ref=sr_1_6?keywords=brewers+yeast+tablets&qid=1659131628&sr= 8-6

Lactase Drops:

https://www.amazon.com/Milkaid-Intolerance-Supplement-VegetarianArtificial/dp/B07YX7C4WM/ref=sr_1_5?crid=1TAYMC4BVBB8B&keywords=lactase+drops &qid=1659131679&sprefix=lactase+drops%2Caps%2C149&sr=8-5

NutriCal:

https://www.amazon.com/Tomlyn-NutriCal-Tube-Dog-4- 25oz/dp/B00063KI8A/ref=sr_1_1_sspa?crid=Z33YA01U8JAR&keywords=NutriCal&qid=1659 131831&sprefix=nutrical%2Caps%2C140&sr=8-1- spons&psc=1&spLa=ZW5jcnlwdGVkUXVhbGlmaWVyPUEyNVZRMzhCU1JMRlk3JmVuY3 J5cHRlZElkPUExMDM0OTk3UEdZVEFRNkNPR0NXJmVuY3J5cHRlZEFkSWQ9QTAxMD k3NzgxTU1TTlBINzExRU5VJndpZGdldE5hbWU9c3BfYXRmJmFjdGlvbj1jbGlja1JlZGlyZW N0JmRvTm90TG9nQ2xpY2s9dHJ1ZQ==

Puritan’s Pride Calcium Citrate 200 mg: (if unavailable on amazon, go to Puritans Pride's website)

https://www.amazon.com/Puritans-Pride-Calcium-CitrateCaplets/dp/B004R65LY8/ref=sr_1_8?crid=305TMTM83GAM5&keywords=Puritan%E2%80% 99s+Pride+Calcium+Citrate+200+mg%3A&qid=1659131798&sprefix=puritans+pride+calcium +citrate+200+mg+%2Caps%2C129&sr=8-8