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Does dietary calcium have a protective effect on bone fractures in women? A meta-analysis of observational studies

Published online by Cambridge University Press:  09 March 2007

Liangzhi Xu*
Centre for Clinical Epidemiology and Biostatistics (CCEB), School of Population Health Sciences, Faculty Health, The University of Newcastle, Australia
Patrick McElduff
Centre for Clinical Epidemiology and Biostatistics (CCEB), School of Population Health Sciences, Faculty Health, The University of Newcastle, Australia
Catherine D'Este
Centre for Clinical Epidemiology and Biostatistics (CCEB), School of Population Health Sciences, Faculty Health, The University of Newcastle, Australia
John Attia
Centre for Clinical Epidemiology and Biostatistics (CCEB), School of Population Health Sciences, Faculty Health, The University of Newcastle, Australia
*Corresponding author: Dr Liangzhi Xu, present address: Department of Obstetrics and Gynaecology, The Second West China Hospital, Sichuan University, Chengdu, China, fax +86 28 8555 9065, email
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It is generally accepted that supplemental Ca and/or vitamin D is effective in reducing the incidence of bone fractures; this is supported by numerous randomised controlled trials and meta-analyses. However, a question that has received much less attention is whether dietary Ca, i.e. Ca in physiological doses in normal food intake, also affects bone fracture risk. The present study aims to review the effect of dietary Ca on bone fractures at the hip, spine and radius in women >35 years old, and to compare these results with previous meta-analyses. MEDLINE (1966–1999) and reference lists in papers were searched for observational dietary Ca studies. Data were extracted in duplicate and separately. Heterogeneity and publication bias were tested. Observational studies failed to show any association between dietary Ca intake and risk of hip fracture (risk ratio 1·01, 95% CI 0·96, 1·07 for each increment of 300mg dietary Ca intake/d). There is a suggestion that either extremely low Ca intake may increase fracture risk, or that East Asian women may respond differently to increasing Ca intake.

Research Article
Copyright © The Nutrition Society 2004


Anderson, JJ (2000) The important role of physical activity in skeletal development: how exercise may counter low calcium intake. Am J Clin Nutr 71, 13841386.CrossRefGoogle ScholarPubMed
Angell, M (1989) Negative studies. New Engl J Med 321, 464466.CrossRefGoogle ScholarPubMed
Block, G, Dresser, CM, Hartman, AM & Carroll, MD (1985) Nutrient sources in the American diet: quantitative data from the NHANES II survey. I. Vitamins and minerals. Am J Epidemiol 122, 1326.CrossRefGoogle ScholarPubMed
Bradburn, MJ, Deeks, JJ & Altman, DG (1998) Metan – an alternative meta-analysis command. Stata Tech Bull 44, 415.Google Scholar
Chan, HH, Lau, EM, Woo, J, Lin, F, Sham, A & Leung, PC (1996) Dietary calcium intake, physical activity and the risk of vertebral fracture in Chinese. Osteoporos Int 6, 228232.CrossRefGoogle ScholarPubMed
Chrischilles, E, Shireman, T & Wallace, R (1994) Costs and health effects of osteoporotic fractures. Bone 15, 377386.CrossRefGoogle ScholarPubMed
Cooper, C, Barker, DJ & Wickham, C (1988) Physical activity, muscle strength, and calcium intake in fracture of the proximal femur in Britain. Br Med J 297, 14431446.CrossRefGoogle ScholarPubMed
Cumming, RG (1990) Calcium intake and bone mass: a quantitative review of the evidence. Calcif Tissue Int 47, 194201.CrossRefGoogle ScholarPubMed
Cumming, RG, Cummings, SR, Nevitt, MC, Scott, J, Ensrud, KE, Vogt, TM & Fox, K (1997) Calcium intake and fracture risk: results from the study of osteoporotic fractures. Am J Epidemiol 145, 926934.CrossRefGoogle ScholarPubMed
Cumming, RG & Klineberg, RJ (1994) Case–control study of risk factors for hip fractures in the elderly. Am J Epidemiol 139, 493503.CrossRefGoogle ScholarPubMed
Cumming, RG & Nevitt, MC (1997) Calcium for prevention of osteoporotic fractures in postmenopausal women. J Bone Miner Res 12, 13211329.CrossRefGoogle ScholarPubMed
Cummings, SR, Nevitt, MC, Browner, WS, Stone, K, Fox, KM, Ensrud, KE, Cauley, J, Black, D & Vogt, TM (1995) Risk factors for hip fracture in white women. New Engl J Med 332, 767773.CrossRefGoogle ScholarPubMed
Egger, M, Davey Smith, G, Schneider, M & Minder, C (1997) Bias in meta-analysis detected by a simple, graphical test. Br Med J 315, 629634.CrossRefGoogle ScholarPubMed
Egger, M, Ebrahim, S & Smith, GD (2002) Where now for meta-analysis? Int J Epidemiol 31, 15.CrossRefGoogle ScholarPubMed
Favero, A, Salvini, S, Russo, A, Parpinel, M, Negri, E, Decarli, A, La Vecchia, C, Giacosa, A & Franceschi, S (1997) Sources of macro- and micronutrients in Italian women: results from a food frequency questionnaire for cancer studies. Eur JCancer Prev 6, 277287.Google ScholarPubMed
Fujita, T & Fukase, M (1992) Comparison of osteoporosis and calcium intake between Japan and the United States. Proc Soc Exp Biol Med 200, 149152.CrossRefGoogle ScholarPubMed
Gillespie, W, Avenell, A, Henry, D, O'Connell, D & Robertson, J (2000) Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis (Cochrane Review). Oxford, UK: Update Software Ltd.Google Scholar
Greenland, S & Longnecker, MP (1992) Methods for trend estimation from summarized dose-response data, with applications to meta-analysis. Am J Epidemiol 135, 13011309.CrossRefGoogle ScholarPubMed
Gregoire, G, Derderian, F & Le Lorier, J (1995) Selecting the language of the publications included in a meta-analysis: is there a Tower of Babel bias? J Clin Epidemiol 48, 159163.CrossRefGoogle Scholar
Holbrook, TL, Barrett Connor, E & Wingard, DL (1988) Dietary calcium and risk of hip fracture: 14-year prospective population study. Lancet 2, 10461049.CrossRefGoogle ScholarPubMed
Jaglal, SB, Kreiger, N & Darlington, G (1993) Past and recent physical activity and risk of hip fracture. Am J Epidemiol 138, 107118.CrossRefGoogle ScholarPubMed
Johnell, O, Gullberg, B, Kanis, JA et al. , (1995) Risk factors for hip fracture in European women: the MEDOS Study (Mediterranean Osteoporosis Study). J Bone Miner Res 10, 18021815.CrossRefGoogle ScholarPubMed
Kreiger, N, Gross, A & Hunter, G (1992) Dietary factors and fracture in postmenopausal women: a case–control study. Int J Epidemiol 21, 953958.CrossRefGoogle ScholarPubMed
Krogh, V, Freudenheim, JL, D'Amicis, A, Scaccini, C, Sette, S, Ferro-Luzzi, A & Trevisan, M (1993) Food sources of nutrients of the diet of elderly Italians: II. Micronutrients. Int J Epidemiol 22, 869877.CrossRefGoogle ScholarPubMed
Lau, E, Donnan, S, Barker, DJ & Cooper, C (1988) Physical activity and calcium intake in fracture of the proximal femur in Hong Kong. Br Med J 297, 14411443.CrossRefGoogle ScholarPubMed
Looker, AC, Harris, TB, Madans, JH & Sempos, CT (1993) Dietary calcium and hip fracture risk: the NHANES I Epidemiologic Follow-Up Study. Osteoporos Int 3, 177184.CrossRefGoogle ScholarPubMed
McAuley, L, Pham, B, Tugwell, P & Moher, D (2000) Does the inclusion of grey literature influence estimates of intervention effectiveness reported in meta-analyses? Lancet 356, 12281231.CrossRefGoogle ScholarPubMed
Messina, M (1999) Legumes and soybeans: overview of their nutritional profiles and health effects. Am J Clin Nutr 70, Suppl. 3, 439S450S.CrossRefGoogle ScholarPubMed
Meyer, HE, Henriksen, C, Falch, JA, Pedersen, JI & Tverdal, A (1995) Risk factors for hip fracture in a high incidence area: a case-control study from Oslo, Norway. Osteoporos Int 5, 239246.CrossRefGoogle Scholar
Meyer, HE, Pedersen, JI, Loken, EB & Tverdal, A (1997) Dietary factors and the incidence of hip fracture in middle-aged Norwegians. A prospective study. Am J Epidemiol 145, 117123.CrossRefGoogle ScholarPubMed
Michaelsson, K, Holmberg, L, Mallmin, H, Sorensen, S, Wolk, A, Bergstrom, R & Ljunghall, S (1995) Diet and hip fracture risk: a case-control study. Int J Epidemiol 24, 771782.CrossRefGoogle ScholarPubMed
Moher, D, Pham, B, Klassen, T, Schulz, KF, Berlin, JA, Jadad, AR & Liverati, A (2000) What contributions do languages other than English make on the results of meta-analyses? J Clin Epidmiol 53, 964972.CrossRefGoogle ScholarPubMed
Morton, AP & Dobson, AJ (1989) Assessing agreement. Med J Aust 150, 384387.CrossRefGoogle ScholarPubMed
Nieves, JW, Grisso, JA & Kelsey, JL (1992) A case–control study of hip fracture: evaluation of selected dietary variables and teenage physical activity. Osteoporos Int 2, 122127.CrossRefGoogle ScholarPubMed
Nordin, BEC (2000) Calcium requirement is a sliding scale. Am J Clin Nutr 71, 13811383.CrossRefGoogle ScholarPubMed
Paganini Hill, A, Chao, A, Ross, RK & Henderson, BE (1991) Exercise and other factors in the prevention of hip fracture: the Leisure World study. Epidemiology 2, 1625.CrossRefGoogle ScholarPubMed
Potter, S, Baum, J, Teng, H, Stillman, R, Shay, N & Erdman, JJ (1998) Soy protein and isoflavones: their effects on blood lipids and bone density in postmenopausal women. Am J Clin Nutr 68, Suppl., 1375S1379S.CrossRefGoogle ScholarPubMed
Riggs, BL & Melton, LJD (1988) Osteoporosis and age-related fracture syndromes. Ciba Found Symp 134, 129142.Google ScholarPubMed
Robertson, J (1995) Study quality: Development and testing of instruments for evaluation of interventions in postmenopausal osteoporosis, pp. 153154. M Med Sci Thesis, University of Newcastle, Australia.Google Scholar
Schulz, KF, Chalmers, I, Hayes, RJ & Altman, DG (1995) Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. J Am Med Assoc 273, 408412.CrossRefGoogle ScholarPubMed
Sharp, S & Sterne, J (1997) Meta-analysis. Stata Tech Bull 38, 914.Google Scholar
Suarez-Almazor, ME, Belseck, E, Homik, J, Dorgan, M & Ramos-Remus, C (2000) Identifying clinical trials in the medical literature with electronic databases: MEDLINE alone is not enough. Control Clin Trials 21, 476487.CrossRefGoogle ScholarPubMed
Tavani, A, Negri, E & La Vecchia, C (1995) Calcium, dairy products, and the risk of hip fracture in women in northern Italy. Epidemiology 6, 554557.CrossRefGoogle ScholarPubMed
Wickham, CA, Walsh, K, Cooper, C, Barker, DJ, Margetts, BM, Morris, J & Bruce, SA (1989) Dietary calcium, physical activity, and risk of hip fracture: a prospective study. Br Med J 299, 889892.CrossRefGoogle ScholarPubMed
Young, RP, Lau, EM, Birjandi, Z, Critchley, J & Woo, J (1996) Interethnic differences in hip fracture rate and the vitamin D receptor polymorphism. Lancet 348, 688689.CrossRefGoogle ScholarPubMed