Elsevier

Bone

Volume 32, Issue 6, June 2003, Pages 694-703
Bone

Original article
Dietary calcium and vitamin D intake in relation to osteoporotic fracture risk

https://doi.org/10.1016/S8756-3282(03)00048-6Get rights and content

Abstract

The etiologic role of dietary calcium and vitamin D intake in primary prevention of osteoporotic fractures is uncertain, despite considerable research efforts. With the aim to examine these associations with an improved precision, we used data from a large population-based prospective cohort study in central Sweden. We estimated nutrient intake from a self-administered food-frequency questionnaire filled in by 60,689 women, aged 40–74 years at baseline during 1987–1990. During follow-up, we observed 3986 women with a fracture at any site and 1535 with a hip fracture. Rate ratio of fractures (RR) and 95% CI were estimated using Cox proportional hazards models. We found no dose–response association between dietary calcium intake and fracture risk. The age-adjusted RR of hip fracture was 1.01 (95% CI 0.96–1.06) per 300 mg calcium/day and the corresponding risk of any osteoporotic fracture was 0.99 (95% CI 0.96–1.03). Furthermore, women with an estimated calcium intake below 400 mg/day and those with a calcium intake higher than 1200 mg/day both had a similar age-adjusted hip fracture risk as those with intermediate calcium intakes: RR 1.07 (95% CI 0.92–1.24) and RR 1.00 (95% CI 0.79–1.27), respectively. Vitamin D intake was not associated with fracture risk. Furthermore, women in the highest quintiles compared to the lowest quintiles of both calcium and vitamin D intake had an age-adjusted RR of 1.02 for all fractures (95% CI 0.88–1.17). Dietary calcium or vitamin D intakes estimated at middle and older age do not seem to be of major importance for the primary prevention of osteoporotic fractures in women.

Introduction

Half of all white women will suffer an osteoporotic fracture after the age of 50 [1]. Such fractures not only entail high health care costs [2], [3], but are also frequently associated with loss of quality of life resulting from deficient healing [4] as well as carrying an increased mortality risk [5]. Several modifiable risk factors for osteoporotic fractures have been proposed [6], [7], [8]. One conceivable factor is the diet. The influence and importance of dietary calcium intake, in particular, and the intake of vitamin D, in primary prevention of osteoporotic fractures have, however, been highly debated [9], [10], [11]. In several randomized trials in postmenopausal women, supplemental calcium has slightly reduced loss of bone mineral density, but its impact on the risk of fracture is uncertain [10], [11]. Furthermore, observational studies have yielded discrepant results, ranging from a reduced fracture risk, mostly in studies with a retrospective design, through a risk near unity, to an increased risk with increasing calcium intake [10]. Supplemental vitamin D has been found to reduce the risk of fracture among nursing home residents [12], but not among older community-dwelling men and women [13]. A combination of supplemental vitamin D and supplemental calcium substantially reduced the fracture risk in institutionalized elderly French women [14], but also reduced nonvertebral fracture risk in community-dwelling American women and men aged 65 years or older [15]. Unfortunately, no trial with a factorial design has addressed the impact of calcium and vitamin D on the risk of osteoporotic fractures. Whether a high natural dietary combination of these nutrients reduces the fracture risk is uncertain. Hence neither the independent contributions of these nutrients nor their interactions with the participants’ customary diet on fracture risk can be determined at present.

Until a sufficiently large randomized trial with an optimal design has been undertaken, we need to consider the results of observational prospective studies with dietary reports in attempts to elucidate the association of calcium and vitamin D intake with the fracture risk. In the present study we have investigated, within a prospective population-based cohort with the largest number of fractures to date, the association between both dietary calcium and dietary vitamin D intake, estimated by a food frequency questionnaire in 40 to 74-year-old women, and the risk of subsequent osteoporotic fracture.

Section snippets

The Swedish Mammography Screening Cohort

The Swedish Mammography Screening Cohort has been described previously [16], [17], [18]. Briefly, in the period between March 1987 through December 1990, women in two counties of central Sweden were asked to respond to a comprehensive six-page food-frequency questionnaire (FFQ) when invited to a mammography screening. In the county of Västmanland, women born during the period from 1917 through 1948 (n = 41,786) were invited and 31,735 of them (76%) returned the completed questionnaire before

Results

During an average follow-up of 11.1 years and a total of 671,100 person-years of observation, we identified in the whole cohort 1535 women with a first fracture of the hip. In the subcohort from Uppsala county (326,640 person-years of observation) we identified 524 women with a first fracture of the pelvis, 405 with a first vertebral fracture, 1972 with a first distal forearm fracture, and 633 women with a first fracture of the proximal humerus. We totally observed 3986 women with a first

Discussion

Despite the fact that we used a substantial number of fractures in the analysis of this large prospective cohort study, we found no evidence to indicate that a high dietary calcium or vitamin D intake is of value in the primary prevention of osteoporotic fractures in women.

An association between a high calcium intake and a low fracture risk has also been difficult to establish in previous prospective observational studies [25], [26], [27], [28], [29], [30], [31]. The number of hip fractures

Acknowledgements

This study was supported by grants for longitudinal studies from the Swedish Research Council and Uppsala University, Sweden.

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