Calcium Supplementation and Osteoporosis

Calcium supplementation is neither safe nor effective as a treatment for osteoporosis.

Osteoporosis, a disease hallmarked by a decline in bone mass and quality, is prevalent in the elderly population of the United States. In 2014 there were 10 million diagnosed cases of osteoporosis1. One risk factor for developing osteoporosis is low intake of calcium and vitamin D. Historically, in an effort to decrease bone resorption and reduce fracture risk, clinicians have prescribed
calcium supplements as a treatment for osteoporosis. However, recent studies suggest that calcium supplements are ineffective in preventing osteoporotic fractures even in studies that showed
an increase in bone density with supplementation2,3. In addition, recent studies have also found
that calcium supplementation is linked to an increased risk of negative cardiovascular outcomes
such as heart attack and CVD2,4,5,6,7,8,9 and an increased risk of kidney stone formation 3,9,10. These
data suggest that the risks of calcium supplementation outweigh the benefits.

Calcium supplementation is unsafe:

1.

2.

Calcium supplementation has been linked to an increased risk of negative CV outcomes.

In a 2013 study of 61,433 women, Michaelsson et al determined that the highest rates of
death from all causes except stroke were correlated to calcium supplementation >1400
mg/day conferring an all cause mortality HR of 1.40, a CVD HR of 1.49, and an ischemic
heart disease HR of 2.144.
Li et al analyzed data from a study of 24,000 adults and concluded that there was a significant increase in risk of MI among calcium supplement users. Those who derived calcium
from dietary sources did not have the same increase in MI risk 5.
Xiao et al reported that in the NIH-AARP study population of over 400,000 elderly subjects,
the risk of death from CVD, heart disease, and cerebrovascular disease increased significantly with calcium supplement use6.
In a meta-analysis of 15 studies on calcium supplementation, Bolland et al concluded that
calcium supplementation increased the risk of myocardial infarction by 30% 8.
In a 2008 study of 1471 postmenopausal women, Bolland et al determined that calcium
supplementation of 1 g/day led to a marginally significant increase in the risk of MI (1.49
relative risk, p=0.058) and a significant increase in the risk of a composite endpoint including heart attack, stroke and sudden death (1.21 relative risk, p=0.043) 7.
Calcium supplementation has been linked to an increased risk of kidney stones.
Jackson, Reid, and Prentice all concur that taking calcium supplements confers an increased risk of kidney stone formation3,9,10.
Reid further suggests that patients with renal disease have both an increased risk of kidney
stone formation and a higher risk of negative CV outcomes 9. This is significant because
nearly 46.8% of people over age 70 have some form of chronic renal disease 11the same
population at highest risk for osteoporosis and likely to be prescribed calcium supplements.

Calcium supplementation in ineffective for treating osteoporosis.

The most dangerous outcome of osteoporosis is hip fracture, conferring a 13-36% mortality
risk one year post-fracture1.
Calcium supplementation has been shown to be ineffective in decreasing fracture risk even
in studies that indicated an increase in BMD with supplementation 2,3,9.
Radford et al found that calcium supplementation of 1 g/day did not reduce the risk of hip
fracture in post-menopausal women2.
Jackson et al analyzed data from 36,282 postmenopausal women in the WHI clinical trial
and determined that while supplementation with 1 g/day of calcium did increase BMD, it
failed to decrease the risk of hip fracture3.
In a review of recent studies and meta-analyses of calcium supplementation, Reid concluded that calcium supplementation is ineffective for preventing fractures in communitydwelling individuals9.

Amy Stackhouse, Katrina Gery,

and Marguerite Girton

Opposing Viewpoints
The debate over the safety
and efficacy of calcium supplements continues.
Clinicians still commonly prescribe
calcium supplements to elderly patients9. The National
Osteoporosis Foundation still
recommends calcium supplements, though there has been
a shift toward recommending
that calcium come primarily
from the diet12.
Researchers who are prosupplements often argue that
the data linking calcium supplements to CVD is equivocal
and based on flawed metaanalyses10.
Some studies have found data
that refutes the link between
calcium supplements and CVD
or kidney stones.
Lewis et al reported that in a
study of 1460 elderly women,
1200 mg/day calcium supplements did not significantly
increase the risk of CVD13.
Jackson and Prentice et al
concur that calcium supplementation is not correlated
with MI3,10.
In a small study of 53 postmenopausal women, Haghighi
et al concluded that calcium
supplements do not increase
the risk of kidney stones14.
In a reanalysis of the WHI
data, Prentice also concludes
that there is a significant decrease in risk of hip fracture
within certain subsets of the
study population10.

Conclusion
Although calcium supplementation is standard protocol for elderly patients, especially postmenopausal women, there is no substantial
evidence that proves calcium supplements increase bone health or reduce fracture risk. The use of calcium supplements has been correlated with negative cardiovascular outcomes and kidney stone formation. Therefore the risks incurred with calcium supplementation
outweigh the benefits. For patients at risk, anti-resorptive medications, such as bisphosphonates, have been proven effective in preventing osteoporotic fractures1. Calcium supplements should not be presecribed to prevent or treat osteoporosis.

References
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2. Radford L, Bolland M, Mason B et al. The Auckland calcium study: 5-year post-trial follow-up. Osteoporos Int.
2013;25(1):297-304
3. Jackson RD, LaCroix A, Gass M, et al. Calcium plus vitamin D supplementation and the risk of fractures. New Engl J
Med. W2006;354(7):669-684.
4. Michaelsson K, Melhus H, Warensjo Lemming E, Wolk A, Byberg L. Long term calcium intake and rates of all cause
and cardiovascular mortality: community based prospective longitudinal cohort study.BMJ. 2013;346(feb12 4):f228
-f228.
5. Li K, Kaaks R, Linseisen J, Rohrmann S. Associations of dietary calcium intake and calcium supplementation with
myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European
Prospective Investigation into Cancer and Nutrition study (EPIC-Heidelberg). Heart. 2012;98(12):920-925.
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8. Bolland M, Avenell A, Baron J et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ. 2010;341(jul29 1):c3691-c3691.
9. Reid IR. Should we prescribe calcium supplements for osteoporosis prevention? J bone Metab. 2014;21:21-28.
10. Prentice RL, Pettinger MB, Jackson RD, et al. Health risks and benefits from calcium and vitamin D supplementation: Womens Health Initiative clinical trial and cohort study. Osteoporos Int. 2013;24:567-580.
11. Stevens LA, Viswanathan G and Weiner DE. Chronic kidney disease and end-stage renal disease in the elderly population: current prevalence, future projections, and clinical significance. Adv Chronic Kidney Dis. 2010;17(4):293301.
12. Calcium and vitamin D: what you need to know. National Osteoporosis Foundation website. http://nof.org/
calcium#CALCIUMSUPPLEMENTS. Accessed March 8, 2015.
13. Lewis JR, Calver J, Zhu K, Flicker L, Prince RL. Calcium supplementation and the risks of atherosclerotic vascular disease in older women: results of a 5-year RCT and a 4.5-year follow-up. J Bone Miner Res. 2011;26(1):35-41.
14. Haghighi A, Samimagham H. Kidney Diseases Calcium and Vitamin D Supplementation and Risk of Kidney Stone
Formation in Postmenopausal Women. 2013;7(3):210-214.