Osteoporosis International

, Volume 16, Issue 7, pp 799–804 | Cite as

A meta-analysis of milk intake and fracture risk: low utility for case finding

  • John A. Kanis
  • Helena Johansson
  • Anders Oden
  • Chris De Laet
  • Olof Johnell
  • John A. Eisman
  • Eugene McCloskey
  • Dan Mellstrom
  • Huibert Pols
  • Jonathan Reeve
  • Alan Silman
  • Alan Tenenhouse
Original Article


A low intake of calcium is widely considered to be a risk factor for future fracture. The aim of this study was to quantify this risk on an international basis and to explore the effect of age, gender and bone mineral density (BMD) on this risk. We studied 39,563 men and women (69% female) from six prospectively studied cohorts comprising EVOS/EPOS, CaMos, DOES, the Rotterdam study, the Sheffield study and a cohort from Gothenburg. Cohorts were followed for 152,000 person-years. The effect of calcium intake as judged by the intake of milk on the risk of any fracture, any osteoporotic fracture and hip fracture alone was examined using a Poisson model for each sex from each cohort. Covariates examined were age and BMD. The results of the different studies were merged by using the weighted β-coefficients. A low intake of calcium (less than 1 glass of milk daily) was not associated with a significantly increased risk of any fracture, osteoporotic fracture or hip fracture. There was no difference in risk ratio between men and women. When both sexes were combined there was a small but non-significant increase in the risk of osteoporotic and of hip fracture. There was also a small increase in the risk of an osteoporotic fracture with age which was significant at the age of 80 years (RR=1.15; 95% CI=1.02–1.30) and above. The association was no longer significant after adjustment for BMD. No significant relationship was observed by age for low milk intake and hip fracture risk. We conclude that a self-reported low intake of milk is not associated with any marked increase in fracture risk and that the use of this risk indicator is of little or no value in case-finding strategies.


Calcium intake Hip fracture Meta-analysis Milk Osteoporotic fracture 



We are grateful to the International Osteoporosis Foundation, the International Society for Clinical Densitometry, the National Osteoporosis Foundation, and the European Community (EU FP 3/5). We acknowledge the Alliance for Better Bone Health, Lunar, Hologic, IGEA, Lilly, Novartis, Pfizer, Roche and Wyeth for their unrestricted support of this work.


  1. 1.
    Heaney RP (1993) Nutritional factors in osteoporosis. Ann Rev Nutr 13:287–316Google Scholar
  2. 2.
    Valimaki MJ, Karkkainen M, Lamberg-Allardt C, Laitinen K, Heikkinen J (1994) Exercise, smoking and calcium intake during adolescence and early adulthood as determinants of peak bone mass. BMJ 309:230–235PubMedGoogle Scholar
  3. 3.
    Bonjour JP, Carrie AL, Ferrari S et al. (1997) Calcium enriched foods and bone mass growth in prepubertal girls: a randomised, double-blind, placebo-controlled trial. J Clin Invest 99:1287–1294PubMedGoogle Scholar
  4. 4.
    Kanis JA, Passmore R (1989) Calcium supplementation of the diet not justified by the present evidence. BMJ 298:137–140 and 205–208PubMedGoogle Scholar
  5. 5.
    Nordin BEC, Heaney RP (1990) Calcium supplementation of the diet: justified by the present evidence. BMJ 300:1056–1060PubMedGoogle Scholar
  6. 6.
    Cumming R, Cummings S, Nevitt M, Scott J, Ensrud K, Vogt T, Fox K (1997) Calcium intake and fracture risk: results from the study of osteoporotic fractures. Am J Epidemiol 145:927–935Google Scholar
  7. 7.
    Kanis JA (1999) The use of calcium in the management of osteoporosis. Bone 24:279–290CrossRefPubMedGoogle Scholar
  8. 8.
    Yates AA, Schlicker SA, Suitor CW (1998) Dietary reference intakes: the new basis for recommendations for calcium and related nutrients, B vitamins, and choline. J Am Diet Assoc 98:699–706CrossRefPubMedGoogle Scholar
  9. 9.
    European Commission (1998) Report on osteoporosis in the European Community—action on prevention. Luxembourg Office for Official Publications of the European Communities, pp 112Google Scholar
  10. 10.
    National Osteoporosis Foundation (1998) Physician’s guide to prevention and treatment of osteoporosis. National Osteoporosis Association, Washington D.C., pp 1–38Google Scholar
  11. 11.
    National Institutes of Health (2001) Osteoporosis prevention, diagnosis and therapy. NIH consensus development conference statement. JAMA 285:785–795PubMedGoogle Scholar
  12. 12.
    Chapuy MC, Arlot ME, Delmas PD, Meunier PJ (1994) Effect of calcium and cholecalciferol treatment for three years on hip fractures in elderly women. BMJ 308:1081–1082PubMedGoogle Scholar
  13. 13.
    Chapuy MC, Arlot ME, Duboeuf F, Brun J, Crouzet B, Arnaud S, Delmas PD, Meunier PJ (1992) Vitamin D3 and calcium to prevent hip fractures in elderly women. N Engl J Med 327:1637–1642PubMedGoogle Scholar
  14. 14.
    Dawson-Hughes B, Harris SS, Krall EA, Dallal GE (1997) Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N Engl J Med 337:670–676CrossRefPubMedGoogle Scholar
  15. 15.
    Shea B, Wells G, Cranney A, Zytaruk N, Robinson V, Griffith L, Ortiz Z, Peterson J, Adachi J, Tugwell P, Guyatt G, the Osteoporosis Methodology Group and the Osteoporosis Research Advisory Group (2002) Meta-analysis of calcium supplementation for the prevention of postmenopausal osteoporosis. Endocr Rev 23:552–559CrossRefPubMedGoogle Scholar
  16. 16.
    American College of Rheumatology, Ad Hoc Committee on glucocorticosteroid-induced osteoporosis (2001) Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthr Rheum 44:1496–1503CrossRefGoogle Scholar
  17. 17.
    Bone and Tooth Society of Great Britain, National Osteoporosis Society and Royal College of Physicians (2002) Guidelines on the prevention and treatment of glucocorticoid-induced osteoporosis. Royal College of Physicians, LondonGoogle Scholar
  18. 18.
    Kanis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D on behalf of the EFFO (1997) Guidelines for the diagnosis and management of osteoporosis. Osteoporos Int 7:390–406PubMedGoogle Scholar
  19. 19.
    Royal College of Physicians (1999) Osteoporosis: clinical guidelines for prevention and treatment. Royal College of Physicians, LondonGoogle Scholar
  20. 20.
    Royal College of Physicians (2000) Osteoporosis: clinical guidelines for prevention and treatment. Update on pharmacological interventions and an algorithm for management. Royal College of Physicians, LondonGoogle Scholar
  21. 21.
    O’Neill TW, Felsenberg D, Varlow J, Cooper C, Kanis JA, Silman AJ (1996) The prevalence of vertebral deformity in European men and women: the European Vertebral Osteoporosis Study. J Bone Miner Res 11:1010–1017PubMedGoogle Scholar
  22. 22.
    Ismail AA, Pye SR, Cockerill WC, Lunt M, Silman AJ, Reeve J, Banzer D, Benevolenskaya LI, Bhalla A, Bruges Armas J, Cannata JB, Cooper C, Delmas PD, Dequeker J, Dilsen G, Falch JA, Felsch B, Felsenberg D, Finn JD, Gennari C, Hoszowski K, Jajic I, Janott J, Johnell O, Kanis JA, Kragl G, Lopez Vaz A, Lorenc R, Lyritis G, Marchand F, Masaryk P, Matthis C, Miazgowski T, Naves-Diaz M, Pols HAP, Poor G, Rapado A, Raspe HH, Reid DM, Reisinger W, Scheidt-Nave C, Stepan J, Todd C, Weber K, Woolf AD, O’Neill TW (2002) Incidence of limb fracture across Europe: results from the European prospective osteoporosis study EPOS. Osteoporos Int 13:565–571CrossRefPubMedGoogle Scholar
  23. 23.
    Felsenberg D, Silman AJ, Lunt M, Ambrecht G, Ismail AA, Finn JD, Cockerill WC, Banzer D, Benevolenskaya LI, Bhalla A, Bruges Armas J, Cannata JB, Cooper C, Dequeker J, Eastell R, Ershova O, Felsch B, Gowin W, Havelka S, Hoszowski K, Jajic I, Janot J, Johnell O, Kanis JA, Kragl G, Lopez Vaz A, Lorenc R, Lyritis G, Masaryk P, Matthis C, Miazgowski T, Parisi G, Pols HAP, Poor G, Raspe HH, Reid DM, Reisinger W, Scheidt-Nave C, Stepan J, Todd C, Weber K, Woolf AD, Reeve J, O’Neill TW (2002) Incidence of vertebral fracture in Europe: results from the European Prospective Osteoporosis Study EPOS. J Bone Miner Res 17:716–724PubMedGoogle Scholar
  24. 24.
    Kreiger N, Tenenhouse A, Joseph L et al. (1999) The Canadian Multicentre Osteoporosis Study CaMos: background, rationale, methods. Can J Ageing 18:376–387Google Scholar
  25. 25.
    Jones G, Nguyen TV, Sambrook PN, Kelly PJ, Gilbert C, Eisman JA (1994) Symptomatic fracture incidence in elderly men and women. The Dubbo osteoporosis Epidemiology Study DOES. Osteoporos Int 4:277–282PubMedGoogle Scholar
  26. 26.
    Hofman A, Grobbee DE, de Jong PT, van den Ouweland FA (1991) Determinants of disease and disability in the elderly: The Rotterdam Elderly Study. Eur J Epidemiol 7:403–422PubMedGoogle Scholar
  27. 27.
    De Laet CEDH, Van Hout BA, Burger H, Hofman A, Weel AEAM, Pols HAP (1998) Hip fracture prediction in elderly men and women: validation of the Rotterdam Study. J Bone Miner Res 13:1587–1593PubMedGoogle Scholar
  28. 28.
    Johansson H, Oden A, Johnell O, Jonsson B, De Laet C, Oglesby A, McCloskey EV, Kayan K, Jalava T, Kanis JA (2004) Optimisation of BMD measurements to identify high risk groups for treatment—a test analysis. J Bone Miner Res (in press)Google Scholar
  29. 29.
    Senstrom M, Olsson J-O, Mellstrom D (2000) Thyroid hormone replacement is not related to increased risk of osteoporosis. Osteoporos Int 11:S144Google Scholar
  30. 30.
    Johnell O, Gullberg B, Kanis JA, Allander E, Elffors L, Dequeker J, Dilsen G, Gennari C, Lopez Vaz A, Lyritis G, Mazzuoli G, Miravet L, Passeri M, Perez-Cano R, Rapido A, Ribot C (1995) Risk factors for hip fracture in European women. The MEDOS study. J Bone Miner Res 10:1802–1815PubMedGoogle Scholar
  31. 31.
    Krough V, Frendenheim JL, D’Amacis 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 22:869–877PubMedGoogle Scholar
  32. 32.
    Cummings SR, Black G, McHenry K, Baron RB (1987) Evaluation of two food frequency methods of measuring dietary calcium intake. Am J Epidemiol 126:796–802PubMedGoogle Scholar
  33. 33.
    Kanis JA, Oden A, Johnell O, Jonsson B, De Laet C, Dawson A (2002) The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int 12:417–424CrossRefGoogle Scholar
  34. 34.
    Higgins JPT, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560CrossRefPubMedGoogle Scholar
  35. 35.
    Michaelsson K, Melhus H, Bellocco R, Wolk A (2003) Dietary calcium and vitamin D intake in relation to osteoporotic fracture risk. Bone 32:694–703CrossRefPubMedGoogle Scholar
  36. 36.
    Cumming RG, Nevitt MC (1997) Calcium for the prevention of osteoporotic fractures in postmenopausal women. J Bone Miner Res 12:1321–1329PubMedGoogle Scholar
  37. 37.
    Kanis JA, Johansson H, Oden A, Johnell O, De Laet C, Melton LJ, Tenenhouse A, Reeve J, Silman AJ, Pols HAP, Eisman JA, McClsokey EV, Mellstrom D (2004) A meta-analysis of prior corticosteroid use and fracture risk. J Bone Miner Res (in press)Google Scholar
  38. 38.
    Kanis JA, Delmas P, Reeve J, Garnero P, Tenenhouse A, Melton LJ, Oden A, McCloskey EV, Pols H, De Laet C (2003) A meta-analysis of previous fracture and fracture risk. Bone 32:S84CrossRefGoogle Scholar
  39. 39.
    De Laet CEDH, Johansson H, Johnell O, Kanis JA, McCloskey EV, Mellstrom D, Melton LJ, Oden A, Delmas P, Garnero P, Oglesby A, Eisman J, Pols H, Reeve J, Silman A, Tenenhouse A (2003) A meta-analysis of body mass index as a predictor of fracture risk. J Bone Miner Res 18:S21Google Scholar
  40. 40.
    Kanis JA, Johnell O, Gullberg B, Allander E, Elffors L, Ranstam J, Dequeker J, Dilsen G, Gennari C, Lopez Vaz A, Lyritis G, Mazzuoli G, Miravet L, Passeri M, Perez-Cano R, Rapado A, Ribot C (1999) Risk factors for hip fracture in men from Southern Europe: the MEDOS Study. Osteoporos Int 9:45–54CrossRefPubMedGoogle Scholar
  41. 41.
    Szulc P, Meunier JP (2003) Synergistic effect of vitamin D and calcium in preventing femoral fractures in older patients. Joint Bone Spine 70:157–160CrossRefPubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2004

Authors and Affiliations

  • John A. Kanis
    • 1
  • Helena Johansson
    • 2
  • Anders Oden
    • 2
  • Chris De Laet
    • 3
  • Olof Johnell
    • 4
  • John A. Eisman
    • 5
  • Eugene McCloskey
    • 6
  • Dan Mellstrom
    • 7
  • Huibert Pols
    • 8
  • Jonathan Reeve
    • 9
  • Alan Silman
    • 10
  • Alan Tenenhouse
    • 11
  1. 1.WHO Collaborating Centre for Metabolic Bone DiseasesUniversity of Sheffield Medical SchoolSheffield UK
  2. 2.GothenburgSweden
  3. 3.Scientific Institute of Public HealthBrusselsBelgium
  4. 4.Department of OrthopaedicsMalmo General HospitalMalmoSweden
  5. 5.Bone and Mineral Research Program, Garvan Institute of Medical ResearchSt Vincent’s Hospital & University of NSWSydneyAustralia
  6. 6.Osteoporosis Centre, University of SheffieldNorthern General HospitalSheffieldUK
  7. 7.Department of Geriatric MedicineGoteborg UniversityGothenburgSweden
  8. 8.Department of Internal MedicineErasmus UniversityRotterdamThe Netherlands
  9. 9.Strangeways Research LaboratoryCambridgeUK
  10. 10.ARC Epidemiology UnitUniversity of ManchesterManchesterUK
  11. 11.Division of Bone MetabolismThe Montreal General HospitalMontrealCanada

Personalised recommendations