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Calcium: What’s Best for Your Bones

and Health? | The Nutrition Source

27-34 minutes

Table of Contents

Introduction

What Is Calcium, and Where Do We Get It?

Growing Healthy Bones

What Is Osteoporosis

How Can Osteoporosis Be Slowed Down?

Preventing Bone Loss in Adulthood

Should You Get Calcium from Milk?

The Bottom Line: Recommendations for Calcium Intake and Bone

Health

References

Introduction

Those advertisements pushing milk as the answer to strong bones

are almost inescapable. But does “got milk?” really translate into
“got strong bones?”

The pro-milk faction believes that increased calcium intake

—particularly in the form of the currently recommended three
glasses of milk per day—will help prevent osteoporosis, the
weakening of bones. Each year, osteoporosis leads to more than
1.5 million fractures, including 300,000 broken hips.

On the other side are those who believe that consuming a lot of
milk and other dairy products will have little effect on the rate of
fractures but may contribute to problems such as heart disease or
prostate cancer.

Which view is right? The final answers aren’t in. But here is a
summary of what’s currently known about calcium and its effects on
the body.

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What Is Calcium, and Where Do We Get It?

Calcium is a mineral that the body needs for numerous functions,

including building and maintaining bones and teeth, blood clotting,
the transmission of nerve impulses, and the regulation of the heart’s
rhythm. Ninety-nine percent of the calcium in the human body is
stored in the bones and teeth. The remaining 1 percent is found in
the blood and other tissues.

The body gets the calcium it needs in two ways. One is by eating
foods or supplements that contain calcium. Good sources include
dairy products, which have the highest concentration per serving of
highly absorbable calcium, and dark leafy greens or dried beans,
which have varying amounts of absorbable calcium. Calcium
supplements often contain vitamin D; taking calcium paired with
vitamin D seems to be more beneficial for bone health than taking
calcium alone. (Read more about calcium and osteoporosis.)

The other way the body gets calcium is by pulling it from bones.
This happens when blood levels of calcium drop too low, usually
when it’s been awhile since having eaten a meal containing
calcium. Ideally, the calcium that is “borrowed” from the bones will
be replaced at a later point. But, this doesn’t always happen. Most
important, this payback can’t be accomplished simply by eating
more calcium.

Food Sources of Calcium

Milk and dairy products are not the only sources of calcium. Here is
a list of foods that are good sources of calcium:

Calcium
Food Amount
(milligrams)
Yogurt, plain, low fat 8 oz 415
Collards, frozen, boiled 1 cup 357
Skim milk 1 cup 306
Yogurt, plain, whole milk 8 oz 275
Black-eyed peas, boiled 1 cup 211
Canned salmon 3 oz 181
3 oz (¼
Calcium-set tofu  163
block)

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Cheese food, pasteurized

1 oz 162
American
Trail mix (nuts, seeds, chocolate
1 cup 159
chips)
Baked beans, canned 1 cup 154
Cottage cheese, 1% milk fat 1 cup 138
Iceberg lettuce 1 head   97
Green peas, boiled 1 cup   94
Soy milk  1 cup  93
Oranges 1 cup   72
1 oz (24
Almonds   70
nuts)
An extensive list of the calcium content of foods is available online
from the U.S. Department of Agriculture.

Growing Healthy Bones

Bone is living tissue that is always in flux. Throughout the lifespan,

bones are constantly being broken down and built up in a process
known as remodeling. Bone cells called osteoblasts build bone,
while other bone cells called osteoclasts break down bone.

In healthy individuals who get enough calcium and physical activity,

bone production exceeds bone destruction up to about age 30.
After that, destruction typically exceeds production.

What Is Osteoporosis?

Osteoporosis, or “porous bones,” is the weakening of bones caused

by an imbalance between bone building and bone destruction.
People typically lose bone as they age, despite consuming the
recommended intake of calcium necessary to maintain optimal
bone health. An estimated 10 million Americans—8 million women
and 2 million men—have osteoporosis. Another 34 million have low
bone mass, placing them at increased risk for osteoporosis. (1)

Achieving adequate calcium intake and maximizing bone stores

during the time when bone is rapidly deposited (up to age 30)
provides an important foundation for the future. But it will not
prevent bone loss later in life. The loss of bone with aging is the
result of several factors, including genetic factors, physical
inactivity, and lower levels of circulating hormones (estrogen in
women and testosterone in men).

Postmenopausal women account for 80 percent of all cases of

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osteoporosis because estrogen production declines rapidly at

menopause. Of course, men are also at risk of developing
osteoporosis, but they tend to do so 5 to 10 years later than
women, since testosterone levels do not fall abruptly the way
estrogen does in women. It is estimated that osteoporosis will
cause half of all women over age 50 to suffer a fracture of the hip,
wrist, or vertebra.

How Can Osteoporosis Be Slowed Down?

Preventing osteoporosis depends on two things: making the

strongest, densest bones possible during the first 30 years of life
and limiting the amount of bone loss in adulthood.

There are a number of lifestyle factors that can help with the latter:

Getting regular exercise, especially weight-bearing and muscle

strengthening exercise.

Getting adequate vitamin D, whether through diet, exposure to

sunshine, or supplements.

Consuming enough calcium to reduce the amount the body has to

borrow from bone.

Consuming adequate vitamin K, found in green, leafy vegetables.

Not getting too much preformed vitamin A.

Preventing Bone Loss in Adulthood

Several complementary strategies can help prevent or minimize

bone loss during adulthood and old age. These include:

Getting Regular Exercise

Physical activity that puts some strain or stress on bones causes

the bones to retain and possibly even gain density throughout life.
Cells within the bone sense this stress and respond by making the
bone stronger and denser. Such “weight-bearing” exercises include
walking, dancing, jogging, weightlifting, stair-climbing, racquet
sports, and hiking.

Swimming is a useful form of exercise for the heart and

cardiovascular system. But because water supports the bones,
rather than putting stress on them, it’s not considered a good
“weight-bearing” exercise for bone strength. In addition, physical
activity doesn’t strengthen all bones, just those that are stressed, so
you need a variety of exercises or activities to keep all your bones
healthy.

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Another function of physical activity, probably at least as important

as its direct effect on bone mass, is its role in increasing muscle
strength and coordination. With greater muscle strength, one can
often avoid falls and situations that cause fractures. Making
physical activity a habit can help maintain balance and avoid falls.

Getting Enough Calcium

Despite the debates surrounding milk and calcium, one thing is

clear: adequate calcium—both for bone development and for non-
bone functions—is key to reducing the risk of osteoporosis.
However, the healthiest or safest amount of dietary calcium hasn’t
yet been established. Different scientific approaches have yielded
different estimates, so it’s important to consider all the evidence.

Maximum-calcium-retention studies, which examine the maximum

amount of calcium that can be forced into bones, suggest a fairly
high requirement. To ensure that 95 percent of the population gets
this much calcium, the National Academy of Sciences established
the following recommended intake levels:

1,000 milligrams/day for those age 19 to 50

1,200 milligrams/day for those age 50 or over

1,000 milligrams/day for pregnant or lactating adult women

But the maximum-calcium-retention studies are short term and

therefore have important limitations. To detect how the body adapts
to different calcium intakes over a long period of time—and to get
the big picture of overall bone strength—requires studies of longer
duration.

The results from such long-term studies may be surprising to some.

While they do not question the importance of calcium in maximizing
bone strength, they cast doubt on the value of consuming the large
amounts currently recommended for adults.

In particular, these studies suggest that high calcium intake doesn’t

actually appear to lower a person’s risk for osteoporosis. For
example, in the large Harvard studies of male health professionals
and female nurses, individuals who drank one glass of milk (or less)
per week were at no greater risk of breaking a hip or forearm than
were those who drank two or more glasses per week. (2, 3) When
researchers combined the data from the Harvard studies with other
large prospective studies, they still found no association between
calcium intake and fracture risk. (4) Also, the combined results of
randomized trials that compared calcium supplements with a
placebo showed that calcium supplements did not protect against

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fractures of the hip or other bones. Moreover, there was some

suggestion that calcium supplements taken without vitamin D might
even increase the risk of hip fractures. A 2014 study also showed
that higher milk consumption during teenage years was not
associated with a lower risk of hip fracture in older adults. (27)

Additional evidence further supports the idea that American adults

may not need as much calcium as is currently recommended. For
example, in countries such as India, Japan, and Peru where
average daily calcium intake is as low as 300 milligrams per day
(less than a third of the U.S. recommendation for adults, ages 19 to
50), the incidence of bone fractures is quite low. Of course, these
countries differ in other important bone-health factors as well—such
as level of physical activity and amount of sunlight—which could
account for their low fracture rates.

Ideally, these issues might be resolved by randomizing a large

group of adults to get different amounts of calcium and following
them to see how many would eventually break a bone. In fact, a
few such studies have been conducted, and they have not provided
evidence of benefit, as noted above. However, most of these
studies were small or of short duration, so they could not rule out
the possibility of a small benefit from supplementation. Other
randomized trials have combined calcium in combination with
vitamin D, which could obscure the true effects of calcium.

To illustrate the different conclusions drawn from examining the

same body of data, a British committee that is comparable to the
U.S. group that established calcium requirements here concluded
that 700 milligrams per day was enough for individuals age 19 and
older.

Getting Enough Vitamin D

 Vitamin D plays a critical role in maintaining bone health. When

blood levels of calcium begin to drop, the body responds in several
ways. It promotes the conversion of vitamin D into its active form,
which then travels to the intestines (to encourage greater calcium
absorption into the blood) and to the kidneys (to minimize calcium
loss in the urine).

For bone health, an adequate intake of vitamin D is no less

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important than calcium. Vitamin D is found in milk and vitamin

supplements, and it can be made by the skin when it is exposed to
sunlight in the summertime. But not all sunlight is created equal.
Above 40 degrees latitude (north of San Francisco, Denver,
Indianapolis, and Philadelphia), the winter sunlight isn’t strong
enough to promote vitamin D formation. Sunscreens also prevent
the formation of vitamin D, although they are still recommended to
reduce risk of sun-induced skin cancer and skin damage.

An examination of clinical trials of vitamin D for the prevention of

osteoporosis found that getting 700 to 800 IUs of vitamin D per day
decreases the risk of hip and non-vertebral fractures; (5) vitamin D
may be even more effective when taken in conjunction with
calcium. (6) A similar analysis of the effect of vitamin D on falls
indicated that supplementation with vitamin D reduces the risk of
falls among older individuals by more than 20 percent. (7)

Look for a multivitamin that supplies 800 to 1,000 IU of vitamin D

per day. If your multi only has 400 IU of vitamin D, consider taking
an extra supplement. Many people may need 2,000 IU per day (or
more) of vitamin D for adequate blood levels, particularly if they
have darker skin, spend winters at higher latitudes (such as the
northern U.S.), or spend little time in the sun. If you fall into one of
these groups, which would include most of the U.S. population,
taking 2,000 IU is reasonable and well within the safe range. As
always, it’s a good idea to discuss use of supplements with your
doctor, and he or she may want to order a vitamin D blood test.

Getting Enough Vitamin K

Vitamin K, which is found mainly in green,

leafy vegetables, likely plays one or more important roles in calcium
regulation and bone formation. Low levels of circulating vitamin K
have been linked with low bone density, and supplementation with
vitamin K shows improvements in biochemical measures of bone
health. (8) A report from the Nurses’ Health Study suggests that
women who get at least 110 micrograms of vitamin K a day are 30
percent less likely to break a hip than women who get less than
that. (9) Among the nurses, eating a serving of lettuce or other
green, leafy vegetable a day cut the risk of hip fracture in half when
compared with eating one serving a week. Data from the
Framingham Heart Study also shows an association between high

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vitamin K intake and reduced risk of hip fracture in men and

women, and increased bone mineral density in women. (10, 11)
Getting one or more servings per day of broccoli, Brussels sprouts,
dark green lettuce, collard greens, or kale should be enough to
meet the daily recommended target of 120 micrograms per day for
men and 90 micrograms per day for women.

Some other factors may also help lower the risk of osteoporosis:

Take care with caffeine and cola. Although the votes aren’t all in,
there is some evidence that drinking a lot of coffee—about four or
more cups per day—can increase the risk of fracture. Caffeine
tends to promote calcium excretion in urine. Meanwhile, the
Framingham Osteoporosis Study has found that older women who
drink cola every day have lower bone mineral density than those
who drink it less than once a month. (12) This may be due to cola’s
high levels of phosphorous, which may alter the dietary balance
between calcium and phosphorous and thereby weaken bones.

Get enough protein, but not too much. The body needs protein
to build healthy bones. But as your body digests protein, it releases
acids into the bloodstream, which the body neutralizes by drawing
calcium from the bones. Following a high-protein diet for a few
weeks probably won’t have much effect on bone strength. Doing it
for a long time, though, could weaken bone. In the Nurses’ Health
Study, for example, women who ate more than 95 grams of protein
a day were 20 percent more likely to have broken a wrist over a 12-
year period when compared to those who ate an average amount of
protein (less than 68 grams a day). (13) But this area of research is
still controversial, and findings have not been consistent. Some
studies suggest increasing protein increases risk of fractures;
others associate high-protein diets with increased bone mineral
density. It is still unclear what level of protein intake provides the
best protection against osteoporosis, and more research is needed.

Get enough vitamin A, but not too much. Long associated with
good vision, vitamin A has also been found to direct the process of
borrowing and redepositing calcium in bone. However, too much
preformed vitamin A (also known as retinol) can promote fractures.
Choose a multivitamin supplement that has all or the majority of its
vitamin A in the form of beta-carotene, a vitamin A precursor, since
beta-carotene does not increase one’s fracture risk. Many
multivitamin manufacturers have already reduced the amount of
preformed vitamin A in their products.

Postmenopausal women may also want to talk to a health care

provider about taking a medication that can strengthen bones. The

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estrogen in postmenopausal hormones can compensate for the

drop in estrogen levels after menopause, helping to prevent—and
perhaps even partially reverse—bone loss. However, hormone
replacement therapy has fallen from grace as the mainstay for
preventing osteoporosis after results from several studies showed
that it increased the risk of breast cancer, stroke, and blood clots.
(14) Other medications such as alendronate (Fosamax),
risedronate (Actonel), calcitonin (Miacalcin), raloxifene (Evista), and
parathyroid hormone (Fortéo) have been approved for the
prevention or treatment of osteoporosis.

Should You Get Calcium from Milk?

When most people in the United States think of calcium, they

immediately think of milk. But should this be so? Milk is actually
only one of many sources of calcium—dark leafy green vegetables
and some types of legumes are among the other sources—and
there are some important reasons why milk may not be the best
source for everyone.

These reasons include the following:

Lactose Intolerance

Many people have some degree of lactose intolerance. For them,

eating or drinking dairy products causes problems like cramping,
bloating, gas, and diarrhea. These symptoms can range from mild
to severe. Certain groups are much more likely to have lactose
intolerance. For example, 90 percent of Asians, 70 percent of
blacks and Native Americans, and 50 percent of Hispanics are
lactose intolerant, compared to only about 15 percent of people of
Northern European descent.

One alternative for those who are lactose intolerant but who still
enjoy consuming dairy products is to take a pill containing enzymes
that digest milk sugar along with the dairy product, or to consume
milk that has the lactase enzyme added to it.

High Saturated Fat Content

Many dairy products are high in saturated fats, and a high saturated
fat intake is a risk factor for heart disease. And while it’s true that
most dairy products are now available in fat-reduced or nonfat
options, the saturated fat that’s removed from dairy products is

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inevitably consumed by someone, often in the form of premium ice

cream, butter, or baked goods.

Strangely, it’s often the same people who purchase these higher fat
products who also purchase the low-fat dairy products, so it’s not
clear that they’re making great strides in cutting back on their
saturated fat consumption. (For more information on dietary fats,
read the Nutrition Source article Fats and Cholesterol: Out with the
Bad, In with the Good.)

Possible Increased Risk of Ovarian Cancer

High levels of galactose, a sugar released by the digestion of

lactose in milk, have been studied as possibly damaging to the
ovaries and leading to ovarian cancer. Although such associations
have not been reported in all studies, there may be potential harm
in consuming high amounts of lactose. A recent pooled analysis of
12 prospective cohort studies, which included more than 500,000
women, found that women with high intakes of lactose—equivalent
to that found in 3 cups of milk per day—had a modestly higher risk
of ovarian cancer, compared to women with the lowest lactose
intakes. (15) The study did not find any association between overall
milk or dairy product intake and ovarian cancer. Some researchers
have hypothesized, however, that modern industrial milk production
practices have changed milk’s hormone composition in ways that
could increase the risk of ovarian and other hormone-related
cancers. (16) More research is needed.

Probable Increased Risk of Prostate Cancer

A diet high in calcium has been implicated as a probable risk factor

for prostate cancer. (17) In a Harvard study of male health
professionals, men who drank two or more glasses of milk a day
were almost twice as likely to develop advanced prostate cancer as
those who didn’t drink milk at all. (18) The association appears to
be with calcium itself, rather than with dairy products in general: A
more recent analysis of the Harvard study participants found that
men with the highest calcium intake—at least 2,000 milligrams a
day—had nearly double the risk of developing fatal prostate cancer
as those who had the lowest intake (less than 500 milligrams per
day). (19)

Clearly, although more research is needed, we cannot be confident

that high milk or calcium intake is safe.

The Bottom Line: Recommendations for Calcium Intake and

Bone Health

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Adequate, lifelong dietary calcium intake is necessary to reduce the

risk of osteoporosis. Consuming adequate calcium and vitamin D
and performing regular, weight-bearing exercise are also important
to build maximum bone density and strength. After age 30, these
factors help slow bone loss, although they cannot completely
prevent bone loss due to aging.

Milk and dairy products are a convenient source of calcium for

many people. They are also a good source of protein and are
fortified with vitamins D and A. At this time, however, the optimal
intake of calcium is not clear, nor is the optimal source or sources of
calcium. As noted earlier, the National Academy of Sciences
currently recommends that people ages 19 to 50 consume 1,000
milligrams of calcium per day, and that those age 50 or over get
1,200 milligrams per day. Reaching 1,200 milligrams per day would
usually require drinking two to three glasses of milk per day—or
taking calcium supplements—over and above an overall healthy
diet.

However, these recommendations are based on very short-term

studies, and are likely to be higher than what people really need.
Currently, there’s no good evidence that consuming more than one
serving of milk per day in addition to a reasonable diet (which
typically provides about 300 milligrams of calcium per day from
nondairy sources) will reduce fracture risk. Because of unresolved
concerns about the risk of ovarian and prostate cancer, it may be
prudent to avoid higher intakes of dairy products.

At moderate levels, though, consumption of calcium and dairy

products has benefits beyond bone health, including possibly
lowering the risk of high blood pressure and colon cancer. (20–25)
While the blood pressure benefits appear fairly small, the protection
against colon cancer seems somewhat larger, and most of the latter
benefit comes from having just one or maybe two glasses of milk
per day in addition to what we get from other foods in our diet.
Getting more than this doesn’t seem to lower risk further.

For individuals who are unable to digest—or who dislike—dairy

products and for those who simply prefer not to consume large
amounts of such foods, other options are available. Calcium can
also be found in dark green, leafy vegetables, such as kale and

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collard greens, as well as in dried beans and legumes.

Calcium is also found in spinach and chard, but these vegetables

contain oxalic acid, which combines with the calcium to form
calcium oxalate, a chemical salt that makes the calcium less
available to the body. A variety of calcium-fortified foods, such as
orange juice and soy milk, are now on the market.

Calcium can also be ingested as a supplement, and if you do go the

supplement route, it’s best to choose one that includes some
vitamin D. Research suggests that calcium-only supplements do
not protect against fractures, and may in fact increase risk of
fractures. (4) There’s also some emerging evidence that taking
calcium-only supplements may possibly increase the risk of heart
attacks—another reason to avoid calcium-only supplements. (26)
Men may want to avoid calcium supplements because of questions
about possible risks of prostate cancer; if men do take a calcium
supplement, limiting supplement intake to 500 milligrams of calcium
per day seems prudent.

Antacids contain calcium, but do not contain vitamin D. So if you

choose antacids as a calcium source, you may want to consider
taking a separate vitamin D supplement. Discuss your options with
a health care provider. (Read more about vitamin D and health.)

References

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Accessed January 24, 2008.

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Colditz GA. Calcium intake and the incidence of forearm and hip
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3. Feskanich D, Willett WC, Stampfer MJ, Colditz GA. Milk, dietary

calcium, and bone fractures in women: a 12-year prospective study.
Am J Public Health. 1997; 87:992–97.

4. Bischoff-Ferrari HA, Dawson-Hughes B, Baron JA, et al. Calcium

intake and hip fracture risk in men and women: a meta-analysis of
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5. Bischoff-Ferrari HA, Willett WC, Wong JB, Giovannucci E,

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Vanderschueren D, Haentjens P. Need for additional calcium to

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