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)

Study Questions:

Is dietary calcium intake and calcium supplementation associated with myocardial infarction (MI), stroke, and overall cardiovascular disease (CVD) mortality?

Methods:

Data from the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC) study were used in this analysis. Participants who were ages 35-64 years and free of major CVD events at baseline were included. A self-administered validated food frequency questionnaire was used to assess consumption of 148 food items in the 12 months before the date of recruitment. Supplement use was assessed at baseline and in follow-up surveys. The primary outcomes of interest were MI, stroke, and CV death.

Results:

A total of 23,980 participants were included. During the 11 years of follow-up, 354 MIs, 260 strokes, and 267 CVD deaths were documented. A higher dietary calcium intake was associated with younger age, higher educational level, healthy weight, and being physically active. Dietary calcium intake was also positively associated with dietary vitamin D, saturated fatty acid and total protein intake, and the likelihood of taking calcium supplements. Compared with nonusers, users of calcium supplements were more likely to be women, physically more active, and less likely to be overweight/obese. However, users of calcium supplements were older, had an overall lower educational level, and had a longer duration of smoking. Compared with the lowest quartile, the third quartile of total dietary and dairy calcium intake had a significantly reduced risk of MI, with a hazard ratio [HR] of 0.69 (95% confidence interval [CI], 0.50-0.94) and 0.68 (95% CI, 0.50-0.93), respectively. There was no association with total dietary and dairy calcium and stroke risk or CVD mortality. In comparison with nonusers of any supplements, users of calcium supplements had a statistically significantly increased MI risk (HR, 1.86; 95% CI, 1.17-2.96), which was more pronounced for calcium supplement only users (HR, 2.39; 95% CI, 1.12-5.12).

Conclusions:

The investigators concluded that increasing calcium intake from diet might not confer significant CV benefits, while calcium supplements, which might raise MI risk, should be taken with caution.

Perspective:

As with other studies, these findings suggest that supplementation is not the same as dietary intake from food sources. This is not a randomized controlled trial, and differences between those who used supplements versus those who did not were apparent. Thus, the results suggest the need for a randomized clinical trial to further our understanding regarding calcium supplementation.

Clinical Topics: Prevention, Nonstatins, Diet, Smoking

Keywords: Myocardial Infarction, Stroke, Neoplasms, Food Habits, Overweight, Body Weight, Smoking, Fruit, Calcium, Dietary, Dietary Supplements, Cardiovascular Diseases, Nutritional Status, Obesity, Diet, Pregnancy, Prolonged, Vitamin D


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