Low Fractional Calcium Absorption Increases the Risk for Hip Fracture in Women with Low Calcium Intake

Low Fractional Calcium Absorption Increases the Risk for Hip Fracture in Women with Low Calcium Intake

Kristine E. Ensrud, MD, MPH;
Tu Duong, MA;
Jane A. Cauley, DrPH;
Robert P. Heaney, MD;
Randi L. Wolf, PhD;
Emily Harris, PhD;
Steven R. Cummings, MD; and
for the Study of Osteoporotic Fractures Research Group*

From Veterans Affairs Medical Center, Minneapolis, Minnesota; University of California, San Francisco, California; University of Pittsburgh, Pittsburgh, Pennsylvania; Creighton University, Omaha, Nebraska; and Kaiser Permanente Center for Health Research, Portland, Oregon.

Abstract

Background: Decreased ability to absorb calcium with age limits adaptation to low calcium intake and is thought to lead to secondary hyperparathyroidism and increased risk for hip and other fractures. However, the associations between fractional calcium absorption, dietary calcium intake, and risk for fracture have never been studied.

Objective: To determine whether low fractional calcium absorption in women with low calcium intake increases the risk for subsequent hip and other nonspine fractures.

Design: Prospective cohort study.

Setting: Four clinical centers in Baltimore County, Maryland; Portland, Oregon; Minneapolis, Minnesota; and the Monongahela Valley, Pennsylvania.

Participants: 5452 nonblack women 69 years of age or older participating in the fourth examination of the Study of Osteoporotic Fractures.

Measurements: Fractional calcium absorption was measured by using a 3-hour single isotope (⁴⁵Ca) technique. Incident fractures were identified prospectively and were confirmed by radiographic report.

Results: During an average of 4.8 years, 729 women (13%) experienced at least one nonspine fracture; 153 of these women had hip fractures. After adjustment for age, women with lower fractional calcium absorption were at increased risk for hip fracture (relative risk per 1-SD [7.7%] decrease in fractional calcium absorption, 1.24 [95% CI, 1.05 to 1.48]). Women with low fractional calcium absorption and low calcium intake were at greatest risk for subsequent hip fracture; among women whose dietary calcium intake was less than 400 mg/d, those who had fractional calcium absorption at or below the median value of 32.3% had a 2.5-fold (CI, 1.29-fold to 4.69-fold) increase in risk for hip fracture compared with those who had greater absorption efficiency. Fractional calcium absorption was not related to risk for other nonspine fractures (relative risk per 1-SD [7.7%] decrease in fractional calcium absorption, 1.05 [CI, 0.96 to 1.14]).

Conclusions: In elderly women, low fractional calcium absorption in the setting of low calcium intake increases the risk for hip fracture. Our findings support the hypothesis of type II osteoporosis, which postulates that decreased calcium absorption is an important risk factor for hip fracture in older persons.

*For members of the Study of Osteoporotic Fractures Research Group, see Appendix.

Article and Author Information

Acknowledgments: The authors thank Ms. Paula Bowman for her help with preparation of the manuscript.
Grant Support: By the National Institutes of Health and by grants from the Public Health Service (AG05407, AR35582, AG05394, AR35584, and AR35583).
Requests for Single Reprints: Kristine E. Ensrud, MD, MPH, General Internal Medicine (111-0), Veterans Affairs Medical Center, One Veterans Drive, Minneapolis, MN 55417; e-mail, ensru001{at}tc.umn.edu.
Requests To Purchase Bulk Reprints (minimum, 100 copies): Reprints Coordinator; phone, 215-351-2657; e-mail, reprints{at}mail.acponline.org.
Current Author Addresses: Dr. Ensrud: General Internal Medicine (111-0), Veterans Affairs Medical Center, One Veterans Drive, Minneapolis, MN 55417.
Ms. Duong and Dr. Cummings: University of California, San Francisco, 74 New Montgomery, Suite 600, San Francisco, CA 94105.
Drs. Cauley and Wolf: University of Pittsburgh, 130 DeSoto Street, Pittsburgh, PA 15261.
Dr. Heaney: Creighton University, 2500 California Plaza, Omaha, NE 68178.
Dr. Harris: Kaiser Permanente Center for Health Research, 3800 North Interstate Avenue, Portland, OR 97227.
Author Contributions: Conception and design: K.E. Ensrud, J.A. Cauley, S.R. Cummings.
Analysis and interpretation of the data: K.E. Ensrud, T. Duong, J.A. Cauley, R.L. Wolf, S.R. Cummings.
Drafting of the article: K.E. Ensrud, J.A. Cauley.
Critical revision of the article for important intellectual content: K.E. Ensrud, J.A. Cauley, R.L. Wolf, S.R. Cummings.
Final approval of the article: K.E. Ensrud, T. Duong, J.A. Cauley, R.P. Heaney, R.L. Wolf, E.L. Harris, S.R. Cummings.
Provision of study materials or patients: K.E. Ensrud, E.L. Harris.
Statistical expertise: T. Duong.
Obtaining of funding: K.E. Ensrud, S.R. Cummings.
Administrative, technical, or logistic support: K.E. Ensrud, R.P. Heaney.
Collection and assembly of data: K.E. Ensrud, T. Duong, R.P. Heaney, E.L. Harris.