• Karl Michaëlsson, Håkan Melhus, Eva Warensjö Lemming, Alicja Wolk, and Liisa Byberg.
• Department of Surgical Sciences, Section of Orthopedics, Uppsala University, SE-751 85 Uppsala, Sweden. karl.michaelsson@surgsci.uu.se
• BMJ. 2013 Jan 1;346:f228.

ObjectiveTo investigate the association between long term intake of dietary and supplemental calcium and death from all causes and cardiovascular disease.DesignProspective longitudinal cohort study.SettingSwedish mammography cohort, a population based cohort established in 1987-90.Participants61 433 women (born between 1914 and 1948) followed-up for a median of 19 years.Main Outcome MeasuresPrimary outcome measures, identified from registry data, were time to death from all causes (n=11 944) and cause specific cardiovascular disease (n=3862), ischaemic heart disease (n=1932), and stroke (n=1100). Diet was assessed by food frequency questionnaires at baseline and in 1997 for 38 984 women, and intakes of calcium were estimated. Total calcium intake was the sum of dietary and supplemental calcium.ResultsThe risk patterns with dietary calcium intake were non-linear, with higher rates concentrated around the highest intakes (≥1400 mg/day). Compared with intakes between 600 and 1000 mg/day, intakes above 1400 mg/day were associated with higher death rates from all causes (hazard ratio 1.40, 95% confidence interval 1.17 to 1.67), cardiovascular disease (1 49, 1.09 to 2.02), and ischaemic heart disease (2.14, 1.48 to 3.09) but not from stroke (0.73, 0.33 to 1.65). After sensitivity analysis including marginal structural models, the higher death rate with low dietary calcium intake (<600 mg/day) or with low and high total calcium intake was no longer apparent. Use of calcium tablets (6% users; 500 mg calcium per tablet) was not on average associated with all cause or cause specific mortality but among calcium tablet users with a dietary calcium intake above 1400 mg/day the hazard ratio for all cause mortality was 2.57 (95% confidence interval 1.19 to 5.55).ConclusionHigh intakes of calcium in women are associated with higher death rates from all causes and cardiovascular disease but not from stroke.

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