Cross-sectional analysis of calcium intake for associations with
vascular calcification and mortality in individuals with type 2 diabetes
from the Diabetes Heart Study1–3
Laura M Raffield, Subhashish Agarwal, Amanda J Cox, Fang-Chi Hsu, J Jeffrey Carr, Barry I Freedman, Jianzhao Xu,
Donald W Bowden, and Mara Z Vitolins
ABSTRACT
Background: The use of calcium supplements to prevent declines in
bone mineral density and fractures is widespread in the United States,
and thus reports of elevated cardiovascular disease (CVD) risk in users
of calcium supplements are a major public health concern. Any ele-
vation in CVD risk with calcium supplement use would be of partic-
ular concern in individuals with type 2 diabetes (T2D) because of
increased risks of CVD and fractures observed in this population.
Objective: In this study, we examined associations between cal-
cium intake from diet and supplements and measures of subclinical
CVD (calcified plaque in the coronary artery, carotid artery, and
abdominal aorta) and mortality in individuals affected by T2D.
Design: We performed a cross-sectional analysis in individuals af-
fected by T2D from the family-based Diabetes Heart Study (n = 720).
Results: We observed no significant associations of calcium from diet
or supplements with any of our measures of calcified plaque, and no
greater mortality risk was observed with increased calcium intake. In-
stead, calcium supplement use was modestly associated with reduced
all-cause mortality in women (HR: 0.62; 95% CI: 0.42, 0.92; P = 0.017).
Conclusion: Our results do not support a substantial association be-
tween calcium intake from diet or supplements and CVD risk in indi-
viduals with T2D. Am J Clin Nutr 2014;100:1029–35.
INTRODUCTION
Patients with type 2 diabetes (T2D)4 have significantly increased
risk of cardiovascular disease (CVD); mortality rates from heart
disease are $2-fold higher in individuals with T2D, with CVD
accounting for as much as 65% of all-cause mortality in T2D
patients (1). Individuals with T2D also have elevated risk of
fracture (2), although T2D is not thought to be associated with
declines in bone mineral density (BMD) (3–5). Calcium supple-
mentation may increase BMD and modestly reduce risk of fracture
(6). The use of calcium supplements is widespread, particularly in
postmenopausal women (7). However, several recent studies have
raised concerns that calcium supplementation may lead to elevated
risk of CVD, in particular higher risk of myocardial infarction (MI)
(8–12). Elevated risk of both fractures and CVD in individuals
with T2D makes potential increases in CVD risk in individuals
who are taking calcium supplements of particular concern; how-
ever, to our knowledge, potential associations between calcium
intake from diet and supplements and CVD risk have not pre-
viously been examined in a cohort of T2D patients.
Am J Clin Nutr 2014;100:1029–35. Printed in USA. Ó 2014 American Society for Nutrition
It has been suggested that the potential negative impacts of
calcium supplements on CVD risk may be mediated by vascular
calcification, which is an important measure of subclinical CVD
risk, the regulation of which has many links to osteogenesis and
bone physiology (10, 13). However, a recent report showed no
impact of calcium intake from diet and supplements on coronary
artery calcified plaque (CAC) (14). In the current study, we
evaluated relations between calcium intake from diet and sup-
plements and subclinical CVD as assessed by CAC, with
a specific focus on patients with T2D at elevated CVD risk. In
addition, the analysis was extended to evaluate potential asso-
ciations of calcium intake with calcified plaque in multiple
vascular beds and with all-cause and CVD mortality.
SUBJECTS AND METHODS
Study design and sample
Diabetes Heart Study (DHS) participants were recruited from
1998 through 2005 from outpatient internal medicine and endo-
crinology clinics and the community in Western North Carolina.
Siblings concordant for T2D without advanced renal insuffi-
ciency were recruited. Ascertainment and recruitment have been
described in detail previously (15–18). T2D was defined as
1
From the Molecular Genetics and Genomics Program (LMR), the Cen-
ters for Human Genomics (LMR, AJC, JX, and DWB) and Diabetes Re-
search (LMR, AJC, JX, and DWB), and the Departments of Biochemistry (AJC
and DWB), Biostatistical Sciences (F-CH), Internal Medicine–Nephrology
(BIF), and Epidemiology & Prevention (MZV), Wake Forest School of Medicine,
Winston-Salem, NC; the Department of Cardiology, Northwestern University
Feinberg School of Medicine, Chicago, IL (SA); and the Department of
Radiology, Vanderbilt University Medical Center, Nashville, TN (JJC).
2
Supported by the NIH [R01 HL67348 and R01 HL092301 (to DWB),
R01 AR48797 (to JJC), and F31 AG044879 (to LMR)].
3
Addresss reprint requests and correspondence to MZ Vitolins, Department
of Epidemiology & Prevention, Wake Forest School of Medicine, Medical
Center Boulevard, Winston Salem, NC. E-mail: mvitolin@wakehealth.edu.
4
Abbreviations used: AACP, abdominal aortoiliac calcified plaque; BMD,
bone mineral density; CAC, coronary artery calcified plaque; CarCP, carotid
artery calcified plaque; CT, computed tomography; CVD, cardiovascular
disease; DHS, Diabetes Heart Study; MI, myocardial infarction; T2D, type
2 diabetes; WHI, Women’s Health Initiative.
Received May 1, 2014. Accepted for publication June 30, 2014.
First published online August 6, 2014; doi: 10.3945/ajcn.114.090365.
1029
1030 RAFFIELD ET AL
diabetes that developed after the age of 35 y and treated with
changes in diet and exercise or oral agents in the absence of
initial treatment solely with insulin and without historical evi-
dence of ketoacidosis. Diabetes diagnosis was confirmed by the
measurement of fasting glucose and glycated hemoglobin.
Analyses described in this study included all self-described
European American individuals with T2D from the DHS with
food-frequency questionnaire data, which included, in total, 720
individuals from 339 DHS families (see Supplementary Figure 1
under “Supplemental data” in the online issue).
Study protocols were approved by the Institutional Review Board
at Wake Forest School of Medicine, and all participants provided
written informed consent. Participant examinations were conducted
in the General Clinical Research Center of the Wake Forest Baptist
Medical Center. Examinations included interviews for medical
history and health behaviors, anthropometric measures, assessment
of resting blood pressure, electrocardiography, fasting blood sam-
pling for laboratory analyses, and spot urine collection. Standard
laboratory analyses were performed, including the assessment of
fasting glucose, glycated hemoglobin, total cholesterol, HDL,
and triglycerides. LDL concentrations were calculated by using
Friedewald’s equation; LDL concentrations were considered
valid for participants whose triglyceride concentrations were
,796 mg/dL (n = 4 individuals excluded on the basis of tri-
glyceride concentrations). Individuals were considered hyper-
tensive if they were prescribed an antihypertensive medication
or had blood pressure measurements that exceeded 140 mm Hg
(systolic) or 90 mm Hg (diastolic). Measures of calcified ath-
erosclerotic plaque by computed tomography (CT) included
CAC as the sum of the left main, left anterior descending, cir-
cumflex, posterior descending, and right coronary arteries,
carotid artery calcified plaque (CarCP) as the sum of the right
and left common, bulb, and internal, and abdominal aortoiliac
calcified plaque (AACP) as the sum of the infrarenal, right, and
left common iliac segments. CT scans were performed on
multidetector CT scanners with cardiac gating in chest and helical
acquisitions in the abdomen. Calcium scores were measured as
previously described and validated (19, 20). Intakes of calcium
and vitamin D from diet and supplements were determined by
using a self-administered Block food-frequency questionnaire (21).
Mortality was assessed for all DHS participants by using the
National Social Security Death Index maintained by the US Social
Security Administration. For deceased participants, the length of
follow-up was determined from the date of initial study visit to the
date of death. For all other participants, the length of follow-up was
determined from the date of the initial study visit to the end of 2012.
Copies of death certificates were obtained from county Vital Records
Offices to determine the cause of death. The cause of death was
categorized on the basis of these death certificates as CVD mortality
(MI, congestive heart failure, cardiac arrhythmia, sudden cardiac
death, peripheral vascular disease, and stroke) or as mortality from
cancer, infection, end-stage renal disease, accidental, or other causes
(including obstructive pulmonary disease, pulmonary fibrosis, liver
failure, and Alzheimer disease). The association with mortality was
assessed for both all-cause mortality and CVD mortality.
Statistical analysis
For statistical analyses, continuous variables were transformed as
necessary to an approximate normality. For our analyses of vascular
calcified plaque, we used the ln of (CAC + 1) and (CarCP + 1) and
the square root of (AACP + 10). Dietary calcium and vitamin D
intakes were adjusted for the total energy intake by using a residual
method as suggested by Willett et al (22). Total calcium and dietary
calcium intakes were considered ordinal (4 quartiles) variables as
was calcium intake from supplements [divided into milligram-
intake ranges (0, 1–500, and .500 mg) similar to those used by
Samelson et al (14)]. Quartile 1 for energy-adjusted total calcium
intake for women ranged from 216 to 614.2 mg, quartile 2 ranged
from 614.3 to 851 mg, quartile 3 ranged from 858 to 2098 mg, and
quartile 4 ranged from 2106 to 5350 mg. Quartile 1 for energy-
adjusted dietary calcium intake for women ranged from 216 to 484
mg, quartile 2 ranged from 487 to 635 mg, quartile 3 ranged from
638 to 834 mg, and quartile 4 ranged from 837 to 3090 mg.
Quartile 1 for energy-adjusted total calcium intake for men ranged
from 280 to 600 mg, quartile 2 ranged from 601 to 783 mg,
quartile 3 ranged from 784 to 1039 mg, and quartile 4 ranged from
1044 to 3212 mg. Quartile 1 for energy-adjusted dietary calcium
intake for men ranged from 263 to 531 mg, quartile 2 ranged from
534 to 681.8 mg, quartile 3 ranged from 682.1 to 829 mg, and
quartile 4 ranged from 831 to 1601 mg.
Relations between calcium intake ranges and CAC, CarCP, and
AACP were examined by using marginal models with generalized
estimating equations. Models accounted for the familial correlation
by using a sandwich estimator of the variance under an exchangeable
correlation. Relations between calcium intake ranges and both all-
cause mortality and CVD mortality were examined by using Cox
proportional hazards models with sandwich-based variance esti-
mation because of the inclusion of related individuals in the study.
Associations were adjusted for covariates including age, total energy
intake (kcal), BMI (in kg/m2), smoking (never, past, or current), any
alcohol consumption, energy-adjusted total vitamin D intake from
diet and supplements (IU), use of lipid-lowering medications, cal-
cium intake from supplements (mg), energy-adjusted dietary cal-
cium intake (mg), menopause status, and estrogen use as indicated,
similar to the analysis performed by Samelson et al (14). In-
dividuals with missing data for outcome variables or covariates
were excluded from relevant models (see Supplementary Figure 1
under “Supplemental data” in the online issue). Of 360 women
included in these analyses, 18 women had missing CAC, 26
women had missing CarCP, 100 women had missing AACP, one
woman had missing smoking status, one woman had missing
mortality status, and 30 women had missing menopause status. Of
360 men included in these analyses, 18 men had missing CAC, 17
men had missing CarCP, 88 men had missing AACP, and one man
had missing smoking status. Data were available for all participants
for all other outcomes and covariates assessed. All analyses were
performed with SAS 9.3 software (SAS Institute).
RESULTS
The goal of this study was to analyze associations between
calcium intake from diet and supplements and CVD risk in
participants with T2D from the DHS. We assessed relationships
between calcium intake and both subclinical CVD and mortality
risk.
Clinical characteristics of 720 European American individuals
with T2D included in this study stratified by both total calcium
intake quartile and sex are summarized in Table 1. As expected
for a cohort affected by T2D, most individuals were overweight
TABLE 1
Demographic characteristics of DHS participants with type 2 diabetes by daily energy-adjusted total calcium intake quartiles1
Energy-adjusted total calcium intake quartiles

Women Men

n 1 (n = 90) 2 (n = 90) 3 (n = 90) 4 (n = 90) P-trend 1 (n = 90) 2 (n = 90) 3 (n = 90) 4 (n = 90) P-trend

Median (IQR) (mg) 720 472 (150) 731 (81) 1078 (402) 2816 (441) — 482 (127) 692 (96) 926 (153) 1261 (1376) —
Range (mg) 720 216–614 614–851 858–2098 2106–5350 — 280–600 601–783 784–1039 1044–3212 —
Age (y) 720 62.1 61.3 57.8 64.4 0.109 64.3 62.8 63.0 60.0 0.048
BMI (kg/m2) 720 32.4 34.4 36.0 31.1 0.660 30.6 31.2 31.3 31.8 0.241
Past smoker (%) 718 18.9 37.1 23.3 33.3 0.225 58.4 53.3 67.8 62.2 0.243
Current smoker (%) 720 22.2 8.9 15.6 11.1 0.121 16.7 20.0 10.0 18.9 0.890
Any alcohol consumption (%) 720 14.4 13.3 18.9 17.8 0.293 20.0 31.1 26.7 38.9 0.025
Hypertension (%) 720 92.2 94.4 85.6 86.7 0.087 82.2 90.0 83.3 90.0 0.210
Heart attacks (%) 713 19.1 12.4 7.8 12.4 0.129 37.1 31.8 31.5 24.4 0.085
Previous CVD events (%) 720 40.0 30.0 18.9 35.6 0.239 63.3 56.7 55.6 48.9 0.095
All-cause mortality (%) 719 30.0 22.2 13.3 16.9 0.014 32.2 27.8 26.7 26.7 0.418
CVD mortality (%) 719 11.1 7.8 6.7 7.8 0.446 17.8 14.4 14.4 10.0 0.163
Coronary artery calcification 684 1187 995 602 866 0.097 3459 3747 2418 3109 0.327
score
Carotid artery calcification 676 296 223 140 405 0.504 604 502 410 408 0.115
score
Abdominal aortoiliac calcification 532 11,796 9424 6395 10,412 0.288 19,490 16,406 16,860 16,996 0.672
score
Systolic blood pressure (mm Hg) 717 137.8 141.3 136.8 141.1 0.459 136.9 141.0 137.5 136.8 0.630
Diastolic blood pressure (mm Hg) 717 72.5 71.2 72.7 69.9 0.211 71.4 74.5 73.6 74.2 0.177
Total cholesterol (mg/dL) 716 191.7 201.0 199.9 187.9 0.599 171.2 172.9 180.0 179.3 0.124
HDL cholesterol (mg/dL) 716 46.0 46.5 46.0 48.4 0.211 37.5 38.3 37.9 39.2 0.193
LDL cholesterol (mg/dL) 663 107.2 109.7 108.6 103.5 0.526 98.4 95.6 99.9 100.5 0.563
CALCIUM INTAKE DIABETES HEART STUDY

Triglycerides (mg/dL) 716 202.3 215.8 233.0 197.2 0.985 182.4 203.3 212.5 213.7 0.095
Hypertension medications (%) 720 73.3 82.2 73.3 83.3 0.320 74.4 84.4 73.3 76.7 0.817
Lipid-lowering medications (%) 720 45.6 48.9 38.9 47.8 0.882 61.1 52.2 50.0 40.0 0.005
Statins (%) 720 43.3 43.3 31.1 44.4 0.707 53.3 50.0 44.4 34.4 0.007
Aspirin (%) 720 54.4 61.1 51.1 66.7 0.252 61.1 62.2 60.0 57.8 0.586
Osteoporosis medications (%) 720 3.3 6.7 3.3 11.1 0.097 1.1 0.0 0.0 1.1 0.997
Postmenopausal (%) 330 88.5 92.6 83.1 93.2 0.596 — — — — —
Estrogen (%) 360 23.3 25.6 25.6 28.9 0.457 — — — — —
1
Relations between calcium intake quartiles and demographic variables were examined by using marginal models with generalized estimating equations. CVD, cardiovascular disease; DHS, Diabetes Heart
Study.
1031
1032 RAFFIELD ET AL

or obese, and the cohort had high rates of dyslipidemia and
hypertension, a high burden of vascular calcified plaque, and
a high rate of previous CVD events. Few measures differed across
energy-adjusted total calcium intake quartiles, although age,
prevalence of alcohol consumption, and use of lipid-lowering
medications (mainly statins) differed significantly in men. These
factors were all considered covariates in fully adjusted models
for vascular calcified plaque and mortality. All models were
stratified by sex.
We first assessed relations between calcium intake from diet
and supplements and measures of vascular calcified plaque. In
minimally adjusted models that accounted for age and total
energy intake only, neither total energy-adjusted calcium in-
take nor calcium intake from diet or supplements was sig-
nificantly associated with any vascular calcified plaque
measure (CAC, CarCP, and AACP) (see Supplementary Table
1 under “Supplemental data” in the online issue). Similarly,
in models adjusted for age, total energy intake, BMI, smok-
ing, alcohol consumption, energy-adjusted total vitamin D
intake from diet and supplements, use of lipid-lowering
medications, calcium intake from supplements or dietary
calcium intake where appropriate, and, in women, menopause
status and estrogen use, no association between total energy-
adjusted calcium intake or calcium intake from diet or sup-
plements and any measure of vascular calcified plaque was
observed (Table 2).
We also assessed associations between calcium intake and both
all-cause and CVD mortality (Table 3). We analyzed both
minimally adjusted models, which were adjusted only for age
and total energy intake (model 1), and more fully adjusted
models, which were further adjusted for BMI, smoking, alcohol
consumption, energy-adjusted total vitamin D intake from diet
and supplements, use of lipid-lowering medications, calcium
intake from supplements or dietary calcium intake where ap-
propriate, and, in women, menopause status and estrogen use
(model 2). For model 1, we observed a modest protective effect
of increased supplemental calcium consumption on all-cause
mortality in women (HR for all-cause mortality for each in-
crease in calcium supplement use tertile: 0.61; 95% CI: 0.46,
0.83; P = 0.001). For CVD mortality, modest protective effects
were also observed in both women (HR for CVD mortality:
0.59; 95% CI: 0.37, 0.94; P = 0.026) and men (HR for CVD
mortality: 0.65; 95% CI: 0.43, 0.98; P = 0.042). These associ-
ations were attenuated in the more fully adjusted model 2, with

TABLE 2
Associations between coronary, carotid, and abdominal aortoiliac calcification and total, dietary, and supplemental calcium intakes1
Coronary artery calcification Carotid artery calcification Abdominal aortoiliac calcification

Women Men Women Men Women Men

(n = 311) (n = 341) (n = 303) (n = 342) (n = 237) (n = 272)

Energy-adjusted total calcium

intake quartiles
1 (216–614.2 mg for women; 5.19 (4.73, 5.66) 6.81 (6.28, 7.34) 3.25 (2.65, 3.85) 4.42 (3.71, 5.13) 83.24 (67.68, 98.80) 126.4 (104.5, 148.2)
280–600 mg for men)
2 (614.3–851 mg for women; 4.95 (4.43, 5.47) 7.11 (6.72, 7.50) 3.53 (3.01, 4.04) 4.45 (3.93, 4.98) 78.32 (65.79, 90.85) 114.9 (100.9, 129.0)
601–783 mg for men)
3 (858–2098 mg for women; 4.80 (4.27, 5.33) 6.91 (6.54, 7.28) 2.59 (2.07, 3.11) 3.88 (3.35, 4.41) 81.03 (66.00, 96.07) 106.9 (91.18, 122.5)
784–1039 mg for men)
4 (2106–5350 mg for women; 4.89 (4.40, 5.38) 6.89 (6.37, 7.40) 3.68 (3.21, 4.15) 4.74 (4.11, 5.37) 68.69 (57.66, 79.72) 97.88 (77.28, 118.5)
1044–3212 mg for men)
P-trend 0.478 0.942 0.436 0.641 0.159 0.137
Energy-adjusted dietary calcium
intake quartiles
1 (216–484 mg for women; 5.03 (4.45, 5.61) 6.71 (6.03, 7.39) 3.16 (2.57, 3.74) 4.94 (4.24, 5.65) 80.54 (62.92, 98.16) 106.7 (82.38, 131.0)
263–531 mg for men)
2 (487–635 mg for women; 5.14 (4.64, 5.65) 7.04 (6.68, 7.40) 3.29 (2.77, 3.82) 4.31 (3.78, 4.84) 82.61 (69.58, 95.63) 108.9 (94.34, 123.5)
534–681.8 mg for men)
3 (638–834 mg for women; 4.75 (4.25, 5.24) 6.90 (6.49, 7.30) 3.23 (2.68, 3.77) 4.18 (3.66, 4.71) 63.39 (50.32, 76.46) 108.0 (92.82, 123.2)
682.1–829 mg for men)
4 (837–3090 mg for women; 4.85 (4.19, 5.51) 7.06 (6.20, 7.92) 3.39 (2.75, 4.03) 4.05 (3.16, 4.94) 79.46 (57.86, 101.1) 124.5 (94.33, 154.6)
831–1601 mg for men)
P-trend 0.516 0.732 0.750 0.169 0.361 0.755
Supplemental calcium intake
0 mg 4.96 (4.53, 5.39) 7.04 (6.67, 7.41) 3.54 (3.06, 4.01) 4.43 (3.93, 4.92) 81.21 (68.58, 93.83) 120.5 (106.1, 134.8)
1–500 mg 5.00 (4.47, 5.52) 6.79 (6.30, 7.27) 2.61 (2.06, 3.16) 4.21 (3.48, 4.93) 83.19 (71.26, 95.12) 98.06 (75.53, 120.6)
.500 mg 4.91(4.46, 5.36) 6.68 (6.06, 7.30) 3.42 (2.97, 3.86) 4.64 (3.77, 5.51) 68.02 (57.64, 78.41) 95.58 (70.95, 120.2)
P-trend 0.845 0.390 0.709 0.646 0.086 0.157
1
All values are least-squares adjusted means; 95% CIs in parentheses. Analysis was performed by using marginal models with generalized estimating
equations. Models were adjusted for age, total energy intake (kcal), BMI (in kg/m2), smoking (never, past, or current), any alcohol consumption, energy-
adjusted total vitamin D intake from diet and supplements (IU), use of lipid-lowering medications, and, in women, menopause status and estrogen use. Models
in which the dietary calcium intake quartile was the main effect were further adjusted for calcium intake from supplements (mg). Models in which tertiles of
calcium intake from supplements were the main effect were further adjusted for energy-adjusted dietary calcium (mg). For these analyses, results displayed are
for the ln (coronary artery calcification + 1) and ln (carotid artery calcification + 1) and the O(abdominal aortoiliac calcification + 10).
 CALCIUM INTAKE DIABETES HEART STUDY 1033
only the association of calcium supplementation with reduced

Model 1 was adjusted for age and total energy intake. Model 2 was adjusted as for model 1 and for BMI (in kg/m2), smoking (never, past, or current), any alcohol consumption, energy-adjusted total vitamin D intake
Analysis was performed by using Cox proportional hazards regression. Calcium intake from supplements was considered as an ordinal variable [divided into milligram-intake ranges (0, 1–500, and .500 mg)].

adjusted for calcium intake from supplements (mg). For model 2, if tertiles of calcium intake from supplements were the main effect, the model was further adjusted for energy-adjusted dietary calcium (mg). CVD,
0.90 (0.66, 1.24)

0.78 (0.53, 1.17)

0.75 (0.49, 1.17)

from diet and supplements (IU), use of lipid-lowering medications, and, in women, menopause status and estrogen use. For model 2, if the dietary calcium intake quartile was the main effect, the model was further
Men (n = 359)
all-cause mortality in women remaining nominally significant

0.528

0.228

0.210
(HR for all-cause mortality: 0.62; 95% CI: 0.42, 0.92; P =
All-cause mortality
0.017).

Women (n = 328)

0.73 (0.53, 1.01)

0.80 (0.42, 1.51)

0.62 (0.42, 0.92)

DISCUSSION
Studies have raised concerns that calcium supplementation
0.061

0.491

0.017
may have the unintended negative consequence of increasing
CVD risk (8–12). Any increase of CVD risk in patients with
Model 2

T2D would be of particular concern because of their already

elevated risk of CVD (1); to our knowledge, this is the first
0.78 (0.52, 1.16)

0.74 (0.41, 1.34)

0.51 (0.25, 1.06)

Men (n = 359)

analysis of the potential negative CVD impacts of calcium

intake that focused specifically on individuals affected by T2D.
0.214

0.321

0.070 CAC, which is a measure of subclinical CVD, has been shown

CVD mortality

in the DHS and other cohorts to be a strong independent pre-

dictor of CVD events and mortality (23–30), with individuals
affected by diabetes tending to have higher CAC (31). The
Women (n = 328)

0.91 (0.61, 1.36)

1.67 (0.66, 4.25)

0.65 (0.37, 1.13)

statistical power is increased for the analysis of continuous

0.658

0.281

0.127

traits such as vascular calcified plaque compared with event

data, and it has also been proposed that associations of calcium
intake with CVD are mediated through vascular calcification
(10), highlighting the suitability of our vascular calcified
0.84 (0.64, 1.09)

0.80 (0.54, 1.19)

0.75 (0.54, 1.04)

plaque measures for the assessment of potential negative CVD

Men (n = 360)

impacts of calcium intake. We replicated the lack of impact of

0.190

0.267

0.079

calcium from diet and supplements on CAC previously ob-

All-cause mortality

served in a general population cohort (14) in patients with

T2D. In addition, we did not find any evidence of negative
CVD impacts of calcium intake in our analyses of CarCP,
Women (n = 359)

0.71 (0.54, 0.93)

0.61 (0.46, 0.83)

0.86 (0.50,1.47)

AACP, and mortality. CAC is the most commonly assessed

Associations between all-cause and CVD mortality and total, dietary, and supplemental calcium intakes1

form of vascular calcified plaque (14, 32, 33); however, dif-

0.012

0.578

0.001

ferent risk factors may contribute to calcification in different

vascular beds (34, 35), highlighting the importance of our
Model 1

additional analysis of AACP and CarCP.

Previous analyses of CAC, notably the analysis in a largely
0.78 (0.55, 1.09)

0.77 (0.43, 1.38)

0.65 (0.43, 0.98)

Men (n = 360)

nondiabetic population from the Framingham Offspring Study,

0.146

0.380

0.042

have also shown no significant impact of calcium intake on CAC

burden (14). Similarly, an analysis of CAC in 754 Women’s
CVD mortality

Health Initiative (WHI) participants (32) and another small co-

hort of men (33) showed no association with previous random
Women (n = 359)

assignment to calcium supplement use. In addition, analyses of

0.84 (0.59, 1.20)

1.79 (0.82, 3.89)

0.59 (0.37, 0.94)

the effect of calcium supplementation on CVD events have had

0.336

0.145

0.026

mixed results. An analysis of WHI calcium and vitamin D

supplementation trial data by WHI investigators failed to sup-
port modestly higher CVD risk reported in a meta-analysis that
used WHI data by Bolland et al (6, 10). A 2010 meta-analysis of
Energy-adjusted dietary calcium intake quartile

several randomized trials also showed no significant change in

Energy-adjusted total calcium intake quartile

risk of CVD events for subjects randomly assigned to receive

calcium supplementation (36).
Initial concerns about negative CVD impacts of calcium
supplements were raised by a randomized clinical trial from New
Zealand of calcium supplementation (1000 mg/d) that reported
Supplemental calcium intake

a modest increase in MI risk in women who were taking calcium

supplements (8). This increase in MI risk was replicated in
cardiovascular disease.

subsequent meta-analyses (9, 10). A similar increase in MI risk

HR (95% CI)

HR (95% CI)

HR (95% CI)

with calcium supplement use was also seen in a recent pro-

spective study of German men and women (11), with a study from
TABLE 3

the United States that also showed increased risk of CVD death in
1

men who were using calcium supplements (12). However, these

P

reports did have limitations. For example, in the initial report by

1034 RAFFIELD ET AL
Bolland et al (8), the reported association was no longer sig-
nificant when events that were not self-reported by participants
but, instead, were sourced through a national hospital admissions
database and death certificate review were included in an analysis
with verified self-reported events. In both the original trial report
(8) and larger subsequent meta-analyses by Bolland et al (9, 10),
studies included were originally designed to assess effects of
calcium on bone density and fracture, with CVD outcomes
considered only in secondary analyses. Additional problems with
reports that calcium supplements increase risk of CVD events
have been reviewed previously (37, 38).
In this study, we did not observe any negative CVD impacts of
differing calcium intakes from diet and supplements in contrast to
some previous reports (8–12). Instead, calcium supplement use
was associated with lower all-cause mortality risk in women.
The association may have been due to a selection bias in terms
of which participants in our cross-sectional analysis chose to
take calcium supplements. Previous research has shown that
individuals taking dietary supplements tend to have higher socio-
economic status, education levels, and physical activity (39, 40).
However, our results were essentially unchanged on additional
adjustment for educational attainment (HR for all-cause mor-
tality: 0.63; 95% CI: 0.43, 0.93; P = 0.02), which suggested
other factors may have been responsible. Positive impacts of
calcium supplements in women, notably increased BMD and
prevention of fractures, may have led to the observed protective
effect (6). Our finding of a slight protective effect for all-cause
mortality for women who were taking calcium supplements was
also not unprecedented. A large cross-sectional study showed
slightly lower risk of CVD and all-cause mortality in women
who were taking calcium supplements in models adjusted for
demographic and health-status covariates (41), which suggested
a protective effect independent of socioeconomic status, and
a Canadian study also showed reduced mortality risk in women
who were using calcium supplements #1000 mg/d (42).
Strengths of the current analysis included the study population
with T2D, a group with elevated risk of CVD and fracture,
comprehensive data for the analysis of vascular calcified plaque
in multiple beds, and a long-term mortality follow-up of mean
(6SD) 9.4 6 5.0 y. Limitations of our cross-sectional analysis
included the concurrent measurement of calcium intake from
diet and supplements and vascular calcification; if a participant’s
dietary habits or supplement use had recently changed, impacts
may not yet have been observed on vascular calcified plaque.
However, our failure to find higher subsequent mortality risk
supported our baseline finding of no association of calcium in-
take with vascular calcification because vascular calcified plaque
has been shown to be a strong predictor of mortality risk in our
cohort (25, 26).
In conclusion, in our analysis of calcium intake from diet and
supplements in patients with T2D, we did not observe any sig-
nificant associations between calcium intake and multiple mea-
sures of vascular calcified plaque, including CAC, CarCP, and
AACP. We also observed no higher risk of all-cause or CVD
mortality in individuals who were taking calcium supplements.
We observed a modest association of an increased use of calcium
supplements with lower risk of all-cause mortality in women. Our
data do not support a significant association between differing
calcium intakes from diet or supplements and CVD risk in in-
dividuals with T2D.
We thank the other investigators, staff, and participants in the DHS study
for their valuable contributions.
The authors’ responsibilities were as follows—LMR: performed the sta-
tistical analysis and wrote the manuscript; SA: helped design the research;
AJC: compiled mortality data and contributed to the statistical analysis;
F-CH: contributed to the statistical analysis; JJC and BIF: were involved
in the initial design of the DHS and contributed to patient ascertainment and
clinical evaluation; JX: contributed to data management and the statistical
analysis; DWB: leads the DHS and was involved in the initial design of the
study, patient ascertainment, and clinical evaluation; MZV: helped design the
research and had primary responsibility for the final content of the manu-
script; and all authors: read and edited the manuscript and approved the final
version of the manuscript. None of the authors had a conflict of interest.
REFERENCES
1. Lloyd-Jones D, Adams R, Brown T, Carnethon M, Dai S, De Simone
G, Ferguson T, Ford E, Furie K, Gillespie C, et al. Heart disease and
stroke statistics–2010 update: a report from the American Heart As-
sociation. Circulation 2010;121:e46–215. (Published erratum appears
in Circulation 2010;121:e260.)
2. Janghorbani M, Dam RMV, Willett WC, Hu FB. Systematic review of
type 1 and type 2 diabetes mellitus and risk of fracture. Am J Epi-
demiol 2007;166:495–505.
3. Register TC, Lenchik L, Hsu FC, Lohman KK, Freedman BI, Bowden
DW, Carr JJ. Type 2 diabetes is not independently associated with
spinal trabecular volumetric bone mineral density measured by QCT in
the Diabetes Heart Study. Bone 2006;39:628–33.
4. Vestergaard P. Discrepancies in bone mineral density and fracture risk
in patients with type 1 and type 2 diabetes–a meta-analysis. Osteoporos
Int 2007;18:427–44.
5. Ma L, Oei L, Jiang L, Estrada K, Chen H, Wang Z, Yu Q, Zillikens
MC, Gao X, Rivadeneira F. Association between bone mineral density
and type 2 diabetes mellitus: a meta-analysis of observational studies.
Eur J Epidemiol 2012;27:319–32.
6. Prentice RL, Pettinger MB, Jackson RD, Wactawski-Wende J, Lacroix
AZ, Anderson GL, Chlebowski RT, Manson JE, Van Horn L, Vitolins
MZ, et al. Health risks and benefits from calcium and vitamin D
supplementation: Women’s Health Initiative clinical trial and cohort
study. Osteoporos Int 2013;24:567–80.
7. Gahche J, Bailey R, Burt V, Hughes J, Yetley E, Dwyer J, Picciano M,
McDowell M, Sempos C. Dietary supplement use among U.S. adults
has increased since NHANES III (1988–1994). NCHS Data Brief
2011;61:1–8.
8. Bolland MJ, Barber P, Doughty R, Mason B, Horne A, Ames R,
Gamble G, Grey A, Reid I. Vascular events in healthy older women
receiving calcium supplementation: randomised controlled trial. BMJ
2008;336:262–6.
9. Bolland MJ, Avenell A, Baron JA, Grey A, MacLennan GS, Gamble
GD, Reid IR. Effect of calcium supplements on risk of myocardial
infarction and cardiovascular events: meta-analysis. BMJ 2010;341:
c369.
10. Bolland M, Grey A, Avenell A, Gamble G, Reid I. Calcium supple-
ments with or without vitamin D and risk of cardiovascular events:
reanalysis of the Women’s Health Initiative limited access dataset and
meta-analysis. BMJ 2011;342:d2040.
11. Li K, Kaaks R, Linseisen J, Rohrmann S. Associations of dietary
calcium intake and calcium supplementation with myocardial in-
farction and stroke risk and overall cardiovascular mortality in the
Heidelberg cohort of the European Prospective Investigation into
Cancer and Nutrition study (EPIC-Heidelberg). Heart 2012;98:
920–5.
12. Xiao Q, Murphy R, Houston D, Harris T, Chow W-H, Park Y. Dietary
and supplemental calcium intake and cardiovascular disease mortality:
the National Institutes of Health-AARP diet and health study. JAMA
Intern Med 2013;173:639–46.
13. Thompson B, Towler D. Arterial calcification and bone physiology:
role of the bone-vascular axis. Nat Rev Endocrinol 2012;8:529–43.
14. Samelson EJ, Booth S, Fox C, Tucker K, Wang T, Hoffmann U,
Cupples L, O’Donnell C, Kiel D. Calcium intake is not associated with
increased coronary artery calcification: the Framingham Study. Am J
Clin Nutr 2012;96:1274–80.
 CALCIUM INTAKE DIABETES HEART STUDY
15. Lange LA, Bowden D, Langefeld C, Wagenknecht L, Carr J, Rich S,
Riley W, Freedman B. Heritability of carotid artery intima-medial
thickness in type 2 diabetes. Stroke 2002;33:1876–81.
16. Bowden DW, Rudock M, Ziegler J, Lehtinen A, Xu J, Wagenknecht L,
Herrington D, Rich S, Freedman B, Carr J, et al. Coincident linkage of
type 2 diabetes, metabolic syndrome, and measures of cardiovascular
disease in a genome scan of the diabetes heart study. Diabetes 2006;55:
1985–94.
17. Bowden DW, Cox A, Freedman B, Hugenschimdt C, Wagenknecht L,
Herrington D, Agarwal S, Register T, Maldjian J, Ng M, et al. Review
of the Diabetes Heart Study (DHS) family of studies: a comprehen-
sively examined sample for genetic and epidemiological studies of type
2 diabetes and its complications. Rev Diabet Stud 2010;7:188–201.
18. Wagenknecht LE, Bowden D, Carr J, Langefeld C, Freedman B, Rich
S. Familial aggregation of coronary artery calcium in families with
type 2 diabetes. Diabetes 2001;50:861–6.
19. Carr JJ, Nelson JC, Wong ND, McNitt-Gray M, Arad Y, Jacobs DR Jr,
Sidney S, Bild DE, Williams OD, Detrano RC. Calcified coronary
artery plaque measurement with cardiac CT in population-based
studies: standardized protocol of Multi-Ethnic Study of Atherosclerosis
(MESA) and Coronary Artery Risk Development in Young Adults
(CARDIA) study. Radiology 2005;234:35–43.
20. Carr JJ, Crouse JR 3rd, Goff DC Jr, D’Agostino RB Jr, Peterson NP,
Burke GL. Evaluation of subsecond gated helical CT for quantification
of coronary artery calcium and comparison with electron beam CT.
AJR Am J Roentgenol 2000;174:915–21.
21. Block G, Woods M, Potosky A, Clifford C. Validation of a self-
administered diet history questionnaire using multiple diet records.
J Clin Epidemiol 1990;43:1327–35.
22. Willett WC, Howe G, Kushi L. Adjustment for total energy intake in
epidemiologic studies. Am J Clin Nutr 1997;65(suppl):1220S–8S.
23. Folsom AR, Kronmal R, Detrano R, O’Leary D, Bild D, Bluemke D,
Budoff M, Liu K, Shea S, Szklo M, et al. Coronary artery calcification
compared with carotid intima-media thickness in the prediction of
cardiovascular disease incidence: the Multi-Ethnic Study of Athero-
sclerosis (MESA). Arch Intern Med 2008;168:1333–9.
24. Detrano R, Guerci A, Carr J, Bild D, Burke G, Folsom A, Liu K, Shea
S, Szklo M, Bluemke D, et al. Coronary calcium as a predictor of
coronary events in four racial or ethnic groups. N Engl J Med 2008;
358:1336–45.
25. Agarwal S, Cox A, Herrington D, Jorgensen N, Xu J, Freedman B, Carr
J, Bowden D. Coronary calcium score predicts cardiovascular mortality
in diabetes: Diabetes Heart Study. Diabetes Care 2013;36:972–7.
26. Agarwal S, Morgan T, Herrington D, Xu J, Cox A, Freedman B, Carr J,
Bowden D. Coronary calcium score and prediction of all-cause mor-
tality in diabetes: the diabetes heart study. Diabetes Care 2011;34:
1219–24.
27. Raggi P, Shaw LJ, Berman DS, Callister TQ. Prognostic value of
coronary artery calcium screening in subjects with and without di-
abetes. J Am Coll Cardiol 2004;43:1663–9.
28. Polonsky TS, McClelland RL, Jorgensen NW, Bild DE, Burke GL,
Guerci AD, Greenland P. Coronary artery calcium score and risk
classification for coronary heart disease prediction. JAMA 2010;303:
1610–6.
1035
29. Erbel R, Mohlenkamp S, Moebus S, Schmermund A, Lehmann N,
Stang A, Dragano N, Gronemeyer D, Seibel R, Kalsch H, et al.
Coronary risk stratification, discrimination, and reclassification im-
provement based on quantification of subclinical coronary athero-
sclerosis: the Heinz Nixdorf Recall study. J Am Coll Cardiol 2010;56:
1397–406.
30. Elias-Smale SE, Proenca RV, Koller MT, Kavousi M, van Rooij FJ,
Hunink MG, Steyerberg EW, Hofman A, Oudkerk M, Witteman JC.
Coronary calcium score improves classification of coronary heart dis-
ease risk in the elderly: the Rotterdam study. J Am Coll Cardiol 2010;
56:1407–14.
31. Hoff JA, Quinn L, Sevrukov A, Lipton R, Daviglus M, Garside D,
Ajmere N, Gandhi S, Kondos G. The prevalence of coronary artery
calcium among diabetic individuals without known coronary artery
disease. J Am Coll Cardiol 2003;41:1008–12.
32. Manson JE, Allison M, Carr J, Langer R, Cochrane B, Hendrix S, Hsia
J, Hunt J, Lewis C, Margolis K, et al. Calcium/vitamin D supple-
mentation and coronary artery calcification in the Women’s Health
Initiative. Menopause 2010;17:683–91.
33. Wang T, Bolland M, van Pelt N, Horne A, Mason B, Ames R, Grey A,
Ruygrok P, Gamble G, Reid I. Relationships between vascular calci-
fication, calcium metabolism, bone density, and fractures. J Bone
Miner Res 2010;25:2777–85.
34. Wagenknecht LE, Langefeld C, Freedman B, Carr J, Bowden D. A
comparison of risk factors for calcified atherosclerotic plaque in the
coronary, carotid, and abdominal aortic arteries: the diabetes heart
study. Am J Epidemiol 2007;166:340–7.
35. Criqui MH, Kamineni A, Allison M, Ix J, Carr J, Cushman M, Detrano
R, Post W, Wong N. Risk factor differences for aortic versus coronary
calcified atherosclerosis: the multiethnic study of atherosclerosis.
Arterioscler Thromb Vasc Biol 2010;30:2289–96.
36. Wang L, Manson J, Song Y, Sesso H. Systematic review: Vitamin D
and calcium supplementation in prevention of cardiovascular events.
Ann Intern Med 2010;152:315–23.
37. Nordin B, Lewis J, Daly R, Horowitz J, Metcalfe A, Lange K, Prince R.
The calcium scare–what would Austin Bradford Hill have thought?
Osteoporos Int 2011;22:3073–7.
38. Hennekens CH, Barice E. Calcium supplements and risk of myocardial
infarction: a hypothesis formulated but not yet adequately tested. Am J
Med 2011;124:1097–8.
39. Harrison RA, Holt D, Pattison D, Elton P. Are those in need taking
dietary supplements? A survey of 21 923 adults. Br J Nutr 2004;91:
617–23.
40. Foote JA, Murphy S, Wilkens L, Hankin J, Henderson B, Kolonel L.
Factors associated with dietary supplement use among healthy adults of
five ethnicities: the Multiethnic Cohort Study. Am J Epidemiol 2003;
157:888–97.
41. Mursu J, Robien K, Harnack L, Park K, Jacobs D. Dietary supplements
and mortality rate in older women: the Iowa Women’s Health Study.
Arch Intern Med 2011;171:1625–33.
42. Langsetmo L, Berger C, Kreiger N, Kovacs C, Hanley D, Jamal S,
Whiting S, Genest J, Morin S, Hodsman A, et al. Calcium and vitamin
D intake and mortality: results from the Canadian Multicentre Osteo-
porosis Study (CaMos). J Clin Endocrinol Metab 2013;98:3010–8.