The Use of Vitamins and Minerals in Skeletal Health

American Association of Clinical Endocrinologists and the American College of Endocrinology Position Statement

Daniel L. Hurley, MD, FACE; Neil Binkley, MD, FACE; Pauline M. Camacho, MD, FACE; Dima L. Diab, MD, FACE, FACP, CCD; Kurt A. Kennel, MD, FACE; Alan Malabanan, MD, FACE, CCD; Vin Tangpricha, MD, PhD, FACE


Endocr Pract. 2018;24(10):915-924. 

In This Article


Calcium and phosphorus represent the two principal minerals that form hydroxyl apatite, the major component of bone. The dairy food group is most associated with bone health, with recommended intake of two to three servings a day. Dairy products contain calcium, phosphorus, magnesium, potassium, and protein, and milk consumption has been positively associated with bone health. Adolescent girls who ingest greater amounts of calcium have a higher bone mineral density (BMD), and children and adults consuming low-calcium diets are at risk of osteoporosis and fractures.[9–11] Few clinical trials have assessed the effects of calcium supplementation on BMD and fracture risk independent of vitamin D administration. Two RCTs of calcium supplementation in elderly women reported reduced bone turnover and decreased bone loss.[12,13] A Cochrane meta-analysis reported calcium alone was not superior to vitamin D alone in preventing fractures in post-menopausal women and older men.[14] However, several meta-analyses showed that calcium given with vitamin D reduces vertebral and nonvertebral fracture risk,[15,16] consistent with vitamin D's action to improve gastrointestinal (GI) absorption of calcium and ensure adequate bone mineralization.

Calcium supplementation has been reported to increase the risk of cardiovascular (CV) disease in cohort studies, clinical trials, and meta-analyses of previously completed trials.[17–19] However, these findings have not been validated in recent studies. A large prospective study of over 9,000 participants taking up to 1,000 mg of calcium daily and followed for 10 years demonstrated no increased risk of CV mortality.[20] An updated meta-analysis of RCTs, prospective cohort studies, and case-control studies reported no CV outcome risk in individuals consuming dietary or supplemental calcium up to 2,000 to 2,500 mg/day.[21] The National Osteoporosis Foundation and the American Society for Preventative Cardiology stated that calcium intake not exceeding 2,000 to 2,500 mg/day should be considered safe from CV risk. The American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE) clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis recommend sufficiency of both calcium and vitamin D as part of the treatment regimen.[22] A patient's total calcium intake should be assessed from both the diet and any supplement use, and the total daily amount of calcium should not exceed 1,200 to 1,500 mg. Studies suggest that it is most prudent to obtain calcium from food sources and to use supplements only as needed to reach the recommended total calcium intake.