Editorial
See corresponding article on page 257.
Does milk intake in childhood protect against later osteoporosis?1,2
Katherine L Tucker
The importance of the intake during childhood and adolescence
of dietary calcium, which in the United States is derived largely
from milk and dairy products, to the risk of osteoporotic fractures
in later life is generally assumed to be fact. Many studies have
shown the contribution of calcium intake during development to
the accretion of peak bone mass, which is assumed to be a criti-
cal factor in later-life osteoporosis. However, relatively few stud-
ies have shown a direct link between early diet and later risk of
osteoporosis. Indeed, the effect of early calcium intake on later
risk has been questioned, because follow-up observations after
calcium supplementation trials usually showed that benefits
regress when the supplements are no longer consumed (1). This
finding raises the question of whether the contribution of high cal-
cium intake in childhood persists into older age, when fracture
risk accelerates.
Studies that examined milk or calcium intake in childhood in
relation to later bone mineral density (BMD) or fracture relied on
recalled data, and the results are inconsistent. Several studies
reported positive associations between earlier reported milk or cal-
cium intake and BMD in premenopausal women, but several other
studies did not find this association. Very few studies examined
early calcium intake and subsequent BMD or fractures in older
women. A retrospective study of elderly patients with osteoporo-
sis and of healthy control subjects found that recalled milk con-
sumption during childhood and adolescence was significantly
associated with later bone status, although knowledge of the prior
diagnosis may have contributed to recall bias (2). Two studies of
postmenopausal women (aged 6079 y) also found significant
associations between reported milk intake in childhood or adoles-
cence (or both) and BMD, but no correction was made for current
intake (3, 4). Fewer studies investigated childhood milk or cal-
cium intake and later adult fractures, and the results among these
studies are mixed. The largest of them, a 12-y prospective follow-
up (5) using data from the Nurses Health Study, found no associ-
ation between reported milk intake in adolescence and fracture.
In this issue of the Journal, Kalkwarf et al (6) present data from
3251 non-Hispanic, white female participants (aged 20 y) in the
nationally representative third National Health and Nutrition
Examination Survey (NHANES III), in which adult women were
asked about the frequency of their milk consumption during child-
hood (ages 512 y) and adolescence (ages 1317 y). Kalkwarf et
al studied the association of BMD and bone mineral content
(BMC) as well as reported histories of fracture after age 13 y
(lifetime fracture) and after age 50 y (osteoporotic fracture) with
these reported milk-intake frequencies in regression analyses.
They found that earlier reported milk intake was associated with
apparent protection against later fracture as well as with greater
bone mass.
10 Am J Clin Nutr 2003;77:101. Printed in USA. 2003 American Society for Clinical Nutrition
Despite limitations in data availability, the study results are
compelling. Milk intake during childhood and adolescence was
associated with BMC and BMD of the hip both in women aged
2049 y (n = 1371) and in those aged 50 y (n = 1880). Younger
adult women who consumed < 1 serving of milk/wk during child-
hood had BMC 5.6% lower than that in younger adult women
who consumed > 1 serving/d. The results for hip BMC and BMD
were similarly significant by earlier milk-intake category for
Downloaded from ajcn.nutrition.org by guest on March 12, 2014
women aged 50 y. Furthermore, low milk intake during child-
hood was associated with a 2-fold greater risk of fracture among
older women, with significant associations between both child-
hood and adolescent milk intakes and greater incidence of life-
time fracture. The authors estimate that low milk intake during
childhood was associated with 11% of osteoporotic fractures in
women later in life.
One of the important considerations in the study by Kalkwarf et
al was that current milk intake was adjusted, which partially
removed the effect of the tendency of women who consumed more
milk in childhood to do the same in adulthood. Earlier intake
remained significant, despite a positive association between cur-
rent adult dietary calcium intake and BMC and BMD. The statis-
tical models were designed to control for important potential con-
founders. The adjustment for current calcium intake may have been
limited by the fact that it was based on a single 24-h recall. How-
ever, calcium intake generally has a relatively low ratio of intra- to
interindividual variance, because of regular patterns of milk usage.
The use of recall for data on milk consumption during child-
hood and adolescence has several limitations, particularly in
women with osteoporotic fracture. There is the possibility of recall
bias among those who know that they have been diagnosed with
osteoporosis. However, this factor is less likely to affect BMD or
BMC results. Furthermore, much of the error associated with the
recall of milk consumption during childhood and adolescence is
likely to be due to random error in memory, which may weaken
the ability to see associations. Another important limitation of
these data is that they cannot describe intakes greater than 1 glass
per day. More than 84% of women reported consumption of at
least one glass of milk per day during childhood and 70% reported
similar consumption during adolescence. The fact that associa-
tions between childhood and adolescent milk intakes and adult
fracture risk were detected despite this truncation is noteworthy,
and the true associations may have been even stronger.
1
From the Jean Mayer US Department of Agriculture Human Nutrition
Research Center on Aging at Tufts University, Boston.
2
Address reprint requests to KL Tucker, Jean Mayer USDA Human Nutri-
tion Research Center on Aging at Tufts University, 711 Washington Street,
Boston, MA 02111. E-mail: katherine.tucker@tufts.edu.
 EDITORIAL
It is interesting that current dietary calcium intake from food
was more consistently associated with bone measures than was
dietary calcium intake plus calcium from supplements or antacids.
Possibly, some current supplement use is stimulated by a diagno-
sis of osteoporosis or a previous fracture. This observation also
raises an important question related to the mechanism of the effect
of greater milk intake, given the frequent observation that
improvements with calcium supplement interventions tended to
regress once the supplement was removed. As noted by the
authors, it is significant that milk contains not only calcium, but
also vitamin D, phosphorous, protein, zinc, and magnesium. This
natural complex of nutrients may have a greater effect on endur-
ing skeletal integrity than does calcium given in a short-term sup-
plementation program.
Whereas further investigation into the effect of lifelong dietary
patterns on bone formation and protection against bone loss in
later life is needed, this study presents evidence that milk con-
sumption during childhood and adolescence is important. Most of
the adult NHANES III participants reported drinking at least one
glass of milk per day during these formative years. In light of both
the current tendency in schools to allow beverage choices such as
fruit punch rather than milk and of the growing pressure on
schools to stock vending machines with soda and other caloric
beverages that lack calcium, attention should be given to the
11
potential for future effects of diminished milk intake on bone sta-
tus and risk of fracture.
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