ing 1,600 mg (40 mmol)/day of calcium, possibly because of the variability in this measure (Shapses et al., 1995). While dietary protein intake increases urinary calcium excretion, it should be recognized that inadequate protein intakes (34 g/day) have been associated with poor general health and poor recovery from osteoporotic hip fractures (Delmi et al., 1990). Similarly, serum albumin values have been shown to be inversely related to hip fracture risk (Huang et al., 1996). Available evidence does not warrant adjusting calcium intake recommendations based on dietary protein intake.

Caffeine. Caffeine has a modest negative impact on calcium retention (Barger-Lux et al., 1990) and has been associated with increased hip fracture risk in women (Kiel et al., 1990). The association of caffeine consumption with accelerated bone loss has been limited to postmenopausal women with low calcium intakes (Harris and Dawson-Hughes, 1994). Specifically, associations with bone loss from the spine and total body were identified in women who consumed less than about 800 mg (20 mmol)/day of calcium and the amount of caffeine present in two or more cups of brewed coffee. Consistent with this is the observation that the negative effect of caffeine on BMD can be offset by the addition of dietary calcium (Barrett-Connor et al., 1994). Caffeine induces a short-term increase in renal calcium excretion (Massey and Wise, 1984) and may modestly decrease calcium absorption (Barger-Lux and Heaney, 1995); its effect on dermal calcium loss has not been evaluated. In summary, the skeletal effects of caffeine are modest at calcium intakes of 800 mg (20 mmol)/day and above. Available evidence does not warrant different calcium intake recommendations for people with different caffeine intakes.

Amenorrheic Women. Conditions that produce lower levels of circulating estrogen alter calcium homeostasis. Young women with amenorrhea resulting from anorexia nervosa have reduced net calcium absorption, higher urinary calcium excretion, and a lower rate of bone formation when compared with healthy eumenorrheic women (Abrams et al., 1993). Exercise-induced amenorrhea also results in reduced calcium retention and lower bone mass (Drinkwater et al., 1990; Marcus et al., 1985).