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Calcium and vitamin D, alone or combined, do not reduce fracture risk in community-dwelling older adults
Clinical Question
Does calcium and vitamin D, alone or in combination, reduce the risk of fracture in community-dwelling older adults?
Bottom line
The use of calcium and vitamin D, alone or in combination, did not significantly reduce the risk of hip, vertebral, nonvertebral, or total fractures in community-dwelling older adults. Results were unchanged based on calcium or vitamin D dosage, patient sex, fracture history, dietary calcium intake, and baseline serum 25-hydroxyvitamin D concentration. Of specific concern: Vitamin D alone significantly increased the risk of hip fracture in the subgroup with baseline vitamin D concentrations of 20 ng/mL or greater and did not reduce the risk of hip fractures in those with concentrations less than 20 ng/mL. 1a
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Foundation
Setting: Various (meta-analysis)
Synopsis
These investigators thoroughly searched multiple databases, including PubMed, the Cochrane Library, Embase, and published systematic reviews without language restrictions for randomized trials comparing calcium, vitamin D, or both, with placebo or no treatment for fracture incidence in community-dwelling adults 51 years or older. Unpublished data were included where available. Two reviewers independently assessed published studies for inclusion criteria and methodologic quality using a standard risk-of-bias scoring tool. Disagreements were resolved by consensus. A total of 33 randomized controlled trials (N = 51,145) met inclusion criteria. Of these, 1 trial was low quality, 6 were high quality, and the remainder were moderate quality. Calcium and vitamin D, alone or in combination, did not significantly reduce the risk of hip, vertebral, nonvertebral, or total fractures. Formal subgroup analyses showed that the results were no different on the basis of calcium or vitamin D dosage, patient sex, fracture history, dietary calcium intake, and baseline serum 25-hydroxyvitamin D concentration. Vitamin D alone significantly increased the risk of hip fracture in the subgroup with baseline vitamin D concentrations of 20 ng/mL or greater. A formal analysis of publication bias was not performed because of the low number of published trials.
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC
Comments
Casts doubt on vitamin D supplements for my elderly LTC residents who have a history or risk of falls.
Wow. Very interesting. I would look forward to a response from an osteoporosis researcher.
I will have to think again about whether I should be taking Calcium or Vit D. Perhaps it is just a long held myth.
The number of articles is low. Authors themselves acknowledge possible publication bias.
more detailed information is required especially re. patient selection and followup
Is vitamin D...
... The new vitamin E? We used to give quite a lot of that miraculous antioxidant before we realized it didn't seem to do any good and possibly a lot of harm!
What about baseline BMDs for each group?
Not sure how to transfer this to patient advice that everyone should take Vit D in Canada.
My lab has <25 nmol as deficient; 25-75 nmol as reduced and 75 and above as normal. As often the case infopoem has not translated >20ng/ml units to metric, reducing the effectiveness of the advice.
Have one pt with real deficiency,>51, elevated PTH and now on several thousand units /day . Hope this paper supports that,
Two questions I like to ask: (1) are these older adults been assessed by BMD- in other word are they known to be osteoporotic or osteopenia? (2) if they are not osteoporotic what can reduce their fracture risk?
Here we go again
A professional lifetime of recommending Vit D and Calcium supplements for risk management for patients has apparently gone out the window with this meta-analysis. No benefit. Next up will be O2supplements to ER patients with acute MI, given that vast studies of it showed that 100% of patients who died had received it- No Benefit
Major flaw is the acute care model application to prevention of chronic issues. Pretty sure there folks were not taking vitamin d titrated to correct levels over a twenty or thirty year period
WHOAH does this mean we should tell patients to stop supplementing with Vitamin D???? Or is the increase risk of hip fracture just for very high doses?
Would be good to compare vs osteoporosis/penia risk/confirmed status.
pretty useless . We are not Calcium deficient and few are truly Vit D deficient. We are mostly weight bearing deficient
This puts a question mark of how to prescribe calcium and vit D.
good poem
Vitamin D and Calcium are surrogate indicators.
How does one get Vitamin D naturally? Either from sunshinevon skin, or through eating omega-3 rich oily cold water fish.
What do those who consume more fish consume less? Cereal grains, pasta, and other starchy carbohydrates. What changes with a diet higher in healthy fats & protein and lower in carbohydrates? Fasting Insulin will be lower.
Insulin affects both osteoclasts and osteoblasts. Hyperinsulinemia is associated with osteoporosis.
Insulin tells the body to conserve energy by minimizing activity, and to seek food for the coming famine. Lowering insulin levels enables patients to feel more motivated to be physically active, which strengthens bones.
I HAVE A GOOD NUMBER OF HANDICAP PATIENTS THAT ARE WHEELCHAIR BOUND. BESIDES THE BASICS OF CALCIUM AND VIT D, I DON'T KNOW IF ADDING BISPHOSPHONATE CAN BE HELPFUL OF NOT.
The risks with vitamin D fracture appear to be with high intermittent dosing, but that doesn't tell us much about regular 2000IU per day.
Excellent