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Published: February 25, 2013
- Current evidence does not support supplementation with daily vitamin D or calcium to reduce the risk of fractures in adults, according to the United States Preventive Services Task Force.
- Note that supplementation at or below 400 IU of vitamin D3 and 1,000 mg of calcium conveys a slightly increased risk for renal stones.
Current evidence does not support supplementation with daily vitamin D or calcium to reduce the risk of fractures in adults, the United States Preventive Services Task Force (USPSTF) concluded.
In particular, the combination of 400 IU of vitamin D and 1,000 mg of calcium has no effect on fracture risk in community-based postmenopausal women, and evidence is insufficient to support higher doses of the supplements in this segment of the population for fracture prevention, a USPSTF panel stated in recommendations published online in Annals of Internal Medicine.
While supplementation with less than 400 IU of vitamin D and less than 1,000 mg of calcium does increase the risk of kidney stones, the “USPSTF assessed the magnitude of this harm as small,” pointed out chair Virginia Moyer, MD, and co-authors.
“Except for postmenopausal women, there is inadequate evidence to estimate the benefits of vitamin D or calcium supplementation to prevent fractures in noninstitutionalized adults,” they wrote. “Due to the lack of effect on fracture incidence and the increased incidence of nephrolithiasis in the intervention group of the Women’s Health Initiative (WHI) trial, the USPSTF concluded with moderate certainty that daily supplementation with 400 IU of vitamin D3 and 1000 mg of calcium has no net benefit for the primary prevention of fractures in noninstitutionalized postmenopausal women.”
“Although women enrolled in WHI were predominately white, the lower risk for fractures in nonwhite women makes it very unlikely that a benefit would exist in this population,” they added.
The panel emphasized that the recommendations apply only to community-dwelling adults with no history of fractures, and that includes adults, ages 65 and older, who are at increased risk for falls. Moreover, the recommendation against supplementation with vitamin D and calcium does not apply to adults with osteoporosis or vitamin D deficiency.
The USPSTF cited a need for more research to assess the potential benefits and harms of supplementation of higher doses of vitamin D and calcium. The panel also noted a need for research into the impact of supplementation in early adulthood on fracture risk later in life, and for studies of supplementation in diverse populations, beyond the traditional focus on white women, who have the greatest risk of osteoporotic fractures.
The task force developed the recommendations after commissioning two systematic evidence reviews and a meta-analysis on vitamin D supplementation, with or without calcium, to assess the effects of supplementation on bone health outcomes in community-dwelling adults. They also looked at the association of vitamin D and calcium levels with bone health outcomes and the adverse effects of supplementation.
The recommendation consists of “terse statements unlikely to settle the debates,” according to the authors of an accompanying editorial. Nonetheless, the USPSTF arrived at an “unambiguous conclusion,” and the recommendation regarding postmenopausal women is equally unambiguous: “Do not supplement.”
“While we wait for the results of further research, the USPSTF’s cautious, evidence-based advice should encourage clinicians to think carefully before advising calcium and vitamin D supplementation for healthy individuals,” said Marion Nestle, PhD, of New York University in New York City, and Malden Nesheim, PhD, of Cornell University in Ithaca, N.Y.
Nutrition authority Walter Willett, MD, had little to quibble about within the narrow focus of the USPSTF recommendation. However, clinicians and patients are likely to be confused by the absence of guidance regarding the potential value of higher doses of vitamin D and calcium, the large population of institutionalized individuals, and other factors that predispose adults to a risk of fracture.
“We need to look at the evidence for calcium and vitamin D separately,” Willett, chair of nutrition at Harvard School of Public Health in Boston, told MedPage Today. “The evidence is quite different for these two essential nutrients.”
A substantial body of evidence suggests that calcium intake, whether by supplementation or food sources, does not reduce the risk of fracture. The optimal dose has yet to be determined, but the World Health Organization recommendation of 500 mg daily probably makes more sense than the 1,200 mg dose commonly recommended in the U.S.
With respect to vitamin D, Willett agreed with the USPSTF that more research is needed to determine the appropriate dose. Available evidence suggests that 1000 to 2000 IU daily is appropriate for most people who get inadequate amounts of vitamin D through the most common natural source, sunlight.
Members of the USPSTF panel reported no conflicts of interest.
Nestle disclosure a royalty intersted related to a book, and Nesheim disclosed a relationship with Steven Barclay Agency.
Willett reported no conflicts of interest.
Primary source: Annals of Internal Medicine
Moyer VA, et al “Vitamin D and calcium supplementation to prevent fractures in adults: US Preventive Services Task Force recommendation statement” Ann Intern Med 2013.
Additional source: Annals of Internal Medicine
Nestle M, Nesheim MC “To supplement or not to supplement: The US Preventive Services Task Force recommendations on calcium and vitamin D” Ann Intern Med 2013.
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