Vitamin D and calcium cannot reduce breaks

reference

ZHAO JG, Zeng XT, Wang J, Liu L. Association between calcium or vitamin D supplementation and fracture incidence of older adults living in the community: a systematic review and meta-analysis. JAMA . 2017; 318 (24): 2466-2482.

draft

A meta-analysis of 33 randomized clinical studies for comparing calcium, vitamin D or combined calcium and vitamin D supplements with a placebo or no treatment of fracture incidence. The literature research was carried out on December 24, 2016 and updated on July 16, 2017.

participant

The 33 randomized studies included 51,145 adults living in community at the age of> 50 years.

target parameter

Two independent experts carried out the data extraction and evaluated the quality of study. A meta-analysis was carried out in order to calculate risk relationships (RRS), absolute risk differences (ARDS) and 95 %confidence intervals (CIS) using models with random effects.

important knowledge

• No significant association of calcium (RR: 1.53; 95 % KI: 0.97–2.42) or vitamin D (RR: 1.21; 95 % KI: 0.99–1.47) with the risk of a hip fracture compared to placebo or no treatment.
• No significant association of combined calcium and vitamin D with hip fractures compared to placebo or no treatment (RR: 1.09; 95 % CI: 0.85-1.39).
• No significant relationships between calcium, vitamin D or combined calcium and vitamin D supplements and the incidence of non-vertebral, vertebral or total fractures. Subgroup analyzes showed that these results were generally independent of the calcium or vitamin D dose, gender, fracture history, the dietary calcium intake or the output concentration of 25-hydroxyvitamin D in serum.

In this meta-analysis of randomized clinical studies, the use of nutritional supplements that contained calcium, vitamin D or both were not connected with a lower risk of fracture for older adults compared to placebo or no treatment. These results do not support the routine use of these nutritional supplements with older people living in community.

practice implications

Because of the high potential for these fractures in our patient populations and the associated considerable morbidity, it is important for most of us in clinical practice to find ways to reduce the risk of osteoporotic fracture. About 40 % of 50-year-old women suffer at least 1 larger osteoporotic fracture in the course of their lives. ^{1 hip fractures are generally considered the most severe type of osteoporotic fractures; In a cohort study carried out between 2000 and 2010, more than 20 % of the patients died within one year after a hip fracture.}

The results of this study are the opposite of what we have believed to be faith.

Over the years, we have strongly recommended patients to take a combination of vitamin D and calcium, as we believe that these nutritional supplements would reduce the risk of fracture. The present study by Zhao et al. suggests that this prescription will bring relatively little benefit. Based on their systematic review and meta-analysis of 33 randomized studies, the authors found that neither calcium alone, calcium plus vitamin D nor vitamin D only the incidence of hip, non-vertebral, vertebral or total fractures in older people who live in community, significantly reduced adults.

previous meta -analyzes have reported slight advantages of a nutritional supplement. Avenell's Cochrane Review from 2014 combined data from 54 clinical studies (n = 91,281), in which vitamin D in the hope was given to reduce broken bones. Based on this overview, it seemed unlikely that vitamin D alone prevents hip or other fractures. Some of the results from Avenell's meta -analysis are listed below:

• It is unlikely that vitamin D alone prevents a hip fracture (RR: 1.12; 95 % AI: 0.98-1.29); 11 tests (n = 27.693).
• It is unlikely that vitamin D alone prevents a new fracture (RR: 1.03; 95 % KI: 0.96–1.11); 15 tests (n = 28.271).
• Vitamin D Plus calcium reduces the risk of any type of fracture (RR: 0.95; 95 % CI: 0.90–0.99) by about 5 %; 10 tests (n = 49.976).
• Vitamin D Plus calcium leads to a 16 % reduction in the hip fracture risk (RR: 0.84; 95 % KI: 0.74–0.96; p = 0.01); 9 tests (n = 49.853).

You also found that neither vitamin D nor vitamin D plus calcium influenced the risk of death (n = 71.032) and that a vitamin D supplementation was connected with a twice as high risk of light hypercalzemia (n = 17.124) and gastrointestinal symptoms (n = 47.761). . ³

A meta-analysis by Bolland et al. examined the effects of a vitamin D supplementation on skeleton, vascular and cancer results. Bolland defined clinical results using a risk reduction threshold of 5 % for mortality and 15 % for other endpoints. Unfortunately, the results did not meet these minimal threshold values, which is why he tries to use a vitamin D supplementation as in vain.

according to Bolland, vitamin D supplement with or without calcium in myocardial infarction or ischemic heart disease (9 studies; n = 48.647), stroke or cerebrovascular disease (8 studies; n = 46.431), cancer (7 studies; n = 48.167), and total fraction (22 studies; n = 76.497) Futility limit, which by definition means that vitamin D changes the relative risk of no endpoints by 15 % or more. Vitamin D supplementation alone did not reduce the hip fracture by 15 % or more (12 studies; n = 27.834). ⁴

a second by Bolland et al. In July 2014, meta -analysis published only dealt with vitamin D, which was administered for fall prevention. Bolland once again set a threshold of 15 % risk reduction. Data from 20 randomized controlled studies (n = 29.535) did not achieve this benefit threshold, which is why a vitamin D supplementation was described as pointless. However, reported in a publication from 2015 that a calcium supplement was significantly associated with a lower incidence of total fractures in the community living in community.

Data from the Women’s Health Initiative (Whi) studies published in 2014 indicate a significant interaction between hormone therapy, calcium and vitamin D. In these studies, supplementation in combination with hormone therapies significantly reduced the risk of a hip fracture. ⁷

A vitamin D supplement may not be risk-free, as we used to think. The latest reports actually indicate that high bolus cans of vitamin D increase the risk of falling in older people. In November 2016, a warning was published in November 2016 that vitamin D bolus or daily doses should not exceed 3,000 IE and serum levels of 25-hydroxyvitamin D 40-45 ng/ml in older people.

The other widespread belief in vitamin D is that taking intersection reduces the risk of cancer. A Cochrane review by Bjelakovic et al. Analyzed data from 18 randomized clinical studies (n = 50,623) for cancer prevention in adults. The participants who came from countries with high incomes and were mainly older women (47-97 years old) were supplemented with vitamin D for an average of 6 years. In the end, 7.6 % of women who received vitamin D developed cancer compared to 7.7 % of women who did not do this.

We should note that in the current meta -analysis by Zhao et al. The hip fracture risk with calcium or vitamin D supplementation tends to increase, although this did not achieve any statistical significance. It was a significant trend for the authors to consider the possibility of a significant connection between nutritional supplements and increased fracture incidence. Perhaps this can be explained by an increased risk of falling. We should certainly think about it because we thought vitamin D for a long time.

The reduction in fracture risk is of great clinical importance in older women. It seems that vitamin D and calcium are not quite as advantageous as we thought in the past, and taking these nutritional supplements can possibly hide risks.

In clinical practice, it seems that women respond well to our proposed osteoporosis treatments with a significant improvement. But the lean advantages that are described in these studies seem to be too low in order to be clinically perceptible. However, we should recognize that we rarely prescribe calcium or vitamin D alone, if at all. Patients often receive vitamin K and strontium citrate in addition to calcium and vitamin D. We also promote the daily one -legged. Perhaps these more complex protocols are more effective, either because they increase the effects of vitamin D and calcium or have a greater effect as independent therapies.

Our patients believe in vitamin D and calcium to increase the bone density, and we would find it difficult to convince them that these pills are unnecessary. Apart from the equilibrium problems associated with large bolus cans of vitamin D, the risk of damage caused by the intake still seems to be low. The data indicate that the mortality rates are not adverse. In the Cochrane Review by Bjelakovic et al. From 2014 vitamin d 3 was associated with a small but significant decline in mortality and deaths by cancer. In the composed studies of studies from 38 studies (n = 75.927), those who took vitamin D had an mortality rate of 11 % compared to 11.4 % in the control group (RR: 0.94; 95 % CI: 0.91–0.98; p = 0.002); In 4 studies (n = 44.492), cancer deaths in the vitamin D group decreased significantly (RR: 0.88; 95 % KI: 0.78–0.98; p = 0.02). The combination of vitamin D 3 and calcium was associated with an increased risk of nephrolithiasis (RR: 1.17; 95 % CI: 1.02-1,34; p = 0.02) in 4 studies (n = 42.876). ⁹

It should be noted that the conclusions of the current study for supplementation were drawn without taking into account laboratory values ​​for circulating vitamin D or calcium levels. Filling those who have a lack of these nutrients can change the associated results.