Recommendations for Vit D and Calcium Supplementation for Fracture Prevention
The role vitamin D plays in regulating bone mineralization is well known. Adequate serum levels of vitamin D have been shown to aid in the prevention of fractures (1). Fractures in older adults, especially of the hip, create havoc. These fractures are associated with chronic pain and disability, a loss of independence, a decrease in quality of life, and an increase in mortality in older adults (3). These fractures are also fairly common with about half of all post-menopausal women having an osteoporosis-related fracture in their lifetime (3).
If fractures are so bad, and higher levels of vitamin D are protective, shouldn’t supplementing vitamin D levels help prevent fractures? This is the question that the United States Preventive Services Task Force (USPSTF) has tried to address in their recent recommendations. The task force reviewed multiple studies. In particular, a 2007 review showed that serum vitamin D levels are inversely associated with fractures and falls (1). A 2011 review in the Annals of Internal Medicine concluded that 300-1100 IU/day of vitamin D with 500-1000 mg/day of calcium reduced the risk of fractures in older adults (2). This effect was larger for institutionalized patients (i.e. those living in nursing homes or assisted living facilities) versus community dwelling patients (2).
From this, the USPSTF has concluded that there is adequate evidence that 400 IU/day of vitamin D plus 1000 mg/day of calcium has no effect on the incidence of fractures. There is insufficient evidence to recommend doses of vitamin D > 400 IU/day or calcium > 1000 mg/day for the primary prevention of fractures in non-institutionalized post-menopausal women. There is also insufficient evidence to support the use of vitamin D or calcium supplementation as primary prevention of fractures in men and premenopausal women. The use of doses < 400 IU/day of vitamin D and < 1000 mg/day of calcium are not recommended for fracture prevention (3).
So what is a provider to do? One must assess the risk of fracture, or recurrent fracture, in your patient to decide if supplementation is needed. If you do decide to supplement, do not use vitamin D alone, but add calcium. Doses should be at least 400 IU/day of vitamin D and 1000 mg/day of calcium.
References: 1. Effectiveness and safety of Vitamin D in relation to bone health. Evid Rep Technol Assess. 2007 Aug; (158): 1-235. 2. Vitamin D With or Without Calcium Supplementation for Prevention of Cancer and Fractures: An Updated Meta-analysis for the U.S. Preventive Services Task Force. Ann Int Med. 2011; 155: 827-838. 3. Vitamin D and Calcium Supplementation to Prevent Fractures in Adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Int Med 2013; 158:
_______________________________________________________________________________ Matt Astin is a physician at the Medical Center of Central Georgia in Macon, Georgia. He is board certified in both internal medicine and emergency medicine.
