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More to Question about Calcium and Vitamin D Supplements for Bone Health

For decades, health care guidelines and medical experts have recommended that older adults take a calcium with vitamin D supplement to strengthen their bones and prevent a bone fracture.  Osteoporosis is a disease in which the bones weaken, leading to an increase in the risk of a fracture. It is more common in older adults, and especially in women after menopause.  An important preventive health care goal for older adults is to prevent a hip fracture, one of the most devastating and feared consequences of osteoporosis. 

Calcium and vitamin D intake is believed to maintain bone health and reduce the risk of developing osteoporosis.  To prevent bone loss in men and women, the National Osteoporosis Foundation recommends an intake of 1000 mg of calcium per day up to age 70 years and 1200 mg per day thereafter, and 800 to 1000 units per day or more of vitamin D for people age 50 and older.   Because most people cannot get enough calcium and vitamin D on a daily basis through the foods they eat, calcium and vitamin D supplements are considered almost universally necessary.   However, over the years, research that has evaluated the benefit of calcium and vitamin D supplements in reducing the risk of bone fractures has found inconsistent results.  The safety of these supplements also has been questioned.  Several studies published in 2010 to 2013 found a possible association between calcium supplements and increased risk of heart attack.  In contrast, dietary intake of calcium showed no such relationship.

A new study sheds light on the value of calcium and vitamin D supplements to reduce the risk of bone fractures and most importantly hip fractures.   

An in-depth analysis of studies evaluating the benefit of calcium, vitamin D, or the combination of the 2 was published in December 2017.  The study evaluated data from 33 separate, smaller studies.  It included information collected from over 51,000 women and men.  Notably, persons studied were 50 years or older and lived in the community setting, meaning that older adults who resided in nursing homes, hospitals or other long-term care facilities were not included in the analysis and the results cannot be applied to them.  The researchers found that calcium, vitamin D, or calcium plus vitamin D supplementation offered no benefit in reducing the risk of fractures in the people studied.  It did not matter how much calcium people got in their diets or what their supplement dose was, if they were male or female, or if they had a previous fracture.  Thus, the findings from this meta-analysis research provide more insight about the role of supplements for bone health.  The take-home message from the study is that calcium and vitamin D supplementation does not appear to be of benefit in preventing hip fractures among older adults living in the community.  

This study still leaves some questions unanswered.  Namely, how might other medications affect the risk of bone fracture?  A drug class called proton pump inhibitors (PPIs) that decreases the production of stomach acid has been associated with increased risk of fracture.  The December 2017 study did not address the use of these or other potentially interacting drugs.  It does not address the role of supplementation in people younger than 50 years of age.  Also, if you already have a diagnosis of osteoporosis and take a medication to treat it or if you reside in a long-term care facility, this most recent study does not apply to your situation.  Follow your physician’s and pharmacist’s advice regarding calcium and vitamin D supplements. 

The December 2017 study suggests that a blanket recommendation for community-dwelling older adults to take a calcium supplement no longer is appropriate.  I gladly interpret the study’s findings as further support that we should increase our focus on eating a healthy, balanced diet and rely less on taking supplements.   However, calcium and vitamin D are nutrients the body needs to build bones, which is an ongoing process throughout our lifetime.  They remain important nutrients that deserve our attention.  Thus, what is the best way to get calcium and vitamin D? 

Strive to get your daily recommended amount of calcium and vitamin D through foods and beverages.  Include low-fat dairy foods and other foods rich in calcium.  If you do not like dairy, remember there is calcium in salmon and sardines, canned tuna, broccoli, kale, and collard greens and in non-dairy milk beverages like almond milk.  You also can find other foods that are fortified with calcium, such as orange juice and cereal bars.  Aim for 3 servings of calcium-rich foods every day, which will provide close to 1000 mg of dietary calcium.  Vitamin D is less abundant through the diet, but is found in whole eggs and fatty fish like salmon and sardines.  It also typically is added to milk, as well as orange juice, cereal, cereal bars and non-dairy milk beverages.  Of note, vitamin D has potential health benefits beyond the bone.  Thus, a vitamin D supplement might still be recommended for other reasons.

While routine use of calcium and vitamin D supplements may fall out of favor, an individual’s medical and medication history, lifestyle, and other risk factors that can affect bone health need to be considered.  Talk with your doctor about your bone health and whether a low-dose supplement in addition to dietary intake might be appropriate for you.

 

By Hedva Barenholtz Levy PharmD, BCPS, BCGP

January 22, 2018

 

Bibliography:

Anon.  Calcium/Vitamin D. National Osteoporosis Foundation. https://www.nof.org/patients/treatment/calciumvitamin-d/ (accessed 1/22/18)

Bolland MJ, et al. Effect of calcium supplments on risk of myocardial infarction and cardiovascular events: meta-anlaysis. BMJ 2010:341:c3691. doi: 10.1136/bmj.c3691.

Michaelsson K, et al. Long term calcium intake and rates of all cause and cardiovascular mortality: community based prospective longitudinal cohort study. BMJ 2013;346:1228. doi: 10.1136/bmj.f228.

Vitamin D Fact Sheet for Health Professionals. National Institutes of Health, Office of Dietary Supplements, updated 2/11/16.  https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/#h3 (accessed 1/23/18). 

Vitamin D. Healthline.com.  https://www.healthline.com/nutrition/9-foods-high-in-vitamin-d#section (accessed 1/23/18)

Warensjo E, et al. Dietary calcium intake and risk of fracture and osteoporosis: prospective longitudinal cohort study. BMJ 2011;342:d1473.  doi: 10.1136/bmj.d1473.

Xiao Q et al. Dietary and supplemental calcium intake and cardiovascular disease mortality. JAMA Intern Med 2013;173(8):639-46. doi:10.1001/jamainternmed.2013.3283.

Zhao JG, et al.  Association between calcium or vitamin D supplementation and fracture incidence in community-dwelling older adults, a systematic review and meta-analysis JAMA 2017;318(24):2466-82.