Don’t confuse vitamin D supplements with calcium AND vitamin D supplements

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In this response to the recent findings of the paper by Bolland et al., the International Osteoporosis Foundation urges patients not to stop taking prescribed supplements without discussing the implications with their doctors first.

The widely reported message that vitamin D supplements are not needed, stemming from the recent publication by Bolland et al. in the Lancet Diabetes and Endocrinology, has caused much confusion and concern, particularly amongst older patients with osteoporosis. This statement sets out the response from the International Osteoporosis Foundation.

In their systematic review, meta-analysis and trial sequential analysis, Bolland et al.(1) conclude that there the current evidence base indicates no benefits of vitamin D supplements for outcomes such as fracture and fall reduction, or improving bone mineral density.

In fact this finding is not new, certainly for fractures and bone mineral density, and the majority of guidelines for the assessment and treatment of osteoporosis worldwide do not advocate the use of vitamin D supplements as sole agents for fracture prevention.(2-4) Indeed Bolland et al. published very similar results a few years earlier,(5-7) with the most recent publication a more comprehensive and up to date account of the evidential landscape.

Professor Cyrus Cooper, President of the International Osteoporosis Foundation comments,

Critically, this study relates to supplementation with vitamin D alone, and not with the combination of calcium and vitamin D, for which there is convincing evidence of modest benefits for fracture reduction, albeit not of great enough magnitude to warrant their use as sole treatments for osteoporosis. Calcium and vitamin D supplements are usually recommended for people who are being treated with bone active drugs such as bisphosphonates or denosumab, since in the majority of trials of these medications participants were supplemented in this way.”

Professor Serge Ferrari, Chair of the IOF Committee of Scientific Advisors said,

Dietary intakes of calcium and vitamin D vary greatly between individuals and between populations, as does the ability to make new vitamin D through the action of sunshine on the skin. Where individuals have insufficient calcium intake, or are deficient in vitamin D, particularly when these low intakes are associated with symptoms or the presence of osteoporosis, supplementation with vitamin D and/or calcium is usually the required therapeutic approach.”

Professor Nicholas Harvey, Vice-Chair of the IOF Committee of Scientific Advisors added,

Although this recent study is consistent with many previous studies demonstrating the limited benefits of pure vitamin D supplementation, it does not address the use of calcium with vitamin D supplements, or of their use with treatments for osteoporosis - it is important for patients not to stop any prescribed supplements without discussing the implications with their doctor first.”

References

1. Bolland MJ, Grey A, Avenell A. Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis. The lancet Diabetes & endocrinology. 2018.
2. Compston J, Cooper A, Cooper C, Gittoes N, Gregson C, Harvey N, et al. UK clinical guideline for the prevention and treatment of osteoporosis. Archives of osteoporosis. 2017;12(1):43.
3. Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster JY. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2013;24(1):23-57.
4. Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, et al. Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int. 2014;25(10):2359-81.
5. Bolland MJ, Grey A, Gamble GD, Reid IR. Vitamin D supplementation and falls: a trial sequential meta-analysis. The lancet Diabetes & endocrinology. 2014;2(7):573-80.
6. Bolland MJ, Grey A, Gamble GD, Reid IR. The effect of vitamin D supplementation on skeletal, vascular, or cancer outcomes: a trial sequential meta-analysis. The lancet Diabetes & endocrinology. 2014;2(4):307-20.
7. Reid IR, Bolland MJ, Grey A. Effects of vitamin D supplements on bone mineral density: a systematic review and meta-analysis. Lancet. 2014;383(9912):146-55.