Vitamin D and Calcium Supplementation to Prevent Fractures in Adults
Tuesday, April 29, 2014
U.S. Preventive Services Task Force Recommendation Statement
The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific clinical preventive services for patients without related signs or symptoms.
It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
Summary of Recommendations and Evidence
The USPSTF concludes that the current evidence is insufficient to assess the balance of the benefits and harms of combined vitamin D and calcium supplementation for the primary prevention of fractures in premenopausal women or in men (I statement).
The USPSTF concludes that the current evidence is insufficient to assess the balance of the benefits and harms of daily supplementation with greater than 400 IU of vitamin D3 and greater than 1,000 mg of calcium for the primary prevention of fractures in noninstitutionalized postmenopausal women (I statement).
The USPSTF recommends against daily supplementation with 400 IU or less of vitamin D3 and 1,000 mg or less of calcium for the primary prevention of fractures in noninstitutionalized postmenopausal women (D recommendation).
The USPSTF has previously concluded in a separate recommendation that vitamin D supplementation is effective in preventing falls in community-dwelling adults aged 65 years or older who are at increased risk for falls (B recommendation).
Rationale
Importance
Fractures, particularly hip fractures, are associated with chronic pain and disability, loss of independence, decreased quality of life, and increased mortality (1). One half of all postmenopausal women will have an osteoporosis-related fracture during their lifetime.
Appropriate intake of vitamin D and calcium are essential to overall health. The Institute of Medicine has published recommended dietary allowances (Table). However, the benefits and harms of daily supplementation with greater than 400 IU of vitamin D3 and greater than 1,000 mg of calcium to prevent fractures are not clearly understood.
Benefits of Preventive Medication
In premenopausal women and in men, there is inadequate evidence to determine the effect of combined vitamin D3 and calcium supplementation on the incidence of fractures. In postmenopausal women, there is adequate evidence that daily supplementation with 400 IU of vitamin D3 combined with 1,000 mg of calcium has no effect on the incidence of fractures. However, there is inadequate evidence regarding the effect of higher doses of combined vitamin D and calcium supplementation on fracture incidence in noninstitutionalized postmenopausal women.
Harms of Preventive Medication
Adequate evidence indicates that supplementation with 400 IU or less of vitamin D3 and 1,000 mg or less of calcium increases the incidence of renal stones. The USPSTF assessed the magnitude of this harm as small.
USPSTF Assessment
Noninstitutionalized, community-dwelling postmenopausal women. The USPSTF concludes that evidence is lacking about the benefit of daily supplementation with greater than 400 IU of vitamin D3 and greater than 1,000 mg of calcium for the primary prevention of fractures, and the balance of benefits and harms cannot be determined.
The USPSTF concludes with moderate certainty that daily supplementation with 400 IU or less of vitamin D3 and 1,000 mg or less of calcium has no net benefit for the primary prevention of fractures.
Men and premenopausal women. The USPSTF concludes that evidence is lacking about the benefit of vitamin D supplementation with or without calcium for the primary prevention of fractures, and the balance of benefits and harms cannot be determined.
Low vitamin B12 levels increase the risk of fractures in older men
Monday, April 21, 2014
Older men who have low levels of vitamin B12 have a higher risk of having fractures. These are the findings of researchers at the Sahlgrenska Academy as a part of an international study of a total of 1000 older men.
Osteoporosis is one of the worlds most widespread diseases, and intensive research is under way worldwide to identify its causes and to be able to prevent fractures.
In an extensive study, researchers at the Sahlgrenska Academy at the University of Gothenburg can now show that low levels of vitamin B12 in the blood increases the risk of fractures in older men.
International research project
This study is a part of an international research project initiated by the National Institutes of Health (NIH) in the US and comprises 11,000 men in total. In their part of the study, the Gothenburg researchers studied 1,000 Swedish men, MrOS Sweden, with an average age of 75, and used various methods to analyze the blood concentrations of the B vitamins B12 and folate, which are found in our food naturally.
Higher fracture risk
The results show that the risk of suffering a fracture six years later was higher among men who had low B12 levels at the beginning of the study than men with normal B12 levels. In the quartile with the lowest B12 content, the risk was elevated by approximately 70 percent compared with the others. The risk increase pertained primarily to fractures in the lumbar region, where the risk increase was up to 120 percent.
"The higher risk also remains when we take other risk factors for fractures into consideration, such as age, smoking, BMI, BMD (bone mineral density), previous fractures, physical activity, the D-vitamin content in the blood and calcium intake," says Catharina Lewerin, researcher at the Sahlgrenska Academy.
Does this mean that older men can prevent fractures by eating more vitamin B12?
"It has not been scientifically established, but such studies are under way, including one large Dutch study where older individuals over the age of 65 are treated with both vitamin B12, folic acid and vitamin D to investigate the occurrence of fractures.
"Right now, there is no reason to eat more vitamin B12, but rather treatment shall only be applied in confirmed cases of deficiencies and in some cases to prevent deficiencies. For anyone who wants to strengthen their bones and prevent fractures, physical activity 30 minutes a day and quitting smoking is good self care," says Catharina Lewerin.
New method
In this study, the researchers used a relatively new method called holotranscobalamin, which measures the amount of vitamin that is taken up in the cells, which is considered to be a more sensitive test for B12 deficiency.
The article was published online in Osteoporosis International.
How to Prevent Osteoporosis and Fractures
Sunday, March 23, 2014
Osteoporosis. You might be thinking, "Im not an old lady, this doesnt concern me, Im going to go back to watching Honey Boo Boo and snacking on mayonnaise." Wrong. Whether youre a man or a woman, young or old, you need to know about osteoporosis. It may be more common in post-menopausal women, but it happens in men too, and how you live in your 20s could have a HUGE impact on whether you fall and break a hip in your 70s. So listen up. Theres a lot of misinformation around this topic, and I dont want you popping calcium, vitamin D, and Boniva pills and thinking everything will be okay. Ready? Lets go.First, some basics.
Osteoporosis: A disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fractures, especially of the hip, spine, and wrist.
In other words, having osteoporosis means you have weak bones thatll break on you a whole lot easier than they should. Osteoporosis is responsible for more than 1.5 million fractures each year. Thats a lot. Whats more, up to 1/3 of hip fracture patients die within one year of their fracture, and up to 75% never walk independently again (1). Obviously, the vast majority happen to older adults. But it may be your bone health in your 20s that best predicts your bone health in your 70s. Why? Peak bone mass.
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| Top line = men, bottom line = women |
Peak bone mass is just what it sounds like: the point in life at which you have the thickest, densest, healthiest bones. And that point is in your late 20s. After that, its very difficult/impossible to build more bone mass, and so it slowly declines into old age. Key point... the more bone mass you can develop in your 20s, the more youll have to work with when youre older. Its never too early to start. How do you do that? You ask and I answer...
Things you should do to build/preserve strong bones.
- Lift weights. This is one of the most important things you can do for your bones. Lift weights, use resistance machines, do pushups, pullups, squats. ESPECIALLY SQUATS. Squatting is the most fundamental human movement. As long as you can do a full, deep squat, youll never have a problem getting up when you fall (provided you dont break a bone of course). But beyond the functionality of being able to squat, resistance training is phenomenal for keeping your bones dense and strong (2). And you dont need to adopt a powerlifting training program. Even doing a total body circuit once a week will help you out.
- Eat calcium. Yes I said eat calcium. Dont take a supplement. I dont care what your doctor tells you, you dont need 1500 mg of calcium every day. This study found an intake of 600-1000 mg/day to be best (3); I wouldnt take that as the end-all-be-all, but its probably a good range to shoot for. Eat leafy green vegetables. Eat some dairy. Eat some canned sardines/salmon. So calcium is one piece of the puzzle, but you need calciums buddies too...
- Vitamin D. Get some sun please. Hold off on the sunscreen, at least for a little while. Or in the winter, take a supplement... maybe 1000-2000 IU/day. If you ever get your vitamin D level tested, it should be between 30-50 ng/ml. Vitamin D increases calcium absorption in the GI tract, thereby decreasing the amount you need to get in the diet. BOOM! More calcium!
- Vitamin K2. And this is where vitamin K2 takes over. Now that youve got more calcium, K2 makes sure its used properly by activating osteocalcin, the protein responsible for depositing calcium in the bones and teeth. Without K2, osteocalcin is useless. We get some K2 from our friendly gut bacteria, but we need more from the diet for this process to run smoothly. The best dietary sources are natto, goose liver pate, gouda, brie, pastured egg yolks, grass-fed butter, etc. (4). In other words, youre not getting enough. Luckily, supplementation works (5). Try this one... or if youre really ambitious, get cod liver oil / butter oil blend from Green Pasture for a nice catch-all dose of K2, D, and vitamin A.
- Eat more protein. Its true! While we used to believe high-protein diets ruined our bones (you see more calcium in the urine on a high-protein diet), it turns out the opposite is true. Eating more protein increases calcium absorption to an even greater degree, tipping the odds in your favor (6). Thanks to my professor Jane Kerstetter for that bit of research. Go have a steak.
- Take calcium supplements. More calcium isnt the answer, especially in supplement form. First of all, calcium supplements dont decrease your chances of breaking a bone (7). But the problems go deeper. High intakes of calcium from either diet or supplements (>1400 mg/day) are associated with higher death rates from all causes and from cardiovascular disease (8). In addition, in a very recent Swedish study, women taking in over 1400 mg calcium per day doubled their risk of dying of heart disease. Doubled! Similar findings were shown in another recent study in men (9)! Why the increased risk? Ill take a stab at it. We need a balance between calcium, vitamin D, and vitamin K2. Calcium may be the raw material, but with too much calcium and not enough K2 to put it into the right places, it ends up in the wrong places... like our coronary arteries. And then we die. Aint nobody got time for that.
- Take prescription drugs. Boniva, Fosamax, Actonel, Reclast... this class of drugs is known as "bisphosphonates". They sound great in theory... they prevent calcium from being taken out of bone, which is a normal part of the cycle of bone maintenance. Keeping calcium around seems like a good idea right? Maybe. They seem to reduce fractures over the course of the first 5 years, but after that, theres no evidence to support their use (10). In addition, they can lead to unusual fractures of the thigh, or femur. Weird since the femur is the strongest bone in the body. Theres some funky shit going here. Shit we dont fully understand. Is anybody looking for a 5-year, temporary reduction in fractures, followed by some weird shit that may or may not involve a broken femur? If so, you know what to do.
So there you have it... my comprehensive list of dos and do nots when it comes to bone health. Remember, preventing osteoporosis starts at a young age. Dont wait til youre 80, start now! Do squats and get some sun! Or do squats in the sun! And take your cod liver oil! And eat a steak! And binge on Brie! Tell all your friends!
Oh and I guess I should cite this book, "Vitamin K2 and the Calcium Paradox", since I thumbed through it for tips on this topic. Check it. Good read.
