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USPSTF recommends against postmenopausal vitamin D/calcium supplementation

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Cautious Approach Praised

The USPSTF’s recommendation "must be interpreted in the light of ongoing disputes about the most effective method for assessing vitamin D deficiency, whether calcium and vitamin D supplements are needed by a large portion of the population, and what level of supplementation might best maximize benefits and minimize risks," according to Marion Nestle, Ph.D., and Malden C. Nesheim, Ph.D.

In particular, they cited the "conflicting perspectives" of the Institute of Medicine (IOM) and the Endocrine Society. Having determined that vitamin D and calcium deficiencies are generally not a serious problem in the United States, the IOM established average adult daily requirements for both, and has expressed concern about the possibility of adverse consequences from oversupplementation. Conversely, because vitamin D is a hormone, and supplementation must be considered a form of hormone replacement therapy, the Endocrine Society in 2011 made intake recommendations from a clinical endocrinology perspective based on the premise that vitamin D deficiencies are common among all age groups.

"The USPSTF’s recommendations can be understood as an attempt to clarify the present situation with respect to one specific outcome of supplementation. In doing so, its recommendations have a substantial advantage. They depend on hard endpoints – fractures – rather than on blood levels of 25-hydroxyvitamin D, at best an indirect measure of vitamin D adequacy. The USPSTF uses the same precautionary approach as did the IOM. In the absence of compelling evidence for benefit, taking supplements is not worth any risk, however small," they wrote.

Dr. Nestle and Dr. Nesheim noted that the USPSTF plans to publish further recommendations on the roles of vitamin D, and they urged the task force to "keep in mind the value of making a single recommendation ... that will encompass all potential benefits and risks" to avoid the confusion of multiple recommendations.

"While we wait for the results of further research, the USPSTF’s cautious, evidence-based advice should encourage clinicians to think carefully before advising calcium and vitamin D supplementation for healthy individuals," they concluded.

Dr. Nestle of New York University and Dr. Nesheim of Cornell University, Ithaca, N.Y., wrote their comments in an editorial responding to the USPSTF’s recommendations. Dr. Nestle disclosed some speakers fees and royalties from published books unrelated to this editorial and Dr. Nesheim disclosed royalties from a book unrelated to this editorial.


 

FROM ANNALS OF INTERNAL MEDICINE

The U.S. Preventive Services Task Force has recommended against vitamin D and calcium supplementation in healthy postmenopausal women, citing research showing that such supplementation increases the risk of kidney stones and does not protect against fractures in this population.

Top:©Kaspri/Fotolia.com; Bottom: ©Elenathewise/fotolia.com
The USPSTF has recommended against vitamin D and calcium supplementation in healthy, postmenopausal women due to research showing that these supplements increased risk of kidney stones and did not protect against fractures. 

Specifically, the USPSTF recommended – with moderate certainty – against supplementation with doses of vitamin D at 400 IU or less, and calcium at 1,000 IU or less in noninstitutionalized postmenopausal women. The evidence with respect to higher doses is insufficient for making a recommendation, Dr. Virginia A. Moyer reported on behalf of the USPSTF.

The evidence is also insufficient to assess the balance of the benefits and harms of combined vitamin D and calcium supplementation for the primary prevention of fractures in men and in premenopausal women, according to the recommendation statement, which was published online in the Feb. 25 issue of Annals of Internal Medicine (doi:10.7326/
0003-4819-158-9-201305070-00605).

Based on previously released recommendation statements, however, the USPSTF does recommend vitamin D supplementation for the prevention of falls in community-dwelling adults aged 65 years or older who are at increased risk for falls, and recommends that women aged 65 years and older be screened for osteoporosis.

Younger women with a fracture risk that is equal to or greater than that of a 65-year-old white woman with no additional risk factors should also be screened.

The new recommendations apply to noninstitutionalized or community-dwelling asymptomatic adults without a history of fractures; they do not apply to persons with osteoporosis or vitamin D deficiency.

The USPSTF acknowledged that the health burden of fractures is substantial in the older population, with nearly half of all women over age 50 years experiencing an osteoporosis-related fracture during their lifetime, but the task force noted that the increased risk of renal stones demonstrated in participants in the Women’s Health Initiative study who were taking supplemental vitamin D and calcium was also substantial.

"One woman was diagnosed with a urinary tract stone for every 273 women who received supplementation over a 7-year follow-up period," according to the recommendation statement.

In developing the recommendations, the USPSTF commissioned two systematic reviews of the evidence from 16 available randomized controlled trials and an updated meta-analysis of vitamin D supplementation with or without calcium supplementation.

The members of the USPSTF said they had no relevant financial disclosures.

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