Vitamin D and Calcium Supplement to Prevent Fractures-Adult

Summary of Recommendations and Evidence

Population	Recommendation	Grade (What's This?)
Premenopausal Women	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. Go to the Clinical Considerations for suggestions for practice regarding the I statements.	I
Men	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 men. Go to the Clinical Considerations for suggestions for practice regarding the I statements.	I
Noninstitutionalized Postmenopausal Women	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 D and greater than 1,000 mg of calcium for the primary prevention of fractures in noninstitutionalized postmenopausal women. Go to the Clinical Considerations for suggestions for practice regarding the I statements.	I
Noninstitutionalized Postmenopausal Women	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
Community-dwelling Adults, 65 Years or Older, at Increased Risk for Falls	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

Importance

Fractures, particularly hip fractures, are associated with chronic pain and disability, loss of independence, decreased quality of life, and increased mortality¹. 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.

Patient Population Under Consideration

This recommendation applies to noninstitutionalized or community-dwelling asymptomatic adults without a history of fractures. "Community-dwelling” is defined as not living in an assisted living facility, nursing home, or other institutional care setting. This recommendation does not apply to persons with osteoporosis or vitamin D deficiency.

Considerations for Practice Regarding the I Statements

Potential preventable burden. The health burdens of fractures is substantial in the older adult population.

Potential harms. In the Women's Health Initiative (WHI), a statistically increased incidence of renal stones occurred in women taking supplemental vitamin D and calcium. One woman was diagnosed with a urinary tract stone for every 273 women who received supplementation over a 7-year follow-up period.

Costs. Vitamin D and calcium supplements are inexpensive and readily available without a prescription.

Current practice. Vitamin D and calcium supplementation are often recommended for women, especially postmenopausal women, to prevent fractures, although actual use is uncertain. Surveys estimate that 56% of women aged 60 years and older take supplemental vitamin D, and 60% take a supplement containing calcium. The exact dosage is not well-known ².

Other Approaches to Prevention

The USPSTF recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. This recommendation statement is available on the USPSTF Web site (www.uspreventiveservicestaskforce.org).

The USPSTF recommends vitamin D supplementation (the median dose of vitamin D in available studies was 800 IU) to prevent falls in community-dwelling adults aged 65 years and older who are at increased risk for falls because of a history of recent falls or vitamin D deficiency (B recommendation). This recommendation statement is available on the USPSTF Web site (www.uspreventiveservicestaskforce.org).