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Review: calcium supplementation, with or without vitamin D, prevents osteoporotic fractures in people ⩾50 years of age

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B M Tang

Dr B M Tang, University of Sydney, Penrith, New South Wales, Australia; benjamin{at}clubsalsa.com.au

QUESTION

In patients ⩾50 years of age, does calcium supplementation, with or without vitamin D, prevent osteoporotic fractures?

METHODS

Data sources:

Medline, EMBASE/Excerpta Medica, Current Contents, CINAHL, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (all to January 2007); clinical trials repositories; resource websites; conference abstracts; review articles; and bibliographies of primary studies.

Study selection and assessment:

published or unpublished randomized controlled trials (RCTs) in any language that compared the effects of calcium, with or without vitamin D, with placebo on fractures or bone-mineral density (BMD) in patients ⩾50 years of age. Exclusion criteria were use of dietary calcium as an intervention; use of calcium as part of a nutritional supplementation regimen or combined with other treatment; patients with secondary osteoporosis; and use of vitamin D without calcium. 29 studies met the selection criteria (n = 63 897, mean age 68 y, 92% women, median baseline risk of fracture 16%). Mean duration of treatment was 3.5 years. Quality assessment of individual studies was based on a 4-item checklist (reporting of randomisation method, allocation concealment, blinding of outcome assessment, and completeness of follow-up).

Outcomes:

fracture of any site including hip, vertebra, and wrist; only the first fracture in a given patient was counted as an event. Secondary outcome was percentage change in BMD.

MAIN RESULTS

Meta-analysis showed that calcium, with or without vitamin D, reduced risk of fractures more than placebo (table) and reduced bone loss in the hip (difference in mean BMD 0.54%, 95% CI 0.35 to 0.73; 24 trials, n = 44 990) and spine (difference in mean BMD 1.19%, CI 0.76 to 1.61; 24 trials, n = 3913).

Calcium, with or without vitamin D, v placebo for prevention of osteoporotic fractures at a mean 3.5 years*

CONCLUSION

Calcium supplementation, with or without vitamin D, prevents osteoporotic fractures and reduces bone loss at the hip and spine in people ⩾50 years of age.

A modified version of this abstract also appears in ACP Journal Club.

ABSTRACTED FROM

Tang BM, Eslick GD, Nowson C, et al. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet 2007;370:657–66.

Clinical impact ratings: Elderly care 5/7

Commentary

The review by Tang et al on the effectiveness of calcium or calcium plus vitamin D supplementation to prevent fractures and bone loss is timely as existing research is contradictory.13 Among the strengths of this review are the large number of included trials that resulted in a large sample size, the extensive and comprehensive search, a sensitivity analysis that assessed the effect of trial quality on effect size, meta-regression that assessed the effect of various factors on treatment efficacy, and assessment of publication bias. The only weakness identified was not examining possible adverse effects of treatment. Previous research has reported constipation to be more frequent in women taking calcium supplementation.3

Subgroup analyses, an additional strength of the review, revealed the additive effect of vitamin D and determined that the best effects were achieved with calcium doses ⩾1200 mg and vitamin D doses ⩾800 IU. Additional subgroup analysis revealed that a compliance rate ⩾80% was associated with a greater reduction in all fractures.

Nurses working with both healthy and frail older adults in the community and in institutions will find these recommendations useful when counselling their clients about preventing fractures and bone loss. The review provides strong evidence that older adults should be taking 1200 mg of calcium with 800 IU of vitamin D supplementation daily over time to prevent fractures and bone loss.

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Footnotes

  • Source of funding: Australian Government.

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References