Article - What is the impact of daily oral supplementation of vitamin D3 (cholecalciferol) plus calcium on the incidence of hip fracture in older people? A systematic review and meta-analysis.

Plain Language Summary

Bone loss is a side effect of ageing, often resulting in a bone disease known as osteoporosis. Calcium and vitamin D are integral components of bone and supplementation of these may help to prevent fractures and bone loss and improve strength. This systematic review and meta-analysis aimed to determine the effect of calcium plus vitamin D3 supplementation on the incidence of hip fracture in the elderly. The results showed that compared to placebo, vitamin D and calcium combined reduced hip fractures by 25%, reduced non-vertebral fractures by 20% and hip fracture in women by 30%. Higher dose combinations were the most effective and 1200mg vitamin D plus 1200mg tricalcium phosphate reduced hip fracture by 32%. Interestingly, although fractures decreased, bone density remained unaffected. It was concluded that combination vitamin D3 and calcium decrease the incidence of hip and non-vertebral fractures and that higher doses were the most effective. This study could be used by healthcare practitioners to recommend vitamin D3 and calcium to people over 65 to decrease fracture risk.

Expert Review

Reviewer: Chloe Steele

24th Apr 2024

Conflict of interest

None

Take home message

It is important to ensure that older people are receiving adequate calcium and vitamin D to prevent fractures.
Supplementation of these nutrients may be an easy and effective way to ensure that older people maintain their health and independence as they age.

Evidence category

A: Meta-analyses, position-stands, randomized-controlled trials (RCTs)

Summary review

Introduction

Calcium and vitamin D are integral to the bone matrix and research on their supplementation for bone health is extensive. This systematic review and meta-analysis aimed to determine the effect of calcium plus vitamin D3 supplementation on the incidence of hip fracture.

Methods

This was a systematic review and meta-analysis of 7 randomised control trials (RCTs) involving 12,620 individuals.
Subjects were ≥65 years of age and living in the community and long-term care with or without risk of hip fracture.
The primary outcome was the incidence of hip fracture following calcium plus vitamin D3 supplementation.
The secondary outcomes were incidence of non-vertebral fracture, incidence of hip fracture in women, and femoral neck bone mineral density (BMD) following vitamin D3 plus calcium supplementation.

Results

Combined vitamin D3 and calcium reduced hip fracture by approximately 25% compared to placebo (OR of 0.75; 95% CI: 0.64, 0.87; p = .0003).
Non-vertebral fractures were reduced by 20% following supplementation compared to placebo (0.80; 95% CI: 0.72, 0.89; p < .0001).
Higher dose combinations were the most effective and 800 IU vitamin D3 and 1200mg tricalcium phosphate reduced hip fracture by 32% (OR = 0.69, CI 95%: 0.58, 0.82; p < .0001) and non-vertebral fracture by 27% (OR = 0.73; 95% CI: 0.64, 0.84: p < .0001).
Doses of 800 IU plus 1000mg of calcium were ineffective at preventing hip fracture (OR = 1.08; 95% CI: 0.74, 1.56; p = .70) and non-vertebral fracture (OR = 0.96 95% CI: 0.81, 1.13; p = .63).
Women reported reduced hip fracture incidence of 30% compared to placebo (OR= 0.70; 95% CI:0.59, 0.83; p < .0001).
BMD of the femoral neck was unaffected by calcium and vitamin D3 supplementation (MD = 1.21; 95% CI: −0.79, 3.20; p = .24).

Conclusion

Vitamin D3 plus calcium supplementation decrease the incidence of hip and non-vertebral fractures.
800 IU vitamin D3 and 1200mg calcium were the most effective.
Supplementation did not affect BMD at the femoral neck.

Clinical practice applications

This study did not take into account serum calcium and vitamin D3 levels and whether fracture incidence is affected by these.
The recommendation of 800 IU/day vitamin D3 plus 1200mg/day calcium should be considered for individuals over 65 years of age to prevent incidence of fractures.

Considerations for future research

The influence of baseline serum vitamin D and calcium levels on incidence of fracture could aid the identification of individuals who would most benefit from supplementation.
How different supplemental forms and doses influence fracture incidence would also be of benefit.

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Abstract

INTRODUCTION

Hip fractures have a huge impact in reducing the quality of life and increasing mortality. This review aims to assess the impact of daily oral supplementation of vitamin D3 plus calcium on the incidence of hip fracture in people over 65 years.

METHODS

PRISMA guidelines were followed and RCTs that evaluated the effectiveness of daily oral supplementation of vitamin D3 plus calcium in preventing hip fracture in adults over 65 years were included in the study. The databases such as Cochrane Library, Embase, Medline, PubMed, CINAHL, Web of Science and Scopus were searched from October 2019- January 2020.The Cochrane risk of bias tool was used to check the quality of the included studies. A meta-analysis with fixed effect model using Review Manager (Revman 5.3) was used to analyse the data.

RESULTS

The meta-analysis of seven RCTs on vitamin D3 plus calcium supplementation and hip fracture (n = 12,620) identified odds ratio (OR) of 0.75; 95% Confidence interval (CI): 0.64, 0.87; p = .0003. Daily oral supplementation of 800 IU of Vitamin D3 plus 1200 mg of calcium was found more effective (n = 5676 participants; OR = 0.69; 95% CI: 0.58, 0.82; p < .0001) than daily oral supplementation of 800 IU of Vitamin D3 plus 1000 mg of calcium (n = 6555,OR = 1.08; 95% CI: 0.74, 1.56; p = .70) in reducing hip fracture. A meta-analysis of the seven RCTs to identify the incidence of non-vertebral fracture gave the OR of 0.80; 95% CI: 0.72, 0.89; p < .0001. A meta-analysis of three RCTs on femoral neck bone mineral density (BMD) (n = 483) gave a mean difference of 1.21; 95% CI: -0.79, 3.20; p = .24.

CONCLUSION

Daily oral supplementation 800 IU of vitamin D3 plus 1200 mg of calcium reduces hip fracture and non-vertebral fracture in older people. Administering vitamin D3 and calcium supplements had no effect in increasing the femoral neck BMD.

IMPLICATIONS FOR PRACTICE

Even though it is evident from the review that optimal daily intake of vitamin D3 plus calcium supplementation help in the prevention of fracture, it is only one essential element in fracture prevention. Also, people who are on dietary supplements should be compliant with same for better result. Efforts to prevent bone loss and osteoporosis should begin from an early age. It includes maintaining a healthy lifestyle, optimal intake of calcium and vitamin D3, proper nutrition, adequate exposure to sunlight, exercise etc. Proper education on healthy lifestyle, avoiding risk factors like smoking, caffeine, alcohol and awareness of bone health should continue throughout life with emphasis during menopause when increased bone loss is expected.