Editorial was confusing

The editorialists, two cardiologists and a physicist, are an unusual choice for a non-peer reviewed editorial on the safety and efficacy of treatments for osteoporosis and fracture prevention.1 The question of the expertise of the editorialists in this discipline is relevant as they make highly contentious statements on the efficacy of calcium and vitamin D, which was not the focus of the issues raised by the paper that they were editorialising. They ignore the fact that the two papers they quote on calcium alone also show calcium and vitamin D to be highly effective in fracture prevention.2 3 Tang et al state a relative risk for any fracture for calcium alone or calcium and vitamin D of 0.87 (95% confidence interval 0.77 to 0.97), Reid et al a relative risk for hip fracture for calcium and vitamin D of 0.84 (0.73 to 0.97).3

Having cardiologists advising on the prevention of osteoporosis by proposing a radical new policy that calcium and vitamin D supplementation should be used only in combination with pharmaceutical agents is also unusual. Pharmaceutical agents to prevent osteoporosis have been studied only in people at high risk with low bone density or spinal fracture, or both, and not in unselected populations, as has been done for calcium and vitamin D. Bisphosphonates in unselected patients without demonstrable low bone density (T score <−2) have been shown to be ineffective.4 5 This policy, if adopted, would therefore apply only to high risk individuals and be the equivalent of turning the clock back to waiting for the first episode of angina before introducing preventive treatment for hypercholesterolaemia.

The alternative, a massive expansion of the use of pharmaceutical agents for preventing osteoporosis and fracture in unselected individuals, would have clear benefits to holders of stock in pharmaceutical companies; the benefits for others are much less clear.