Vitamin D supplements do not protect bone health, analysis finds
BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4223 (Published 08 October 2018) Cite this as: BMJ 2018;363:k4223
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Bolland’s et al recent meta-analysis (1), reported by the BMJ (2) has been upsetting because it will now deter many people from taking a vitamin D-supplement. I have 3 comments:
Firstly, Bolland et al assessed relatively short lasting trials (1-5 years) in mostly older people and found no benefit for bone health. However, healthy bones are well known to develop with good nutrition, sufficient vitamin D and minerals in the first 20-30 years of life. I am therefore not surprised about this Null-finding in older folk.
Secondly, Bolland et al admits that rickets and osteomalacia with 25(OH)D concentrations below 25 nmol/l should be avoided. It is therefore ironic that one of the authors (AA) is based in Aberdeen, the town of our Scottish Food Standard Agency, who reported 5 years ago that 33% of all Scots have those very low 25(OH)D concentrations (3).
Thirdly, it was disappointing that the BMJ reported about this head-line grabbing negative study, which will now have detrimental effects, instead of publicising a recent consensus statement of Roth et al (3) calling for public health measures like food fortification, “if a high prevalence of vitamin D deficiency is identified (>20% prevalence of 25(OH)D < 30 nmol/L)”. In Scotland the prevalence is very high at 33%. Fortunately, one of the authors, Adrian Martineau, was allowed to comment in the BMJ report and spoke about saving lives by avoiding such extreme vitamin D deficiency. I hope Scottish Public Health departments take note.
(1)Bolland MJ, Grey A, Avenell A. Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis. Lancet Diabetes Endocrinol 2018
Published Online October 4, 2018 http://dx.doi.org/10.1016/ S2213-8587(18)30265-1
(2) BMJ 2018;363:k4223
(3) Food Standards Agency in Scotland. Vitamin D status of Scottish adults: Results from the 2010 & 2011 Scottish Health Surveys . Purdon G, Comrie F, Rutherford L, et al. September 2013
(4) Roth D, Abrams S, Aloia J, et al. Global prevalence and disease burden of vitamin D deficiency: a roadmap for action in low- and middle-income countries. Ann. N.Y. Acad. Sci. xxxx (2018) 1–36 ⃝C 2018 New York Academy of Sciences.
Competing interests: No competing interests
Unfortunately, the experts’ comments in the news article by Ingrid Torjesen1 about our recent systematic review2 on the effects of vitamin D on falls, fracture and bone density in adults are either incorrect or mistargeted.
Professor Clarke’s comments are wrong. He stated that the trials in our meta-analysis had too few participants, used an insufficient dose of vitamin D, and had an insufficient duration of treatment to warrant changing health recommendations. He suggested waiting for the results of ongoing trials. In fact, there are ample trial data to permit reliable conclusions. The trials on falls, hip fracture or total fracture in our review included more than 34,000 participants, and there were 3534 individuals with a fracture, 870 with a hip fracture, and 14139 who had a fall. Almost all the recent trials of falls or fracture in our review used a vitamin D dose of >800IU/day, and overall 52% of trials used such doses. 17 trials of falls and fractures lasted >12 months, and 8 trials with >33,000 participants followed people for 3-5y. Trial sequential analyses show that there is reliable evidence that vitamin D supplementation does not have clinically relevant beneficial effects on falls, total and hip fracture.
The large ongoing trials of vitamin D supplements are not targeting populations most likely to benefit from supplementation (eg those with 25-hydroxyvitamin D <25 nmol/L).3 Instead, they are studying cohorts with similar vitamin D status to populations in the existing trials, using similar study designs to the existing trials.3 In our review, the trial sequential analyses indicate that future similar trials are unlikely to alter conclusions drawn from existing evidence. Thus, there is no reason to defer drawing conclusions about vitamin D supplementation for these outcomes when there exists a reliable body of evidence that is unlikely to be altered by further trials.
Professor Martineau suggests that supplementing the entire UK population with vitamin D will prevent the most extreme complications of rickets. This comment is not relevant to our paper. Our systematic review deals with vitamin D supplementation of adults for musculoskeletal health and should not be used in the debate about prevention of rickets in children. As noted in the BMJ news story, we specifically stated in our paper that individuals at high risk of rickets and osteomalacia should receive vitamin D supplementation. Supplementing population groups, such as the adults studied in the trials in our review, who are recommended vitamin D supplementation to maintain or improve musculoskeletal health in many clinical guidelines, will not prevent rickets but will mean that vast numbers of individuals take vitamin D supplements for no benefit.
Ingrid Torjesen also incorrectly states the vitamin D dose from the Scientific Advisory Committee on Nutrition report and Public Health England’s guidance as 10mg/day. The correct dose is 10 mcg/day, one thousand times less.
1. Torjesen I. Vitamin D supplements do not protect bone health, analysis finds. BMJ 2018;363.
2. Bolland MJ, Grey A, Avenell A. Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis. Lancet Diabetes Endocrinol 2018.
3. Bolland MJ, Grey A, Avenell A. Assessment of research waste part 2: wrong study populations- an exemplar of baseline vitamin D status of participants in trials of vitamin D supplementation. BMC Med Res Methodol 2018;18(1):101.
Competing interests: We are the authors of the paper discussed in the news article.
There is an incorrect statement in the article, where they state that Public Health England (PHE) recommend taking a daily (10mg) vitamin D supplement. In fact PHE recommended taking 10µg not 10 mg!
Competing interests: No competing interests
I and many others would like to know:
1. Is it clear that in this England of today, nobody needs vit D supplements?
Or,
2.Do people above a certain age need vit D supplements? In ENGLAND
Or
Do people with certain dietary habits need vit D supplements? In ENGLAND.?
There was, in my youth, a Textbook of Physiology , I forget the name of the author, which mentioned that the liver in winter, of POLAR BEARS had so much stored Vit D, that humans eating it suffered from Vit D toxicity.
Competing interests: I take vit D supplements
Re: Vitamin D supplements do not protect bone health, analysis finds
The article also quoted another organisation's advice about dosing incorrectly. It stated that the SACN advised daily dose of 10mg.This is 1000 the recommended dose and amounts to a massive drug error/overdose. Though the authors probably intended to write 10ug, this typo error is common place in clinical practice.
The lesson here is that the industry and clinicians should not abbreviate such units and less errors will occur if they are fully written out as microgram and not as mcg or ug.
Competing interests: No competing interests