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Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials

BMJ 2004; 328 doi: (Published 18 March 2004) Cite this as: BMJ 2004;328:680

Rapid Response:

Vitamin D largely overlooked in review of interventions for the prevention of falls in older adults

The three papers in this issue of BMJ on preventing falls in elderly
people [1-3] are interesting and indicate the seriousness of the problem.
While vitamin D and calcium are essential for proper development and
maintenance of the musculoskeletal condition [4,5], there appeared to be
only one reference to vitamin D in [1-3], that of [6] in [1], and it did
not find a beneficial effect for vitamin D supplementation. However,
another review through July 2003 by the author of [2] identified 3 trials
involving 461 participants tested with vitamin D supplementation, with or
without calcium [7].

There are a number of papers indicating that vitamin D, often with
calcium supplements, can reduce falls in elderly people [8-18]. Vitamin D
and calcium improve the condition of both bones and muscles, as does
exercise, and muscle strength and fitness may be as important in
preventing falls among the elderly as is bone density [8-11,15].

Those living in nursing homes generally have low serum 25-
hydroxyvitamin D (25(OH)D) status [19]. Calcium and vitamin D
supplementation has been identified as a cost-effective way to reduce
falls among the elderly in a number of studies [20-28].

Ways to obtain vitamin D include diet [26], supplements [8,16,17,25],
injections [21], sunlight [29], and artificial ultraviolet B (UVB) [30-
32]. One or more of these approaches may be chosen depending on the
circumstances. However, dietary sources are generally insufficient to
bring serum 25(OH)D up to adequate levels to combat diseases such as
colorectal cancer [33]. Further work is required to determine whether
different levels of 25(OH)D are optimal for different diseases. It was
recently determined that average levels of serum 25(OH)D appear to provide
more protection against prostate cancer than do either lower or higher
levels [34,35].

It is also noted that UVB and vitamin D are important risk reduction
factors for over a dozen types of internal cancers [36], as well as a host
of other diseases [37-41] including muscle pain [42], multiple sclerosis
[43,44], and high blood pressure [45].

In my opinion, "Sunshine is the best medicine."


1. Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp
MJ, et al. Interventions for the prevention of falls in older adults:
systematic review and meta-analysis of randomised clinical trials. BMJ

2. Gillespie L. Preventing falls in elderly people. BMJ. 2004;328:653

3. Haines TP, Bennell KL, Osborne RH, Hill KD. Effectiveness of
targeted falls prevention programme in subacute hospital setting:
randomised controlled trial. BMJ 2004;328:676-0.

4. DeLuca HF. New concepts of vitamin D functions. Ann N Y Acad Sci.
1992;669:59-68; discussion 68-9.

5. Pfeifer M, Begerow B, Minne HW. Vitamin D and muscle function.
Osteoporos Int. 2002;13:187-94.

6. Latham NK, Anderson CS, Lee A, Bennett DA, Moseley A, Cameron ID;
Fitness Collaborative Group. A randomized, controlled trial of quadriceps
resistance exercise and vitamin D in frail older people: the Frailty
Interventions Trial in Elderly Subjects (FITNESS). J Am Geriatr Soc.

7. Gillespie L, Gillespie W, Robertson M, Lamb S, Cumming R, Rowe B.
Interventions for preventing falls in elderly people. Cochrane Database
Syst Rev. 2003;4:CD000340.

8. Pfeifer M, Begerow B, Minne HW, Abrams C, Nachtigall D, Hansen C.
Effects of a short-term vitamin D and calcium supplementation on body sway
and secondary hyperparathyroidism in elderly women. J Bone Miner Res.
2000;15:1113-8. Erratum in: J Bone Miner Res 2001;16:1935. J Bone Miner
Res 2001;16:1735.

9. Bischoff HA, Stahelin HB, Tyndall A, Theiler R. Relationship
between muscle strength and vitamin D metabolites: are there therapeutic
possibilities in the elderly? Z Rheumatol. 2000;59 Suppl 1:39-41.

10. Pfeifer M, Begerow B, Minne HW, Schlotthauer T, Pospeschill M,
Scholz M, et al. Vitamin D status, trunk muscle strength, body sway,
falls, and fractures among 237 postmenopausal women with osteoporosis. Exp
Clin Endocrinol Diabetes. 2001;109:87-92.

11. Dhesi JK, Bearne LM, Moniz C, Hurley MV, Jackson SH, Swift CG,
Allain TJ. Neuromuscular and psychomotor function in elderly subjects who
fall and the relationship with vitamin D status. J Bone Miner Res.

12. Dhesi JK, Moniz C, Close JC, Jackson SH, Allain TJ. A rationale
for vitamin D prescribing in a falls clinic population. Age Ageing.

13. Janssen HC, Samson MM, Verhaar HJ. Vitamin D deficiency, muscle
function, and falls in elderly people. Am J Clin Nutr. 2002;75:611-5.

14. Srivastava M, Deal C. Osteoporosis in elderly: prevention and
treatment. Clin Geriatr Med. 2002;18:529-55.

15. Bischoff-Ferrari HA, Conzelmann M, Dick W, Theiler R, Stahelin
HB. [Effect of vitamin D on muscle strength and relevance in regard to
osteoporosis prevention] Z Rheumatol. 2003;62:518-21. German.

16. Bischoff HA, Stahelin HB, Dick W, Akos R, Knecht M, Salis C, et
al. Effects of vitamin D and calcium supplementation on falls: a
randomized controlled trial. J Bone Miner Res. 2003;18:343-51.

17. Latham NK, Anderson CS, Reid IR. Effects of vitamin D
supplementation on strength, physical performance, and falls in older
persons: a systematic review. J Am Geriatr Soc. 2003;51:1219-26.

18. Dukas L, Bischoff HA, Lindpaintner LS, Schacht E, Birkner-Binder
D, Damm TN, et al. Alfacalcidol reduces the number of fallers in a
community-dwelling elderly population with a minimum calcium intake of
more than 500 mg daily. J Am Geriatr Soc. 2004;52:230-6.

19. Bates CJ, Carter GD, Mishra GD, O'Shea D, Jones J, Prentice A. In
a population study, can parathyroid hormone aid the definition of adequate
vitamin D status? A study of people aged 65 years and over from the
British National Diet and Nutrition Survey. Osteoporos Int. 2003;14:152-9.

20. Torgerson DJ, Kanis JA. Cost-effectiveness of preventing hip
fractures in the elderly population using vitamin D and calcium. QJM.

21. Torgerson D, Donaldson C, Reid D. Using economics to prioritize
research: a case study of randomized trials for the prevention of hip
fractures due to osteoporosis. J Health Serv Res Policy. 1996 Jul;1:141-6.

22. Meunier P. Prevention of hip fractures by correcting calcium and
vitamin D insufficiencies in elderly people. Scand J Rheumatol Suppl.
1996;103:75-8; discussion 79-80.

23. Vestergaard P, Rejnmark L, Mosekilde L. Hip fracture prevention:
cost-effective strategies. Pharmacoeconomics. 2001;19:449-68.

24. Willis MS. The health economics of calcium and vitamin D3 for the
prevention of osteoporotic hip fractures in Sweden. Int J Technol Assess
Health Care. 2002;18:791-807.

25. Buckley LM, Hillner BE. A cost effectiveness analysis of calcium
and vitamin D supplementation, etidronate, and alendronate in the
prevention of vertebral fractures in women treated with glucocorticoids. J
Rheumatol. 2003;30:132-8.

26. Feskanich D, Willett WC, Colditz GA. Calcium, vitamin D, milk
consumption, and hip fractures: a prospective study among postmenopausal
women. Am J Clin Nutr. 2003;77:504-11.

27. Lilliu H, Pamphile R, Chapuy MC, Schulten J, Arlot M, Meunier PJ.
Calcium-vitamin D3 supplementation is cost-effective in hip fractures
prevention. Maturitas. 2003;44:299-305.

28. Larsen ER, Mosekilde L, Foldspang A. Vitamin D and calcium
supplementation prevents osteoporotic fractures in elderly community
dwelling residents: A pragmatic population-based 3-year intervention
study. J Bone Miner Res. 2004;19:370-8.

29. Webb AR, Holick MF. The role of sunlight in the cutaneous
production of vitamin D3. Annu Rev Nutr. 1988;8:375-99.

30. Chel VG, Ooms ME, Popp-Snijders C, Pavel S, Schothorst AA,
Meulemans CC, Lips P. Ultraviolet irradiation corrects vitamin D
deficiency and suppresses secondary hyperparathyroidism in the elderly. J
Bone Miner Res. 1998;13:1238-42.

31. Snell AP, MacLennan WJ, Hamilton JC. Ultra-violet irradiation and
25-hydroxy-vitamin D levels in sick old people. Age Ageing. 1978;7:225-8.

32. Chuck A, Todd J, Diffey B. Subliminal ultraviolet-B irradiation
for the prevention of vitamin D deficiency in the elderly: a feasibility
study. Photodermatol Photoimmunol Photomed. 2001;17:168-71.

33. Grant WB, Garland CF. A critical review of studies on vitamin D
in relation to colorectal cancer. Nutr Cancer. in press.

34. Tuohimaa P, Tenkanen L, Ahonen M, Lumme S, Jellum E, Hallmans G,
et al. Both high and low levels of blood vitamin D are associated with a
higher prostate cancer risk: a longitudinal, nested case-control study in
the Nordic countries. Int J Cancer. 2004;108:104-8.

35. Grant WB. Geographic variation of prostate cancer mortality rates
in the U.S.A.; implications for prostate cancer risk related to vitamin D.
Int. J. Cancer. in press.

36. Grant WB. An estimate of premature cancer mortality in the United
States due to inadequate doses of solar ultraviolet-B radiation. Cancer.

37. Holick MF. Vitamin D: A millenium perspective. J Cell Biochem.

38. Zittermann A. Vitamin D in preventive medicine: are we ignoring
the evidence? Br J Nutr. 2003;89:552-72.

39. Holick MF. Vitamin D: importance in the prevention of cancers,
type 1 diabetes, heart disease, and osteoporosis. Am J Clin Nutr.

40. Grant WB, de Gruijl FR. Health benefits of solar UV-B radiation
through the production of vitamin D. Comment and response. Photochem
Photobiol Sci. 2003;2:1307-8; discussion 1308-10.

41. Grant WB, Strange RC, Garland CF. Health benefits of ultraviolet-
B radiation through production of vitamin D. J Cos Dermatol. in press.

42. Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D
in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin
Proc. 2003;78:1463-70.

43. Goldacre MJ, Seagroatt V, Yeates D, Acheson ED. Skin cancer in
people with multiple sclerosis: a record linkage study. J Epidemiol
Community Health. 2004;58:142-4.

44. Embry AF. Vitamin D supplementation in the fight against multiple
sclerosis. J Orthomolec Med. in press.

45. Krause R, Buhring M, Hopfenmuller W, Holick MF, Sharma AM.
Ultraviolet B and blood pressure. Lancet. 1998;352:709-10.

Competing interests:
None declared

Competing interests: No competing interests

20 March 2004
William B. Grant
President, Sunlight, Nutrition and Health Research Center (SUNARC)
2107 Van Ness Avenue, Suite 403b, San Francisco, CA 94109-2536, USA