The IOM’s report on calcium and vitamin D: Should it change the way you practice?

Applied Evidence

The IOM’s report on calcium and vitamin D: Should it change the way you practice?

J Fam Pract. 2011 January;60(1):18-28

References

1. National Osteoporosis Foundation. America’s bone health: the state of osteoporosis and low bone mass in our nation. Washington, DC: National Osteoporosis Foundation; 2002.

2. Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res. 2007;22:465-475.

3. Wells GA, Cranney A, Peterson J, et al. Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008;(1):CD001155.-

4. Wells G, Cranney A, Peterson J, et al. Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008;(1):CD004523.-

5. Wang Q, Decai C. Ibandronate sodium for osteoporosis in post-menopausal women (Protocol). Cochrane Database Syst Rev. 2007;CD006514.-DOI:10.1002/14651858.

6. Albergaria BH, Gomes Silva BN, Atallah AN, et al. Intravenous zoledronate for postmenopausal osteoporosis (Protocol). Cochrane Database Syst Rev. 2010;(1):CD008332.-DOI:10.1002/14651858.

7. Anonymous. Australian Medicines Handbook. Adelaide, Australia: Australian Medicines Handbook Pty Ltd; 2007.

8. Silverman SL, Landesberg R. Osteonecrosis of the jaw and the role of bisphosphonates: a critical review. Am J Med. 2009;122 (suppl 2):S33-S45.

9. Reid IR. Osteonecrosis of the jaw: who gets it, and why? Bone. 2009;44:4-10.

10. Black DM, Schwartz AV, Ensrud KE, et al. Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA. 2006;296:2927-2938.

11. Cummings SR, Black DM, Thompson DE, et al. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA. 1998;280:2077-2082.

12. Reginster J, Minne HW, Sorensen OH, et al. Randomized trial of the effects of risedronate on vertebral fractures in women with established postmenopausal osteoporosis. Vertebral Efficacy with Risedronate Therapy (VERT) Study Group. Osteoporos Int. 2000;11:83-91.

13. Mellstrom DD, Sorensen OH, Goemaere S, et al. Seven years of treatment with risedronate in women with postmenopausal osteoporosis. Calcif Tissue Int. 2004;75:462-468.

14. Cranney A, Wells GA, Yetisir E, et al. Ibandronate for the prevention of nonvertebral fractures: a pooled analysis of individual patient data. Osteoporos Int. 2009;20:291-297.

15. Chesnut IC, Skag A, Christiansen C, et al. Effects of oral ibandronate administered daily or intermittently on fracture risk in postmenopausal osteoporosis. J Bone Miner Res. 2004;19:1241-1249.

16. Delmas PD, Recker RR, Chesnut CH, et al. Daily and intermittent oral ibandronate normalize bone turnover and provide significant reduction in vertebral fracture risk: results from the BONE study. Osteoporosis Int. 2004;15:792-798.

17. Recker R, Stakkestad JA, Chesnut CH, et al. Insufficiently dosed intravenous ibandronate injections are associated with suboptimal antifracture efficacy in postmenopausal osteoporosis. Bone. 2004;34:890-899.

18. Adami S, Felsenberg D, Christiansen C, et al. Efficacy and safety of ibandronate given by intravenous injection once every 3 months. Bone. 2004;34:881-889.

19. Delmas PD, Adami S, Strugala C, et al. Intravenous ibandronate injections in postmenopausal women with osteoporosis. One-year results from the dosing intravenous administration study. Arthritis Rheum. 2006;54:1838-1846.

20. Epstein S, Delmas PD, Emkey R, et al. Oral ibandronate in the management of postmenopausal osteoporosis: review of upper gastrointestinal safety. Maturitas. 2006;54:1-10.

21. Ettinger MP, Felsenberg D, Harris ST, et al. Safety and tolerability of oral daily and intermittent ibandronate are not influenced by age. J Rheumatol. 2005;32:1968-1974.

22. Black DM, Delmas PD, Eastell R, et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med. 2007;356:1809-1822.

23. Lyles KW, Colon-Emeric CS, Magaziner JS, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357:1799-1809.

24. Shane E, Burr D, Ebeling PR, et al. Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2010;25:2267-2294.

25. US Food and Drug Administration. FDA Drug Safety Communication: Safety update for osteoporosis drugs, bisphosphonates, and atypical fractures. October 13, 2010. Available at: http://www.fda.gov/drugs/drugsafety/ucm229009.htm. Accessed December 7, 2010.

26. Seeman E, Compston J, Adachi J, et al. Non-compliance: the Achilles’ heel of anti-fracture efficacy. Osteoporos Int. 2007;18:711-719.

27. Cramer JA, Gold DT, Silverman SL, et al. A systematic review of persistence and compliance with bisphosphonates for osteoporosis. Osteoporos Int. 2007;18:1023-1031.

28. Adami S, Giannini S, Bianchi G, et al. Vitamin D status and response to treatment in post-menopausal osteoporosis. Osteoporos Int. 2009;20:239-244.

CORRESPONDENCE Tania Winzenberg, MBBS, Menzies Research Institute, Private Bag 23, Hobart, Tasmania, Australia 7001; tania.winzenberg@utas.edu.au

The IOM’s report on calcium and vitamin D: Should it change the way you practice?

“Dietary Reference Intakes for Calcium and Vitamin D,” the consensus report released by the Institute of Medicine (IOM) late last year (http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx) generated a great deal of attention because it concluded that postmenopausal women taking supplements may be getting too much calcium, and that few people need to take vitamin D. These findings, among others, left many physicians wondering how, or if, the IOM’s report should change the way they practice.

The Journal of Family Practice posed that question to Susan Williams, MD, MS, FACN, FACP, an internist at the Cleveland Clinic and a diplomate with the American Board of Physician Nutrition Specialists. Her response: The report probably shouldn’t change the way you practice.

Here, Dr. Williams explains why.

Recommended daily allowances are guidelines. The new dietary reference intakes (DRIs), like the recommended daily allowances (RDAs) they replace, are quantitative estimates of nutrient intakes intended for planning and assessing diets of healthy populations. They were never intended to be applied “across the board,” or used as a benchmark for the dietary adequacy of individual patients.

Testing is still advisable when there is clinical suspicion of a calcium or vitamin D deficiency. Because parathyroid hormone (PTH) compensates for calcium deficiency by drawing calcium from the bones, an adequate serum calcium level alone does not necessarily reflect an adequate calcium intake. In fact, a low serum calcium level is likely to be the result of abnormally low levels of vitamin D. Thus, the best way to get an accurate picture of a patient’s status is to simultaneously test serum calcium, vitamin D, and PTH levels.

Some patients require considerably larger doses of vitamin D than the recommended quantities.^1,2 This is particularly true for obese individuals and patients who have undergone bariatric surgery, for example.^3-5 The safety of daily dosing of vitamin D in far greater quantities has been established,^6,7 and the risks of chronic undersupplementation^8-10 outweigh the risks associated with hypervitaminosis D, particularly when D3 (cholecalciferol) supplements are recommended.

Calcium supplementation is safe for postmenopausal women. Many older women have poor dietary intake of calcium, and again, the consequences of a deficiency are far greater than those associated with an excess. The risk of kidney stones in women taking calcium supplements can be averted by advising patients to take calcium citrate, which tends to neutralize urine and has better fractional uptake into the bone than calcium carbonate.

The IOM report serves to remind us that getting adequate calcium and vitamin D is important for everyone. Age and gender-specific recommendations should be emphasized, remembering that in general, the IOM’s DRIs are likely to meet the actual needs of most healthy patients, but may well fall short in the presence of chronic illness and disease.

Remember, too, that while we should always emphasize the importance of eating foods that are rich in calcium and vitamin D, patients’ diets often fall short. In such cases—with the exception of patients with certain conditions (eg, renal failure or hyperparathyroidism)—supplements such as calcium citrate and vitamin D3 can be safely and confidently recommended.

Susan Williams, MD, MS, FACN, FACP, reported no potential conflict of interest relevant to this article.

References

1. Holick MF. The role of vitamin D for bone health and fracture prevention. Curr Osteoporos Rep. 2006;4:96-102.

2. Grant WB, Holick MF. Benefits and requirements of vitamin D for optimal health. Altern Med Rev. 2005;10:94-111.

3. Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357:266-281.

4. Bischoff-Ferrari HA, et al. Estimation of optimal serum concentrations of 25-hydroxyvitamin D for multiple health outcomes. Am J Clin Nutr. 2006;84:18-28.

5. Flores L, et al. Calcium and vitamin D supplementation after gastric bypass should be individualized to improve or avoid hyperparathyroidism. Obes Surg. 2010;20:738-743.

6. Vieth R, et al. Efficacy and safety of vitamin D intake exceeding the lowest observed adverse eff ect level. Am J Clin Nutr. 2001;73:288-294.

7. Barger-Lux MJ, et al. Vitamin D and its major metabolite: serum levels after graded oral dosing in healthy men. Osteoporos Int. 1998;8:222-230.

8. Sakuma M, et al. Vitamin D and intact PTH status in patients with hip fracture. Osteoporos Int. 2006;17:1608-1614.

9. Broe KE, et al. A higher dose of vitamin D reduces the risk of falls in nursing home residents. J Am Geriatr Soc. 2007;55:234-239.

10. Lips P. Vitamin D deficiency and secondary hyperparathyroidism in the elderly. Endocr Rev. 2001;22:477-501.