Faculty/Presenter Disclosure
Vitamin D and Calcium in Midlife Women JoAnn E. Manson, MD, DrPH, NCMP Chief, Division of Preventive Medicine Brigham and Women's Hospital Professor of Medicine and the Michael and Lee Bell Professor of Women's Health Harvard Medical School
I have no financial conflicts of interest related to this presentation.
North American Menopause Society Annual Meeting Orlando, FL October 8, 2016
Objectives
Calcium and Vitamin D Dietary Reference Intakes for Adults, by Life Stage
• To review current guidelines for intake of calcium and vitamin D in midlife women.
Calcium
• To summarize the evidence on calcium/vitamin D and the risk of fractures, falls, cardiovascular disease, cancer, and all-cause mortality. • To present an update on the status of ongoing randomized trials of vitamin D nationally and internationally.
Vitamin D
Life Stage (gender)
RDA (mg/d)
Tolerable upper intake level (mg/d)*
19-50 yr (men and women)
1,000
2,500
600
4,000
51-70 yr (men)
1,000
2,000
600
4,000
51-70 yr (women)
1,200
2,000
600
4,000
71+ yr (men and women)
1,200
2,000
800
4,000
RDA (IU/d)
Tolerable upper intake level (IU/d)*
RDA = Recommended Dietary Allowance *The tolerable upper intake level is the threshold above which is a risk of adverse events. Source: Ross AC, Manson JE, Abrams SA, et al. J Clin Endocrinol Metab 2011; 96(1):53.
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Osteoporosis : Public Health Impact • At age 50, lifetime risk of fracture is • 1:2 women • 1:5 men • Affects 10 million Americans • 8 million women • 2 million men
WHI Calcium/Vitamin D (Ca/D) Trial Design: Double Blind N=36,282 women
Intervention (CaD supplement) • 1000 mg elemental calcium as calcium carbonate and 400 IU vitamin D3
(50%) Randomization
(50%)
• 2 million fractures yearly
Control (Placebo)
(more common in women than MI, stroke, and breast cancer combined) NOF Fast Facts, www.nof.org Burge R, et al. J Bone Miner Res 2007; 22:465-475.
Calcium/Vitamin D Supplementation and Risk of Hip Fracture: WHI
Bone Mineral Density Results 20
Average differences between CaD and placebo groups: • 0.59% at year 3 • 0.86% at year 6 • 1.01% at year 9
Rate of Hip Fracture (Cases/10,000/Yr)
Greater preservation in total hip BMD
15
Placebo Group
N = 175
HR = 0.88 10
(95% CI, 0.72-1.08)
5
(n=374 cases)
P = 0.23
0 Source: Jackson RD, et al. NEJM 2006; 354:669-83.
Ca/D Group
N = 199
Ca/D Group Placebo Group
Source: Jackson RD, et al. NEJM 2006; 354:669-83.
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Calcium/Vitamin D and Risk of Hip Fracture, Stratified by Baseline Intake of Supplemental and Dietary Calcium
(HR 0.79; 95% CI 0.64-0.98; p for interaction by age = 0.05)
1.8
CaD Placebo
1.5
Hazard Ratio
• 21% fewer hip fractures among women ≥60 years
0.005 0.010 0.015 0.020 0.025
(>80% of study pills)
2.0
Hip Fracture – Adherent Women
HR = 0.71 (95% CI, 0.52-0.97) P-value = 0.03
1.3
1.22
1.0
0.87
0.8
0.70
0.5
Time (years)
0.0
• 29% fewer hip fractures in CaD than placebo (HR 0.71; 95% CI 0.52-0.97) in adherent women
Cumulative Hazard
Additional Fracture Findings
0
1
2
3
4
5
*
0.3 6
7
8
0.0
* p 1000 mg/d is rarely needed. • Vitamin D 1000-2000 IU/d is reasonable supplement for most midlife women. • For higher-risk patients, measure 25-OH D, with a target blood level ≥30 ng/dl (75 nmol/L). • More is not necessarily better!
Thank you!
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