October 2022: Supplemental Vitamin D and Incident Fractures in Midlife and Older Adults
The issue
A large U.S. trial (VITAL) gave 25,871 generally healthy adults ≥ 50 yrs either vitamin D₃ 2000 IU/day or placebo for a median 5.3 yrs and found no reduction in total, non‑vertebral, or hip fractures (hazard ratio for any fracture 0.98; 95 % CI 0.89–1.08).
What do I need to know?
Volunteers were not selected for vitamin‑D deficiency, low bone mass, or osteoporosis; mean baseline 25‑hydroxy‑vitamin D was ~31 ng/mL. Even in subgroups with low vitamin‑D levels, high fracture risk, or calcium use, supplements made no difference. Adherence topped 85 % and adverse events matched placebo, confirming that failure to benefit was not due to poor compliance or toxicity.
Potential risk of fracture but normal vitamin‑D status
You’re ≥ 60, have no osteoporosis diagnosis, and a recent blood test shows 25‑OH‑D ≥ 20 ng/mL.
Recommended Actions
Focus on strength training, balance work, and 1 000–1 200 mg/day of dietary calcium.
Keep outdoor activity or a standard multivitamin (≤ 800 IU) if desired; higher‑dose pills are unlikely to add bone protection.
Re‑check bone density every 5 yrs.
Imminent risk of fracture
You have osteopenia, a parental hip fracture, or take steroids—but vitamin‑D level is still ≥ 20 ng/mL.
Recommended Actions
Ask about prescription osteoporosis drugs (bisphosphonate, denosumab, etc.) rather than ramping up vitamin D.
Ensure adequate protein (1 g/kg) and balance training to cut fall risk.
Re‑check 25‑OH‑D only if diet, sun, or gut‑absorption changes.
Confirmed high fracture risk or proven deficiency
You have osteoporosis or a recent fragility fracture and 25‑OH‑D < 20 ng/mL.
Recommended Actions
Correct deficiency with short‑term high‑dose vitamin D (e.g., 50 000 IU weekly for 6–8 wks) then maintain 800–1 000 IU/day to keep levels ≥ 20 ng/mL.
Start or continue anti‑resorptive or anabolic therapy per guidelines; vitamin D alone will not suffice.
Arrange fall‑prevention home modifications and follow‑up DXA in 1–2 yrs.
What can I do?
Ask your clinician, “Am I at potential, imminent, or confirmed fracture risk, and is my vitamin D actually low?” Bring bone‑density results, medication lists, and any lab numbers. Remember: routine high‑dose vitamin D hasn’t shown fracture benefits if your level is already adequate; stronger evidence supports exercise, calcium‑rich meals, and proven osteoporosis drugs when indicated. Family members can help track supplements, encourage safe exercise, and check the home for trip hazards.
