NCHR Comment on Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Falls and Fractures in Community-Dwelling Adults

January 21, 2025


Question: Based on the evidence presented in this draft Recommendation
Statement, do you believe that the USPSTF came to the right conclusions?

Yes; I believe the USPSTF came to the right conclusions.

Question: Please provide additional evidence or viewpoints that you think should
have been considered.

1. Role of Fall Reduction in Fracture Prevention:
Studies like the meta-analysis by Bischoff-Ferrari et al. (2004) show a reduction
in fall risk with vitamin D supplementation in populations that include (but are not
limited to) institutionalized older patients. Although we agree with the USPSTF
conclusion of no benefit for older patients who live in the community, subgroup
analyses focusing on older adults with a history of falls, known Vitamin D
insufficiency, or frailty might provide important new recommendations.

Question: How could the USPSTF make this draft Recommendation Statement
clearer?

1. Clarify Population-Specific Recommendations:
USPSTF should emphasize that the recommendation is based on older adults
living in the community, and may not apply to institutionalized adults or people
living in the community with greater risks, such as those who have previously
fallen, are more frail, or who are likely to have insufficient calcium or vitamin D.

2. Highlight Non-Supplemental Strategies:
The draft could place greater emphasis on evidence-based alternatives, such as
exercise programs, home hazard reduction, and medication reviews, which are
more effective in preventing falls and fractures.

3. Transparency on Risks:
The increased risk of kidney stones (RR, 1.11; 95% CI, 1.03–1.21) should be
prominently highlighted, along with the magnitude of risk stratified by
supplementation dose and duration (USPSTF, 2024).

Question: What information, if any, did you expect to find in this draft
Recommendation Statement that was not included?

1. Ethnic and Racial Disparities:
The draft does not address how racial and ethnic differences in vitamin D
metabolism (e.g., lower baseline levels in African Americans) might influence the
benefits or risks of calcium or Vitamin D supplements (Kahwati et al., 2024). If no
data are available on this, that should be stated.

2. Interaction with Medications:
Interactions between supplements and commonly prescribed medications, such
as bisphosphonates and anticoagulants, were not explored but could be relevant
given the population’s high medication use (Camacho et al., 2020).

Question: What resources or tools could the USPSTF provide that would make
this Recommendation Statement more useful to you in its final form?

1. Clinical Decision Algorithms:
If possible, evidence-based tools that stratify risks and benefits based on patient
characteristics, including age, baseline vitamin D levels, and comorbidities, would
support individualized care.

2. Educational Materials for Patients:
Visual aids indicating that supplements do not prevent falls or fractures
compared to the benefits to lifestyle interventions (e.g., improving one’s diet,
increasing weight-bearing exercises, removal of small area rugs) could help
provide useful information for people who are motivated to avoid falls and
fractures.

Question: The USPSTF is committed to understanding the needs and
perspectives of the public it serves. Please share any experiences that you think
could further inform the USPSTF on this draft Recommendation Statement.

Many patients overestimate the benefits of vitamin D and calcium supplementation due
to widespread marketing claims. In clinical practice, providers often encounter
resistance when discouraging dietary supplements. Public health messaging that
emphasizes the best ways to prevent falls and fractures could help align public
perception with evidence.

Question: Do you have other comments on this draft Recommendation
Statement?

All our comments are previously included.

References
1. Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, et al. Effect of Vitamin D on
falls: a meta-analysis. JAMA. 2004;291(16):1999-2006.
doi:10.1001/jama.291.16.1999
2. Camacho PM, Petak SM, Binkley N, et al. Clinical practice guidelines for the
diagnosis and treatment of postmenopausal osteoporosis. Endocr
Pract. 2020;26(Suppl 1):1-46. doi:10.4158/GL-2020-0524.
3. Kahwati LC, Weber RP, Pan H, et al. Vitamin D, Calcium, or Combined
Supplementation for the Primary Prevention of Fractures in Community-Dwelling
Adults: Evidence Report and Systematic Review for the US Preventive Services
Task Force. JAMA. 2018;319(15):1600-1612. doi:10.1001/jama.2017.21640.