How to proceed when it comes to vitamin D

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doi:10.12788/jfp.0215

Practice Alert

How to proceed when it comes to vitamin D

J Fam Pract. 2021 July;70(6):289-292 | 10.12788/jfp.0215

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References

1. USPSTF. Screening for vitamin D deficiency in adults: US Preventive Services Task Force recommendation statement. JAMA. 2021;325:1436-1442.

2. Michos ED, Kalyani RR, Segal JB. Why USPSTF still finds insufficient evidence to support screening for vitamin D deficiency. JAMA Netw Open. 2021;4:e213627.

3. Burnett-Bowie AAM, Cappola AR. The USPSTF 2021 recommendations on screening for asymptomatic vitamin D deficiency in adults: the challenge for clinicians continues. JAMA. 2021;325:1401-1402.

4. Institute of Medicine. Dietary reference intakes for calcium and vitamin D. National Academies Press; 2011. Accessed May 22, 2021. https://pubmed.ncbi.nlm.nih.gov/21796828/

5. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinolgy Metab. 2011;96:1911-1930.

6. Shahangian S, Alspach TD, Astles JR, et al. Trends in laboratory test volumes for Medicare part B reimbursements, 2000-2010. Arch Pathol Lab Med. 2014;138:189-203.

7. Herrick KA, Storandt RJ, Afful J, et al. Vitamin D status in the United States, 2011-2014. Am J Clin Nutr. 2019;110:150-157.

8. Forrest KYZ, Stuhldreher WL. Prevalence and correlates of vitamin D deficiency in US adults. Nutr Res. 2011;31:48-54.

9. Kahwati LC, LeBlanc E, Weber RP, et al. Screening for vitamin D deficiency in adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2021;325:1443-1463.

10. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2016. Endocr Pract. 2016;22(supp 4):1-42.

11. AAFP. Clinical preventive services. Accessed May 22, 2021. www.aafp.org/family-physician/patient-care/clinical-recommendations/aafp-cps.html

12. USPSTF. Falls prevention in community-dwelling older adults: interventions. Accessed May 22, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/falls-prevention-in-older-adults-interventions

13. USPSTF. Vitamin supplementation to prevent cancer and CVD: preventive medication. Accessed May 22, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/vitamin-supplementation-to-prevent-cancer-and-cvd-counseling

14. USPSTF. Vitamin D, calcium, or combined supplementation for the primary prevention of fractures in community-dwelling adults: preventive medication. Accessed May 22, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/vitamin-d-calcium-or-combined-supplementation-for-the-primary-prevention-of-fractures-in-adults-preventive-medication

15. NIH. Vitamin D. Accessed May 22, 2021. https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

16. Ross AC, Manson JE, Abrams SA, et al. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab. 2011;96:53-58.

17. Jackson RD, LaCroix AZ, Gass M, et al. Calcium plus vitamin D supplementation and the risk of fractures. N Engl J Med. 2006;354:669-683.

Specific USPSTF topics related to vitamin D

The Task Force has specifically addressed 3 topics pertaining to vitamin D. In each instance, the recommendation relates not to providing vitamin D to those who have vitamin D deficiency, but to providing vitamin D supplementation universally to specific groups at risk of a particular condition (TABLE 1).

Prevention of falls in the elderly. In 2018 the Task Force recommended against the use of vitamin D to prevent falls in community-dwelling adults ≥ 65 years.¹² This reversed its 2012 recommendation advising vitamin D supplementation to prevent falls. The Task Force re-examined the old evidence and looked at newer studies and concluded that their previous conclusion was wrong and that the evidence showed no benefit from vitamin D in preventing falls in the elderly. The reversal of a prior recommendation is rare for the USPSTF because of the rigor of its evidence reviews and its policy of not making a recommendation unless solid evidence for or against exists.

Prevention of cardiovascular disease and cancer. The Task Force concludes that current evidence is insufficient to assess the balance of benefits and harms in the use of single- or paired-nutrient supplements to prevent cardiovascular disease or cancer.¹³ (The exceptions are beta-carotene and vitamin E, which the Task Force recommends against.) This statement is consistent with the lack of evidence the Task Force found regarding prevention of these conditions by vitamin D supplementation in those who are vitamin D deficient.

Prevention of fractures in men and in premenopausal and postmenopausal women. For men and premenopausal women, the Task Force concludes that evidence is insufficient to assess the benefits and harms of vitamin D and calcium supplementation, alone or in combination, to prevent fractures.¹⁴ For prevention of fractures in postmenopausal women, there are 2 recommendations. The first one advises against the use of ≤ 400 IU of vitamin D and ≤ 1000 mg of calcium because the evidence indicates ineffectiveness. The second one is another “I” statement for the use of doses > 400 IU of vitamin D and > 1000 mg of calcium. These 3 recommendations apply to adults who live in the community and not in nursing homes or other institutional care facilities; they do not apply to those who have osteoporosis.

What should the family physician do?

Encourage all patients to take the recommended dietary allowances (RDA) of vitamin D. The RDA is the average daily level of intake sufficient to meet the nutrient requirements of nearly all (97%-98%) healthy individuals. Most professional organizations recommend that adults ≥ 50 years consume 800 to 1000 IU of vitamin D daily. TABLE 2 lists the RDA for vitamin D by age and sex.¹⁵ The amount of vitamin D in selected food products is listed in TABLE 3.¹⁵ Some increase in levels of vitamin D can occur as a result of sun exposure, but current practices of sun avoidance make it difficult to achieve a significant contribution to vitamin D requirements.¹⁵

Continue to: Alternatives to universal screening