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Journal of Osteoporosis
Volume 2011, Article ID 875249, 6 pages
doi:10.4061/2011/875249

Research Article
Calcium and Vitamin D Supplementation in Men

Evelien Gielen,1, 2, 3 Steven Boonen,1, 2, 3 Dirk Vanderschueren,3, 4 Mieke Sinnesael,4

Annemieke Verstuyf,4 Frank Claessens,5 Koen Milisen,1, 6 and Sabine Verschueren7
1 Division of Geriatric Medicine, Leuven University Hospital, Herestraat 49, 3000 Leuven, Belgium
2 Gerontology and Geriatrics Section, Department of Experimental Medicine, K.U.Leuven, 3000 Leuven, Belgium
3 Leuven University Centre for Metabolic Bone Diseases, 3000 Leuven, Belgium
4 Experimental Medicine and Endocrinology, Department of Experimental Medicine, K.U.Leuven, 3000 Leuven, Belgium
5 Molecular Endocrinology Laboratory, Department of Molecular Cell Biology, K.U.Leuven, 3000 Leuven, Belgium
6 Centre for Health Services and Nursing Research, K.U.Leuven, 3000 Leuven, Belgium
7 Research Centre for Musculoskeletal Rehabilitation, Department of Rehabilitation Sciences, K.U.Leuven, 3000 Leuven, Belgium

Correspondence should be addressed to Steven Boonen, steven.boonen@uzleuven.be

Received 13 April 2011; Accepted 4 July 2011

Academic Editor: Pawel Szulc

Copyright © 2011 Evelien Gielen et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Calcium and vitamin D supplements reverse secondary hyperparathyroidism and are widely prescribed to prevent osteoporotic
fractures, with proven antifracture efficacy when targeted to individuals with documented insufficiencies. Men who should
particularly be considered for calcium and vitamin D supplements include elderly or institutionalized individuals, patients with
documented osteoporosis on antiresorptive or anabolic medication, and individuals receiving glucocorticoids. Benefits are most
apparent when a daily dose of 1000–1200 mg calcium is complemented with 800 IU vitamin D. Compliance is the key to optimizing
clinical efficacy. While (conventionally dosed) vitamin D has not been associated with safety concerns, recent meta-analytic data
have provided evidence to suggest that calcium supplements (without coadministered vitamin D) may potentially be associated
with cardiovascular risks.

1. Introduction which enhances bone turnover and accelerates bone loss [4].
Additionally, vitamin D deficiency leads to muscle weakness
Osteoporosis is a systemic skeletal disease characterized by and increases the risk of falling [5], low physical performance
low bone mass and microarchitectural deterioration of bone [6], and dynamic and postural instability [7].
tissue, with a consequent increase in bone fragility [1]. Taken together, low serum calcium and vitamin D defi-
Together with the age-related increase in the risk of falling, ciency increase fracture risk by enhancing bone metabolism
this compromised bone strength results in an increased as well as by increasing the risk of falling. Substitution with
fracture risk [2]. Key determinants of this age-related bone calcium and vitamin D reduces both bone loss and the
fragility are calcium intake and levels of vitamin D, which risk of falling and is therefore recommended as first-line
promotes intestinal calcium absorption [3]. In older individ- strategy in the prevention and treatment of osteoporosis
uals, low dietary calcium intake and vitamin D deficiency are and osteoporotic fractures. Guidelines typically apply this
common because of less sunlight exposure, reduced capacity recommendation to both men and women, although most
of the skin for vitamin D synthesis, inadequate vitamin individual trials and meta-analyses have only or mainly
D dietary intake, or less efficient intestinal absorption of included women, with limited data in men [8]. This paper
vitamin D, resulting in a negative calcium balance. This reviews the existing evidence for the effect of calcium and
stimulates the secretion of parathyroid hormone (PTH) vitamin D supplementation on bone mineral density (BMD),
and induces age-associated secondary hyperparathyroidism, muscle strength, and the risk of falls and fractures in men.
2 Journal of Osteoporosis

2. Effect of Calcium and Vitamin D on Vitamin D receptors (VDRs) are present in skeletal muscle
Secondary Hyperparathyroidism, Bone cells and may account for these effects [20, 21]. In a recent
Mineral Density, and Bone Turnover meta-analysis, vitamin D therapy (200–1000 IU per day)
lowered the risk of falling with 14% (RR 0.86, 95% CI 0.79–
Both calcium and vitamin D supplements reverse the age- 0.93) compared with calcium or placebo [22]. In this meta-
associated secondary hyperparathyroidism in older individu- analysis of ten trials, the number needed to treat with vitamin
als. This reduction in serum PTH is greater with combined D to prevent one fall was 15, and—although a dose of 800 IU
calcium and vitamin D supplementation than with vitamin vitamin D or greater was most effective—a significantly
D alone [3] and depends on baseline calcium balance, lower fall risk was also seen with 400 IU [22].
with the greatest effect of supplementation observed in In an earlier meta-analysis of eight double blind ran-
individuals with the lowest calcium intake and/or vitamin domized controlled trials, on the other hand, a 19% fall
D levels [9]. Gender, however, apparently is an independent reduction (RR 0.81, 95% CI 0.71–0.92) was only observed
determinant of serum vitamin D [10], and to keep PTH with a dose of at least 700 IU vitamin D per day and a 23% fall
within the normal range, women seem to require higher reduction (RR 0.77, 95% CI 0.65–0.90) with serum vitamin
levels of vitamin D than men [11]. D concentrations of at least 60 nmol/L (24 ng/mL), while less
A decrease in levels of PTH is associated with an increase than 700 IU vitamin D per day did not reduce fall risk (RR
in BMD, as has been demonstrated in a recent meta-analysis 1.10, 95% CI 0.89–1.35) [23]. Subgroup analyses were unable
in more than 40000 men and women aged 50 years and older to document a significant reduction in falls in men but the
[12]. In this meta-analysis of 24 trials reporting BMD as an subset was small (N = 211) and the analyses underpowered.
outcome, 19 trials included only women, while four trials In an earlier meta-analysis of the effect of vitamin D on
included men and women [13–16], and one trial included falls, sex-specific subgroup analyses suggested that the fall-
only men [17]. Of the five trials that included men, two trials preventing effect of vitamin D is independent of sex: vitamin
determined the difference in bone loss between calcium in D reduced the odds ratio of falling in men by 21% (OR
monotherapy (±750 mg per day) and placebo [13, 15], while 0.79, 95% CI 0.57–1.1; P = 0.17) and in women by 19%
the others compared calcium (500 mg to 1000 mg per day) (OR 0.81, 95% CI 0.65–1.00; P = 0.05). Again, the result of
plus vitamin D (500 IU to 1000 IU per day) with placebo the sex-specific subgroup analysis in men was not significant
[14, 16, 17]. Overall, treatment with calcium plus vitamin
due to the small number of men in the included trials, but
D or with calcium alone was associated with a significantly
numerically similar to the reduction seen in women [24].
reduced rate of bone loss at the hip and spine. No subgroup
analyses were performed to evaluate the influence of sex Future research should determine the optimal dose of
on treatment effect on BMD, but in line with the overall vitamin D to prevent falls, but available evidence suggests
conclusion of this meta-analysis, reduced bone loss was seen that men benefit to a similar extent as women.
in most of the studies that included men [13–16]. However,
the one available men-only trial could not demonstrate a 4. Antifracture Efficacy of Calcium
reduction of bone loss in spite of supplementation with and Vitamin D
1000 mg calcium and 1000 IU vitamin D per day during three
years [17]. This negative result may reflect the high baseline A negative calcium balance contributes to fracture risk
dietary calcium intake in the men included in the study by enhancing bone degradation through secondary hyper-
(1160 mg per day) compared to lower doses of calcium in the parathyroidism and by increasing the risk of falling through
other trials, such as a daily dose of 700 mg calcium [14] or a negative effect on muscle strength, muscle function, and
less (550 mg [15]), supporting the concept that substitution balance. Substitution with calcium and vitamin D is there-
therapy only makes sense when calcium balance is negative. fore considered the first-line strategy in the prevention of
The decrease in PTH with calcium and vitamin D sup- osteoporotic fractures. To establish the antifracture efficacy
plementation is also associated with reduced bone turnover of substitution, several individual trials and meta-analyses
[15, 16]. Meier et al. observed that calcium and vitamin D have been performed with calcium or vitamin D alone or
supplementation during winter prevented seasonal changes combined calcium plus vitamin D.
in PTH and bone loss in both men and women, although
the effect on bone turnover was stronger in women. In this 4.1. Effect of Calcium or Vitamin D Alone on Fracture Risk.
context, it should be noted that seasonal changes of bone Meta-analyses comparing the effect of calcium alone with
turnover markers are only significant in women and almost placebo showed that calcium in monotherapy does not
absent in men [16]. significantly reduce fracture risk [25, 26]. Of these meta-
analyses, one included only women [25], while the other
3. Effect of Calcium and Vitamin D on Muscle included both genders and conducted sex-specific analyses
Strength and the Risk of Falls on the reduction of hip fracture risk [26]. Although data
in men were limited, this meta-analysis did not reveal a
Supplementation with calcium and vitamin D not only redu- differential effect of calcium in men or women: in both sexes
ces bone loss but also reduces the risk of falling by improving calcium in monotherapy was unable to reduce (hip) fracture
muscle strength, muscle function, and balance [7, 18, 19]. risk.
Journal of Osteoporosis 3

The same holds true for the effect of vitamin D alone on fractures [12]. Six of these trials included men and
versus placebo: a meta-analysis of four randomized con- women, 11 included only women, and there were no men-
trolled trials (N = 9083) showed that vitamin D alone was only trials. Calcium or calcium plus vitamin D was associated
insufficient for fracture prevention, even when trials with with a 12% risk reduction in fractures of all types (RR
vitamin D used in higher dose (700–800 IU per day) were 0.88, 95% CI 0.83–0.95). This treatment effect was similar
evaluated separately [27]. A more recent meta-analysis came across women and men, as suggested indirectly (since there
to the same conclusion: irrespective of sex, 400 to 800 IU were no men-only trials) by the comparison of the women-
vitamin D alone is no more effective in preventing fractures only to the mixed-sex trials. In this meta-analysis, subgroup
than placebo [28]. analyses showed that reduction in fracture risk was greater
These results should not come as a surprise because in individuals with low dietary calcium intake (<700 mg per
the negative calcium balance in older and institutionalized day) and in those with low serum vitamin D concentration
adults is often the result of insufficiencies in both calcium (<25 nmol/L or <10 ng/mL). Treatment effect was most
and vitamin D. For example, community-dwelling French effective with at least 1200 mg calcium and at least 800 IU
women aged 75–90 years had a mean daily calcium intake of vitamin D. In this particular analysis, the combination
of just 569 mg and 39% had a serum vitamin D less of calcium and vitamin D (RR 0.87, 95% CI 0.77–0.97)
than 30 nmol/L (12 ng/mL) [29]. In another trial, 66% of and calcium in monotherapy (RR 0.90, 95% CI 0.80–1.00)
institutionalized women had a daily calcium intake less than were equally effective (P = 0.63) in the prevention of
800 mg and a serum vitamin D less than 30 nmol/L [30]. osteoporotic fractures, a finding that is difficult to reconcile
As a result, in these elderly and institutionalized individuals, with evidence from other meta-analyses that calcium alone
supplementation with calcium alone or vitamin D alone does not significantly reduce fracture risk [25, 26].
would fail to restore calcium balance and prevent fractures Overall, there is increasing evidence from several meta-
[8]. analyses for a beneficial effect of combined calcium and
vitamin D supplementation on fracture risk with no firm
4.2. Effect of Combined Calcium and Vitamin D Supplemen- reasons to assume that men would respond differently
tation on Fracture Risk. A meta-analysis of six randomized from women. However, results of individual trials assessing
controlled trials (N = 45509) comparing the effect of fracture reduction with combined calcium and vitamin
combined calcium and vitamin D supplementation with D supplementation have been inconsistent. Some of these
placebo [27] showed that this combination therapy, contrary individuals trials, such as the Women’s Health Initiative
to calcium or vitamin D alone, significantly reduced fracture (WHI) trial [31] and the RECORD trial [33], failed to
risk. The risk reduction was 12% for all nonvertebral demonstrate a significant reduction in fracture risk, whereas
fractures, 18% for hip fractures, and 21% for hip fractures other trials found a beneficial effect of calcium and vitamin
when the one trial in this meta-analysis that did not use D supplementation on fracture risk [14, 30, 34]. These
700 to 800 IU but 400 IU vitamin D [31] was excluded. inconsistencies can be attributed to several factors, including
Similarly, a recent Cochrane review found that calcium plus differences in targeting of the supplementation and differ-
vitamin D prevented hip fractures in frail elderly [32] and the ences in compliance [8].
DIPART group concluded that the combination of calcium
and vitamin D significantly reduced the risk of any fractures 4.3. Determinants of Antifracture Efficacy of Calcium and
and hip fractures and probably reduced the risk of clinical Vitamin D Supplementation. To be effective, supplementa-
vertebral fractures [28]. In their meta-analysis, the DIPART tion with calcium and vitamin D has to be targeted to men
group adjusted analyses for several factors including sex and with documented or particularly at risk of calcium and/or
found that the risk reduction of combined calcium and vitamin D insufficiencies, while general supplementation
vitamin D was independent of sex [28]. in the community is not necessary. Except for extremely
Compared with vitamin D alone, combined calcium and minor subsets, baseline vitamin D status was not assessed
vitamin D supplementation reduced the risk for hip fractures in participants of the WHI trial and the RECORD trial [31,
by 25% in an indirect comparison of meta-analyses [27]. 33]. In fact, most of these study participants were mobile,
This might be explained by the greater effect of combined healthy, and community-dwelling, who are less likely to have
calcium and vitamin D on secondary hyperparathyroidism vitamin D insufficiency and therefore less likely to benefit
and bone loss [3]. In this context, it should be noted that from substitution. This may have contributed significantly
the only trial that directly compared the effect of combined to the negative results of these studies [8]. Men who will
calcium and vitamin D supplementation with vitamin D [33] benefit most from substitution therapy are older (>75 years
could not document a beneficial effect of the combination of age) or institutionalized persons in whom calcium and
therapy, but this study—like many individual trials in this vitamin D insufficiency is highly prevalent, as well as men
field—suffered from a lack of statistical power, a lack of with documented osteoporosis or receiving glucocorticoids.
targeting of the supplements to individuals with documented The addition of calcium and vitamin D to antiresorptive or
insufficiencies and a lack of compliance [27], which we will anabolic therapy in patients with established osteoporosis
discuss in more detail later. is essential, given that calcium and vitamin D insufficiency
Finally, one meta-analysis including 17 trials compared is common in patients with osteoporosis and osteoporosis
the effect of calcium plus vitamin D with calcium alone medication is most effective in calcium and vitamin D
4 Journal of Osteoporosis

replete individuals. Glucocorticoids suppress intestinal and 6. Conclusion

renal calcium absorption and increase urinary calcium
excretion, resulting in a negative calcium balance [35]. Age-associated bone loss due to secondary hyperparathy-
Therefore, patients on glucocorticoids are particularly prone roidism and an increased risk of falling are key determinants
to fractures and supplementation therapy should be initiated of osteoporosis and osteoporotic fractures. Substitution with
as soon as glucocorticoids are prescribed [3, 8]. Most meta- calcium and vitamin D reduces bone loss by reversing sec-
analyses recommend a combination of 1000 to 1200 mg ondary hyperparathyroidism and prevents falls by improving
calcium with 700 to 800 IU vitamin D per day [12, 27] or muscle strength, muscle function, and balance. As a result,
at least a dose in excess of 400 IU (482–770 IU) vitamin D calcium and vitamin D supplementation is generally recom-
[36]. The aim is to increase serum levels of vitamin D to the mended in the prevention of osteoporotic fractures. In men,
50–75 nmol/L (20–30 ng/mL) range [37, 38]. data on the effect of calcium and vitamin D supplements on
In addition to adequate targeting of supplementation, BMD and the risk of falls and fractures are limited. However,
compliance with calcium and vitamin D is critical as well, from the mechanism of bone loss and from the available evi-
to optimize clinical efficacy. Within 6 weeks after calcium dence, there is no reason to assume that men would respond
and vitamin D have been discontinued, bone remodeling differently to calcium and vitamin D supplementation
resumes to pretreatment levels [39]. In line with these compared to women. Combined supplementation with 1000
findings, any positive effects of calcium and vitamin D to 1200 mg calcium and 800 IU vitamin D per day should
on bone density will not persist after discontinuation of be particularly considered in older or institutionalized men,
the supplements [40]. Therefore, to prevent osteoporotic men receiving glucocorticoids, and in male osteoporosis
fractures, compliance and persistence with calcium and patients on antiresorptive or anabolic medication.
vitamin D are essential. However, even in relatively healthy
trial participants in studies like the WHI and the RECORD
trial, a significant proportion of individuals did not comply Conflict of Interests
with supplementation: in both trials, estimated compliance The authors have no conflict of interests.
was only 40–60% [31, 33]. The negative outcome of these
trials can, at least partly, be explained by this lack of
compliance and emphasizes the importance of adherence to Acknowledgments
treatment [8].
S. Boonen is a senior clinical investigator of the Fund for
Scientific Research (FWO-Vlaanderen) and holder of the
5. Safety Concerns about Supplementation Leuven University Chair in Gerontology and Geriatrics. This
work was supported by grant G.0488.08 from the Fund
While (conventionally dosed) vitamin D has not been
for Scientific Research (FWO-Vlaanderen) to S. Boonen. D.
associated with safety concerns, a recent meta-analysis has
provided evidence to suggest that calcium supplements Vanderschueren is a senior clinical investigator of the Leuven
(without coadministered vitamin D) may potentially be University Hospital Clinical Research Fund.
associated with cardiovascular risks. This safety concern may
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