Jump to comment:

• Cost-effectiveness of vitamin D3 supplementation in older adults with vitamin D deficiency in Ireland, by Lacey et al.
  Federica Amati, Lucy J McCann, Tim D Spector and Celine Tabche
  Published on: 21 September 2022

• Published on: 21 September 2022

  Cost-effectiveness of vitamin D3 supplementation in older adults with vitamin D deficiency in Ireland, by Lacey et al.

  • Federica Amati, Medical Scientist Imperial College London
  • Other Contributors:
    • Lucy J McCann, Medical Doctor
    • Tim D Spector, Professor of Genetic Epidemiology
    • Celine Tabche, Teaching Fellow

  Lacey et al. recommended that a vitamin D3 supplementation strategy be first considered in adults ≥70 years of age.1 Their analysis assessed the cost-effectiveness of a systematic public health programme in older adults, measuring serum 25(OH)D levels and treating and monitoring deficient adults with vitamin D3 supplements. We wish to highlight several omissions in the debate.
  Firstly, Lacey et al. worked under the assumption that vitamin D3 supplementation decreases the risk of excess morbidity and mortality, including those related to cancer and fractures. However, these ideas remain controversial within the literature. The Cochrane meta-analysis discussed by Lacey et al., in fact, concludes that the risks of biases, including attrition and reporting bias, have meant their findings among population groups remain inconclusive to recommend or refute vitamin D in the prevention of mortality or cancer-related mortality.2 A more recent meta-analysis by Zhang et al. (2019) found no association between supplementation and all-cause mortality.3 The discrepancy of findings amongst meta-analyses must be acknowledged when producing cost-effective analyses and recommendations such as this one.
  Notably, supplementation cannot be advocated without mentioning its dangers. The failure to consider evidence on the potential risks of vitamin D3 supplementation as shown in trials of high dose products increasing fractures (ref) and recently when Kassis et al. found more signif...

  Show More

  Lacey et al. recommended that a vitamin D3 supplementation strategy be first considered in adults ≥70 years of age.1 Their analysis assessed the cost-effectiveness of a systematic public health programme in older adults, measuring serum 25(OH)D levels and treating and monitoring deficient adults with vitamin D3 supplements. We wish to highlight several omissions in the debate.
  Firstly, Lacey et al. worked under the assumption that vitamin D3 supplementation decreases the risk of excess morbidity and mortality, including those related to cancer and fractures. However, these ideas remain controversial within the literature. The Cochrane meta-analysis discussed by Lacey et al., in fact, concludes that the risks of biases, including attrition and reporting bias, have meant their findings among population groups remain inconclusive to recommend or refute vitamin D in the prevention of mortality or cancer-related mortality.2 A more recent meta-analysis by Zhang et al. (2019) found no association between supplementation and all-cause mortality.3 The discrepancy of findings amongst meta-analyses must be acknowledged when producing cost-effective analyses and recommendations such as this one.
  Notably, supplementation cannot be advocated without mentioning its dangers. The failure to consider evidence on the potential risks of vitamin D3 supplementation as shown in trials of high dose products increasing fractures (ref) and recently when Kassis et al. found more significant aortic valve replacements and mortality rates in older patients with mild-moderate aortic stenosis taking calcium and Vit D supplements4. Furthermore, the burden of polypharmacy is a crucial concern in older adults, particularly the oldest age-groups. Potentially adverse outcomes include medicine non-adherence, increased risk of taking inappropriate medications, hospitalisation, falls, and increased mortality.5
  The cost/QALY estimates in all age-groups were substantially below the 20,000 cost/QALY required to be acceptable. Whilst Lacey et al. finish by advising that supplementation be first considered in adults ≥70 years of age, we feel this recommendation is inappropriate. These findings demonstrate that a systematic public health vitamin D3 supplementation programme is not cost-effective, even within age groups most at risk. Consequently, advice should be to look elsewhere for alternative preventative strategies that promote healthy lifestyles and effective habits.
  Whilst the clinical outcomes of vitamin D3 supplementation remains inconclusive, and the risks unknown, we propose that current recommendations focus on patient-centred strategies which do not increase the pill burden. Evidence-based, low-risk health promotion strategies include:
  1. Optimised dietary intake encompassing a variety of foods, including those rich in vitamin D, calcium, and other micronutrients.
  2. Increased muscle mass and balance by regular weight-bearing, resistance exercises, and physiotherapy if necessary.
  3. Stop smoking.
  4. Limit alcohol intake to ≤14 units/week.
  5. Safe and regular sunlight exposure.

  Although these recommendations do not preclude the potential benefits of vitamin D3 supplementation in some high risk sub-groups, in order to fully determine the cost-effectiveness of this supplementation there needs to be greater reference to the potential risks and prevention strategies that can (and should) be promoted.

  References
  1. Lacey LF, Armstrong DJ, Royle E et al. Cost-effectiveness of vitamin D3 supplementation in older adults with vitamin D deficiency in Ireland. BMJ Nutrition, Prevention & Health 2022;0:e000382.
  2. Bjelakovic G, Gluud LL, Nikolova D, et al. Vitamin D supplemetaiton for prevention of mortality in adults (Review). Cochrane Database of Systematic Reviews 2014; (1):CD007470.
  3. Zhang Y, Fang F, Tang J, et al. Association between vitamin D supplementation and mortality: systematic review and meta-analysis. BMJ 2019; 336:l4673.
  4. Kassis N, Hariri EH, Karrthik AK, et al. Supplemental calcium and vitamin D and long-term mortality in aortic stenosis. Heart 2022;108:964–972.
  5. Wastesson JW, Morin L, Tan EDK, et al. An update on the clinical consequences of polypharmacy in older adults: a narrative review. Expert Opinion on Drug Safety 2018; 17(12):1185-1196.
  6. Quit smoking - Better Heath. nhs.uk. https://www.nhs.uk/better-health/quit-smoking/. Accessed June 14, 2022.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top