Issue #77 (March 2021)

Issue #77 March 2021
Table of Contents
NERD Mini: Takeaways from the ISSN's position on caffeine and exercise performance
We break down some key takeaways from the International Society for Sports Nutrition's
newly-updated position stance on caffeine's use in exercise performance.
D-creasing asthma symptoms with supplementation

Calcifediol is the form of vitamin D that's often checked in the blood to monitor vitamin D
levels. This trial found that supplementing this form of vitamin D can improve asthma
symptoms in people with vitamin D insufficiency.
Deep Dive: Micronutrients with micro-effects for preventing and treating acute respiratory
infections
This meta-analysis found evidence that supplementing vitamins C and D may prevent the
risk of acute respiratory infections, but only by a tiny amount. Zinc has a more sizable
effect, but only once symptoms have set in.
The effects of full fasting vs. modified fasting on cognitive performance

How does full fasting impact mental functioning compared to very low-calorie intake over
the course of a day? This study aimed to find out.
Nulls: November–December 2020

Highlights include omega-3's lack of impact on bipolar disorder, whether adding vitamin C
to iron helps iron deficiency anemia outcomes, and more!
Battling exercise-induced muscle damage with omega-3s

This small study provides preliminary evidence that a high-dose mix of EPA and DHA may
combat early post-exercise muscle soreness.
Deeper Dive: Shining a light on the effects of vitamin D on fall risk in older adults
This study suggests that higher vitamin D dosing doesn't prevent falls compared to lower
dosing. Instead, it may cause more.
Deeper Dive: Do I have to choose between osteoporosis and heart disease?

A recent meta-analysis suggests that calcium supplementation leads to a small but
significant increased risk of heart disease. In this review, we put this risk in context.
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From the Editor
Some housekeeping news: NERD is changing up its name to Study Deep Dives. The new name is
far less catchy, in my honest opinion, but there are a couple of good reasons for switching things
up.
The first comes from a theme that emerged when we interviewed current and prospective Examine
subscribers: people found our product names confusing. I can see where they’re coming from.
“NERD” doesn’t tell you much about what subscribers are actually getting, even when it’s spelled
out as the “Nutrition Examination Research Digest.” The new name makes it more clear: what you
get is what it’s called. Deep dives into studies!
The second is that prospective subscribers found our subscription levels really confusing, and
didn’t always know what they were getting. For instance, NERD subscribers also got a subscription
to our Personalized research summaries, but that wasn’t clear at all. After all, if you were just
subscribing to one thing, NERD, why would you think that you also had access to other things?
So, to make things clearer for our current and future subscribers, we’ve made two changes.
First, we’ve collapsed all of our subscription products into one single Examine Membership. As a
NERD subscriber, what you’re getting hasn’t changed: you still get Study Deep Dives (NERD)
along with monthly personalized short research updates and access to our study database. But we
think this will help future subscribers understand what they’re getting. Since there’s just one
subscription, they’re getting it all!
Second, we’ve renamed our offerings so that their names better reflect what they are. NERD is
now Study Deep Dives, since the point of what we’re doing here is to take a close, detailed look at
nutrition and supplementation studies. Personalized is now called Study Summaries, since they’re
shorter summaries of the latest nutrition research. The Human Effect Matrix (HEM, a name that
stuck with almost none of our subscribers!) is now the Study Database, since that’s what it is: a
sortable database that summarizes studies by health topic.
With these two changes, we hope to make things clearer for both current and future subscribers.
But we’re not just changing names—we’re also doing some reorganization in the background that
will allow these different offerings to work better together. While it’s a little too early to spill the
beans on the details, our hope is to translate these changes to get you more information that’s
most relevant to you and your needs.
We haven’t fully swapped out “NERD” for “Study Deep Dives” yet, but the process is ongoing and
should be complete in the next month or so. Stay tuned for more, and feel free to reach out with
any questions or concerns!
3
Gregory Lopez, MA, PharmD
Editor-in-chief, Study Deep Dives
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NERD Mini: Takeaways from the ISSN's
position on caffeine and exercise
performance
 Tags: Caffeine, Exercise Performance
 Read this article online at Examine.com
In January 2021, the International Society of Sports Nutrition (ISSN) released a position on
caffeine’s effects on exercise performance. Here are some key points about timing, dosages,
delivery methods, side effects, and more.
Dosages of caffeine
• Caffeine is most frequently consumed in doses of 3–6 mg per kg of body mass, 30 to 90
minutes before training.
• Very high doses of caffeine (around 9 mg/kg) do not provide increased benefits and are
associated with negative side effects.
Caffeine’s effect on muscular endurance, strength, and

power
• May delay muscle fatigue during resistance training.
• May provide a small benefit for strength (2–7%), which is not particularly meaningful for
recreational weightlifters, but may provide benefits to elite-level athletes.
• Improved power output in sprinting, but only when sprints were separated by a longer rest
period (90 seconds to 2 minutes). -Small (2–4%) increases in vertical jump height and
throwing distance.
Caffeine’s effects on endurance performance

• The evidence consistently shows that caffeine benefits endurance performance, with
varying effects between people.
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• May decrease perceived exertion and delay fatigue during endurance training.
• Doses of 3–6 mg/kg of body mass have shown the most efficacy for improving endurance
exercise performance by 2–4%, with a possible minimal effective dose of 2 mg/kg of body
mass.
Caffeine consumption and sport-specific performance

• Basketball players increased jump height, the number of free throws, and rebounds.
• Soccer players increased distance covered, passing accuracy, and jumping height.
• Volleyball players increased their precision.
• Rugby players increased the number of body impacts, speed, and jumping ability.
• Field hockey players increased their sprinting time and possibly experienced decreased
fatigue.
• Combat sports participants increased the number of offensive actions and number of
throws.
• Cross-country skiers increased speed and endurance.
Individual response to caffeine

• Individual response to caffeine varies partly due to genes associated with either fast or slow
caffeine metabolism. Fast metabolizers have been shown to have significant improvements
in exercise performance, while slow metabolizers may have worsened performance.
• The average half-life of caffeine is 4–6 hours, but individual genetic variability, hormones
during pregnancy, contraception use, gender, and cigarette use may decrease caffeine
metabolism.
• Adverse effects of caffeine, like sleep problems and anxiety, differ between people. This
may be due to genetic variations. Athletes with these predispositions should prioritize rest
and recovery and be mindful of the timing of caffeine intake, particularly before sleep.
• Whether habitual caffeine intake dampens its ergogenic effect requires further study.
Caffeine timing
• Taking caffeine an hour before exercise seems to be the most common timing strategy.
6
• Taking caffeine during a longer exercise session during which fatigue sets in later in the
event may be more beneficial than taking it before the start of the event.
• Timing of caffeine may depend on the source. For example, caffeinated gum may be
absorbed faster than ingested forms like capsules and drinks.
Training status
• Both trained and untrained people may benefit from caffeine’s ergogenic effects.
Side effects of caffeine

• Side effects include jitters and anxiety. These effects vary between people. Some athletes,
like tennis players, may not benefit from these effects, but other athletes engaged in
physical sports like football might, though this is not a well-explored topic.
• Side effects increase with increased doses of caffeine. Smaller doses are ergogenic and
may produce fewer side effects.
Caffeine and cognitive performance

• May improve mood, attention, focus, vigilance, reaction time, alertness, motivation, and
effort in some people, particularly in sleep-deprived people.
Environmental influences on caffeine response

• The evidence supports the use of caffeine in endurance training in the heat (3–6 mg/kg)
and at altitude (4–6 mg/kg).
• Caffeine does not seem to affect hydration status, exacerbate dehydration, or alter
thermoregulation in high heat environments.
• Caffeine seems to benefit athletes at high altitudes by offsetting the negative effects of
hypoxia.
Forms of caffeine
• Caffeine’s maximum concentration levels may be reached in 30 minutes for coffee, tea, and
pill forms, and two hours in cola and chocolate.
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• Caffeine in brewed coffee has shown improved performance in running and cycling.
However, the caffeine content of coffee differs due to brewing techniques and the type of
coffee, so trainers typically prefer non-liquid forms.
• Energy drinks have been found to improve endurance, strength, sprinting, and jumping
performance, but their ergogenic effects cannot be attributed solely to caffeine because
many of these drinks contain taurine and B-vitamins.
• Caffeine in gum is absorbed through the oral mucosa, which is extensively vascularized.
This results in faster absorption. Gum as a delivery method eliminates the need for
digestion, which may have advantages over drinks and gels for athletes performing
moderate to intense exercise.
• Caffeinated nasal sprays and mouth aerosols may affect the brain more quickly than drinks
and capsules.
• Caffeine mouth rinsing for 5–20 seconds may activate pathways in the brain associated
with reward and information processing and may reduce gastrointestinal distress resulting
from ingesting caffeine.
• Gels, when consumed 10 minutes before exercise, have shown improved performance, but
not when taken 60 minutes before the event.
• Little is currently known about caffeinated bars, but one study found that a bar containing
100 mg of caffeine improved time to exhaustion and information processing.
Caffeine in combination with other compounds

• Creatine taken before caffeine seems to not affect caffeine’s ergogenic effect. More
research is needed to understand the effects of co-ingesting creatine and caffeine, so it
may be best to consume them separately.
• There is some evidence that shows co-ingesting caffeine with carbohydrates may improve
endurance performance than taking carbohydrate alone.
• Post-exercise muscle glycogen repletion rates may be increased when higher doses of
caffeine (8 mg/kg of body mass) are taken in combination with carbohydrates.
Never dismiss the placebo effect!

• When athletes believed that they were taking varying doses of caffeine but were ingesting a
placebo, their performance improved with the perceived dose of caffeine.
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^ Go back to table of contents
9
D-creasing asthma symptoms with
supplementation
 Tags: Asthma, Supplementation, Vitamin D
 Study under review: Effect of vitamin D supplementation on asthma control in patients

with vitamin D deficiency: the ACVID randomised clinical trial
Quick Takes
• What was the question? Can vitamin D help control asthma
in adults with low plasma vitamin D levels?
• How was it answered? Researchers conducted a
randomized controlled trial.
• Who was studied? The participant population was made up
of 112 adults with asthma who had 25-OH-D3 levels under 30
ng/mL (75 nM).
• What was the intervention? Participants took 16,000 IU of
calcifediol (25-OH-D3, the metabolite that’s measured in
blood to get vitamin D levels, and which may be more potent
than typical vitamin D3 supplements) once a week for six
months.
• What's the main takeaway? Vitamin D supplementation
improved asthma control by around 17% compared to the
control group.
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• Any caveats? This study used a relatively uncommon form
of vitamin D that’s not found in most supplements, raising the
question of how well regular D3 supplementation would have
performed.
What was the question?

Is vitamin D supplementation beneficial for asthma control and severity in asthmatic adults with
plasma 25-OH-D levels under 30 ng/mL (less than 75 nM)?
Why was the question worth asking?

Asthma is an inflammatory disease of the lung’s airways that affects 339 million people worldwide.
Currently, there is no cure. The main ways to manage asthma include avoiding triggers and using
medications such as inhaled corticosteroids and bronchodilators. Some cases of asthma don’t
respond well to established treatments, and the medications have side effects. Therefore, there is
interest in identifying new drugs or supplements that may help with asthma.
Vitamin D stands out as a promising candidate for many reasons. Vitamin D receptors are present
in all immune cells and throughout the respiratory system. It modulates many aspects of immune
function, such as increasing regulatory T cell activities and reducing inflammatory cytokine
secretions. It seems to boost[1] the respiratory tract’s responsiveness to corticosteroids while
protecting against respiratory tract infections. Vitamin D is also thought to inhibit[2] asthmatic airway
remodeling, a potentially permanent change that increases smooth muscles in the airway wall and
narrows the airway. Regular[3] vitamin D3 supplements are inexpensive, well-tolerated over the
long term and effective at increasing levels of 25-OH-D, which is the “vitamin D level” found on lab
results.
Many people with asthma have low vitamin D, and their vitamin D levels seem to correlate with
disease[4] severity[5]. However, it remains unclear whether the low vitamin D is the cause or the
effects of asthma because systemic[6] inflammation[7] may suppress blood 25-OH-D levels. Also,
vitamin D insufficiency is found in 41.4%[8] of US adults.
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Most clinical trials that evaluated the effects of vitamin D on asthma have been relatively small,
although a few were large enough to achieve the required statistical power. The results of these
trials have been[9] mixed. A 2016 Cochrane review[10] found that vitamin D protects against severe
exacerbation of asthma in mild and moderate cases. However, a 2015 meta-analysis[11] found that
vitamin D in addition to asthma medications did not significantly reduce asthma exacerbation or
other disease outcomes. Both of these meta-analyses involved mostly small trials (less than 60
participants) and only involved two[12] studies[13] with larger sample sizes (408 and 250
participants). This highlights the need for more well-controlled trials with sufficient sample size to
test this hypothesis.
Although most vitamin D supplements and natural hormones produced from sun exposure are in
the form of cholecalciferol (D3), the vitamin D used in this study, calcifediol, is the same as 25-OH-
D. In the U.S., calcifediol is a medication approved for treating secondary hyperparathyroidism in
people with stage 3–4 chronic kidney disease, who have trouble converting vitamin D3. In Spain[14],
where calcifediol is less expensive and where the study under review was conducted, either
calcifediol (13.11 €/10 units of 16,000 IU ampules) and vitamin D3 (15.61 €/4 units of 25,000 IU
ampules) may be prescribed to treat vitamin D deficiency.
Figure 1: Cholecalciferol vs. calcifediol
Although calcifediol supplementation skips the conversion from vitamin D3, it may work very
differently from vitamin D3 supplements. Because vitamin D3 is more lipophilic than calcifediol, the
half-life[15] in the body is about two months[16] for vitamin D3 and two weeks for calcifediol.
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Calcifediol does not require bile or fat digestion to absorb, and is thus much better absorbed[17] in
the intestine. At identical dosage, calcifediol increases 25-OH-D about 3.2[17] times more than
vitamin D3. This number varies[14] widely, from 1–8 times, depending on age, initial vitamin D
status, and gender. Due to the higher absorption, the potential danger from overdose[15] is much
higher for calcifediol. Last but not least, vitamin D3 has had a longer history of use and many more
clinical studies that examined its safety and effectiveness at various doses than calcifediol.
The lack of data on calcifediol coupled with lack of sufficiently larger clinical trials studying vitamin
D’s effects on asthma motivated the study under review, which is a randomized controlled trial with
sufficient statistical power to test the effect of oral calcifediol on asthma control, exacerbation rate,
and quality of life in adults with asthma and insufficient vitamin D status.
Vitamin D is a potentially useful supplement for asthma due to its

immune modulating effects and the observation that many people
with asthma have insufficient blood 25-OH-D levels, which
correlates with disease severity. This study is the first randomized
controlled trial designed to determine whether calcifediol
supplementation by participants with asthma and low 25-OH-D
levels helps with asthma control and attack frequency.
How was the question answered?

The authors conducted the six-month preregistered triple-blind single-center randomized controlled
trial out of a hospital in Spain. “Triple-blind” means that the study analysts, in addition to the
participants and treatment administrators, were blinded to the treatment and placebo’s identity. A
total of 112 participants met the study criteria and completed the trial. The mean age of the
participants was 55 years and 78% of them were women. Half of the participants were randomly
assigned to the intervention group and the other half to the control group.
The inclusion criteria included a confirmed bronchial asthma diagnosis, ongoing asthma medication
use, plasma 25-OH D of no more than 30 ng/mL (75 nM), and no ongoing vitamin D
supplementation. People who smoked more than 10 packs of cigarettes per year, or had kidney
disease, kidney stones, hypercalcemia, vitamin D malabsorption, were pregnant, breastfeeding, or
had severe psychological problems were excluded. During the first visit, lung function tests or
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airway hyperresponsiveness tests were also performed to ensure that the participants met the
diagnosis criteria for asthma.
The intervention was one ampule of 16,000 IU of calcifediol (Hidroferol) per week, while the
placebo was the contents of an identically-looking ampule. Calcifediol may increase blood 25-OH D
at 3.2[17] times the rate of vitamin D3. Assuming this value is applicable, the 16,000 IU dose chosen
in this study reflects the 50,000 IU per week[18] of vitamin D3 recommended by the Endocrine
Society to treat vitamin D deficiency.
The primary endpoint was changes in asthma control over six months. The latter were assessed by
the well-established asthma control test[19] (ACT) questionnaire. The sum score ranges from 5
(poor control) to 25 (excellent control). An increase of over 3 points is considered a clinically[20]
significant improvement.
The secondary endpoints included quality of life, corticosteroid doses and number of corticosteroid
treatments required to control asthma, number of asthma attacks, unscheduled primary care visits
due to asthma, and number of asthma-related emergency room visits and hospitalizations. The
quality of life was assessed using the Spanish version of the 15-question Mini Asthma Quality of
Life Questionnaire[21] (Mini-AQLQ).
The participants visited the clinic three times, once at randomization and inclusion, then at
baseline, and last at the follow-up visit after six months. The remainder of contacts and data
collection happened over the phone, at which point the researchers interviewed participants about
therapeutic compliance, adverse events, and any factors related to the secondary endpoints. The
participants were also allowed to call the researchers if they had any questions or experienced side
effects.
This was a six-month triple-blind randomized controlled trial

involving 112 adults with low levels of vitamin D in their blood. The
study aimed to test whether vitamin D supplementation improved
asthma control better than placebo. The primary endpoint was
asthma control, as assessed by the Asthma Control Test
questionnaire. Secondary endpoints included corticosteroid
requirements, asthma attacks, unscheduled physician visits, and
emergency care during the treatment follow-up period.
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What was the answer?
After six months, the serum 25-OH D3 in the intervention group was 59 ng/mL (147 nM) compared
to 17 ng/mL (43 nM) in the control group. Seven participants in the intervention group still had
levels under 30 ng/mL (75 nM), while two participants in the control group achieved levels of more
than 30 ng/mL.
At the end of the trial, the average ACT score increased by 3.09 points in the vitamin D group,
compared to a decrease of 0.57 in the placebo group. This difference of 3.66 between groups
(95% CI 0.89–5.43) was statistically significant. Aside from being statistically significant, this effect
is considered clinically significant based on the established threshold of 3 points.
The number of participants needed to treat with vitamin D to improve ACT scores by over 3 points
was 3.7. At the end of the study, 31 participants in the intervention group, compared to 16 in the
placebo group, achieved an ACT increase of more than 3 points (p=0.003).
Figure 2: Change in ACT score within and between

groups
The Mini-AQLQ scores were 5.34 in the intervention group and 4.64 in the control group. The
mean improvement was 1.05 point in the intervention group, compared to -0.09 in the control
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group. The differences were statistically significant after adjusting for the initial score.
Small but statistically significant differences were found in the number of oral corticosteroid
treatments (-0.38), number of asthma attacks (-0.36), and number of asthma-related unscheduled
physician visits (-0.40), possibly due to the small sample size. However, there were no statistically
significant differences in the final doses of corticosteroids, and the number of asthma-related
emergency room visits or hospitalizations.
A post hoc analysis found that the participants’ serum 25-OH-D levels at baseline moderately
correlated with asthma control (r = 0.45, p = 0.01), even though all participants had insufficient
vitamin D levels. At the end of the study, a weaker correlation was observed. Also, at the end of the
study, good asthma control was associated with healthy levels of vitamin D (more than 30 ng/mL or
75 nM).
No serious side effects that could be attributed to the calcifediol were observed.
Compared to placebo, weekly use of the calcifediol supplement

significantly improved asthma control and quality of life in
medicated adults with asthma. Participants who took vitamin D had
improved blood 25-OH D levels. They also needed fewer
corticosteroid doses, had fewer asthma attacks, and needed fewer
unscheduled physician visits. Blood vitamin D levels appeared to
correlate with ACT scores both before and after the trial. No
serious side effects were observed.
How much should you trust the answer?

Overall, this was a fairly well-conducted study. The strengths of the study included that it was triple-
blinded, placebo-controlled, and preregistered. It is one of the two clinical trials that screened for
people with asthma and low vitamin D levels. The registered study also listed a single primary
outcome, so there were no potential additional errors due to multiple comparisons. However, this
study has several limitations, including sample size, data collection timelines, recall bias, conflicts
of interest, participant heterogeneity, and other individual factors that may affect vitamin D levels.
16
The sample size of 112 participants was relatively small and the study was conducted from a single
hospital in Spain. However, according to the authors’ calculation, their study had enough people
enrolled to detect significant improvements in asthma control. In addition, this is one of the larger
clinical trials in the literature that examined the effects of vitamin D on asthma. Still, a larger study
would provide more statistical power for subgroup analyses and more robust observations for
secondary outcomes, where small but statistically significant differences were observed.
The study enrolled participants with all different levels of asthma severity, ongoing treatments, and
immune abnormalities (endotypes), which may have introduced some heterogeneity in the results.
It is likely that vitamin D supplementation may have different effects on participants based on these
differences. It may be useful for future studies to stratify participants according to asthma features
in order to gain a better understanding of the effectiveness of vitamin D in asthma control.
Although the study was sufficiently powered to detect clinical improvements, it did have a few minor
limitations that did not invalidate the results. The six-month study duration should have been
enough to reach a steady state of 25-OH-D level. However, due to individual differences in vitamin
D metabolism, it would have been better and safer to monitor participant 25-OH-D and asthma
control more frequently throughout the follow-up period. In fact, the Endocrine Society recommends
[18] re-testing at eight weeks after administering weekly high doses of vitamin D to prevent
hypercalcemia or hypercalciuria, and to ensure that vitamin D levels rise accordingly.

Subsequently, if the blood vitamin D levels reached 30 ng/mL (75 nM), participants should have
been switched to a safer maintenance dosage. It’s unclear why this part of the protocol wasn’t
adhered to.
It’s important to note that other factors that may modify 25-OH D levels, such as food or sun
exposure, or individual responses to calcifediol, were not discussed or accounted for. These factors
may explain why a few participants in each group had unexpected vitamin D levels at six months.
Finally, the main results of the study were based on subjective questionnaires rather than direct
physiologic measurements or lab tests, which introduces some subjectivity into the primary
outcome. However, given the amount of blinding that went on, this isn’t a big concern.
Overall, the results of this study are persuasive, but it remains unclear how well they would
generalize to the much more common vitamin D3 supplements available to most people.
This study was well-conducted and well-powered enough to detect

significant clinical improvements in asthma control, although there
were some minor limitations. Additionally, the use of the
17
uncommon calcifediol supplement instead of regular vitamin D3
supplements raises the question of whether D3 supplements that
raised 25-OH-D levels to the same degree would have a similar
effect.
What’s the take-home?

Vitamin D supplementation using a relatively uncommon form (25-OH-D, or calcifediol) improved
asthma control and quality of life, and reduced asthma exacerbations in people with asthma and
low starting vitamin D levels.
This was a convincing and well-performed clinical trial with reliable results and a few minor
methodologic issues that did not invalidate the results. It’s also unclear whether similar results
could have been obtained with the more common form of vitamin D3 found in supplements, as
opposed to calcifediol.
If cholecalciferol were used in this trial and raised 25-OH-D levels

to the same degree, do you think it would have worked? Have your
say and read other people’s thoughts on this research at the
private Study Deep Dives Facebook forum.
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 References
1. ^ Paul E Pfeffer, et al. Vitamin D influences asthmatic pathology through its action on
diverse immunological pathways. Ann Am Thorac Soc. (2014)
2. ^ Sannette C Hall, Kimberly D Fischer, Devendra K Agrawal. The impact of vitamin D
on asthmatic human airway smooth muscle. Expert Rev Respir Med. (2016)
3. ^ Emma O Billington, et al. Safety of High-Dose Vitamin D Supplementation:
Secondary Analysis of a Randomized Controlled Trial. J Clin Endocrinol Metab.
(2020)
4. ^ E Rand Sutherland, et al. Vitamin D levels, lung function, and steroid response in
adult asthma. Am J Respir Crit Care Med. (2010)
5. ^ John M Brehm, et al. Serum vitamin D levels and severe asthma exacerbations in
the Childhood Asthma Management Program study. J Allergy Clin Immunol. (2010)
6. ^ David Reid, et al. The relation between acute changes in the systemic inflammatory
response and plasma 25-hydroxyvitamin D concentrations after elective knee
arthroplasty. Am J Clin Nutr. (2011)
7. ^ Waldron JL, et al. Vitamin D: a negative acute phase reactant. J Clin Pathol. (2013)
8. ^ Liu X, Baylin A, Levy PD. Vitamin D deficiency and insufficiency among US adults:
prevalence, predictors and clinical implications. Br J Nutr. (2018)
9. ^ A Turkeli, et al. Effects of vitamin D levels on asthma control and severity in pre-
school children. Eur Rev Med Pharmacol Sci. (2016)
10. ^ Adrian R Martineau, et al. Vitamin D for the management of asthma. Cochrane
Database Syst Rev. (2016)
11. ^ Jian Luo, Dan Liu, Chun-Tao Liu. Can Vitamin D Supplementation in Addition to
Asthma Controllers Improve Clinical Outcomes in Patients With Asthma?: A Meta-
Analysis. Medicine (Baltimore). (2015)
12. ^ Mario Castro, et al. Effect of vitamin D3 on asthma treatment failures in adults with
symptomatic asthma and lower vitamin D levels: the VIDA randomized clinical trial.
JAMA. (2014)
13. ^ Martineau AR, et al. Double-blind randomised placebo-controlled trial of bolus-dose
vitamin D3 supplementation in adults with asthma (ViDiAs). Thorax. (2015)
14. ^ a b Manuel Sosa Henríquez, M Jesús Gómez de Tejada Romero. Cholecalciferol or
Calcifediol in the Management of Vitamin D Deficiency. Nutrients. (2020)
15. ^ a b Glenville Jones. Pharmacokinetics of vitamin D toxicity. Am J Clin Nutr. (2008)
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16. ^ Robert P Heaney, et al. Human serum 25-hydroxycholecalciferol response to
extended oral dosing with cholecalciferol. Am J Clin Nutr. (2003)
17. ^ a b c J M Quesada-Gomez, R Bouillon. Is calcifediol better than cholecalciferol for
vitamin D supplementation?. Osteoporos Int. (2018)
18. ^ a b Holick MF, et al. Evaluation, treatment, and prevention of vitamin D deficiency:
an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. (2011)
19. ^ Robert A Nathan, et al. Development of the asthma control test: a survey for
assessing asthma control. J Allergy Clin Immunol. (2004)
20. ^ Michael Schatz, et al. The minimally important difference of the Asthma Control
Test. J Allergy Clin Immunol. (2009)
21. ^ E F Juniper, et al. Development and validation of the Mini Asthma Quality of Life
Questionnaire. Eur Respir J. (1999)
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Deep Dive: Micronutrients with micro-
effects for preventing and treating acute
respiratory infections
 Tags: Respiratory Tract Infection, Meta-analysis, Supplementation, Zinc, Vitamin C, Vitamin D
 Study under review: Effect of micronutrient supplements on influenza and other

respiratory tract infections among adults: a systematic review and meta-analysis
Quick Takes
• What was the question? How does vitamin and mineral
supplementation affect the risk of contracting acute
respiratory infections (ARIs) and their symptom duration?
• How was it answered? Researchers conducted a meta-
analysis of randomized controlled trials.
• Who was studied? A broad range of people mostly from
high-income countries participated in the study.
• What was the intervention? Participants took mostly
vitamin C, vitamin D, zinc, and mixed micronutrient
supplements.
• What’s the main takeaway? Supplementation with vitamin
C and D lowered the risk of ARIs and their duration by a
small but measurable amount. There was no clear evidence
that zinc supplementation prevented ARIs, but it cut the
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duration of symptoms by roughly half.
• Any caveats? The trials included in the meta-analysis often
had moderate to high risk of bias, which may mean these
estimates have a decent chance of being off. The
researchers were unable to assess impact on symptom
severity due to the wide variety on how this outcome was
measured across studies, making the studies very difficult to
compare.
Introduction
Acute respiratory tract infections (ARIs) are the third leading cause of death globally, accounting for
approximately 4 million deaths worldwide each year. ARIs are primarily caused by viruses[1] (e.g.,
rhino, corona, adeno, and influenza) infecting the respiratory tract, meaning the nose, sinuses,
throat, and lung. To date, there are over 200 viruses[2] known that cause ARIs. Common symptoms
of RTIs[3] include coughing, a sore throat, nasal congestion, runny nose, sneezing, and fever. In
severe cases, ARIs can become life-threatening, especially in people with an underlying health
condition or a weakened immune system[4]. One of the most common and severe ARIs is seasonal
influenza[5], with an annual 3–5 million cases and more than 300,000 deaths globally[6]. Since
antibiotics are useless for treating ARIs caused by respiratory viruses, other potential prevention
and treatment options[7] are of substantial public health interest. The current COVID-19 pandemic[8]
highlights the urgency of finding effective, safe, and widely available ways to prevent and treat
ARIs.
Supplementation with micronutrients[9] is one possible strategy for preventing and treating ARIs.
Decades of research have accumulated a large body of evidence on various micronutrients, most
notably vitamin C[10], which has been researched for over 80 years. Micronutrients with the most
robust evidence for immune support are vitamins C and D and zinc[11]. However, there remains a
substantial controversy concerning the effectiveness of supplemented micronutrients for preventing
and treating ARIs. Here is a quick look at the current literature on the three main micronutrients
used for the prevention and treatment of ARIs:
22
Vitamin C
Vitamin C (ascorbic acid)[12] is a water-soluble essential nutrient and a very popular dietary
supplement due to its antioxidant properties, safety, and low price. In 1970, Nobel laureate Linus
Pauling[13] claimed that vitamin C prevents the onset and alleviates symptoms of the common cold.
Over 50 years later, many researchers ask: Was he right? A recent Cochrane meta-analysis[2]
found that vitamin C supplementation did not influence getting a cold, but once infected, vitamin C
reduced the duration of symptoms by 8% in adults and 14% in children, and lowered the severity of
symptoms. In contrast, marathon runners, skiers, and soldiers showed a 50% decreased risk of
getting a cold when supplementing vitamin C. However, the authors advise treating these findings
with caution, as their practical relevance still seems unclear. Why is that? Overall, the current
evidence and low level of benefit do not justify long-term supplementation in its own rights, the
authors claim. Yet, given its low cost and high safety, vitamin C supplementation may be worth
considering for people prone to infections and in periods of intensified stress, such as physical
exertion. Two recent[14] meta-analyses[15] also concluded that vitamin C does not prevent the
incidence of the common cold and has minimal or no effect on its duration. Overall, the use of
vitamin C for ARI prevention or treatment remains a subject of considerable controversy.
Vitamin D
Low levels of vitamin D are linked to worse immune function[16] and increased incidence rates of
ARIs[17], suggesting that supplementation could prevent them. A recent review[18] outlines the
mechanisms of vitamin D’s modulatory effects on innate and adaptive immunity in the context of
viral infections. Based on its immunomodulatory functions, the authors concluded that vitamin D is
a safe and inexpensive form of adjunct therapy. Indeed, there is a large body of evidence on
vitamin D’s ability to prevent and treat ARIs. Two major-meta-analyses support this idea:
A preprint of the most recent meta-analysis[19] from November 2020 investigated the effect of
vitamin D supplementation in 46,331 participants ages 0–95 years from 45 randomized controlled
trials (RCTs). In this study, vitamin D reduced the odds of incident ARI by 9% (odds ratio, OR
0.91). Interestingly, this effect was independent of baseline vitamin D levels, dose frequency, dose
size, and study duration. Furthermore, the researchers also reported a significant heterogeneity
across trials (I2 = 37%) and potential publication bias. Using subgroup analysis, they found that
vitamin D’s protective effects were most notable when given at a daily dose of 400–1,000 IU (OR
0.70) for up to 12 months (OR 0.82). A subsequent exploratory analysis of RCTs fulfilling these
criteria yielded a more significant protective effect of vitamin D (OR 0.58) without significant
heterogeneity. These findings indicate that dose and duration could matter when it comes to
vitamin D supplementation to prevent ARIs.
23
Another previous meta-analysis from 2017[20] covered in Study Deep Dives #31 (May 2017)
analyzed individual participant data from 25 studies. This study also showed that vitamin D
supplementation (daily or weekly, but not in large bolus) lowered the odds of ARI if vitamin D levels
were deficient (less than 10 ng/mL or less than 25 nmol/L), but not in people with greater than 10
ng/mL (greater than 25 nmol/L) levels. Combined with the meta-analysis from 2020, these findings
suggest that dose and duration, as well as frequency and baseline levels, may matter when it
comes to judging the efficacy of vitamin D supplementation.
Zinc
Zinc is an essential mineral that plays numerous roles in the body, most notably as a catalytic and
structural cofactor in hundreds of metalloproteins[21]. Often regarded as the gatekeeper of immune
function[22], zinc plays an essential role in regulating pathways involved in innate and adaptive
immunity. When taken in small doses repeatedly over the day, total daily doses of 10–40 mg zinc
seem to substantially reduce the duration of common colds, as suggested by a recent meta-
analysis[23]. However, it’s unclear if zinc also reduces the risk of getting colds. Furthermore, high
doses may have notable side effects[24], including nausea, diarrhea, and vomiting. In severe cases,
chronic zinc toxicity[25] (ingestion of more than 1 gram of zinc once or long-term supplementation
with more than 100 mg zinc daily) manifests as copper and iron deficiency, with case[26] studies[27]
reporting fatal outcomes.
In summary, the evidence suggests that zinc, vitamin C, and D supplementation may have some
benefits for preventing and treating ARIs. Yet, the influence of dose and combinations of multiple
micronutrients on individuals of different age groups remains mostly unclear. Understanding these
influences is crucial to develop suitable supplementation strategies for effective and safe
prevention and treatment of ARIs. The present systematic review and meta-analysis was thus
designed to synthesize the current evidence from RCTs on micronutrient supplementation to
prevent and treat ARIs in adults.
24
Figure 1: The lowdown on previous evidence about
vitamin C, vitamin D, and zinc
Does it prevent ARIs? Does it reduce Which dosing regimen has
symptoms? the best chance of
working?
Vitamin Not for most people, but Not duration, 1–8 grams daily at the onset
C probably in highly active but maybe of symptoms, ceasing after
athletes. severity: around symptom resolution.
8% in adults,
and 14% in
children.
Vitamin Reduces odds of infection by Unclear: not 400–1,000 IU daily over the
D around 9%, with better well studied. longer term.
outcomes over longer time
periods, lower dose, or in
people with lower baseline
levels
Zinc Probably not. Maybe severity, Lozenges containing zinc

but more likely acetate or gluconate at the
duration, which onset of symptoms and
is cut by ceasing after symptom
roughly three resolution.
days. Daily total dose above 75 mg
of elemental zinc daily may
work best.
There’s some reason to
suspect zinc acetate may be
more effective than the
gluconate salt, but there’s
evidence that both work.
References: Hemilä et al. Cochrane Database Syst Rev. 2013 Jan.[2]
25
Martineau et al. BMJ. 2017 Feb.[20]
Jolliffe et al. medRxiv. 2020 Nov.[19]
Wang et al. Am J Trop Med Hyg. 2020 Jul.[23]
Hemilä et al. Open Forum Infect Dis. 2017 Apr.[28]
ARIs are a leading cause of death globally. Supplementation with

micronutrients such as vitamin C, vitamin D, and zinc may be a
beneficial, relatively safe, and cost-effective strategy to prevent
and treat ARIs. However, the evidence remains mostly obscure,
specifically regarding the influence of dosage and combinations of
micronutrients in various age groups.
What was studied?

The present study is a systematic review and meta-analysis of 70 RCTs published as of March
2020 that investigated the effects of micronutrients (vitamins A, B, C, D, E, and zinc) on ARI
prevention and treatment. The researchers included 80 RCTs in the qualitative analysis and 70
RCTs in the quantitative meta-analysis. The collected studies are from 17 high-income and 5 low-
and middle-income countries between 1942 and 2019. Notably, the researchers did not preregister
the meta-analysis.
The researchers focused on four micronutrients in their meta-analysis: vitamin C (32 studies),
vitamin D (20 studies), zinc (16 studies), and multiple micronutrient supplementation (MMS, 7
studies). Vitamin A (3 studies) and vitamin E (4 studies) were evaluated but not meta-analyzed due
to the low number of available RCTs. The researchers assessed the effectiveness of micronutrient
supplements in two aspects: preventing ARIs (as risk ratios, RR) and reducing the duration of ARI
symptoms (as percent change). The effect of different doses and specific types of ARIs such as the
common cold were examined, when possible.
Figure 2: Study characteristics
26
The researchers used a random-effects model for the meta-analysis. Heterogeneity was evaluated
using the Higgins’ I2 statistic[29], which measured the total variability of between-study variation.
The researchers defined 50% to 90% as substantial heterogeneity and more than 90% as
considerable heterogeneity. The risk of bias was analyzed using the Cochrane Collaboration’s
revised tool for assessing the risk of bias in randomized trials[30]. Publication bias was assessed
using funnel plots. Notably, the researchers state that the risk of bias did not influence inclusion or
analysis decisions.
The present study is a meta-analysis of 70 randomized controlled

trials investigating the effects of micronutrient supplementation on
27
the occurrence of ARIs and the duration of ARI symptoms. The
researchers reported on four primary micronutrients: vitamins C
and D, zinc, and mixed micronutrient supplements.
What were the findings?

The researchers meta-analyzed four micronutrients: vitamin C, vitamin D, zinc, and multiple
micronutrient supplementation (MMS).
Vitamin C
Vitamin C supplementation showed a small but significant 4% risk reduction for the occurrence of
ARIs and the common cold, respectively. Furthermore, the duration of symptoms was significantly
reduced by 9% for both ARIs and the common cold. However, the data set used to investigate the
duration showed substantial heterogeneity, meaning the participants pooled from the individual
RCTs were very different.
All effects were independent of dose and age but influenced by sex and geographical location.
Vitamin C reduced the risk of ARI occurrence by 18% for men, while no significant effect was found
for women. Furthermore, with 35% the risk reduction with supplemental vitamin C was higher in
middle-income countries than in high-income countries.
Vitamin D
Second, vitamin D reduced the risk of ARIs by 3% and the duration of symptoms by 6% without
showing any significant heterogeneity or evidence of publication bias. Yet, the effect was
dependent on the data acquisition of the clinical diagnosis: When considering clinical diagnosis and
laboratory testing while removing self-reported diagnosis by participants, vitamin D reduced the risk
of ARI occurrence even more, by 18%. In contrast to vitamin C, the effect of vitamin D on ARI
occurrence (but not the duration of symptoms) was dose-dependent: Higher doses of vitamin D
(more than 2,000 IU per day, 10% risk reduction) had a more substantial effect than lower doses
(0–2,000 IU per day, 3% risk reduction) on the occurrence of ARIs. The optimal amount for a
loading dose was less than 60,000 IU, which reduced risk by 8%.
28
Zinc
Zinc supplementation had no significant effect on preventing ARI, irrespective of dose, sex,
geographical location, and study duration. However, zinc substantially shortened the duration of
ARI symptoms by 47% and the common cold by 59%. Yet, the researchers found considerable
heterogeneity across trials on ARIs (I2 = 94%) and the common cold (I2 = 93%). For example,
zinc’s effect on the reduction of symptom duration was opposite in Australia (+440%) and North
America (-268%). However, both effect estimates showed very high confidence intervals and were
not statistically significant. The implications of this considerable heterogeneity is discussed in detail
below.
Figure 3: Relative reduction in risk of contracting ARI

and length of ARI symptoms, with 95% confidence
intervals
29
Lastly, the researchers aimed to analyze the effect of multiple micronutrient supplements (MMS) on
the occurrence of ARI and duration of symptoms. However, the diverse formulations used in the
available RCTs made a pooled meta-analysis impossible. Instead, they evaluated the RCTs on an
individual basis. Overall, seven studies examined the effect of MMS on ARI occurrence among
4,510 adults. Four studies found no significant ARI-preventive effects, while two RCTs reported
significant risk reductions. The first RCT found a significant risk reduction of 40% for 59 Mexican
participants over 13 weeks. The MMS supplement consisted of a wide variety of vitamins (A, B1,
B2, B3, B6, B12, C, and D) and minerals (zinc, copper, manganese, selenium, calcium), some above
RDA and some below. The second RCT was performed with 178 ultra-marathon runners in South
Africa over five weeks and found a significant ARI-preventive effect (RR 0.79) for a mixture of
vitamin A, C, and E. However, due to the low number of RCTs and lack of any meta-analysis, the
researchers were unable to make any general conclusions on this specific topic.
30
Overall, vitamin C, and D lowered the risk of ARI occurrence and
the duration of symptoms to a small but measurable amount. In
contrast, zinc showed no ARI-preventive effect but reduced the
duration of symptoms for ARIs (-47%) and the common cold
(-59%) substantially. However, the data showed considerable
heterogeneity. Furthermore, the study found a dose-dependent
effect only for vitamin D, but not vitamin C and zinc. Also, some
results differed based on sex and geographical region.
The bigger picture

After decades of research on micronutrients, one might assume that the current evidence is
compelling and clear. Yet, the present meta-analysis illustrates that this is not the case. While zinc
showed a substantial reduction of ARI duration, vitamin C and D were only modestly effective in
preventing and treating ARIs. Hence, the authors questioned if the effects of vitamin C and D
would be clinically meaningful. In the era of COVID-19, this conclusion can seem frustrating.
Unfortunately, the present topic is far too complex to come up with a simple conclusion. Each
micronutrient should be discussed independently to evaluate their effectiveness and the level of
certainty of the evidence.
Vitamin C
Vitamin C showed a small ARI-protective effect and shortened the duration of symptoms
significantly for ARIs and the common cold. These findings are consistent with evidence from the
most recent Cochrane meta-analysis[2] described above. However, there are three surprising
findings worth discussing.
First, the effects of vitamin C on ARIs were independent of dose. This lack of dose-dependency is
surprising, as previous literature suggests otherwise. For example, a recent meta-analysis[31] found
that extra doses of vitamin C upon incident common cold (i.e., increasing vitamin C intake when
getting a cold) reduced the duration and severity of symptoms. Another meta-analysis[32] also
found greater benefits for children taking more than 2 grams of vitamin C daily, compared to only 1
31
gram per day. One possible way to explain this discrepancy may be found in the inherently high
heterogeneity across trials, as reported by the present study’s authors. For now, the data on the
dose-dependency of vitamin C are scattered, and further trials are needed before any clear
conclusion can be made.
Second, vitamin C’s effect on ARIs was larger in low- and middle-income than in high-income
countries. As suboptimal vitamin C intakes are more common in low- and middle-income than in
high-income countries, one possible explanation is that the effectiveness of vitamin C hinges upon
the baseline levels. In other words, if your vitamin C levels are low, you may benefit more than
someone whose vitamin C status is high. Unfortunately, baseline vitamin C levels could not be
assessed in the present study, as most RCTs did not report them. Nevertheless, the observed
effect suggests that people from low- and middle-income countries benefit more from vitamin C
supplementation regarding ARIs.
Third, the ARI-preventive effect of vitamin C was stronger in men than in women. Previous[33]
research[34] also found sex differences in the effectiveness of vitamin C for preventing and treating
ARIs. How can that be? One explanation might be that men and women metabolize vitamin C
differently. However, previous research suggests that the pharmacokinetics of vitamin C[35] and the
metabolic adaptations induced by vitamin C deficiency are similar between men and women.
Another explanation would be that women often have higher vitamin C status and a lower
prevalence of deficiency than men[36]. However, the exact reasons remain unclear until more
research is conducted.
Overall, the current evidence suggests that vitamin C is safe and moderately effective in preventing
and treating ARIs, showing the most benefits for male participants and participants from low- and
middle-income countries.
Vitamin D
Vitamin D also showed a reduced risk of getting an ARI and shortened the duration of symptoms.
These results are in agreement with previous[20] meta-analyses[19]. However, in contrast to these
previous studies and the present findings of vitamin C, vitamin D’s effect was dose-dependent. The
authors found an optimal daily dose of more than 2,000 IU of vitamin D. In contrast, the dose-
response relationship for the loading dose was inverted: loading doses up to 60,000 IU showed
ARI-preventive effects, while doses of more than 60,000 IU did not. One possible explanation here
is that large amounts of vitamin D could disrupt the enzymatic metabolism of vitamin D[37].
However, to gain the most protective effects of vitamin D, dosing should both be sufficiently high
and stable over time. As evidenced by a previous meta-analysis[20], more frequent vitamin D doses
are most effective in preventing colds. Why? One possible explanation is that vitamin D may play a
32
role as a negative acute phase reactant[38], meaning vitamin D is reduced during acute infection or
inflammation. If this were true, frequent medium doses of vitamin D would work best.
Another important issue worth discussing is the type of ARI diagnosis used in the RCTs. The ARI-
preventive effect of vitamin D was stronger when the researchers analyzed the data based on
clinical diagnosis and laboratory testing rather than self-reporting. This finding may illustrate the
importance of data quality: self-reporting seems to be a less accurate measure of ARI incidence
than clinical diagnosis and laboratory testing. Thus, self-reporting may dilute the data to an extent
where it becomes more difficult to identify significant associations due to reduced statistical power.
In other words, assessing outcomes by self-reporting of participants seems to be a considerable
risk of bias. Future RCTs with improved outcome assessment are required to delineate the effects
of vitamin D in preventing and treating ARIs.
Another point worth discussing is that one study had a disproportionately large effect on the results
of vitamin D. Without this study, the pooled effect estimates would be not significant. One possible
explanation is that this study included primarily young participants (mean age: 19 years) taking high
doses (10,000 IU daily). Further, the outcome assessment was performed with laboratory tests
rather than self-reporting. This study illustrates that adequate dosing and accurate outcome
assessment are relevant issues to control for.
Overall, the present meta-analysis supports a beneficial role of vitamin D in treating and preventing
ARIs. Future studies should take into account vitamin D dosing and include better outcome
assessments.
Zinc
In contrast to vitamin C and D, zinc did not help in terms of contracting ARI. Yet, it lowered the
duration of symptoms of both ARIs and common cold substantially (-47% and -59%, respectively).
Zinc’s symptom-shortening effect agrees with previous research: A recent systematic review from
2020[23] also found that zinc supplementation did not prevent getting a cold, but reduced the
common cold duration by 2.25 days on average.
However, this average should be taken skeptically because of the huge heterogeneity (I2= 94%). A
vivid example from the present study illustrates this point: Subgroup analysis showed that zinc
supplementation in Australia increased the duration of symptoms by 440% while being shortened
by 268% in the U.S. Averaging the overall effect estimates then yields the above-stated -47%
reduction in duration of symptoms. Does this sound ridiculous? Well, the data is what the data
is—and this is what the researchers had to work within their meta-analysis.
To summarize, there is moderate certainty of evidence across multiple meta-analyses that zinc
33
supplementation reduces the duration of symptoms for ARIs. However, the high heterogeneity
across RCTs impedes the determination of accurate and precise effect sizes.
The results of the present study are in good agreement with

previous meta-analyses. Overall, there is moderate evidence that
zinc, vitamin C, and D may help treat ARIs, and that vitamin C and
D may help prevent ARIs. However, the available research exhibits
significant limitations, most notably: substantial heterogeneity, a
considerable risk of bias, suboptimal outcome assessment,
unknown baseline parameters, and lack of well-defined dose-
response relationships. These limitations combined with the overall
small effect size make it difficult to conclude if the observed effects
are real or clinically meaningful. More research taking these
limitations into account is desperately needed.
Frequently asked questions

Q. Which micronutrients can be used to prevent and treat SARS-CoV-2?
SARS-CoV-2 is a relatively new coronavirus that emerged in December 2019 in Wuhan, China.
Hence, there are no long-term RCTs available investigating the effects of micronutrients to prevent
and treat SARS-CoV-2.
However, there are a lot of hypotheses[39][40][41] based on in vitro data and/or study results from
different viral infections outlining the potential mechanisms of micronutrients in COVID-19 and often
recommend supplementation, especially for older people and people with deficiencies. In these
studies, the authors often claim that the protective effects of micronutrients could be used for
COVID-19. However, extrapolating from colds to COVID-19 is speculative and potentially
dangerous. A position statement by the International Society For Immunonutrition also
recommends increasing the intake of micronutrients (vitamin C, E, D, and zinc). However, they
make a crucial distinction and disclaimer, by stating, “There is no specific evidence these nutritional
measures can help protect against or even lessen the effects of COVID-19 infection.”
34
In summary, it’s clear that a diverse and well-balanced diet covering all essential micronutrients in
adequate amounts (but not exceeding RDAs) supports and strengthens the immune system.
Whether this is helpful for preventing and treating SARS-CoV-2 remains to be researched in RCTs.
Q. How do I know if micronutrients might be beneficial for me?
If you are healthy and eat a well-balanced, diverse diet, chances are you don’t need a
micronutrient supplement. However, in special cases, micronutrient supplementation could make
sense. People with deficiencies often benefit more from micronutrient supplementation. For
example, vitamin D supplementation is most beneficial for people with low baseline levels[20].
However, people with sufficient baseline levels showed only a slight risk reduction for ARI. Another
example is high-performing athletes, especially during periods of intensified training and/or
competition. The most recent Cochrane review[2] showed that marathon runners, skiers, and
soldiers performing subarctic exercises showed a substantial risk reduction (RR 0.48) of getting a
cold when supplementing vitamin C. If you are a high-performing athlete, this could make a
practical difference to your performance.
In general, beware of toxic overdosing and the potential side effects when supplementing minerals
such as zinc[25] and water-insoluble vitamins such as vitamin D[42]. Overall, the usefulness of
micronutrient supplementation most often requires individual consideration. Hence, it’s difficult to
make any generalized recommendations.
What should I know?

ARIs are a leading cause of death globally. Each year, influenza alone accounts for 3–5 million
cases and more than 300,000 deaths globally. Supplementation with micronutrients such as zinc,
vitamin C, and D is one strategy some people recommend to prevent and treat ARIs.
The present study is a meta-analysis of 70 RCTs from 1942 to 2020 that investigated the effects of
these micronutrients for preventing and treating ARIs. Vitamin C and D reduced the risk of infection
and duration of symptoms moderately. In contrast, zinc did not show any ARI-preventive effect but
shortened the duration of ARI symptoms.
Overall, these results are in agreement with multiple previous meta-analyses. However, the current
body of literature exhibits significant issues, such as high heterogeneity, risk of bias, and
suboptimal study quality. These limitations make it difficult to judge if the observed effects are
clinically meaningful and thus restrict any generalized recommendations. Nevertheless, due to the
relatively high safety and low costs, micronutrients hold a great promise of being used as an
adjunct therapy one day. Until then, more research is required to reinforce the present findings.
35
Do the micro-effects of micronutrient supplementation justify their
usage for you? Have your say in the Study Deep Dives Facebook
forum.
36
 References
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Diagn Pathol. (2019)
2. ^ a b c d e Hemilä H, Chalker E. Vitamin C for preventing and treating the common
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4. ^ Elie Azoulay, et al. Diagnosis of severe respiratory infections in
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Response against Viral Infections. Nutrients. (2020)
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Rev. (2008)
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Function. Nutrients. (2017)
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39. ^ Juliana Arruda de Souza Monnerat, et al. Micronutrients and bioactive compounds
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Nutr. (2021)
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Nutrients. (2013)
39
The effects of full fasting vs. modified
fasting on cognitive performance
 Tags: Fasting, Cognition, Food Cravings, Hunger
 Study under review: Modified Fasting Compared to True Fasting Improves Blood
Glucose Levels and Subjective Experiences of Hunger, Food Cravings and Mental Fatigue,
But Not Cognitive Function: Results of an Acute Randomised Cross-Over Trial
Quick Takes
• What was the question? How does full fasting affect hunger
and mental functioning compared to partial fasting?
• How was it answered? Researchers conducted a
randomized crossover trial.
• Who was studied? Adult women with an average BMI of
25.8 (borderline overweight) in generally good health
participated in the study.
• What was the intervention? The participants followed three
conditions, separated by a week: an overnight fast followed
by no food for most of the following day (“full fasting”), or
around 500 calories spread out over the day, or two meals
both early in the day (“modified fasting”).
• What’s the main takeaway? Cognition was not affected by
any fasting regimen, while fatigue and hunger increased in all
40
regimens. People in the full fasting group also may have
experienced increased mental fatigue.
• Any caveats? The researchers measured multiple
outcomes, which suggests these results should be seen as
preliminary. Also, the meals used in the modified fasting
protocols were liquid replacement meals and snack bars,
raising the question of whether the results would have been
different with typical foods. In addition, all groups were given
100 kcal of vegetable snacks to eat if they wanted to
throughout the day, which isn’t quite consistent with full
fasting.

How does modified fasting (around 500 kcal per day spread out over either two or three meals)
compare to true fasting (0 kcal per day) with respect to blood glucose, hunger, food cravings,
mental fatigue, and cognitive performance?

An increasingly popular method for weight loss is fasting.
Fasting can be implemented in many different ways. One example is alternate day fasting, which
can improve chronic disease risk factors and cause weight loss[1]. Another example is the
Buchinger method[2], characterized by medically supervised fasting that involves consuming a
liquid diet and relaxing activities such as reading, music, viewing paintings, nature, humor, and
meditation. A less esoteric type is intermittent fasting, with periods of fasting interspersed by
periods of eating in the same day, which has also shown promise for the treatment of obesity[3].
The authors of this study used a similar method of intermittent fasting, which they called modified
41
fasting. True fasting is another form of fasting, which includes a zero calorie diet on some days.
True fasting was the focus of this study.
One of the issues with dieting, and even more so with fasting, is that it might affect mood and work
capacity, so it’s important to understand how different types of diets affect cognitive performance.
Previous research indicates that two days of a 313 kcal diet doesn’t affect cognitive performance,
ambulatory vigilance, activity, or sleep[4]. Other research agrees, finding a zero calorie diet does
not affect cognitive performance[5]. The current study adds to these findings by comparing true
fasting to two forms of modified fasting (about 500 kcal) and measuring how they affect mood,
hunger, cravings, blood glucose, and cognitive performance over the course of a typical 7.5 hour
workday.
True fasting is a method of fasting during which zero calories are

consumed. The current study compared true fasting to modified
fasting, during which small amounts of calories are consumed, by
measuring changes in cognitive performance, blood glucose,
satiety, and hunger.

The trial was preregistered and used a randomized crossover design, which incorporated three
different fasting conditions with outcomes tested over 7.5 hours. There was a seven-day washout
period between conditions. There were 18 women 21–49 years old with a BMI of 25.8 and in good
health who participated in the study.
The participants were randomized to start the trial in one of three groups: fasting, 2-meal, or
3-meal. The two non-fasting groups together were termed “modified-fasting groups” by the authors,
so this review uses that terminology in the absence of internationally accepted terms for different
types of fasting.
Once the participants were assigned their group, they were instructed to show up for a day of
experimentation. All participants arrived in the morning of each phase in a fasted state, which was
confirmed via a blood glucose reading of no more than 4.5 mmol/L (81 mg/dL). Then the
experiment began, with the details depending on the condition.
42
The fasting group ate no food over the 7.5 hours. The two modified-fasting groups were given
liquid meal replacements and snack bars. As shown in Figure 1, the 2-meal group consumed two
liquid meal replacements (512 kcal total) with one meal eaten at 9:30 a.m. and the other at 11:30
a.m. The 3-meal group received one liquid meal replacement and two snack bars (522 kcal total)
with the liquid meal consumed at 9:30 a.m. and the snack bars eaten at 12:30 p.m. and 3:30 p.m.
All groups were also given three small baggies of celery, cucumber, and pepper totalling 100 kcal,
and were allowed to consume these if they felt they needed to stave off hunger. They were also
allowed to consume unlimited amounts of water, but no other beverages were permitted.
Figure 1: Study design
While the authors did not declare a single primary outcome, one of the main outcomes of the study
was cognitive function as measured by the CSIRO Computerise Fatigue Battery, which consists of
three tasks. These tasks measure psychomotor vigilance, interference, and arithmetic. Another
outcome, subjective fatigue, was measured using a visual analog scale. The cognitive
measurements were taken at 7:30 a.m. (practice), 8:30 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m.,
and 4:00 p.m. Other outcomes included blood glucose as well as food and satiety questionnaires.
These measurements were taken at 8:30 a.m., 10:00 a.m., 11:00 a.m., 12:30 p.m., 1:00 p.m., 2:00
p.m., 3:00 p.m., and 4:00 p.m.
43
Once the first phase was over, there was a seven-day washout period before the participants
returned to participate in a different dieting condition. This process continued until the participants
completed all three phases.
Healthy middle-aged women were studied in a randomized cross-

over design for 7.5 hours per day on three different days while they
were following fasting or modified fasting diets. Measures of
cognitive function, mental fatigue, blood glucose, satiety, and
hunger were taken at multiple points between 8:30 a.m. and 4:00
p.m.

Cognitive performance did not significantly change over the course of the day as measured by the
CSIRO Computerised Fatigue Battery in any of the groups. Some of the subtasks did show worse
performance late in the day, but there was no difference between the groups. Overall, this data
indicates cognitive performance was not strongly affected over 7.5 hours when using a fasting or
modified fasting approach.
Blood glucose decreased over the course of the day for the fasting group. When measuring overall
glucose levels throughout the day, the 3-meal group had higher blood glucose than the fasting
group, but was not different from the 2-meal group. These changes were likely due to the meal
timing and blood glucose response because the 2-meal group had all of their food by 11:30 a.m.,
but the 3-meal group had snack bars at 12:30 p.m. and 3:30 p.m.
Mental fatigue was significantly higher than baseline for the fasting group only at 2:00 p.m., at
which point mental fatigue was also significantly higher than the 2-meal group. There was also a
difference in that the fasting group had higher mental fatigue than both other groups at 12:00 p.m.
These changes may be a result of food intake because the 2-meal group ate at 11:30 a.m. while
the 3-meal group did not.
Hunger increased throughout the day for the fasting group, and was significantly higher compared
to the 2-meal and 3-meal group at all timepoints except baseline. There were no differences in
hunger between the 2-meal or 3-meal group, which is understandable since they consumed about
44
the same amount of calories during the 7.5 hour experimental period.
There was a significant increase in sweet, salty, savory, and fatty cravings from 12:00 p.m. onward
for all groups, with all types of cravings generally being higher in the fasting group compared to the
two other groups. The frequency of questions asked about food over this short time might have
affected these results.
The results, with more nitty-gritty details for mental fatigue, are summarized in Figure 2.
Figure 2: Results in a nutshell
Cognitive performance was not affected over 7.5 hours during a

fasting or modified fasting approach. There were significant
45
decreases in blood glucose, fullness, and significant increases in
fatigue and hunger for all forms of fasting. Mental fatigue was
higher in the afternoon in the fasting group than the other groups.

There are several different types of fasting, with true fasting (0 kcal) being the most extreme
version. This study found there was no difference in cognitive performance between true fasting
and modified fasting. On the other hand, the subjective experience of modified fasting appears to
be different for true fasting, which is due to an increase in hunger and food cravings. The
participants in the fasting group also had more mental fatigue at some time points, and a general
increase over time.
A meta-analysis of 10 studies[6] examining the cognitive impact of fasting on healthy individuals

was completed in 2014. The authors found no major effects of fasting on cognition in healthy adults
— not one cognitive function was consistently affected. The fasting period in these studies ranged
from 5 to 24 hours. Another study[4] using two days of very low calorie diets (313 kcal) or true
fasting (0 kcal) found that neither condition affected cognitive performance, activity, sleep, and
mood of healthy young adults. This combination of data clearly supports the results of the study at
hand, which found that fasting doesn’t decrease the ability to perform mentally in the short term.
The participants in this study were healthy, which is exemplified by their normal blood glucose
levels[7] at the beginning of the study. In the fasting group, blood glucose declined over the course
of the day. There is some debate about how low blood glucose can drop when fasting, with some
data indicating fasting blood glucose levels off[8] at about 8 hours. There is also data indicating that
cognitive performance declines when blood glucose falls less than 3.6 mmol/L[9]. This could be one
of the reasons cognitive performance was maintained in this study because all groups stayed
about 4.0 mmol/L during the experiment. The results of the current study are limited to the 7.5 hour
time course the authors used. It could be that over consecutive days of fasting, cognitive
performance and mental fatigue decreases. Research on longer periods of fasting indicates a
positive shift in mood that coincides with the metabolic shift to ketone utilization[10] when fasting for
10 days.
A major limitation of the current study is the duration of the fast lasting only 7.5 hours. Practically,
this is equivalent to skipping breakfast and lunch but eating dinner. This method could be relevant
46
to time-restricted feeding, but not necessarily longer fasting periods, which is a common way of
implementing fasting. However, the relevance to TRF is also limited because most people would do
TRF every day with a smaller deficit, rather than only fasting once.
Another limitation is that the participants were offered a snack consisting of celery, peppers, and
cucumbers. It’s unclear how many of the participants ate the snack because this wasn’t reported,
but if they did, then this study may not represent true fasting. How much this deviation matters is
debatable, but it’s something to keep in mind.
An additional limitation to consider is the large amount of variables the researchers measured
without making adjustments for multiple comparisons and without naming a single, clear primary
outcome. The combination of the small size of the study alongside the multiple measurements
suggests that these results should be taken as preliminary.
Another limitation is that the study only included women. There is some evidence to suggest there
are sex differences in neural activity related to hunger and satiety[11], which may translate into
gender differences in cognitive performance or mental fatigue. So, extrapolating the current
findings to men should be done with caution.
Finally, the current study used liquid meal replacements and snack bars, neither of which have a lot
of food volume. This could influence cravings or satiety because fluid content can influence satiety
and hunger[12] and the authors did not report the volume or amount of liquid in the meal
replacements or the amount of water consumed throughout the day.
Both this study and other evidence suggests that fasting and
modified fasting does not reduce cognitive performance in the
short term, but true fasting alone may increase mental fatigue.
Modified fasting also appears to help alleviate hunger pangs a bit
more than full fasting, which could be explained by the more
steady blood glucose levels in the modified fasting group.
However, this study has several limitations that suggest these
results should be taken as preliminary.
47
This study suggests that neither fasting nor modified fasting with low calories has an effect on
cognitive performance throughout a standard workday. As could be expected, true fasting results in
higher levels of hunger and more cravings alongside greater decreases in blood glucose levels.
These results fall in line with previous research on the cognitive aspects of fasting, but may not
reflect the long-term effects of fasting for more than 7.5 hours. However, given the limitations of this
study, these findings should be viewed as preliminary.
Are you hungry just thinking about this study? Share your thoughts
with other readers at the Study Deep Dives Facebook forum!
48
 References
1. ^ Yuanshan Cui, et al. Health Effects of Alternate-Day Fasting in Adults: A
Systematic Review and Meta-Analysis. Front Nutr. (2020)
2. ^ Françoise Wilhelmi de Toledo, et al. Fasting therapy - an expert panel update of
the 2002 consensus guidelines. Forsch Komplementmed. (2013)
3. ^ Stephanie Welton, et al. Intermittent fasting and weight loss: Systematic review.
Can Fam Physician. (2020)
4. ^ a b Harris R Lieberman, et al. A double-blind, placebo-controlled test of 2 d of
calorie deprivation: effects on cognition, activity, sleep, and interstitial glucose
concentrations. Am J Clin Nutr. (2008)
5. ^ Rima Solianik, Artūras Sujeta. Two-day fasting evokes stress, but does not affect
mood, brain activity, cognitive, psychomotor, and motor performance in overweight
women. Behav Brain Res. (2018)
6. ^ Erik M Benau, et al. A systematic review of the effects of experimental fasting on
cognition. Appetite. (2014)
7. ^ Maria Güemes, Sofia A Rahman, Khalid Hussain. What is a normal blood
glucose?. Arch Dis Child. (2016)
8. ^ Susanne Moebus, et al. Impact of time since last caloric intake on blood glucose
levels. Eur J Epidemiol. (2011)
9. ^ Bernd Schultes, et al. Processing of food stimuli is selectively enhanced during
insulin-induced hypoglycemia in healthy men. Psychoneuroendocrinology. (2005)
10. ^ Yongin Cho, et al. The Effectiveness of Intermittent Fasting to Reduce Body Mass
Index and Glucose Metabolism: A Systematic Review and Meta-Analysis. J Clin Med.
(2019)
11. ^ Rudolf Uher, et al. Cerebral processing of food-related stimuli: effects of fasting and
gender. Behav Brain Res. (2006)
12. ^ B J Rolls, et al. Volume of food consumed affects satiety in men. Am J Clin Nutr.
(1998)
49
Nulls: November–December 2020
 Tags: NERD Nulls
Here’s a very quick summary of some randomized controlled trials (RCTs) and meta-analyses of
RCTs that were published in November and December of 2020 and didn’t find evidence of an
effect. This is known as a null effect.
Keep the following in mind when interpreting a null effect:
While one study can provide evidence that something doesn’t work, it doesn’t prove it. Similar,
repeatable results from multiple studies make for stronger evidence, whether the finding is positive
or negative. Not all null effects are the same. A meta-analysis of low-quality studies or a small
clinical trial usually won’t provide strong evidence, whether the finding is positive or negative. The
population matters. For instance, the lack of an effect in healthy young people doesn’t necessarily
mean that an intervention wouldn’t work in people who are older and have a specific health
condition.
Depression, anxiety & stress

A year of omega-3s on top of standard treatment doesn’t budge bipolar disorder[1]
• What was studied? Researchers investigated whether 1 gram of EPA plus 1 gram of DHA
daily for a year in combination with standard treatment could help prevent relapse in adults
with bipolar I or II disorder, based on the older DSM-IV criteria.
• Why study it? Emerging evidence suggests that omega-3 supplementation could affect
depressive symptoms. Studies looking at its effects on bipolar disorder have been mixed,
though, possibly due to suboptimal dosing of DHA (which seems to have a bigger effect on
depression) or short study lengths. This randomized controlled trial was designed to use
higher DHA and longer time frames to overcome these past problems.
• What was(n’t) found? Supplementation on top of standard treatment did not improve time
to relapse to depressive, manic, hypomanic, or mixed mood episodes compared to
standard treatment alone.
• How null was it? While relatively small, consisting of 80 participants, this is one of the
50
largest and longest trials examining the effects of omega-3 fatty acids on bipolar disorder to
date. While it can’t rule out small effects, it is moderate evidence against omega-3
supplementation producing clinically relevant benefits above and beyond what standard
medication provides on its own.
Cancer
High-dose vitamin D doesn’t affect body composition in people with advanced colorectal cancer[2]
• What was studied? Researchers evaluated how 4,000 IU of vitamin D3 daily affected body
composition in people with advanced colorectal cancer, compared to 400 IU daily, for 16
weeks during chemotherapy.
• Why study it? Vitamin D can stimulate activity in both muscle and fat tissues, both of which
are indicators of colorectal cancer prognosis. It’s possible that vitamin D’s ability to delay
cancer deaths could be, in part, due to its effects on lean and fatty tissues.
• What was(n’t) found? There was no difference between the 4,000 and 400 IU groups in
any anthropometric measurement, including bodyweight, muscle, or fatty tissue area.
• How null was it? This was an exploratory substudy of the SUNSHINE trial, which wasn’t
specifically designed to test these outcomes. That said, both the 400 and 4,000 IU groups
both lost weight and muscle mass, and the data are pretty consistent with there being no
clinically significant differences between groups.
Lycopene doesn’t seem to lower prostate-specific antigen levels in men with prostate cancer[3]
• What was studied? This meta-analysis included randomized clinical trials examining
whether lycopene supplementation can lower prostate-specific antigen levels (a marker for
prostate cancer progression) in men with prostate cancer.
• Why study it? Observational evidence suggests an inverse correlation between lycopene
intake and prostate cancer risk, and petri dish evidence suggests that lycopene could affect
prostate cancer cells. However, evidence in humans has provided mixed results,
suggesting that a meta-analysis could provide more clarity.
• What was(n’t) found? There was no clear effect of lycopene supplementation on prostate-
specific antigen levels.
• How null was it? There’s room for more evidence, given that only six trials were found and
there was a substantial amount of difference between them. Subgroup analysis suggested
that men with higher starting prostate-specific antigen levels may have benefited, but this
51
requires higher-quality evidence to confirm.
Cognition & memory

Souvenaid probably doesn’t improve Alzheimer’s very much[4]
• What was studied? Researchers meta-analyzed randomized controlled trials that were at
least 16 weeks in duration and examined the effects of Souvenaid on Alzheimer’s
outcomes.
• Why study it? Souvenaid is a drink consisting of a patented blend of compounds (Fortasyn
Connect™), including omega-3 fatty acids and various trace elements, that is claimed to
promote synaptic growth.
• What was(n’t) found? There was no clear effect on mild-to-moderate Alzheimer’s disease
after 24 weeks, but there may be a mild effect on mild cognitive impairment after 24 months
that is likely to be of little clinical significance.
• How null was it? Moderately null. Only three trials explored this issue, but combined, they
included over 1,000 participants. The quality of evidence was graded as moderate by the
authors. The data was consistent with possibly relevant risk reduction, leaving open the
possibility of mild benefit.
Healthy aging & longevity

Study suggests that creatine may not add much to older men’s strength training regimen[5]
• What was studied? Researchers investigated how adding 0.1 grams of creatine
monohydrate per kilogram of bodyweight per day to a thrice-weekly whole-body split
resistance training program using 3x10 reps with load progressed over the course of a year
affected bone, muscle, and strength outcomes in men over 50.
• Why study it? While shorter-term use of creatine has found to be useful for older men,
longer term studies have been relatively sparse.
• What was(n’t) found? No significant differences in bone, strength, or muscle

measurements was found between the supplemented and placebo groups after 12 months.
• How null was it? Not very. This was a small study (n = 46) with almost a quarter of men
dropping out and multiple outcomes measured. While this study probably rules out large
52
differences, no power calculation was performed so it can’t be said for sure. However, it’s
unlikely that a study this small would have been able to discern many medium or small
differences between the groups. Also, there were discrepancies in recruitment details
between the published paper and the preregistration.
Infants, children & teenagers

D3 didn’t help with childhood asthma[6]
• What was studied? This study was designed to investigate whether 1,000 IU of vitamin D3
per day could reduce asthma in children ages 4–12 who had vitamin D deficiency (less than
20 ng/mL) for nine months.
• Why study it? Vitamin D is known to influence key immune and inflammatory markers that
contribute to asthma. However, clinical trial data has been inconsistent.
• What was(n’t) found? No difference between the supplement and placebo groups was
found for the primary outcome: the proportion of children having a Childhood Asthma
Control Test of at least 20 (which is considered well-controlled asthma).
• How null was it? This was a well-designed study that had a clear primary outcome and
was powered to detect a 15% difference in the primary outcome. However, the dose of
vitamin D or compliance may have been too low, since only about 35% of the children in the
supplemented group had vitamin D levels over 20 ng/mL by the end of the study. This
issue, coupled with the fact that most childrens’ asthma (almost 80%) was already well
controlled at the study’s start, may have contributed to the null result seen here.
Muscle gain & exercise

Betaine doesn’t have a huge impact on aerobic capacity and oxidative stress[7]
• What was studied? Researchers looked at how 1.25 grams of betaine daily for two weeks
affected aerobic capacity, oxidative stress, and other programmed cell death after
exhaustive endurance exercise in healthy men.
• Why study it? Exhaustive exercise can generate oxidative stress and lead to white blood
cells to undergo apoptosis (programmed cell death) which may lower immune function.
Betaine has been found to dampen oxidation and also affect apoptotic pathways in cell
53
cultures.
• What was(n’t) found? Betaine had no effect on aerobic capacity or oxidative stress.
• How null was it? So-so. This was a small trial, but it used a cross-over design that
increased its ability to find positive results. However, there was no power calculation done,
which makes it difficult to interpret these null results.
• Anything else? Lymphocyte apoptosis was lower in the betaine group, which suggests a
possible benefit for immune function for people undertaking exhaustive exercise. This
finding justifies further study to determine if these changes persist over the long term and
what practical consequences there are, if any.
Beetroot juice may not help with low-oxygen performance[8]
• What was studied? In this study, researchers examined how daily consumption of beetroot
juice containing 12.4 mmol of nitrate affected the endurance performance of male athletes
undergoing high-intensity intermittent exercise at different oxygen levels meant to simulate
different altitudes.
• Why study it? Dietary nitrate’s transformation to nitric oxide is dependent on how much
oxygen there is: lower oxygen leads to more conversion to nitric oxide. Since nitric oxide is
ergogenic, it’s possible that dietary nitrate may be especially potent in lower oxygen
environments, and thus could be especially helpful for athletic performance at higher
altitudes.
• What was(n’t) found? There was no effect of nitrate supplementation on time to

exhaustion in normal oxygen conditions, or in conditions simulating oxygen levels at an
altitude of 2,400 meters.
• How null was it? This was a small study that, while well designed, didn’t have a power
calculation, making it hard to interpret the null result. This study probably rules out large or
medium effects, but may not rule out small effects that could matter to professional athletes.
Bovine colostrum didn’t affect immune markers in elite basketball players[9]
• What was studied? Researchers investigated whether 24 weeks of supplementing 3.2

grams of bovine colostrum twice daily would affect the blood immune markers of elite
female basketball players after a stress test.
• Why study it? One of the functions of “first milk,” or colostrum, is to help boost the immune
systems of newborns, and it has been shown to have several effects on immune cells.
Since extreme exercise is known to suppress immune function, it’s possible that bovine
colostrum could help fend off sickness in athletes. However, this hasn’t been very well
54
studied.
• What was(n’t) found? No difference in any immune marker was found between the
placebo and colostrum groups after stress tests.
• How null was it? Not very. The study was small, and although a power calculation was
done, the details are somewhat unclear, making the null results hard to interpret. Also, the
stress tests didn’t affect any of the immune markers measured except for IL-10 at one time
point, suggesting that the exercise performed during the stress test may not have been
sufficient to suppress immunity, or that the markers were not measured at an appropriate
time relative to the stress tests in order to observe differences in immune markers.
Quinine doesn’t help with longer cycling races[10]
• What was studied? This study was designed to evaluate whether trained male cyclists
consuming a drink containing about 16 mg of quinine just over halfway through a
3-kilometer cycling time trial could boost power output at the end of the race.
• Why study it? Quinine has been found to improve short-term sprint performance, but its
effects on longer-term performance remain unclear.
• What was(n’t) found? There was no difference in power output in the last kilometer of the
time trial between quinine and two control conditions: plain water and a placebo made to
taste similar to quinine.
• How null was it? Pretty null. While this study was small, it had a crossover design that
boosted its power. The study may not rule out tiny improvements that could matter to elite
cyclists, though.
Acute capsiate ingestion didn’t boost 10 km running time[11]
• What was studied? Researchers investigated whether taking 12 mg of capsiate (a less

harsh analog of capsaicin) 45 minutes before and again immediately before a 10-km time
trial could boost times in amateur male athletes.
• Why study it? There’s some evidence that capsiate can boost shorter and medium-
distance aerobic performance in humans, but longer-distance human data is lacking.
• What was(n’t) found? There was no advantage in time trial performance for the capsiate
group over placebo.
• How null was it? This study was well-powered to detect a medium effect size, but can’t
rule out small effects.
55
Outside the box
Vitamin D supplementation doesn’t provide clear benefit for people with cystic fibrosis[12]
• What was studied? This meta-analysis included clinical trials that explored how vitamin D
supplementation affects clinical outcomes in people with cystic fibrosis.
• Why study it? People with cystic fibrosis have low vitamin D levels, and the Cystic Fibrosis
Foundation recommends that vitamin D levels be maintained above 30 ng/dL. Given
vitamin D’s wide-ranging effects on body tissues, it’s possible that vitamin D
supplementation could influence cystic fibrosis outcomes. However, clinical trials exploring
the effects of supplementation have been equivocal due in large part to their small sample
sizes. Meta-analysis may be able to pool these trials together to increase the chances of
finding effects.
• What was(n’t) found? No immunological, respiratory, or bone-related outcomes were

clearly influenced by vitamin D supplementation.
• How null was it? Not very null. Why high doses were used in some cases, the quality of
evidence was assessed to be very low in general. Higher quality evidence could shed more
light on this issue.
Vitamins & minerals

Not much need for vitamin C on top of iron for iron deficiency anemia[13]
• What was studied? This study was designed to evaluate whether adding 200 mg of
vitamin C on top of 100 mg of ferrous succinate taken every eight hours for eight weeks
would help with iron deficiency anemia more than just the ferrous succinate alone.
• Why study it? Vitamin C can improve iron absorption by creating a more acidic
environment and prevent iron oxidation. But, whether this translates to improved outcomes
for people with iron deficiency anemia remains unclear.
• What was(n’t) found? Adding vitamin C didn’t boost hemoglobin (the primary outcome),
nor did it strongly affect iron absorption.
• How null was it? Pretty null for the main outcome, but see below for some notes on the
secondary outcomes. The study was well designed, had a large sample size of over 400
people, and the researchers predeclared the primary outcome and tested for a clinically
important change in hemoglobin of 1 g/dL. There are two caveats, though: the study was
56
short and these results may not extend to the long term, and the population was mostly
women so whether the same effect carries over to men remains less clear.
• Anything else? There were some mild benefits found in mean corpuscular volume (the
average size of red blood cells) and mean corpuscular hemoglobin (how much hemoglobin
is packed inside red blood cells on average) in the vitamin C group.
Vitamin supplementation provides little relief for rheumatoid arthritis[14]
• What was studied? Researchers reviewed and meta-analyzed trials examining the effects
of vitamin supplementation on rheumatic inflammatory diseases.
• Why study it? Vitamins play many roles in inflammatory processes, so supplementation
could help relieve inflammation. The aim of this study was to systematically review and
meta-analyze the literature on how several vitamins could affect inflammatory rheumatic
diseases to give a broad view of the state of the literature.
• What was(n’t) found? Although all inflammatory rheumatic disorders were included in the
search, only studies on rheumatoid arthritis were found. Overall, supplementation with
vitamins D, E, K, or folic acid were not found to have any clear effect on rheumatoid arthritis
outcomes.
• How null was it? Not very. First, there weren’t many studies uncovered and some were of
low quality, leaving room for more evidence in many cases. Also, vitamin D had a
borderline significant effect on one measure of rheumatoid arthritis activity, which may bear
fruit with more study.
• Anything else? The authors still recommend folic acid supplementation to help prevent
side effects when people with rheumatoid arthritis are treated with methotrexate, and
suggest that vitamin D supplementation may also be useful due to the high rate of vitamin D
deficiency in people with rheumatoid arthritis.
57
 References
1. ^ Genevieve McPhilemy, et al. A 52-week prophylactic randomised control trial of
omega-3 polyunsaturated fatty acids in bipolar disorder. Bipolar Disord. (2020)
2. ^ Justin C Brown, et al. Effect of High-Dose vs Standard-Dose Vitamin D 3
Supplementation on Body Composition among Patients with Advanced or Metastatic
Colorectal Cancer: A Randomized Trial. Cancers (Basel). (2020)
3. ^ Mehdi Sadeghian, et al. Lycopene Does Not Affect Prostate-Specific Antigen in
Men with Non-Metastatic Prostate Cancer: A Systematic Review and Meta-Analysis of
Randomized Controlled Trials. Nutr Cancer. (2020)
4. ^ Marion Burckhardt, et al. Souvenaid for Alzheimer's disease. Cochrane Database
Syst Rev. (2020)
5. ^ Darren G Candow, et al. Effect of 12 months of creatine supplementation and
whole-body resistance training on measures of bone, muscle and strength in older
males. Nutr Health. (2020)
6. ^ Kana Ram Jat, et al. Efficacy of vitamin D supplementation in asthmatic children
with vitamin D deficiency: A randomized controlled trial (ESDAC trial). Pediatr Allergy
Immunol. (2020)
7. ^ Ming-Ta Yang, et al. Effects of Two-Week Betaine Supplementation on Apoptosis,
Oxidative Stress, and Aerobic Capacity after Exhaustive Endurance Exercise.
Antioxidants (Basel). (2020)
8. ^ George P Robinson, et al. Influence of Dietary Nitrate Supplementation on High-
Intensity Intermittent Running Performance at Different Doses of Normobaric Hypoxia
in Endurance-Trained Males. Int J Sport Nutr Exerc Metab. (2020)
9. ^ Anna Skarpańska-Stejnborn, et al. Effects of Long-Term Supplementation of
Bovine Colostrum on the Immune System in Young Female Basketball Players.
Randomized Trial. Nutrients. (2020)
10. ^ Naroa Etxebarria, et al. Quinine Ingestion During the Latter Stages of a 3,000-m
Time Trial Fails to Improve Cycling Performance. Int J Sport Nutr Exerc Metab. (2020)
11. ^ Ana Elisa von Ah Morano, et al. Capsaicin Analogue Supplementation Does Not
Improve 10 km Running Time-Trial Performance in Male Amateur Athletes: A
Randomized, Crossover, Double-Blind and Placebo-Controlled Study. Nutrients.
(2020)
12. ^ Márk Félix Juhász, et al. Vitamin D supplementation in patients with cystic fibrosis:
A systematic review and meta-analysis. J Cyst Fibros. (2020)
58
13. ^ Nianyi Li, et al. The Efficacy and Safety of Vitamin C for Iron Supplementation in
Adult Patients With Iron Deficiency Anemia: A Randomized Clinical Trial. JAMA Netw
Open. (2020)
14. ^ Yann Nguyen, et al. Efficacy of Oral Vitamin Supplementation in Inflammatory
Rheumatic Disorders: A Systematic Review and Meta-Analysis of Randomized
Controlled Trials. Nutrients. (2020)
59
Battling exercise-induced muscle damage
with omega-3s
 Tags: Omega 3, Exercise Recovery, Muscle
 Study under review: The effect of Omega-3 polyunsaturated fatty acid supplementation
on exercise-induced muscle damage
Quick Takes
• What was the question? How does omega-3
supplementation affect eccentric exercise-induced muscle
damage?
• How was it answered? Researchers conducted a single-
blinded randomized controlled trial.
• Who was studied? Healthy, physically active men ages
18–35 who didn’t regularly engage in strenuous eccentric-
focused exercise or supplement with omega-3 prior to the
study made up the participant group.
• What was the intervention? Participants took 2,145 mg of
EPA and 858 mg of DHA daily for four weeks.
• What’s the main takeaway? Muscle soreness was reduced
24 hours after exercise in the supplementation group, but not
at other time points. No other clear differences between the
supplementation and placebo groups were observed for
60
inflammation, muscle damage markers, or performance
indicators.
• Any caveats? The study was very small and measured a lot
of outcomes, so these results should be regarded as
preliminary. Further research is necessary to confirm that
omega-3 supplementation positively affects muscle damage.

What is the effect of omega-3 fatty acid supplementation on markers of exercise-induced muscle
damage and performance over three days?

Exercise, especially when it involves high-force eccentric or unaccustomed[1] loading, can produce
substantial muscle fiber damage. This exercise-induced muscle damage (EIMD) typically manifests
[2] as muscle pain and swelling, strength and power loss, reduced range of motion (ROM), and
delayed onset muscle soreness (DOMS), with these symptoms usually subsiding[3] 5–7 days after
exercise. The typical time course of key muscle damage markers are laid out in Figure 1.
Figure 1: The time course of muscle function,

soreness, and inflammation post-exercise
61
Adapted from: Owens et al. Eur J Sport Sci. 2019 Feb.[4]
One proposed strategy for speeding up the recovery from EIMD is the use of omega-3 (n-3)
polyunsaturated fatty acids. By down-regulating[5] the production of pro-inflammatory cytokines,
such as tumor necrosis factor alpha (TNF-α) and interleukin 6 (IL-6), and by blunting the production
of reactive oxygen species (ROS), n-3 fatty acids may reduce EIMD, and improve functional
recovery from exercise.
Although several trials have examined the potential effects of n-3 supplementation on EIMD, their
results have been inconsistent. Moreover, it’s unclear if the potential effects of n-3 on EIMD
manifest through improvements in the rate of recovery of physical performance, through reductions
in pro-inflammatory markers, or both. As such, the goal of the randomized controlled trial under
review was to add to the body of literature looking at the effects of n-3 supplementation on
symptoms of EIMD in healthy adults.
62
While omega-3 fatty acid supplementation may improve symptoms
of exercise-induced muscle damage, it’s unclear if these potential
effects manifest through improvements in the rate of recovery of
physical performance, through reductions in pro-inflammatory
markers, or both. The study under review is a randomized
controlled trial that assessed the potential effects of omega-3
supplementation on symptoms of exercise-induced muscle
damage in healthy adults.

The authors conducted a randomized, single-blind, placebo-controlled trial involving 14 healthy
men ages 18–35 who were physically active but did not regularly perform eccentric exercise during
the previous six months. The participants also did not smoke, take any medications, or consume
fish oil supplements.
Following baseline measurements and a treadmill maximal oxygen uptake (VO2max) test, the
participants were randomized to take either 3 grams of n-3 fatty acids per day (containing a total of
2,145 mg of EPA and 858 mg of DHA) or a placebo for four weeks. Then, on the second visit, the
participants performed a muscle-damaging exercise bout involving 60 minutes of downhill running
at 65% VO2max.
The participants were requested to maintain their usual diet and physical activity throughout the
study. Dietary intake was assessed using two 48-hour food diaries at baseline and before the
second visit.
The researchers did not specify any primary outcomes. Outcomes of interest included biochemical
markers of muscle damage (creatine kinase) and inflammation (TNF-α and IL-6), muscle soreness
measured on a 10-point-validated visual analogue scale (VAS), maximal voluntary isometric
contraction (MVIC) assessed using a dynamometer, and peak power output measured using a
cycle ergometer. These were measured at baseline, immediately after the exercise bout, and at 24,
48, and 72 hour post-exercise. The trial was not preregistered, and no adjustments for multiple
comparisons were made.
63
This was a randomized, single-blind, placebo-controlled trial
involving 14 healthy young men that evaluated the effects of 3
grams per day of omega-3 fatty acids (containing a total of
2,145 mg of EPA and 858 mg of DHA) for four weeks on
biochemical markers of exercise-induced muscle damage and
inflammation, muscle soreness, maximal voluntary isometric
contraction, and peak power output.

With regard to biochemical markers, creatine kinase (a marker of muscle damage) increased, as
compared to baseline, at 24, 48, and 72 hours after the exercise bout in both the n-3 and placebo
groups, with no statistically significant differences between groups. IL-6 (a marker of inflammation)
increased at 24 hours after the exercise bout in both groups, with no differences between groups.
TNF-α remained unchanged.
With regard to functional outcomes, muscle soreness increased in both groups immediately after
exercise and at 24 hours post-exercise, and also at 48 hours in the placebo group. The only
statistically significant difference between groups was at 24 hours post-exercise, when muscle
soreness was lower with n-3 than with placebo.
Finally, there were statistically significant reductions in MVIC immediately after exercise in both
groups, and a statistically significant reduction in peak power at 24 hours with placebo, but not with
n-3, with no significant differences between groups.
The functional outcomes are graphed in Figure 2.
Figure 2: Functional outcomes
64
The only statistically significant difference observed between the
treatments was in muscle soreness, with participants in the n-3
group reporting less muscle soreness 24 hours after the exercise
bout.

There’s good news and bad news found in the results of this study. The good news is that the
exercise the participants underwent was sufficient to damage muscle and induce soreness. This is
evident from the increases observed in creatine kinase and muscle soreness, as well as the
decreases observed in performance outcomes after the exercise bout. Moreover, the
supplementation intervention also achieved its intended purpose, since, according to data from the
two 48-hour food diaries, the participants in the n-3 group significantly increased their dietary n-3
intake from 1.4 to 3.9 grams per day, while the participants in the placebo group maintained their
baseline n-3 intake of about 1.7 grams per day, with no differences in total macronutrient or caloric
intakes between groups.
The bad news is that the study has some serious limitations, which make the evidence pretty weak
in terms of evaluating the effects of n-3s on practical, functional post-exercise outcomes.
The biggest limitation was the study’s sample size of 14 participants, which is very small for a
parallel trial. Although the researchers performed a power calculation and determined that a
sample size of 12 participants was large enough to detect a medium effect size, they did not
65
specify the outcome for which the power calculation was performed or the method they used in the
calculation. While these details may not be exciting, they’re crucial for interpreting the lack of
statistically significant effects. Without these details, the power calculation the authors provided is
meaningless.
A close runner up in terms of serious limitations is that the researchers did not specify a primary
outcome. On top of this, they assessed several outcomes at multiple timepoints without making
adjustments to the statistical tests performed to control for the problem of multiple comparisons.
This means that it’s likely that the significant difference detected in muscle soreness between
groups at 24-hours post exercise was a false positive, especially when considering that the p-value
of 0.034 in this outcome was quite close to the 0.05 cut-off.
These two limitations imply that the lack of statistically significant results cannot necessarily be
taken at face value, since it’s possible that the study wasn’t well powered enough to see any
effects. But at the same time, the single found statistically significant difference could also have
been due to chance. In short: all the results from this study, both the positive and negative ones,
should be taken lightly.
Two other limitations are worth mentioning. First, the study was single-blinded, which means that
the researchers and outcome assessors knew which participants received the placebo, and which
participants received n-3. This is an issue because it introduces “observer” or “detection” bias,
which may exaggerate the effects of the treatment in trials with subjective measurement scale
outcomes (such as muscle soreness). Another issue relating to blinding is that five of of the seven
participants in the n-3 group correctly guessed which treatment they were receiving, compared to
only two of seven participants in the placebo group, which suggests inadequate participant
blinding. This may also be a source of bias[6], as participants who know that they have been
assigned to a group receiving the treatment may be more likely to report exaggerated effects in
subjective measurement scale outcomes.
Second, there may be large interindividual variability in creatine kinase levels in response to
exercise, making it potentially inappropriate to use creatine kinase as a marker of muscle damage
in small scale parallel trials. For example, in a 2007 trial[7], the peak creatine kinase levels in
response to the same full body resistance training workout varied between participants from around
2,000 up to a little over 50,000 units/liter. Small scale parallel trials, like the one under review, are
likely underpowered to detect statistically significant changes in an outcome with such high levels
of interindividual variability.
Also, although not a limitation, it’s worth noting that the supplement dose of 3 grams of combined
EPA and DHA used in this study is relatively high. Specifically, to reach this intake from
supplemental n-3, one would have to take 10 capsules of “typical” omega 3 supplements from fish
66
oil, which usually contain 300 milligrams of combined EPA and DHA per 1 gram capsule.
Overall, the limitations of the study under review, especially those relating to the small sample size,
failure to adjust for multiple comparisons, and blinding of participants and researchers, reduce
confidence in the results.
That said, the study does hint at the potential efficacy of n-3 for improving performance post-
exercise. Note that, as shown in Figure 2, while there were almost no clear differences between
groups, the participants who took n-3s did have slightly better, but not statistically significant,
outcomes. These outcomes could be further investigated in larger scale trials. So while this study
doesn’t provide strong evidence that n-3 supplementation could be worthwhile post-exercise, it
does provide justification for other researchers to follow up on these findings.
Although the study suffers from several methodological limitations

that suggest the conclusions should be evaluated with caution, the
results hint at the potential efficacy of n-3 for improving some
aspects of muscle damage, which could be investigated in larger
scale trials.

According to the researchers, the results of study under review indicate that n-3 supplementation
may reduce muscle soreness in response to a muscle-damaging exercise bout. However, due to
several methodological limitations, such as the small sample size, failure to adjust for multiple
comparisons, lack of blinding of the outcome assessors and researchers, and potentially
inadequate participant blinding, the results of the study under review should be interpreted
cautiously.
What has been your experience with omega-3 and muscle

soreness? Let us know in the private Study Deep Dives Facebook
forum!
67
68
 References
1. ^ Stéphanie Hody, et al. Eccentric Muscle Contractions: Risks and Benefits. Front
Physiol. (2019)
2. ^ Robert D Hyldahl, Monica J Hubal. Lengthening our perspective: morphological,
cellular, and molecular responses to eccentric exercise. Muscle Nerve. (2014)
3. ^ Peake JM, et al. Muscle damage and inflammation during recovery from exercise. J
Appl Physiol (1985). (2017)
4. ^ Daniel J Owens, et al. Exercise-induced Muscle Damage: What Is It, What Causes
It and What Are the Nutritional Solutions?. Eur J Sport Sci. (2019)
5. ^ Timothy D Mickleborough. Omega-3 polyunsaturated fatty acids in physical
performance optimization. Int J Sport Nutr Exerc Metab. (2013)
6. ^ Kenneth F Schulz, David A Grimes. Blinding in randomised trials: hiding who got
what. Lancet. (2002)
7. ^ Jonas Pettersson, et al. Muscular exercise can cause highly pathological liver
function tests in healthy men. Br J Clin Pharmacol. (2008)
69
Deeper Dive: Shining a light on the effects
of vitamin D on fall risk in older adults
 Tags: Vitamin D, Supplementation, Older Adults
 Study under review: The Effects of Four Doses of Vitamin D Supplements on Falls in
Older Adults : A Response-Adaptive, Randomized Clinical Trial
Quick Takes
• What was the question? How do four different doses of
vitamin D supplementation affect the risk of falling?
• How was it answered? The researchers conducted a
randomized controlled adaptive trial.
• Who was studied? People over 70 years old with low
baseline vitamin D levels (average starting 25(OH)D levels of
55 nmol/L or 22 ng/mL) and an elevated risk of falling made
up the participant population.
• What was the intervention? Participants took 200–4,000 IU
of vitamin D3 daily.
• What’s the main takeaway? Vitamin D supplementation at
1,000 IU daily or more increased the risk of falls, raising
safety concerns about higher-dose vitamin D
supplementation in older people with low baseline vitamin D
levels.
70
• Any caveats? There was no placebo group, which means
that the study can’t speak to the efficacy of supplementation
on fall prevention compared to no treatment. Also, the
adaptive trial broke its own pre-planned protocol, which, in
theory, could open the door to biased results. In this case,
however, the authors were open about the fact that they
broke their protocol for safety concerns, and they seemed to
have good reason to do so.
Introduction
An estimated one in four (28.7%) U.S. adults older than 65 had a fall in 2014[1]. One in four (25%)
of those falls resulted in an injury. Falls among older adults ultimately resulted in nearly $32 billion
in related medical expenses in 2015[2]. Alleviating this burden represents an opportunity to foster
the health and safety of older people and decrease medical expenses. This is, however, a complex
problem.
Vitamin D has been suggested as a primary target for intervention for two main reasons. First, it
plays a critical role in bone formation, healthy bone structure, and bone mineral density. These
effects on bone integrity could mitigate the damage done by falls when they occur. (Read more
about fractures and vitamin D in this March 2018 Study Deep Dives article.) Vitamin D is also
essential for muscle function, suggesting it could play a role in preventing falls in the first place by
maintaining strength, balance, and coordination[3]. However results from a 2018 clinical trial in post-
menopausal women suggests that higher dose (2,800 IU) supplementation might actually decrease
muscle strength[4] (read the Mini here).
Second, vitamin D deficiency and insufficiency is widespread, with 28.9% of U.S. adults meeting
the Endocrine Society’s criteria for deficiency (25(OH)D of less than 50 nmol/L) and 41.4% of
adults considered to have insufficient levels[5] (25(OH)D levels (50–75 nmol/L). Furthermore, adults
older than 60 years old are around 63% more likely to have vitamin D deficiency and 46% more
likely to have vitamin D insufficiency than young adults[5]. This age-related decrease in vitamin D
status may be the result of decreased synthesis from ultraviolet light[6], decreased mobility and thus
71
decreased exposure to ultraviolet light[7], decreased vitamin D receptor expression[8], and
inadequate dietary vitamin D intake[9]. Overall, the high prevalence of vitamin D insufficiency and
deficiency in high-risk older populations means that plenty of people could potentially benefit from
supplementation.
It’s reasonable to say, based on previous research, that vitamin D supplementation in the context
of severe vitamin D deficiency (less than 20–25 nmol/L) is important for modifying the risk of falls
[10], muscle function[11], and improving bone mineral density[12]. But what about the efficacy of
supplementing in a population with marginal deficiency or insufficiency, i.e. people who probably
don’t need high doses of vitamin D to achieve adequacy? Unfortunately, the results of numerous
individual studies are mixed, with some studies suggesting mild benefit, others no benefit, and still
others implying potential harm.
For example, one nine-month RCT testing the effects of 150,000 IU of vitamin D3 supplementation
every three months in older, community-dwelling, postmenopausal women showed no differences
between vitamin D and placebo on adverse effects, falls, mobility, or muscle strength[13]. A three-
year RCT testing 800 IU of D3 daily with 500 mg of calcium vs. placebo in community dwelling
older men and women showed that supplementation reduced fall risk in women, especially those
with low baseline physical activity, but did not show a significant effect on men[14]. Another study of
note showed that among older community-dwelling women, annual oral administration of 500,000
IU of D3 resulted in an increased risk of falls and fractures[15], confirming the lackluster or
sometimes detrimental effects of vitamin D supplements on fall risk.
One comparative review has attempted to clarify why different meta-analyses of vitamin D and fall
risk come to different conclusions. The authors conclude that it comes down to issues that could be
found in any meta-analysis: differences in study inclusion/exclusion, differences in data extraction,
and differences in statistical analysis[16].
When it comes to falls and frailty, all the evidence points to a U-shaped relationship between
vitamin D levels and fall risk, similar to what researchers have noted for cancer, cardiovascular
disease[17], and fractures[18]. Supplementing with vitamin D to adequacy appears to significantly
improve fall risk, but supplementing beyond adequacy may do more harm than good.
Prior to the initiation of the present study in 2015, there had been a number of recommendations
for vitamin D supplementation for fall prevention in older adults, each based on extensive reviews.
Even though each set of guidelines aims to summarize the totality of clinical evidence, each one
arrived at a different, sometimes substantially different, conclusion. The main takeaways of these
guidelines are laid out in Figure 1.
72
Figure 1: Recommendations on vitamin D targets from
various professional organizations and working groups
Organization Blood level targets Dose of supplemental Applicable
vitamin D population
American 25(OH)D concentration of At least 1,000 IU daily Everyone over

Geriatrics 75 nmol/L (30 ng/mL) as alongside calcium. 65 years old,
Society a minimum goal. whether or not
Workgroup on they live
Vitamin D independently
Supplementation or in an
for Older Adults institutionalized
[19] setting.
Endocrine States that an exact At least 600–800 IU daily, 600 IU is the

Society[20] target is somewhat but up to 2,000 IU daily lowest dose for
controversial, but defers may be needed to raise people ages
to the standard definitions 20(OH)D to sufficient 50–70, an 800
of 25(OH)D) levels of 50 levels. IU for people
nmol/L (20 ng/mL) 70 and above.
indicating deficiency, and
75 nmol/L (30 ng/mL)
indicating insufficiency.
International 25(OH)D concentration of 800–1,000 IU daily would People ages

Osteoporosis 75 nmol/L (30 ng/mL) as make many, but not all, 60–65 years
Foundation[21] a minimum goal. people vitamin D and up.
sufficient. But since higher Doses can be
doses haven’t been adjusted up or
established to prevent down based on
falls, they don’t sun exposure
necessarily recommend (down) or
higher doses for all older obesity status
adults. (up).
73
Organization Blood level targets Dose of supplemental Applicable
vitamin D population
US Preventive Only to prevent deficiency Not applicable: This group Community-

Services Task (25(OH)D concentration recommends against the dwelling
Force[10] below 50 nmol/L or 20 ng/ routine use of vitamin D people over 65
mL). supplementation to years without
prevent falls or fractures. osteoporosis
and without
vitamin D
deficiency.
Institute of Not applicable for fall Insufficient evidence for Adults 70

Medicine[22] prevention. fall prevention. This group years and
recommends sticking with older.
the RDA of 800 IU daily
intake for this age group,
supplementing as needed
to achieve that intake
level.
As a result of the suggestive, but ultimately inconclusive, research around vitamin D

supplementation and fall risk, the National Institute on Aging (NIA) funded a clinical trial to assess
the dose-response relationship between vitamin D ranging from the minimum dose necessary for
adequacy to the upper limit of official recommendations and falls in a high-risk population.
Vitamin D deficiency is associated with poor bone health, poor

muscle health, general frailty, and increased risk for falls, yet it is
not entirely clear whether this relationship is causal. Vitamin D
supplementation has been recommended for preventing falls in
older adults by a number of organizations, and recommended
against by others, reflecting the inconsistent results seen in clinical
trials. This study, funded by the National Institute of Aging, aimed
74
to clarify the effect of different doses of vitamin D on risk of falls in
community-dwelling older adults with baseline deficient/insufficient
vitamin D status.
What was studied?

The primary outcome of the preregistered “Study To Understand Fall Reduction and Vitamin D in
You” (STURDY) trial was time to first fall or death over two years. Participants were included if they
were community-dwelling residents of Hagerstown or Woodlawn, Maryland, 70 years of age or
older, had elevated fall risk based on self-reported previous falls or presence of other risk factors
for falls, and had a serum 25-hydroxyvitamin D (25(OH)D) level of 25 to 72.5 nmol/L. For reference,
Woodlawn and Hagerstown are both at about 39° latitude, with about 105 clear, sunny days per
year. Participants were not eligible if they had a cognitive impairment, abnormal calcium levels,
kidney stones, or were already supplementing with daily vitamin D doses higher than 1,000 IU or
calcium doses higher than 1,200 mg.
By the end of the study, 677 of the 688 enrolled participants were considered to have completed
the trial. Average age at enrollment was 77.2 years, 56.4% of the participants were men, 18.2%
identified as Black, and the mean 25(OH)D level was 55.3 nmol/L. In addition, 71.2% of
participants were frail or had pre-frail status, and more than half had substantial functional
impairment, which explains why 65.4% had fallen one or more times in the prior year. People with
severe vitamin D deficiency (less than 25 nmol/L) were excluded.
The basics of the study design are laid out in Figure 2. This adaptive trial was divided between a
dose-finding stage to determine the optimal dose of vitamin D, and a second stage to evaluate the
primary outcome. In the first stage of the trial, participants were randomly assigned to 200 (control),
1,000, 2,000, or 4,000 IU of vitamin D3 per day. The first phase was set to conclude after the target
sample size of 1,200 people were enrolled or once the probability that a specific non-control dose
was superior to the others rose to 95%.
After two years and four months from the start of the trial, the best dose was identified as 1,000 IU
per day, according to prespecified interim analysis, and participants were subsequently randomly
assigned to the best dose or the control dose. The trial continued until the next interim analysis
determined that there would be no point in continuing the study.
75
Figure 2: The basics of the adaptive study design
Sidebar: Adaptive trial design 101

This randomized controlled trial was unique due to its adaptive nature. Adaptive trials
evaluate participant outcomes while the trial is still going on, and then modify the study
protocol in real time based on those observations. Adaptive trials were first recommended
by the FDA in 2010 to address high dropout rates in drug development trials, but have since
been applied to many types of interventions.
Adaptive trial designs have potential benefits, like decreasing the cost and length of a study,
but come with their own set of limitations[23]. An example from this study is the use of
outcome-adaptive randomization: new participants were placed in the treatment groups that
were performing best, i.e. the dose associated with the fewest falls. Although this technique
ensures more people are assigned to the best intervention group, it limits the quantity and
precision of the data for the groups that weren’t performing well.
Due to the two-part study design, early participants in the other non-control dose groups
who were never assigned to the best-dose vitamin D group were not part of the final
analysis. This means the final outcomes were not analyzed on an intention-to-treat basis,
introducing bias in this kind of adaptive trial design.
Another adaptive design technique used in this trial, so-called “interim assessment of futility
or efficacy,” has the advantage of allowing researchers to end an expensive trial as soon as
76
the primary outcome has been answered. However, this strategy comes with the tradeoff of
decreasing the number of primary and secondary outcomes observed, and thus limits the
secondary analyses that are so often used to uncover tentative links and inform future
research. It’s a give and take!
Adaptive designs are relatively new, but are growing in popularity. They can be a powerful
tool in the researcher’s toolbox, but they can also add a lot of complexity if not used
correctly!
This study was designed to test the effects of different doses of

vitamin D on the rate of falling or death in high-risk people over 70.
The researchers accomplished this by using an adaptive
randomized controlled trial design. This design has two parts. The
first part identified which dose of vitamin D (1,000, 2,000, or 4,000
IU per day) was associated with the fewest falls or other adverse
events compared to the control arm of 200 IU per day (a dose that
helps most people achieve sufficient levels). Once the best dose
was identified, participants in non-control arms were reassigned to
the best dose, and new participants were randomized to the best
dose or the control dose.

Participants were largely adherent to the intervention and total 25(OH)D levels increased
progressively across the dosing groups initially and persisted through the second half of the study.
The initial dose-finding stage of the trial was halted early for two reasons. First, the 1,000 IU dose
had been consistently predicted to be the best dose. Second, at this time point the rate of
hospitalization or death was 2.69 times higher in the 2,000 IU per day group than the rate among
77
those in the 200 IU per day group (33.6 per 100 vs. 12.1 per 100 person-years; hazard ratio: 2.69
with a 95% CI: 1.50 to 4.82). The 4,000 IU per day group also had a higher rate of hospitalization
or death, although not a statistically significant one (hazard ratio: 1.68 with a 95% CI: 0.86 to 3.27).
At the same time, compared to the low-dose control group, the primary composite outcome of time
to first fall or death was higher in all groups taking higher doses (a statistically significant hazard
ratio of 1.54 and a nonsignificant 1.41 for 2,000 and 4,000 IU, respectively). This is why the “best
dose” was thus determined to be 1,000 IU per day and the trial moved on from the dose-finding
phase to the next phase, which compared 1,000 to 200 IU.
However, this phase didn’t last long, either. Ultimately, the trial was terminated 13 months into the
second phase (three years and seven months from the beginning of the study) due to a lack of
projected benefit. You might imagine that a trial terminated early due to a lack of effect would have
few, if any, statistically significant effects. And you would be right: in the confirmatory stage of this
trial, the only difference was the rate of adverse events, which occurred at a higher rate among
participants receiving 1,000 IU per day than among those receiving 200 IU per day. Some more
details are laid out in Figure 3.
Figure 3: Main outcomes from this study
78
The first half of this adaptive trial suggested that vitamin D doses
of 2,000 and 4,000 IU per day are associated with increased risk of
falls requiring hospitalization and deaths. At this point, the 2,000
and 4,000 IU per day arms were dropped, and the second phase
of the trial continued with just the 200 and 1,000 IU per day arms.
The second half of the trial was then halted early due to a lack of
effect on falls and an increase in risk for adverse events
(hospitalizations from falls, first fall) in the 1,000 IU per day arm.
79
The bigger picture
This trial gives a somewhat clear answer to one question: Does supplementation beyond a low
maintenance dose do anything for falls, harmful or beneficial? The answer: Probably not in the
context of a moderate dose of 1,000 IU. Though the study provides an answer to one question, it
also raises another: does high-dose vitamin D supplementation increase the risk of falls?
Similar results have been hinted at in previous studies. For example, one randomized controlled
trial on the effect of high dose vitamin D supplementation and risk of acute respiratory infections
showed that high dose vitamin D (100,000 IU per month) may increase the risk of falls[24]. Another
trial assessing the effect of high dose vitamin D (60,000 IU per month) on preventing functional
decline, showed a similar increase in fall risk[25]. One other dose-response trial reported a U-
shaped relationship between vitamin D status and risk of falls. Together, these results suggest a
relationship between decreased fall risk with 1,600, 2,400, and 3,200 IU per day, and no decrease
in falls with low (400 and 800 IU) vitamin D doses and with high doses (4,000 and 4,800 IU)
compared to placebo[26]. One other study looking at the relationship between high dose (4,000 and
10,000 IU per day) vitamin D and bone mineral density suggested that these high doses may in
fact decrease bone mineral density[27]. Lastly, during this trial, the 2018 U.S. Preventive Services
Task Force reversed its 2012 recommendation, updating their guidelines to say only older adults
with osteoporosis or documented vitamin D deficiency should supplement with vitamin D for the
prevention of falls[10].
However, not all studies have found a risk of harm. One relevant meta-analysis suggests that there
is moderately-certain evidence that vitamin D does not measurably reduce the risk of falls in older
adults[28]. Also, a landmark vitamin D study, the VITamin D and OmegA-3 TriaL (VITAL)[29], used
higher doses of vitamin D (2000 IU per day) over the course of five years and found no decrease in
risk of falls for community dwelling older adults without vitamin D insufficiency and deficiency. Most
importantly, though, it did not find an increase in adverse events, either. Additionally, five other
related studies report no difference in adverse events between placebo and vitamin D
supplementation[15][13][14][30][31]. What could explain these differences?
Most high quality, recent studies take baseline D level into account, so now the most important and
often unmeasured variable is a participant’s individual response to vitamin D supplementation[32].
In the present trial, 37.2% of the study participants were already taking a vitamin D supplement
(less than 1,000 IU, median 700 IU daily), yet their average serum vitamin D status was still low.
One explanation may be that the average BMI of the study population was 30.5, just above the
cutoff for obesity. People with obesity are known to have lower vitamin D levels than lean
individuals due to a volumetric dilution effect, and it takes a higher dose of vitamin D to raise serum
levels to that seen in normal-BMI individuals[33]. Thus, BMI and body fat differences in the study
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population could account for some of the differences between studies.
There are other hypotheses for why some individuals can take vitamin D on a daily basis and yet
still have deficient or insufficient vitamin D levels. One suggests that chronic conditions may have a
vitamin D depleting effect[34]. Another theory has to do with genetic polymorphisms of proteins
involved in vitamin D metabolism, which may be associated with variability of vitamin D levels after
supplementation[35][36] and the incidence of bone diseases[37][38].
Then there’s the issue of the large interindividual variability in response to vitamin D supplements.
The same dose of vitamin D in a supplement can produce markedly different increases in serum
vitamin D levels[39][40][36] depending on the person (read more in issue #32 of Study Deep Dives
here).
The interaction between vitamin D and physical activity is another area not investigated in this
study that could help to determine who really benefits from a vitamin D supplement. Previous
research has shown that vitamin D receptor (VDR) expression declines with age, but VDR
expression increases after an acute bout of exercise, and baseline cardiorespiratory fitness level
predicts greater VDR expression. If there was a difference in physical activity among participants in
different studies (ie. differences in built environment, severity of self-reported frailty, availability of
physical activity programs, differences in living situation, etc.), then this could explain some of the
variability across studies.
Finally, the lack of comprehensive data collection prevents the authors from making any educated
guesses on why higher doses of daily vitamin D are associated with an increased risk of falls.
Specifically, subgroup analyses could have provided a hint as to whether participants with low
blood pressure, or participants with lower lean body mass or higher fat mass, or participants with
greater functional impairment were more likely to have a negative effect from high-dose vitamin D
supplementation. More importantly, this information would help assess whether these potentially
confounding attributes were uniformly distributed across the intervention groups.
While these are all possibilities, in the end they’re just guesses. More evidence exploring
interindividual differences in vitamin D metabolism could help illuminate the mechanistic
underpinnings of the ill effects seen in this study.
This trial suggests that higher doses of vitamin D are not helpful for
preventing falls and may in fact increase the chance falls in older
at-risk people. This is not the first trial to suggest that vitamin D
doses of over 1,000 IU could increase fall risk in older people.
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However, not all the evidence points toward this risk. More
research, focusing especially on individual differences in reactions
to vitamin D supplementation, may shed more light on the matter.

Q. Is megadose supplementation a safe practice?
Many physicians provide vitamin D supplements to correct severe vitamin D deficiency through
bolus injections of 60,000 once a month or up to 300,000 IU doses every three months until blood
levels indicate adequacy. If the “high dose” of 2,000 IU per day (comparable to 60,000 IU per
month) incurs an increased risk for falls in this study, it may make sense that megadose
supplementation could transiently increase the risk for adverse outcomes due to vitamin D as well.
The researchers behind a recent meta-analysis attempted to find an answer to this question
(reported on in the recent January 2019 Mini), but the results were mostly inconclusive. Individual
factors introduce so much variability that the answer depends on the person. Vitamin D megadoses
may or may not be associated with increased risk of adverse events, kidney stones, and high blood
calcium levels. Each of these adverse events could be more concerning for someone with a
condition that affects vitamin D metabolism (diseases of the gastrointestinal system, liver, thyroid,
kidneys, etc.).
Regular, seasonal serum vitamin D readings help providers determine the ideal dose regimen for
an individual. The Food and Nutrition Board (FNB) at the National Academies of Sciences,
Engineering, and Medicine (NASEM) recommend that people should avoid serum 25(OH)D levels
above 125–150 nmol/L (50–60 ng/mL), and that even lower serum levels (75–120 nmol/L; 30–48
ng/mL) are associated with increased risk of mortality, some cancers (e.g. pancreas and prostate),
cardiovascular events, and falls and fractures among older adults[22].
Acute vitamin D poisoning is exceedingly rare. One case report[41] documents a son and his father
who had somehow mixed crystalline vitamin D into their table sugar. The pair had been ingesting
1.7 million IUs per day, but even at that dose it took seven months for adverse reactions to
precipitate!
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What should I know?
The results of this study indicate that, compared to a maintenance dose (200 IU per day) of vitamin
D, supplementing with higher doses (1000–4000 IU per day) may result in a higher chance of falls
and increased mortality in high-risk community-living adults over 70 years of age.
Not all evidence suggests harm, and these results do not exclude the possibility that higher doses
of vitamin D may still be beneficial for some populations. Nor is the harm of higher doses of vitamin
D set in stone, given the inconsistent results across different trials. However, given the lack of
benefit seen in doses over 1,000 IU per day, coupled with the hint of possible harm, the risks of
higher-dose supplementation should be taken into account when considering whether or not to
supplement.
To vitamin D or not to D? Share your thoughts at the private Study

Deep Dives Facebook forum.
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 References
1. ^ Gwen Bergen, Mark R Stevens, Elizabeth R Burns. Falls and Fall Injuries Among
Adults Aged ≥65 Years - United States, 2014. MMWR Morb Mortal Wkly Rep. (2016)
2. ^ Elizabeth R Burns, Judy A Stevens, Robin Lee. The direct costs of fatal and non-
fatal falls among older adults - United States. J Safety Res. (2016)
3. ^ Hennie C J P Janssen, Monique M Samson, Harald J J Verhaar. Vitamin D
deficiency, muscle function, and falls in elderly people. Am J Clin Nutr. (2002)
4. ^ Lise Sofie Bislev, et al. Effects of Vitamin D3 Supplementation on Muscle Strength,
Mass, and Physical Performance in Women with Vitamin D Insufficiency: A
Randomized Placebo-Controlled Trial. Calcif Tissue Int. (2018)
5. ^ a b Liu X, Baylin A, Levy PD. Vitamin D deficiency and insufficiency among US
adults: prevalence, predictors and clinical implications. Br J Nutr. (2018)
6. ^ Jenna R Chalcraft, et al. Vitamin D Synthesis Following a Single Bout of Sun
Exposure in Older and Younger Men and Women. Nutrients. (2020)
7. ^ Billie Bonevski, et al. The ABC of vitamin D: a qualitative study of the knowledge
and attitudes regarding vitamin D deficiency amongst selected population groups.
Nutrients. (2013)
8. ^ J Christopher Gallagher. Vitamin D and aging. Endocrinol Metab Clin North Am.
(2013)
9. ^ Meehan M, Penckofer S. The Role of Vitamin D in the Aging Adult. J Aging
Gerontol. (2014)
10. ^ a b c US Preventive Services Task Force, et al. Interventions to Prevent Falls in
Community-Dwelling Older Adults: US Preventive Services Task Force
Recommendation Statement. JAMA. (2018)
11. ^ Charlotte Beaudart, et al. The effects of vitamin D on skeletal muscle strength,
muscle mass, and muscle power: a systematic review and meta-analysis of
randomized controlled trials. J Clin Endocrinol Metab. (2014)
12. ^ Ian R Reid, Mark J Bolland, Andrew Grey. Effects of vitamin D supplements on
bone mineral density: a systematic review and meta-analysis. Lancet. (2014)
13. ^ a b Paul Glendenning, et al. Effects of three-monthly oral 150,000 IU cholecalciferol
supplementation on falls, mobility, and muscle strength in older postmenopausal
women: a randomized controlled trial. J Bone Miner Res. (2012)
14. ^ a b Heike A Bischoff-Ferrari, E John Orav, Bess Dawson-Hughes. Effect of
cholecalciferol plus calcium on falling in ambulatory older men and women: a 3-year
84
randomized controlled trial. Arch Intern Med. (2006)
15. ^ a b Sanders KM, et al. Annual high-dose oral vitamin D and falls and fractures in
older women: a randomized controlled trial. JAMA. (2010)
16. ^ Mark J Bolland, Andrew Grey, Ian R Reid. Differences in overlapping meta-
analyses of vitamin D supplements and falls. J Clin Endocrinol Metab. (2014)
17. ^ Michal L Melamed, JoAnn E Manson. Vitamin D and cardiovascular disease and
cancer: not too much and not too little? The need for clinical trials. Womens Health
(Lond). (2011)
18. ^ Ian R Reid, Mark J Bolland. Calcium and/or Vitamin D Supplementation for the
Prevention of Fragility Fractures: Who Needs It?. Nutrients. (2020)
19. ^ American Geriatrics Society Workgroup on Vitamin D Supplementation for Older
Adults. Recommendations abstracted from the American Geriatrics Society
Consensus Statement on vitamin D for Prevention of Falls and Their Consequences.
J Am Geriatr Soc. (2014)
20. ^ Holick MF, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an
Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. (2011)
21. ^ B Dawson-Hughes, et al. IOF position statement: vitamin D recommendations for
older adults. Osteoporos Int. (2010)
22. ^ a b Institute of Medicine (US) Committee to Review Dietary Reference Intakes for
Vitamin D and Calcium, et al. Dietary Reference Intakes for Calcium and Vitamin D.
23. ^ James M S Wason, Peter Brocklehurst, Christina Yap. When to keep it simple -
adaptive designs are not always useful. BMC Med. (2019)
24. ^ Ginde AA, et al. High-Dose Monthly Vitamin D for Prevention of Acute Respiratory
Infection in Older Long-Term Care Residents: A Randomized Clinical Trial. J Am
Geriatr Soc. (2017)
25. ^ Bischoff-Ferrari HA, et al. Monthly High-Dose Vitamin D Treatment for the
Prevention of Functional Decline: A Randomized Clinical Trial. JAMA Intern Med.
(2016)
26. ^ Lynette M Smith, J Christopher Gallagher, Corinna Suiter. Medium doses of daily
vitamin D decrease falls and higher doses of daily vitamin D3 increase falls: A
randomized clinical trial. J Steroid Biochem Mol Biol. (2017)
27. ^ Burt LA, et al. Effect of High-Dose Vitamin D Supplementation on Volumetric Bone
Density and Bone Strength: A Randomized Clinical Trial. JAMA. (2019)
28. ^ Bolland MJ, Grey A, Avenell A. Effects of vitamin D supplementation on
musculoskeletal health: a systematic review, meta-analysis, and trial sequential
analysis. Lancet Diabetes Endocrinol. (2018)
29. ^ Meryl S LeBoff, et al. VITamin D and OmegA-3 TriaL (VITAL): Effects of Vitamin D
Supplements on Risk of Falls in the US Population. J Clin Endocrinol Metab. (2020)
85
30. ^ J C Gallagher, et al. Combination treatment with estrogen and calcitriol in the
prevention of age-related bone loss. J Clin Endocrinol Metab. (2001)
31. ^ Laurent Dukas, et al. Alfacalcidol reduces the number of fallers in a community-
dwelling elderly population with a minimum calcium intake of more than 500 mg daily.
J Am Geriatr Soc. (2004)
32. ^ Barbara J Boucher. Why do so many trials of vitamin D supplementation fail?.
Endocr Connect. (2020)
33. ^ Jennifer S Walsh, Simon Bowles, Amy L Evans. Vitamin D in obesity. Curr Opin
Endocrinol Diabetes Obes. (2017)
34. ^ Aysegül Aksan, et al. Measuring Vitamin D Status in Chronic Inflammatory
Disorders: How does Chronic Inflammation Affect the Reliability of Vitamin D
Metabolites in Patients with IBD?. J Clin Med. (2020)
35. ^ Houra Mohseni, et al. Genetic Variations in VDR could Modulate the Efficacy of
Vitamin D3 Supplementation on Inflammatory Markers and Total Antioxidant Capacity
among Breast Cancer Women: A Randomized Double Blind Controlled Trial. Asian
Pac J Cancer Prev. (2019)
36. ^ a b Houra Mohseni, et al. Circulating 25-Hydroxy Vitamin D Relative to Vitamin D
Receptor Polymorphism after Vitamin D3 Supplementation in Breast Cancer Women:
A Randomized, Double-Blind Controlled Clinical Trial. Asian Pac J Cancer Prev.
(2017)
37. ^ Liang Zhang, et al. Associations between VDR Gene Polymorphisms and
Osteoporosis Risk and Bone Mineral Density in Postmenopausal Women: A
systematic review and Meta-Analysis. Sci Rep. (2018)
38. ^ Dewei Wang, et al. Vitamin D receptor Fok I polymorphism is associated with low
bone mineral density in postmenopausal women: a meta-analysis focused on
populations in Asian countries. Eur J Obstet Gynecol Reprod Biol. (2013)
39. ^ Elizabeth L Barry, et al. Genetic variants in CYP2R1, CYP24A1, and VDR modify
the efficacy of vitamin D3 supplementation for increasing serum 25-hydroxyvitamin D
levels in a randomized controlled trial. J Clin Endocrinol Metab. (2014)
40. ^ Cashman KD, et al. Improved Dietary Guidelines for Vitamin D: Application of
Individual Participant Data (IPD)-Level Meta-Regression Analyses. Nutrients. (2017)
41. ^ Reinhold Vieth, et al. Vitamin D poisoning by table sugar. Lancet. (2002)
86
Deeper Dive: Do I have to choose between
osteoporosis and heart disease?
 Tags: CVD, Meta-analysis, Bone Health, Supplementation, Calcium
 Study under review: Calcium Supplements and Risk of Cardiovascular Disease: A Meta-
Analysis of Clinical Trials
Quick Takes
• What was the question? What are the associations
between calcium supplements and the risk of cardiovascular
disease (CVD)?
• How was it answered? Researchers conducted a meta-
analysis of 13 double-blinded, placebo-controlled randomized
clinical trials (RCTs) with a total of 28,935 participants.
• Who was studied? Healthy and sick adults, 93% women,
between 35 and 97 years old living in various countries made
up the participant population.
• What was the intervention? Participants took calcium in
carbonate, citrate, or gluconate forms at doses of at least 500
milligrams per day for one to seven years, with a follow-up of
one to eight years.
• What’s the main takeaway? The use of calcium
supplements significantly increased the risk of CVD and
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coronary heart disease (CHD) by about 15%.
• Any caveats? Most of the participants were postmenopausal
women with a mean age of 66 years, so the results of this
study mostly applies to this population, even though other
populations were included in the study. When one of the
larger studies with a postmenopausal population was
excluded, calcium supplementation was only marginally
associated with an increased risk of CVD and not significantly
associated with an increased risk of CHD, suggesting that
these results hinge largely on this particular study.
Introduction
Approximately 54 million Americans have osteoporosis, a debilitating disease that causes a loss of
bone density and mass and increases the risk of fracture. Guidelines from several organizations,
including the U.S. National Osteoporosis Foundation[1], recommend dietary calcium intake of at
least 700 milligrams per day for the prevention and treatment of osteoporosis for adults 50 years
and older. The U.K. National Osteoporosis Guideline Group advocates the use of supplements to
promote optimal bone health for people who do not eat the recommended intake of calcium
through dietary sources.
However, there may be a downside to higher calcium intake. In the early 2010s, evidence emerged
that calcium supplementation may cause an increased risk of cardiovascular disease[2] (CVD), a
group of disorders of the heart and blood vessels that includes coronary heart disease (CHD, a
disease of blood vessels supplying the heart muscle) and cerebrovascular disease (a disease of
the blood vessels supplying the brain).
However, later studies found that calcium supplementation did not increase[3] the risk of CHD.
Based on the results of a 2016 meta-analysis and systematic review[4] showing no significant
difference in risk of CVD events or mortality between calcium supplementation (with or without
vitamin D) and placebo groups, the National Osteoporosis Foundation and the American Society
88
for Preventive Cardiology[5] issued a clinical guideline that there is moderate quality evidence that
calcium intake, with or without vitamin D, from food or supplements does not increase the risk of
CVD in healthy adults.
Given the conflicting findings from studies on this subject, the authors of the study under review
aimed to investigate the associations between calcium supplementation and the risk of CVD
through a comprehensive meta-analysis of placebo-controlled double-blind RCTs and subgroup
analyses that addressed the controversial findings from previous studies. They also evaluated the
differences in findings and study characteristics of previous systematic reviews and meta-analyses
versus the current study.
Professional health organizations stress the importance of an

adequate amount of calcium for the prevention and treatment of
osteoporosis, and supplementation has been recommended if
dietary intake is insufficient. There is conflicting evidence regarding
the risk of CVD associated with calcium supplementation. The
purpose of this study was to evaluate the association between
calcium supplementation and the risk of CVD.
What was studied?

The present study was a meta-analysis of randomized controlled trials examining the effect of
calcium supplementation on the risk of CVD, CHD, and cerebrovascular disease. The authors do
not state that the study was conducted in accordance with the Preferred Reporting Items for
Systematic Review and Meta-analysis (PRISMA) guidelines and the study was not preregistered.
The meta-analysis included RCTs published between 1990 and 2013. The search extended to
November 2020 but didn’t find anything past 2013. The included RCTs were conducted in
participants with a mean age of 66.3 years of age (ranging from 33–97 years), 93% of whom were
women. Only one study provided vitamin D3[6] (400 IU per day) in conjunction with calcium. The
calcium salts that were used were carbonate, citrate, or gluconate. There was a low degree of
heterogeneity between most of the studies, except in those where dietary calcium intake was less
than 700 mg per day (I2 = 55, indicating moderate heterogeneity). Other study characteristics are
laid out in Figure 1.
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Figure 1: Study characteristics
Primary outcomes were CVD, CHD, and cerebrovascular disease. The researchers attempted to
estimate both absolute and relative risk of calcium supplementation, when possible. See here for a
refresher on absolute versus relative risks.
The researchers conducted subgroup analyses on demographics, supplementation and dietary

details, and study characteristics. Also, trials were excluded one at a time to assess the influence
of individual trials on the summary effect.
Heterogeneity among the studies was measured and found to be low. A random effects model,
which allows the true effect sizes to differ across studies, was used in this meta-analysis.
The quality of the studies was assessed using the Cochrane Risk of Bias Tool. Those studies with
a low risk of bias, i.e, at least five items, were considered to have an overall low risk of bias. The
slim majority of studies were at low risk of bias. Publication bias was assessed and no evidence for
bias was found.
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Finally, the authors also compared and contrasted their results with the results of previous meta-
analyses.
The study under review was a systematic review and meta-

analysis examining the effect of calcium supplementation on the
risk of CVD, CHD, and cerebrovascular disease. A total of 13
RCTs with 28,935 participants were evaluated. The majority of
participants (93%) were women. Risk of bias in individual studies
was found to be low in just over half the studies. There was no
solid evidence for publication bias. Heterogeneity was also
evaluated and found to be low.

Calcium supplementation significantly increased the risks of CVD (RR=1.15, 95% CI 1.06–1.25)
and CHD (RR=1.16, 95% CI 1.05–1.28). Furthermore, calcium supplementation caused a
nonsignificant increase in risk of cerebrovascular disease (RR=1.13, 95% CI 0.97–1.31). Several
subgroup analyses were also performed. While these analyses all knocked heterogeneity down to
zero, at best, or moderate levels, at worst, they didn’t really change the results all that much:
regardless of age, dose, baseline dietary calcium intake, or population variables, there was an
increased relative risk of CVD seen with calcium supplementation of roughly 15%. Some of the
subgroups’ results became statistically nonsignificant, but that’s to be expected since the sample
sizes are lower in each subgroup than they are for the whole population. While uncertainty
increased, no clear trends were apparent—the results stayed roughly the same.
The absolute risk difference for CVD and CHD from using calcium supplements was 8.6 per 1,000
people and 8.8 per 1,000 people, respectively. The leave-one-out sensitivity analysis showed that
when a reanalysis[7] of a study that included 16,718 post-menopausal women was excluded,
supplementation with calcium was only marginally associated with an increased risk in CVD and
not associated with increased risk of CHD.
The authors’ evaluation of differences between the current study and five previous systematic
reviews and/or meta-analyses showed that three[8] of the reviews[2] (all having the same first
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author) resulted in calcium supplementation having an increased risk of CVD, similar to the findings
of the current study. Two reviews differed. The first review[3] concluded that calcium
supplementation did not increase the risk of CHD, which can be attributed to its inclusion of open-
label trials without control groups, which this meta-analysis excluded. The other review[4] that
disagreed with the study under review concluded that calcium supplementation had a small and not
clinically important risk of CVD. This difference is likely due to the fact that the authors did not
meta-analyze the literature, but only reviewed it qualitatively. Also, they did not search for
unpublished data as the study under review did, and thus is a bit more likely to be subject to
selection bias.
Calcium supplementation increased the risks of CVD and CHD,

although the effect size was not very high. Calcium
supplementation did not significantly increase the risk of
cerebrovascular disease. The subgroup analyses all came to
roughly the same conclusion as the main analysis. Dose, disease
state, and other factors didn’t change the results much. The results
of this meta-analysis were similar to three of five previous reviews,
with disagreement likely attributable to different inclusion criteria or
analytical methods.
The bigger picture

Overall, this study suggests that calcium supplementation can indeed increase the relative risk of
CVD and CHD by roughly 15% in a population mainly consisting of postmenopausal women. The
absolute risk increase was close to 10 in 1,000 or, 1%. These numbers don’t imply that there’s a
high chance that taking calcium supplements will cause CVD in any individual woman on average.
However, given the fact that around 30–50% of older women[9] in some Western countries take
calcium supplements, this small absolute risk can add up to a lot more CVD in the population.
Since there are about 50 million women over age 55 in the U.S, a conservative assumption that
25% of them take calcium supplements suggests that calcium supplementation would lead to over
100,000 more instances of CVD in the U.S. than there would have been otherwise. Thus, these
findings are especially important for people in policy-making and medical professional roles, who
92
are in the position to make recommendations that affect a lot of people.
That said, keep in mind that people aren’t taking calcium for fun. One of its main uses is for
preventing fractures. This raises the question: do the risks outweigh the benefits? It’s possible to
guess at the answer by comparing the absolute risk of CVD found in the study under review and
compare it to the absolute risk of fracture prevention found in other sources. One systematic review
[9] fits the bill, providing an absolute risk reduction for fractures. It comes up with around 13
fractures prevented per 1,000 people supplemented. Thus, as depicted in Figure 2, slightly more
fractures are prevented than CVD cases are caused, but it’s a pretty delicate balance, and the
comparison overall has to do with relatively minor risks and minor benefits. The relative size of the
absolute benefit of calcium supplementation is made more apparent by comparing its impact to
bisphosphonate drugs[10], which prevent roughly 10 times as many fractures as calcium
supplementation. These comparisons should be taken lightly because these numbers come from
different populations and studies, so comparisons can be subject to bias. While not perfect, these
numbers at least provide a starting point for being able to think about the relative risks and benefits
more clearly. However, the main takehomes from this study is that the evidence suggests that
there are risks concerning calcium supplementation.
Figure 2: The absolute risks and benefits in context
This study had several strengths. The researchers did their due diligence by digging up
unpublished data to fight selection bias, and they also evaluated the quality of the evidence.
Fortunately, the evidence was pretty free of heterogeneity and over half the studies were at low risk
of bias, with no good reason to suspect publication bias. This raises confidence in these findings.
93
Another aspect of the study that improves confidence is that the results were pretty robust. The
results changed very little in subgroup analysis and when individual studies were left out.
However, there was one exception to that robustness. Recall that when one particular re-analysis[7]
of a trial of over 16,000 participants was left out, the link between CVD risk and supplementation
went down, and the link with CHD in particular became statistically nonsignificant. Thus, the
specific results of the study under review lean more heavily on this particular study than the others
that were included. This problem may be compounded by the fact that the original study[11] did not
find a link between CVD and calcium supplementation; the link was only found in the reanalysis.
However, the author of the reanalysis had good reason to suspect that calcium’s impact on CVD
may have been obscured by personal calcium supplement use. The point of the reanalysis was to
take that into account. Be that as it may, it should be noted that the strength of the results of the
study under review hinges to a significant extent on the quality of this reanalysis. But even
assuming that the reanalysis isn’t valid, a smaller, and still statistically significant, rise in CVD risk
remains.
A final limitation that’s worth mentioning in brief is that the study under review was not
preregistered, which, in theory, leaves the authors more leeway to fish for significant results. While
there’s no evidence that this occurred, preregistering systematic reviews like this instills more
confidence in the results since it mitigates the risk of fishing.
The absolute risk of calcium causing cardiovascular disease in

postmenopausal women is relatively small, but given how many
women take calcium supplements, this effect can lead to a big rise
in CVD at the population level. Calcium supplementation may
prevent slightly more fractures than the amount of CVD cases it
causes, but these specific numbers may not be directly
comparable. While this study was well conducted in many ways
and the evidence shows an overall low risk of bias, it had two
limitations: its results rely in large part on the results of a
reanalysis of a study, and it wasn’t preregistered.
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Q. What is the recommended intake for calcium?
The intake recommendation for calcium provided in the Dietary Reference Intakes (DRIs)
developed by the Food and Nutrition Board) (FNB) at the Institute of Medicine of the National
Academies established a recommended daily allowance (RDA) for adults 19–50 years of age is
1,000 mg per day from food and/or supplements for men and women. The RDA increases to 1,200
mg per day for women over 51 years old and men over 71 years old.
The RDA is based on the amount of calcium required for bone health and maintaining adequate
rates of calcium retention in healthy people, although the recommendation was based on calcium
balance studies that were very short term. They also set an upper tolerance limit of 2,500 mg per
day for men and women ages 19–50. The upper tolerance limit is lowered to 2,000 mg per day for
men and women over the age of 51.
The American Society for Preventive Cardiology and the National Osteoporosis Foundation states
that[5] based on the evidence to date, “calcium intake from food and supplements that does not
exceed the upper tolerance limit should be considered safe from a cardiovascular standpoint.”
Q. Is it hard to get an adequate amount of calcium from a normal diet?
For most people, it’s not too difficult to get an adequate amount of calcium from their typical diet.
The combination shown in Figure 3 of 8 ounces of yogurt, 1 cup of broccoli, 1 serving of cereal, 2
slices of bread, and a can of salmon adds up to about 1,200 milligrams. Some vegetables, like kale
and spinach, are also good sources of calcium. However, calcium in vegetables may not always be
absorbed as well as from dairy. As a rule of thumb[12], vegetables with lower oxalate levels, such
as kale and bok choy, have more bioavailable calcium.
Figure 3: Food that provides about 1,200 milligrams of

calcium
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What should I know?
Adequate calcium intake is necessary for many critical biological functions, including the
maintenance of healthy bones. Several international organizations promote the use of calcium
supplements for preventing and treating osteoporosis in postmenopausal women. However,
several individual studies and meta-analyses, including the one under review, have shown a
significant association between calcium supplementation and risk of CVD.
Overall, this study suggests a 15% relative increase in CVD or just under a 1% absolute increase in
risk. While these risks are somewhat small, they could lead to a lot more CVD worldwide, given
how many women supplement with calcium. While the study has some limitations, its results are
pretty robust and suggest that the cardiovascular risks should be taken into account when deciding
whether or not to supplement with calcium.
Are the benefits of calcium supplementation to prevent fractures

worth the risk? Have your say in the Study Deep Dives Facebook
discussion forum.
96
 References
1. ^ Cosman F, et al. Clinician's Guide to Prevention and Treatment of Osteoporosis.
Osteoporos Int. (2014)
2. ^ a b Bolland MJ, et al. Calcium supplements with or without vitamin D and risk of
cardiovascular events: reanalysis of the Women's Health Initiative limited access
dataset and meta-analysis. BMJ. (2011)
3. ^ a b Joshua R Lewis, et al. The effects of calcium supplementation on verified
coronary heart disease hospitalization and death in postmenopausal women: a
collaborative meta-analysis of randomized controlled trials. J Bone Miner Res. (2015)
4. ^ a b Mei Chung, et al. Calcium Intake and Cardiovascular Disease Risk: An Updated
Systematic Review and Meta-analysis. Ann Intern Med. (2016)
5. ^ a b Stephen L Kopecky, et al. Lack of Evidence Linking Calcium With or Without
Vitamin D Supplementation to Cardiovascular Disease in Generally Healthy Adults: A
Clinical Guideline From the National Osteoporosis Foundation and the American
Society for Preventive Cardiology. Ann Intern Med. (2016)
6. ^ Michel Brazier, et al. Clinical and laboratory safety of one year's use of a
combination calcium + vitamin D tablet in ambulatory elderly women with vitamin D
insufficiency: results of a multicenter, randomized, double-blind, placebo-controlled
study. Clin Ther. (2005)
7. ^ a b Mark J Bolland, et al. Calcium and vitamin D supplements and health
outcomes: a reanalysis of the Women's Health Initiative (WHI) limited-access data
set. Am J Clin Nutr. (2011)
8. ^ Bolland MJ, et al. Effect of calcium supplements on risk of myocardial infarction
and cardiovascular events: meta-analysis. BMJ. (2010)
9. ^ a b Mark J Bolland, et al. Calcium intake and risk of fracture: systematic review.
BMJ. (2015)
10. ^ Dennis M Black, Clifford J Rosen. Clinical Practice. Postmenopausal Osteoporosis.
N Engl J Med. (2016)
11. ^ Judith Hsia, et al. Calcium/vitamin D supplementation and cardiovascular events.
Circulation. (2007)
12. ^ C M Weaver, W R Proulx, R Heaney. Choices for achieving adequate dietary
calcium with a vegetarian diet. Am J Clin Nutr. (1999)
97
Credits
Researchers
Antonis Damianou, MSc; Brad Dieter, PhD; Nick Milazzo, MS(c); Thomas Reichhart, MSc; Brandon
Roberts PhD, MS, CSCS; Lucas Roldos, BSc, MSc(c); Jill Ryer-Powder, PhD; Detrick Snyder,
MPH, RDN; Lucas Tafur, PhD; Nattha Wannissorn, PhD, RNH, FDN-P
Editors
Gregory Lopez, MA, PharmD
Reviewers
Stephan Guyenet, PhD & Adel Moussa, PhD
Copy Editor
Dmitri Barvinok
Infographics
Antonius Khengdro & Calla Lee
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Issue #77 (March 2021)

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Issue #77 (March 2021)

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Issue #77 March 2021

D-creasing asthma symptoms with supplementation

The effects of full fasting vs. modified fasting on cognitive performance

Nulls: November–December 2020

Battling exercise-induced muscle damage with omega-3s

Deeper Dive: Do I have to choose between osteoporosis and heart disease?

 Read this article online at Examine.com

Caffeine’s effect on muscular endurance, strength, and

Caffeine’s effects on endurance performance

Caffeine consumption and sport-specific performance

• Volleyball players increased their precision.

• Cross-country skiers increased speed and endurance.

Individual response to caffeine

Side effects of caffeine

Caffeine and cognitive performance

Environmental influences on caffeine response

Caffeine in combination with other compounds

Never dismiss the placebo effect!

 Study under review: Effect of vitamin D supplementation on asthma control in patients

 Read this article online at Examine.com

What was the question?

Why was the question worth asking?

Figure 1: Cholecalciferol vs. calcifediol

Vitamin D is a potentially useful supplement for asthma due to its

How was the question answered?

This was a six-month triple-blind randomized controlled trial

Figure 2: Change in ACT score within and between

Compared to placebo, weekly use of the calcifediol supplement

How much should you trust the answer?

hypercalcemia or hypercalciuria, and to ensure that vitamin D levels rise accordingly.

This study was well-conducted and well-powered enough to detect

What’s the take-home?

If cholecalciferol were used in this trial and raised 25-OH-D levels

^ Go back to table of contents

 Study under review: Effect of micronutrient supplements on influenza and other

 Read this article online at Examine.com

Zinc Probably not. Maybe severity, Lozenges containing zinc

References: Hemilä et al. Cochrane Database Syst Rev. 2013 Jan.[2]

ARIs are a leading cause of death globally. Supplementation with

What was studied?

Figure 2: Study characteristics

The present study is a meta-analysis of 70 randomized controlled

What were the findings?

Figure 3: Relative reduction in risk of contracting ARI

The bigger picture

The results of the present study are in good agreement with

Frequently asked questions

Q. How do I know if micronutrients might be beneficial for me?

What should I know?

^ Go back to table of contents

 Read this article online at Examine.com

What was the question?

Why was the question worth asking?

True fasting is a method of fasting during which zero calories are

How was the question answered?

Figure 1: Study design

Healthy middle-aged women were studied in a randomized cross-

What was the answer?

Figure 2: Results in a nutshell

Cognitive performance was not affected over 7.5 hours during a

How much should you trust the answer?

A meta-analysis of 10 studies[6] examining the cognitive impact of fasting on healthy individuals

^ Go back to table of contents

 Read this article online at Examine.com