Editorials
Age and Ageing 2005; 34: 425–426  The Author 2005. Published by Oxford University Press on behalf of the British Geriatrics Society.
doi:10.1093/ageing/afi147 All rights reserved. For Permissions, please email: journals.permissions@oupjournals.org
Vitamin D for older people: how much,
for whom and—above all—why?
Vitamin D is a nutrient with physiological actions in people
of all ages. Its clearest role is in bone health at the extremes
of life, and there is longstanding concern over the adequacy
of vitamin D provision for skeletal development in child-
hood and for the prevention of bone loss in older adults.
More recently, it has become evident from basic and clinical
research that vitamin D has many other actions. Many geria-
tricians have been following the story of its role in the main-
tenance of neuromuscular function as expressed through
gait and balance [1]. However, it also acts as a regulator of
cell growth and differentiation in the skin and probably in
many other tissues, leading to putative roles in autoimmune
disease, allergy and suppression of carcinogenesis [2].
Population-based nutrition surveys have been carried
out in several countries over the past 60 or so years, and a
paper in this issue of the journal presents results from the
latest of these, the Health Survey for England 2000. The
research is of high quality and was particularly successful at
capturing a good sample of care home residents, a group
often under-represented in such work. The authors find
evidence of widespread vitamin D insufficiency in older
adults, and note that despite a number of recent initiatives
[3] there has been no improvement since the previous large
study in the UK, the National Diet and Nutrition Survey
(NDNS) in 1994–1995 [4].
Vitamin D is a rather unusual vitamin; not, in the precise
sense, a vitamin at all. It is not an essential dietary compo-
nent, as it is perfectly possible for humans living in most lat-
itudes to synthesise wholly adequate quantities of it if skin is
exposed to sunlight. For most of human history, our agrar-
ian ancestors have spent enough time outdoors to achieve
these levels without any dietary intake at all. It is found in a
fairly narrow range of foodstuffs except oily fish, and a large
minority of dietary intake in most Western countries comes
from fortification of processed foods such as breakfast
cereals.
Finally, whereas most other vitamins act as participants
or co-factors in essential biochemical reactions, vitamin D is
for all practical purposes a steroid hormone precursor. It is
unusual, to say the least, for any major endocrine pathway
to depend on ingestion of the intact pre-hormone.
For these reasons it seems sensible to regard dietary vita-
min D intake as supplementary to the primary pathway of
synthesis in the skin. From this perspective, it is perhaps
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easier to understand why there is very little consensus on
how much oral vitamin D we should be encouraging people
to take. How much is ‘enough’? ‘Enough’ vitamin D used to
mean an amount sufficient to prevent the onset of rickets or
osteomalacia—the ‘anti-rachitic dose’. This still forms the
definition of vitamin D deficiency, generally taken as a
serum level of the main circulating vitamin D metabolite 25-
hydroxyvitamin D (25-OH-D) below about 20–25 nmol/l.
However, even at vitamin D levels above this there is
impaired calcium absorption and urinary calcium loss which
tend to lower serum calcium levels. This induces parathy-
roid hormone (PTH) production, maintaining serum cal-
cium at the expense of increased bone resorption. This
occurs with 25-OH-D levels of up to ~50 nmol/l, and this
state of subclinical deficiency is usually described as vitamin
D insufficiency. Most governmental authorities now base
their guidance on vitamin D intake on avoiding insuffi-
ciency, and this approach underlies current UK recommen-
dations [5].
Another approach to nutrition is to ask what nutrient
levels minimise the risk of future disease. This has led to the
concept of an optimal dietary intake (ODI), where the goal,
for vitamin D, is reduction in risk of fracture. Many propo-
nents of this approach regard 25-OH-D levels of 75–
125 nmol/l as the natural normal range and lower levels as
‘hypovitaminosis D’ [2, 6]. In modern times, however, we
do not get out in the sunshine enough. Most readers of this
article and practically all people over 70 would require addi-
tional vitamin D. Moreover, such levels are effectively unat-
tainable in a modern Western diet, indicating that very
widespread supplementation would be required.
The authors of the paper in this issue [7] grapple with
these uncertainties but come down broadly on the side of
supplementation in older people. Their reasoning is uncon-
tentious but their conclusions less so. Geriatricians as a spe-
cies are automatically uncomfortable with requiring older
people to take extra medication unless both the purpose of
the intervention and the evidence of benefit are very clear,
which is not the case for vitamin D.
The problem is that evidence of benefit on laboratory
outcomes such as calcium homeostasis or gait and balance
is good [8], evidence on intermediate clinical outcomes such
as falls is less so [9] and evidence on the principal outcome
of interest (fracture) is conflicting. There are no major trials
425
F. Anderson
of dietary modification or increased sunlight exposure in
fracture prevention, but eight of vitamin D supplements. Of
the eight, four [10–13] show benefit and four [14–17] show
none; indeed some tend towards a suggestion of harm [14,
17]. These studies differ in dose, frequency and route of
administration, co-prescription of calcium, age group and
whether their goal is primary or secondary fracture preven-
tion. The Cochrane Collaboration systematic review found
it impractical to combine more than two of these studies in
any one analysis [18].
Based on the available evidence it seems reasonable that
we should target vitamin D supplementation at those most
likely to be deficient and with most to gain from replace-
ment therapy. Older people who are housebound or in insti-
tutional care probably warrant both vitamin D and calcium
supplements. For the fitter community-dwelling elderly
there is insufficient gain to recommend either at present.
For anyone who has had a fracture, vitamin D supplementa-
tion with or without calcium is insufficient except as part of
a full fracture risk assessment including consideration of
bisphosphonate or strontium therapy, with which its co-
prescription is in most cases obligatory.
The authors of the paper in this issue are to be congratu-
lated on adding significantly to our knowledge of the cur-
rent vitamin D status of older people in the UK—but we
should not be rushing to put vitamin D in the drinking
water just yet.
FRAZER ANDERSON
University of Southampton, Southampton General Hospital,
Southampton, UK
Email: frazer@soton.ac.uk
References
1. Venning G. Recent developments in vitamin D deficiency and
muscle weakness among elderly people. BMJ 2005; 330: 524–6.
2. Holick MF. Sunlight and vitamin D for bone health and pre-
vention of autoimmune diseases, cancers, and cardiovascular
disease. Am J Clin Nutr 2004; 80(6 Suppl.): 1678S–88S.
3. Anonymous. National Service Framework for Older People.
2001. London: Department of Health.
4. Finch S, Doyle W, Lowe C. National Diet and Nutrition
Survey: people aged 65 years and older. Volume 1: report of
the diet and nutrition survey. 1998. London: Stationery
Office.
426
5. Department of Health. Report on Health and Social Subjects
49: Nutrition and bone health, with particular reference to cal-
cium and vitamin D. 1998. London: Stationery Office.
6. Hollis BW. Circulating 25-hydroxyvitamin D levels indicative
of vitamin D sufficiency: implications for establishing a new
effective dietary intake recommendation for vitamin D. J Nutr
2005; 135: 317–22.
7. Hirani V, Primatesta P. Vitamin D concentrations among people
aged 65 years and over living in private households and institutions
in England: population survey. Age Ageing 2005; 34: 485–491.
8. Pfeifer M, Begerow B, Minne HW. Vitamin D and muscle
function. Osteoporosis Int 2002; 13: 187–94.
9. Latham NK, Anderson CS, Reid IR. Effects of vitamin D supple-
Downloaded from https://academic.oup.com/ageing/article/34/5/425/40418 by Mu'tah University user on 24 January 2022
mentation on strength, physical performance, and falls in older
persons: a systematic review. J Am Geriatr Soc 2003; 51: 1219–26.
10. Chapuy MC, Arlot ME, Duboeuf F et al. Vitamin D3 and cal-
cium to prevent hip fractures in the elderly women. N Engl J
Med 1992; 327: 1637–42.
11. Dawson-Hughes B, Harris SS, Krall EA, Dallal GE. Effect of
calcium and vitamin D supplementation on bone density in
men and women 65 years of age or older. N Engl J Med 1997;
337: 670–6.
12. Trivedi DP, Doll R, Khaw KT. Effect of four monthly oral vita-
min D3 (cholecalciferol) supplementation on fractures and
mortality in men and women living in the community: ran-
domised double blind controlled trial. BMJ 2003; 326: 469.
13. Heikinheimo RJ, Inkovaara JA, Harju EJ et al. Annual injec-
tion of vitamin D and fractures of aged bones. Calcified Tissue
Int 1992; 51: 105–10.
14. Lips P, Graafmans WC, Ooms ME, Bezemer PD, Bouter LM.
Vitamin D supplementation and fracture incidence in elderly
persons. A randomized, placebo-controlled clinical trial. Ann
Intern Med 1996; 124: 400–6.
15. Meyer HE, Smedshaug GB, Kvaavik E, Falch JA, Tverdal A,
Pedersen JI. Can vitamin D supplementation reduce the risk
of fracture in the elderly? A randomized controlled trial. J
Bone Min Res 2002; 17: 709–15.
16. Grant AM, Avenell A, Campbell MK et al. Oral vitamin D3
and calcium for secondary prevention of low-trauma fractures
in elderly people (Randomised Evaluation of Calcium Or vita-
min D, RECORD): a randomised placebo-controlled trial.
Lancet 2005; 365: 1621–8.
17. Anderson FH, Smith HE, Raphael HM, Crozier SR, Cooper
C. Effect of annual intramuscular vitamin D3 supplementa-
tion on fracture risk in 9440 community-living older people:
the Wessex Fracture Prevention Trial. J Bone Min Res 2004;
19(Suppl. 1): S57.
18. Gillespie WJ, Avenell A, Henry DA, O’Connell DL, Robertson J.
Vitamin D and vitamin D analogues for preventing fractures
associated with involutional and post-menopausal osteoporosis.
Cochrane Database of Systematic Reviews 2001; 1: CD000227.