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Vitamin D Supplementation and Total Mortality
A Meta-analysis of Randomized Controlled Trials
Philippe Autier, MD; Sara Gandini, PhD Background: Ecological and observational studies sug-
varied from 300 to 2000 IU. The trial size–adjusted mean gest that low vitamin D status could be associated with higher daily vitamin D dose was 528 IU. In 9 trials, there was a 1.4- mortality from life-threatening conditions including cancer, to 5.2-fold difference in serum 25-hydroxyvitamin D be- cardiovascular disease, and diabetes mellitus that account tween the intervention and control groups. The summary for 60% to 70% of total mortality in high-income countries.
relative risk for mortality from any cause was 0.93 (95% con- We examined the risk of dying from any cause in subjects fidence interval, 0.87-0.99). There was neither indication who participated in randomized trials testing the impact of for heterogeneity nor indication for publication biases. The vitamin D supplementation (ergocalciferol [vitamin D2] or summary relative risk did not change according to the ad- cholecalciferol [vitamin D3]) on any health condition.
dition of calcium supplements in the intervention.
Conclusions: Intake of ordinary doses of vitamin D supple-
Methods: The literature up to November 2006 was
ments seems to be associated with decreases in total mor- searched without language restriction using the following tality rates. The relationship between baseline vitamin D databases: PubMed, ISI Web of Science (Science Citation status, dose of vitamin D supplements, and total mortal- Index Expanded), EMBASE, and the Cochrane Library.
ity rates remains to be investigated. Population-based,placebo-controlled randomized trials with total mortal- Results: We identified 18 independent randomized con-
ity as the main end point should be organized for confirm- trolled trials, including 57 311 participants. A total of 4777 deaths from any cause occurred during a trial size–adjustedmean of 5.7 years. Daily doses of vitamin D supplements Arch Intern Med. 2007;167(16):1730-1737 ECOLOGICALSTUDIESINNORTH productsmayalsorepresentasourceofvi-
tamin D, although of highly variable content (eg, fortified foods, oily fish, eggs, and but- ter). Hence, low vitamin D status could pro- ceed from the conjunction of insufficient in- cer, cardiovascular diseases, and diabetes takes (exogenous source) and of insufficient mellitus would increase with increasing lati- skin synthesis (endogenous source) of vita- tude, that is, with residence increasingly dis- min D. Biological findings have reinforced tant from the equator.1,2 Other studies have the likelihood of the vitamin D hypothesis.
shown that the survival of patients with car- First, vitamin D receptors have been found diovascular disease or with some cancer (eg, in various organs, and activation of these re- greaterifthediagnosiswasmadeduringsum-mer as compared with the winter.3,4 Increas- For editorial comment
ing distance from the equator and winter pe- see page 1709
riod were equated to decreasing exposure tosunlight, especially to UV-B radiation (280- CME available online at
315 nm) because with increasing latitude, www.archinternmed.com
amountsofUV-BradiationreachingtheearthsurfacedecreasefasterthanamountsofUV-A (calcitriol), the physiologically active form radiation(315-400nm).5Also,seasonalvaria- of vitamin D, induces cell differentiation and tions are more pronounced for UV-B radia- inhibitsproliferation,invasiveness,angiogen- tion than for the UV-A radiation.5 Because esis, and metastatic potential.11,12 These bio- UV-B radiation is necessary for the synthe- logical phenomena are typical of cancer gen- Author Affiliations:
sis of vitamin D in the skin, it has been hy- pothesized that associations found between proliferation) are also involved in cardiovas- latitudeorseasonalityandmortalityfromsev- cular ischemic diseases. Second, many tis- France (Dr Autier); and theEuropean Institute of Oncology, eral chronic conditions could be owing to sues express the 1␣-hydroxylase enzyme.11 variations in vitamin D status.6-10 Some food So, after 25-hydroxylation of vitamin D in ARCH INTERN MED/ VOL 167 (NO. 16), SEP 10, 2007 2007 American Medical Association. All rights reserved.
tervals (CIs) (ie, crude data or adjusted were used: vitamin D, cholecalciferol, and RRs and standard errors, 95% CIs, or P ergocalciferol. For methods, the follow- vitamin D intake vs placebo or control.
MeSH terms used were randomized con- trolled trial and placebo. A first general DESCRIPTION OF STUDIES
RETRIEVED
A total of 992 articles or abstracts were re- trieved and checked for relevance in terms words with the following outcome key-words (and their corresponding MeSH of intervention, design, and reporting of terms): congestive heart failure, coro- mortality data. This process resulted in re- nary heart disease, cardiovascular dis- trieving a total of 27 articles or abstracts ease, fracture, bone mineral density, and bone turnover. Mortality was not a help- ized clinical trials evaluating effects of vi- point and reporting data on deaths. Ofthese 27 articles, 9 were not included in 1 trial in the United Kingdom,16 had mor- sons: (1) Two articles referred to the same trial.17,18 (2) Three did not report deaths erences cited in the selected articles and trieved.19-21 (3) In 2 trials, the interven-tion consisted of a set of drugs including stract or article whose title or summarycontained at least 1 intervention key- vitamin D.22,23 (4) Two trials were basedon cluster randomization,24,25 and 1 of synthesis of randomized controlled trials cluding 3717 participants with a mean age SELECTION OF ARTICLES
of 85 years. The intervention was equiva-lent to a daily dose of 1100 IU of ergocal- INTERVENTION
ciferol. (5) A placebo-controlled random- AND OUTCOME
label trial with a subgroup of the placebo- ation of Calcium Or vitamin D) trial.28 We used the data from the open-label trial and trial to have independent studies. For the estimates derived from the same trial.
Table 1 summarizes the 18 studies that
calcidol), the physiologically active form D3 [calcitriol]), or other vitamin D ana- STATISTICAL ANALYSIS
end-stage renal disease or in patients un- rates in each randomization group were all (intent-to-treat analysis). Some trials, such LITERATURE SEARCH
as the RECORD trial,28 had a factorial de- ARCH INTERN MED/ VOL 167 (NO. 16), SEP 10, 2007 2007 American Medical Association. All rights reserved.
Table 1. Vitamin D Supplements and All-Cause Mortality: Overview of Trials Selected for Meta-analysis
Baseline,
in Control
Follow-up,
Point(s)
Population
Intervention
(300 IUϩcalcium [0.5 g]during 3 first years and 100IUϩcalcium [0.5 g] in thelast year) 1 group with single-injectionergocalciferol(300 000 IU)ϩoral calcium(1 g), 1 group with daily oralcholecalciferol (800IUϩcalcium [1 g]) (10 000 IU), followed by dailyoral ergocalciferol (1000 IU) a Women randomized to multivitamin supplement containing vitamin D were not included in the meta-analysis.
b Women randomized to hormone therapy or to hormone therapy and vitamin D groups were not included in the meta-analysis.
c Cod liver oil without cholecalciferol.
d The same article reported 2 randomized controlled trials. We took into account only the open label trial because the placebo-controlled trial was a part of the RECORD trial.28 Mortality data of the open label trial we used were those reported by Avenell et al15 in 2005.
e Intervention assumed to be the same as in the RECORD Trial.28 ARCH INTERN MED/ VOL 167 (NO. 16), SEP 10, 2007 2007 American Medical Association. All rights reserved.
Table 2. Serum Levels of 25-Hydroxyvitamin D in Randomized Trials With Vitamin D Supplementsa
Mean Serum 25-Hydroxyvitamin D3 (ng/mL)b
Daily Dose
of Vitamin D
Ratio for In-Study Level,
Intervention Group
Control Group
Follow-up,
in Intervention
Intervention vs
Group, IU
Baseline
Baseline
Control Group
a Trials in Table 1 not included in Table 2 did not report serum 25-hydroxyvitamin D levels.
b Measurements of serum levels were always performed in subsamples of subjects in intervention and control groups.
c In-study serum 25-hydroxyvitamin D levels were derived from Figure 1 in the original publication.33 d Estimated from oral cholecalciferol, 100 000 IU every 4 mo.
studies that is attributable to heterogeneity coming from the “intervention group” and data related to groups not receiving vita- ments in the largest trials (see “Trials tality was a relatively rare event, and we lication bias: the sensitivity analysis of Figure) was 48% in the RECORD
tween the various measures of relative risk Copas and Shi47 and the funnel plot regres- (ie, odds ratio, rate ratio, and risk ratio).
Initiative trial,42,43 63% in the trial by the corresponding variance using the for- mula proposed by Greenland44 in 1987.
culated them from tabular data, and weused the Woolf formula to evaluate the trial by Lips et al,30 and 95% in the trial standard error of the log odds ratio.44 Logit 0.5 in every cell of those tables that con- tality across selected trials was computed results of the 18 trials indicated a sig- as a summary RR (SRR) with 95% CIs. TheSRR was considered statistically signifi- cant if the 95% CI did not include 1.0.
effect across studies using the large sample test based on the ␹2 statistic. Since the ␹2 for heterogeneity (P=.52) or of pub- test has limited power, we considered that lication bias (P=.37 with the method statistically significant heterogeneity ex- was 528 IU. Table 2 indicates a sub-
of Copas and Shi47 and P=.77 with the isted when the P value was Յ.10.45 Sub- A subgroup analysis (Table 3)
heterogeneity focusing on type of study,type of control, length of follow-up, vita- groups, translating to a 1.4- to 5.2-fold using the I2 parameter, which represents ARCH INTERN MED/ VOL 167 (NO. 16), SEP 10, 2007 2007 American Medical Association. All rights reserved.
Subtotal SRR (95% CI)
0.92 (0.86-0.99)
Subtotal SRR (95% CI)
1.15 (0.79-2.73)
All trials
2330/28 500
2447/28 811
0.93 (0.87-0.99)
χ2 Test for heterogeneity: P = .52 Figure. Meta-analysis of data on all-cause mortality in 18 randomized controlled trials with vitamin D. SRR indicates summary relative risk.
Table 3. Vitamin D Supplements and All-Cause Mortality:
Subgroup and Sensitivity Analysis
on all-cause mortality is not likely be-cause total mortality did not consti- No. of Trials
Parameter, Heterogeneity,
Variable
Meta-Analysis
P Value
18 trials included in the meta-analysis except 1.16 Timing of deaths calcium supplements. No relation-ship was found with dose of vita- Abbreviation: CI, confidence interval; SRR, summary relative risk.
The I2 parameter represents the percentage of total variation across studies that is attributable to b No placebo for vitamin D in the control group.
tively narrow (ie, 400-830 IU), andlarge variations in size of trials andin compliance to interventions pre- neity. In this respect, exclusion of this ARCH INTERN MED/ VOL 167 (NO. 16), SEP 10, 2007 2007 American Medical Association. All rights reserved.
have less of an effect (or not at all) on probability to die because of falls.
P o p u l a t i o n - b a s e d , p l a c e b o - Accepted for Publication: April 18,
Correspondence: Philippe Autier,
Author Contributions: Drs Autier
sibility for the integrity of the data and Study concept and design: Autier. Ac- quisition of data: Autier and Gandini.
Analysis and interpretation of data: Autier and Gandini. Drafting of the manuscript: Autier. Statistical analy- sis: Gandini. Administrative, techni- cal, and material support: Autier. Study Financial Disclosure: None re-
en’s Health Initiative trial, rate ratios Additional Contributions: The li-
ARCH INTERN MED/ VOL 167 (NO. 16), SEP 10, 2007 2007 American Medical Association. All rights reserved.
20. Graafmans WC, Ooms ME, Hofstee HM, Beze- ized, controlled trial of quadriceps resistance ex- mer PD, Bouter LM, Lips P. Falls in the elderly: a ercise and vitamin D in frail older people: the Frailty prospective study of risk factors and risk profiles.
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ARCH INTERN MED/ VOL 167 (NO. 16), SEP 10, 2007 2007 American Medical Association. All rights reserved.
Serum 25 hydroxyvitamin D levels in early and ad- 55. Lee IM, Cook NR, Gaziano JM, et al. Vitamin E in 58. Pe´rez-Castrillo´n JL, Vega G, Abad L, et al. Effects vanced breast cancer. J Clin Pathol. 2006;59 the primary prevention of cardiovascular disease of atorvastatin on vitamin D levels in patients with and cancer: the Women’s Health Study: a ran- acute ischemic heart disease. Am J Cardiol. 2007; 53. Giovannucci E, Liu Y, Rimm EB, et al. A prospec- domized controlled trial. JAMA. 2005;294(1): t i v e S t u d y o f p r e d i c t o r s o f v i t a m i n D 59. Pittas AG, Dawson-Hughes B, Li T, et al. Vitamin D status and cancer incidence and mortality 56. Bouillon R, Eelen G, Verlinden L, Mathieu C, Car- in men. J Natl Cancer Inst. 2006;98(7): meliet G, Verstuyf A. Vitamin D and cancer. J Ste- diabetes in women. Diabetes Care. 2006;29(3): roid Biochem Mol Biol. 2006;102(1-5): 54. Bjelakovic G, Nikolova D, Simonetti RG, Gluud C.
60. Barbeau WE, Bassaganya-Riera J, Hontecillas R.
Antioxidant supplements for prevention of gas- 57. Penda´s-Franco N, Gonzalez-Sancho JM, Suarez Putting the pieces of the puzzle together—a se- trointestinal cancers: a systematic review and Y, et al. Vitamin D regulates the phenotype of hu- ries of hypotheses on the etiology and pathogen- meta-analysis. Lancet. 2004;364(9441):1219- man breast cancer cells. Differentiation. 2007; esis of type 1 diabetes. Med Hypotheses. 2007; Error in Figure. In the Original Investigation by Fito´ et al titled
“Effect of a Traditional Mediterranean Diet on Lipoprotein Oxi-
dation: A Randomized Controlled Trial” published in the June
11, 2007, issue of the ARCHIVES (2007;167[11]:1195-1203), an
error occurred in Figure 2 wherein the y-axis labels in parts
A and C were mistakenly transposed. A corrected figure and
legend appears below.
Figure 2. Mean±SD changes in plasma ␣-linolenic acid (A), urinary tyrosol (B),
and hydroxytyrosol (C) after 3-month interventions. *PϽ.05 vs the
corresponding baseline. †PϽ.05 vs low-fat diet group. ‡PϽ.05 vs TMDϩnuts
group. TMD indicates traditional Mediterranean diet; VOO, virgin olive oil.
ARCH INTERN MED/ VOL 167 (NO. 16), SEP 10, 2007 2007 American Medical Association. All rights reserved.

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