Agreement: I Agree Body: To the editor, We read with great interest the meta-analysis by Massé et al. examining the effects of calcium and vitamin D supplementation to prevent fractures and falls, recently published by the BMJ (1). While the authors should be commended for their extensive work on the important topic of such supplementation and their impact of the fragility fracture rate, the overall conclusion of the study might be misleading for the health care community. We do not question the methodology per se but limitations regarding the study generalizability, especially the fracture prevention results, should be addressed. The meta-analysis largely includes healthy individuals (87% community dwelling older adults) who are neither deficient nor at significant risk of fractures. In that context, the conclusion is almost predictable. For instance, supplementing vitamin D in people who already have adequate levels is unlikely to produce a meaningful benefit. The present meta-analysis studied very few participants who were truly vitamin D deficient as only 3% of included trials enrolled participants with baseline 25(OH) vitamin D levels below 25 nmol/L. Twenty-seven of the 69 trials (39%) included in this analysis enrolled participants with baseline serum 25-hydroxyvitamin D (25OHD) concentrations ≥50 nmol/L, while baseline 25OHD data were unavailable for 20 studies (almost 30%). Consequently, supplementation was evaluated primarily in non-deficient individuals rather than as targeted correction of deficiency. Other high-quality studies provide important context. For instance, a notable cluster-randomized controlled trial published in the BMJ (2) and conducted in older adults living in residential care facilities (rather than community dwelling older adults) reported a 33% reduction in total fracture risk, 46% reduction in hip fracture risk and a 11% reduction in falls if calcium and protein intake were optimized. This distinction is particularly relevant in Canada, where approximately 68 % of adults do not achieve the recommended calcium intake of 1,200 mg/day, as stated in a recent Canadian population survey (3) Similarly, Chapuy et al. (4), in a randomized controlled trial involving institutionalized elderly women, demonstrated a 43% reduction in hip fractures and a 32% reduction in non-vertebral fractures for those under calcium and vitamin D daily supplementation. Moreover, benefit regarding the calcium-vitamin D and parathormone axis was also demonstrated as 44% reduction in parathormone (PTH) levels, 162% increase in serum 25(OH)D concentrations were shown, resulting in a clear correction of secondary hyperparathyroidism and translating a mean bone mineral density increment by 2.7% in the treatment group versus a 4.6% decline in the placebo group. Importantly, subjects’ follow-up duration was most probably insufficient as the median follow-up for most selected studies was only 2 years while 41% of studies lasted one year or less. Because fractures are long-term outcomes, particularly in younger populations at low baseline fracture risk, short follow-up periods may substantially underestimate the effect of treatment on fracture incidence. A final comment, as clearly stated in this paper, is that important patients’ populations were already excluded from the meta-analysis such as patients receiving osteoporosis treatments and patients on long-term corticosteroid therapy, those being the very subjects that would benefit largely of calcium/vitamin D supplementation in addition to the anti-osteoporotic treatments (5). Therefore, the findings of this meta-analysis do not fully reflect real-world clinical practice, where optimization of the phosphocalcic axis remains a fundamental component of bone health management. Sincerely, References: 1. Massé O, Mercurio CM, Dupuis S, Al Sahwi M, Arruda A, Dallaire G, Desforges K, Dugré N, Williamson D. Calcium, vitamin D, or combined supplementation to prevent fractures and falls: systematic review and meta-analysis. BMJ. 2026 May 20;393:e088050. 2. Iuliano S, Poon S, Robbins J, Bui M, Wang X, De Groot L et al. Effect of dietary sources of calcium and protein on hip fractures and falls in older adults in residential care: cluster randomised controlled trial BMJ 2021;375: n2364 3. Vatanparast H, Islam N, Patil R et al. Calcium Intake from Food and Supplemental Sources Decreased in the Canadian Population from 2004 to 2015 The Journal of Nutrition 2020 (4); 150: 833-841 4. Chapuy MC, Arlot ME, Duboeuf F, Brun J, Crouzet B, Arnaud S, Delmas PD, Meunier PJ. Vitamin D3 and calcium to prevent hip fractures in elderly women. N Engl J Med. 1992 Dec 3;327(23):1637-42. 5. Morin SN, Feldman S, Funnell L, et al. Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update. CMAJ. 2023 Oct 10;195(39). No competing Interests: No competing interests The following competing Interests: Dr Raynauld has received honoraria for lectures from Amgen, Mantra Pharma and Orimed Pharma. Dre Bégin has no conflicts of interest to declare Electronic Publication Date: Saturday, July 4, 2026 - 11:40 AI use: No, I have not used AI Highwire Comment Subject: Calcium, vitamin D, or combined supplementation to prevent fractures and falls: systematic review and meta-analysis Workflow State: Released Full Title: Re: Calcium, vitamin D, or combined supplementation to prevent fractures and falls: systematic review and meta-analysis Highwire Comment Response to: Calcium, vitamin D, or combined supplementation to prevent fractures and falls: systematic review and meta-analysis Check this box if you would like your letter to appear anonymously:: Last Name: Raynauld MD First name and middle initial: Jean-Pierre Email: jp.raynauld@videotron.ca Address: CHUM, Rheumatology Clinic, 5th Floor, Pavillon C, Montreal, Quebec, CANADA Occupation: Rheumatologist and Assistant-Director, Fracture Liaison Service Other Authors: Marie-Josée Bégin, MD, Endocrinologist and Director, Fracture Liaison Service Affiliation: Montreal University Medical Center (CHUM) BMJ: Additional Article Info: Rapid response
Re: Calcium, vitamin D, or combined supplementation to prevent fractures and falls: systematic review and meta-analysis
