Short-term vitamin A supplementation does not affect bone turnover in men

Effects of primary or secondary prevention with vitamin A supplementation on clinically important outcomes: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis

OBJECTIVES

This systematic review with meta-analyses of randomised trials evaluated the preventive effects of vitamin A supplements versus placebo or no intervention on clinically important outcomes, in people of any age.

METHODS

We searched different electronic databases and other resources for randomised clinical trials that had compared vitamin A supplements versus placebo or no intervention (last search 16 April 2024). We used Cochrane methodology. We used the random-effects model to calculate risk ratios (RRs), with 95% CIs. We analysed individually and cluster randomised trials separately. Our primary outcomes were mortality, adverse events and quality of life. We assessed risks of bias in the trials and used Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) to assess the certainty of the evidence.

RESULTS

We included 120 randomised trials (1 671 672 participants); 105 trials allocated individuals and 15 allocated clusters. 92 trials included children (78 individually; 14 cluster randomised) and 28 adults (27 individually; 1 cluster randomised). 14/105 individually randomised trials (13%) and none of the cluster randomised trials were at overall low risk of bias. Vitamin A did not reduce mortality in individually randomised trials (RR 0.99, 95% CI 0.93 to 1.05; I²=32%; p=0.19; 105 trials; moderate certainty), and this effect was not affected by the risk of bias. In individually randomised trials, vitamin A had no effect on mortality in children (RR 0.96, 95% CI 0.88 to 1.04; I²=24%; p=0.28; 78 trials, 178 094 participants) nor in adults (RR 1.04, 95% CI 0.97 to 1.13; I²=24%; p=0.27; 27 trials, 61 880 participants). Vitamin A reduced mortality in the cluster randomised trials (0.84, 95% CI 0.76 to 0.93; I²=66%; p=0.0008; 15 trials, 14 in children and 1 in adults; 364 343 participants; very low certainty). No trial reported serious adverse events or quality of life. Vitamin A slightly increased bulging fontanelle of neonates and infants. We are uncertain whether vitamin A influences blindness under the conditions examined.

CONCLUSIONS

Based on moderate certainty of evidence, vitamin A had no effect on mortality in the individually randomised trials. Very low certainty evidence obtained from cluster randomised trials suggested a beneficial effect of vitamin A on mortality. If preventive vitamin A programmes are to be continued, supporting evidence should come from randomised trials allocating individuals and assessing patient-meaningful outcomes.

PROSPERO REGISTRATION NUMBER

CRD42018104347.

Vitamin A and Bone Health: A Review on Current Evidence

Vitamin A is a fat-soluble micronutrient essential for growth, immunity, and good vision. The preformed retinol is commonly found in food of animal origin whereas provitamin A is derived from food of plant origin. This review summarises the current evidence from animal, human and cell-culture studies on the effects of vitamin A towards bone health. Animal studies showed that the negative effects of retinol on the skeleton were observed at higher concentrations, especially on the cortical bone. In humans, the direct relationship between vitamin A and poor bone health was more pronounced in individuals with obesity or vitamin D deficiency. Mechanistically, vitamin A differentially influenced the stages of osteogenesis by enhancing early osteoblastic differentiation and inhibiting bone mineralisation via retinoic acid receptor (RAR) signalling and modulation of osteocyte/osteoblast-related bone peptides. However, adequate vitamin A intake through food or supplements was shown to maintain healthy bones. Meanwhile, provitamin A (carotene and β-cryptoxanthin) may also protect bone. In vitro evidence showed that carotene and β-cryptoxanthin may serve as precursors for retinoids, specifically all-trans-retinoic acid, which serve as ligand for RARs to promote osteogenesis and suppressed nuclear factor-kappa B activation to inhibit the differentiation and maturation of osteoclasts. In conclusion, we suggest that both vitamin A and provitamin A may be potential bone-protecting agents, and more studies are warranted to support this hypothesis.

Nutritional Supplements and Skeletal Health

PURPOSE OF REVIEW

Nutrition influences skeletal health throughout the lifespan, from the impact of maternal intakes during development, through the development of peak bone mass, to the rate of bone loss during aging. However, there are limited data available on the effects of nutritional supplements on bone density, let alone fracture risk. This review will assess the current literature, focusing on human studies, and emphasizing nutrients where bone density or fracture data are available.

RECENT FINDINGS

Calcium and vitamin D supplements, in combination, reduce fracture risk, particularly in populations with low intakes. Extensive recent analyses have supported the safety of these interventions at recommended intakes. There is growing evidence that specific isoflavones may improve bone density although fracture data are lacking. Multiple other nutrient supplements may benefit skeletal health, but data are limited. The effect size of nutrient interventions are relatively small, requiring large sample sizes for trials with bone outcomes, may be difficult to blind, and the impact of supplementation may depend on baseline intake. However, nutrition is the only intervention that can be implemented life long and on a population wide basis. Further investigation is needed into the potential benefits of nutritional supplements to determine in which settings supplements may add benefit in addition to dietary intakes.

High Serum Retinol as a Relevant Contributor to Low Bone Mineral Density in Postmenopausal Osteoporotic Women

There is controversial information about the impact of vitamin A on bone. Some epidemiological studies show that excessive intake of vitamin A, or an excess of serum vitamin A, has related with adverse impact on bone mass; however, other studies did not find these links, and some authors have proposed that this vitamin might promote a better bone health. The present work aims to contribute to clarify the real role of vitamin A in bone tissue. For this purpose, a cross-sectional study of 154 osteoporotic non-treated postmenopausal women (> 65 years old) was carried out. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry. We assessed concentrations of serum retinol, osteocalcin, parathyroid hormone, alkaline phosphatase, calcium, and phosphorus. We also studied demographic and anthropometric parameters. Spearman's correlations between retinol levels and other variables found negative correlations with BMD in both lumbar spine (R = - 0.162, P < 0.01) and femoral neck (R = - 0.182, P < 0.01), as well as alkaline phosphatase (R = - 0.110; P < 0.05) and phosphorus (R = - 0.110; P < 0.05). A positive correlation between retinol and fertile window was observed (R = 0.158; P < 0.01). After multivariable adjustment, we still found a negative correlation between serum retinol and BMD, both at the lumbar spine (R = - 0.210; P < 0.01) and at the femoral neck (R = - 0.324, P < 0.001). It is concluded that elevated serum-retinol levels are associated with an increased risk of low bone mass and thus with osteoporotic fractures. Therefore, osteoporosis-risk assessment should include quantification of serum metabolite of vitamin A.

The role of vitamin A and retinoic acid receptor signaling in post-natal maintenance of bone

Vitamin A and retinoid derivatives are recognized as morphogens that govern body patterning and skeletogenesis, producing profound defects when in excess. In post-natal bone, both high and low levels of vitamin A are associated with poor bone heath and elevated risk of fractures. Despite this, the precise mechanism of how retinoids induce post-natal bone changes remains elusive. Numerous studies have been performed to discover how retinoids induce these changes, revealing a complex morphogenic regulation of bone through interplay of different cell types. This review will discuss the direct and indirect effects of retinoids on mediators of bone turnover focusing on differentiation and activity of osteoblasts and osteoclasts and explains why some discrepancies in this field have arisen. Importantly, the overall effect of retinoids on the skeleton is highly site-specific, likely due to differential regulation of osteoblasts and osteoclasts at trabecular vs. cortical periosteal and endosteal bone surfaces. Further investigation is required to discover the direct gene targets of retinoic acid receptors (RARs) and molecular mechanisms through which these changes occur. A clear role for RARs in regulating bone is now accepted and the therapeutic potential of retinoids in treating bone diseases has been established.

Retinoid receptors in bone and their role in bone remodeling

Vitamin A (retinol) is a necessary and important constituent of the body which is provided by food intake of retinyl esters and carotenoids. Vitamin A is known best for being important for vision, but in addition to the eye, vitamin A is necessary in numerous other organs in the body, including the skeleton. Vitamin A is converted to an active compound, all-trans-retinoic acid (ATRA), which is responsible for most of its biological actions. ATRA binds to intracellular nuclear receptors called retinoic acid receptors (RARα, RARβ, RARγ). RARs and closely related retinoid X receptors (RXRα, RXRβ, RXRγ) form heterodimers which bind to DNA and function as ligand-activated transcription factors. It has been known for many years that hypervitaminosis A promotes skeleton fragility by increasing osteoclast formation and decreasing cortical bone mass. Some epidemiological studies have suggested that increased intake of vitamin A and increased serum levels of retinoids may decrease bone mineral density and increase fracture rate, but the literature on this is not conclusive. The current review summarizes how vitamin A is taken up by the intestine, metabolized, stored in the liver, and processed to ATRA. ATRA's effects on formation and activity of osteoclasts and osteoblasts are outlined, and a summary of clinical data pertaining to vitamin A and bone is presented.

Vitamin a metabolism, action, and role in skeletal homeostasis

Vitamin A (retinol) is ingested as either retinyl esters or carotenoids and metabolized to active compounds such as 11-cis-retinal, which is important for vision, and all-trans-retinoic acid, which is the primary mediator of biological actions of vitamin A. All-trans-retinoic acid binds to retinoic acid receptors (RARs), which heterodimerize with retinoid X receptors. RAR-retinoid X receptor heterodimers function as transcription factors, binding RAR-responsive elements in promoters of different genes. Numerous cellular functions, including bone cell functions, are mediated by vitamin A; however, it has long been recognized that increased levels of vitamin A can have deleterious effects on bone, resulting in increased skeletal fragility. Bone mass is dependent on the balance between bone resorption and bone formation. A decrease in bone mass may be caused by either an excess of resorption or decreased bone formation. Early studies indicated that the primary skeletal effect of vitamin A was to increase bone resorption, but later studies have shown that vitamin A can not only stimulate the formation of bone-resorbing osteoclasts but also inhibit their formation. Effects of vitamin A on bone formation have not been studied in as great a detail and are not as well characterized as effects on bone resorption. Several epidemiological studies have shown an association between vitamin A, decreased bone mass, and osteoporotic fractures, but the data are not conclusive because other studies have found no associations, and some studies have suggested that vitamin A primarily promotes skeletal health. In this presentation, we have summarized how vitamin A is absorbed and metabolized and how it functions intracellularly. Vitamin A deficiency and excess are introduced, and detailed descriptions of clinical and preclinical studies of the effects of vitamin A on the skeleton are presented.

No dose-dependent increase in fracture risk after long-term exposure to high doses of retinol or beta-carotene

Uncertainty remains over whether or not high intakes of retinol or vitamin A consumed through food or supplements may increase fracture risk. This intervention study found no increase in fracture risk among 2,322 adults who took a controlled, high-dose retinol supplement (25,000 IU retinyl palmitate/day) for as long as 16 years. There was some evidence that beta-carotene supplementation decreased fracture risk in men.

INTRODUCTION

There is conflicting epidemiological evidence regarding high intakes of dietary or supplemental retinol and an increased risk for bone fracture. We examined fracture risk in a study administering high doses of retinol and beta-carotene (BC) between 1990 and 2007.

METHODS

The Vitamin A Program was designed to test the efficacy of retinol and BC supplements in preventing malignancies in persons previously exposed to blue asbestos. Participants were initially randomised to 7.5 mg retinol equivalents (RE)/day as retinyl palmitate, 30 mg/day BC or 0.75 mg/day BC from 1990 to 1996; after which, all participants received 7.5 mg RE/day. Fractures were identified by questionnaire and hospital admission data up until 2006. Risk of any fracture or osteoporotic fracture according to cumulative dose of retinol and BC supplementation was examined using conditional logistic regression models adjusting for age, sex, smoking, body mass index, medication use and previous fracture.

RESULTS

Supplementation periods ranged from 1 to 16 years. Of the 2,322 (664 females and 1,658 males) participants, 187 experienced 237 fractures. No associations were observed between cumulative dose of retinol and risk for any fracture (OR per 10 g RE=0.83; 95% CI, 0.63-1.08) or osteoporotic fracture (OR per 10 g RE=0.95; 95% CI 0.64-1.40). Among men, cumulative dose of BC was associated with a slightly reduced risk of any fracture (OR per 10 g=0.89; 95% CI 0.81-0.98) and osteoporotic fracture (OR per 10 g=0.84; 95% CI 0.72-0.97).

CONCLUSIONS

This study observed no increases in fracture risk after long-term supplementation with high doses of retinol and/or beta-carotene.

Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases

BACKGROUND

Our systematic review has demonstrated that antioxidant supplements may increase mortality. We have now updated this review.

OBJECTIVES

To assess the beneficial and harmful effects of antioxidant supplements for prevention of mortality in adults.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, LILACS, the Science Citation Index Expanded, and Conference Proceedings Citation Index-Science to February 2011. We scanned bibliographies of relevant publications and asked pharmaceutical companies for additional trials.

SELECTION CRITERIA

We included all primary and secondary prevention randomised clinical trials on antioxidant supplements (beta-carotene, vitamin A, vitamin C, vitamin E, and selenium) versus placebo or no intervention.

DATA COLLECTION AND ANALYSIS

Three authors extracted data. Random-effects and fixed-effect model meta-analyses were conducted. Risk of bias was considered in order to minimise the risk of systematic errors. Trial sequential analyses were conducted to minimise the risk of random errors. Random-effects model meta-regression analyses were performed to assess sources of intertrial heterogeneity.

MAIN RESULTS

Seventy-eight randomised trials with 296,707 participants were included. Fifty-six trials including 244,056 participants had low risk of bias. Twenty-six trials included 215,900 healthy participants. Fifty-two trials included 80,807 participants with various diseases in a stable phase. The mean age was 63 years (range 18 to 103 years). The mean proportion of women was 46%. Of the 78 trials, 46 used the parallel-group design, 30 the factorial design, and 2 the cross-over design. All antioxidants were administered orally, either alone or in combination with vitamins, minerals, or other interventions. The duration of supplementation varied from 28 days to 12 years (mean duration 3 years; median duration 2 years). Overall, the antioxidant supplements had no significant effect on mortality in a random-effects model meta-analysis (21,484 dead/183,749 (11.7%) versus 11,479 dead/112,958 (10.2%); 78 trials, relative risk (RR) 1.02, 95% confidence interval (CI) 0.98 to 1.05) but significantly increased mortality in a fixed-effect model (RR 1.03, 95% CI 1.01 to 1.05). Heterogeneity was low with an I(2)- of 12%. In meta-regression analysis, the risk of bias and type of antioxidant supplement were the only significant predictors of intertrial heterogeneity. Meta-regression analysis did not find a significant difference in the estimated intervention effect in the primary prevention and the secondary prevention trials. In the 56 trials with a low risk of bias, the antioxidant supplements significantly increased mortality (18,833 dead/146,320 (12.9%) versus 10,320 dead/97,736 (10.6%); RR 1.04, 95% CI 1.01 to 1.07). This effect was confirmed by trial sequential analysis. Excluding factorial trials with potential confounding showed that 38 trials with low risk of bias demonstrated a significant increase in mortality (2822 dead/26,903 (10.5%) versus 2473 dead/26,052 (9.5%); RR 1.10, 95% CI 1.05 to 1.15). In trials with low risk of bias, beta-carotene (13,202 dead/96,003 (13.8%) versus 8556 dead/77,003 (11.1%); 26 trials, RR 1.05, 95% CI 1.01 to 1.09) and vitamin E (11,689 dead/97,523 (12.0%) versus 7561 dead/73,721 (10.3%); 46 trials, RR 1.03, 95% CI 1.00 to 1.05) significantly increased mortality, whereas vitamin A (3444 dead/24,596 (14.0%) versus 2249 dead/16,548 (13.6%); 12 trials, RR 1.07, 95% CI 0.97 to 1.18), vitamin C (3637 dead/36,659 (9.9%) versus 2717 dead/29,283 (9.3%); 29 trials, RR 1.02, 95% CI 0.98 to 1.07), and selenium (2670 dead/39,779 (6.7%) versus 1468 dead/22,961 (6.4%); 17 trials, RR 0.97, 95% CI 0.91 to 1.03) did not significantly affect mortality. In univariate meta-regression analysis, the dose of vitamin A was significantly associated with increased mortality (RR 1.0006, 95% CI 1.0002 to 1.001, P = 0.002).

AUTHORS' CONCLUSIONS

We found no evidence to support antioxidant supplements for primary or secondary prevention. Beta-carotene and vitamin E seem to increase mortality, and so may higher doses of vitamin A. Antioxidant supplements need to be considered as medicinal products and should undergo sufficient evaluation before marketing.

Retinol may counteract the negative effect of cadmium on bone

Cadmium and high vitamin A intake are both proposed risk factors for low bone mineral density (BMD), but potential interactions have not been studied. Within the Women's Health in the Lund Area, a population-based study in southern Sweden, we measured retinol in serum among 606 women aged 54-64 y. Data on BMD were measured by DXA at the distal forearm. Parathyroid hormone (PTH), bone alkaline phosphatase (bALP), and osteocalcin in serum and deoxypyridinoline (DPD) and cadmium in urine were available. Associations were evaluated using multivariable-adjusted linear regression analysis. Serum retinol concentrations (median, 1.9; range, 0.97-4.3 μmol/L) were inversely associated with the bone formation markers bALP and osteocalcin (P ≤ 0.04) and with PTH (P = 0.07) and tended to be positively associated with BMD (P = 0.08) but not with the bone resorption marker DPD, indicating different effects on bone compared to urinary cadmium (median, 0.66; range, 0.12-3.6 nmol/mmol creatinine). Women with serum retinol less than the median and cadmium greater than the median had lower BMD than those with retinol greater than the median and cadmium less than the median (P = 0.016 among all women and P = 0.010 among never-smokers). Our findings suggest that adequate vitamin A status may counteract the adverse association between cadmium and BMD.

Efeito de diferentes doses de ácido retinoico sobre a resistência óssea de ratos jovens

OBJETIVO: Avaliar os efeitos da suplementação de diferentes doses de todo-trans ácido retinóico sobre a resistência óssea, por meio de ensaio biomecânico de flexão, em tíbia de ratos jovens. MÉTODOS: Foram estudados 58 ratos jovens, com quatro diferentes doses de vitamina A em suas dietas, sendo divididos em 4 grupos: grupo-controle (n=15), sem acréscimo de todo-trans ácido retinoico; grupo com acréscimo de 0,3mg de todo-trans ácido retinoico por kg de ração (n=13); grupo com 10mg de todo-trans ácido retinoico por kg de ração (n=15); e grupo com 50mg de todo-trans ácido retinoico por kg de ração (n=15). O estudo durou 30 dias. Após o sacrifício dos animais, suas patas esquerdas foram congeladas, dissecadas e as tíbias submetidas ao ensaio de flexão. Foram avaliados a carga máxima e o coeficiente de rigidez. Foi aplicada análise de variância one-way. O nível de significância estatístico adotado foi p<0,05. RESULTADOS: Os valores médios de carga máxima (em Newton) foram: grupo-controle =37,94, DP=4,76; grupo todo-trans ácido retinoico 0,3=36,49, DP= 4,38; grupo todo-trans ácido retinoico 10=40,12, DP=6,03; grupo todo-trans ácido retinoico 50=35,68, DP=5,22 (p=0,107). Os valores médios de coeficiente de rigidez (em Newton/milímetros) foram: grupo-controle =31,84 DP=6,75; grupo todo-trans ácido retinoico 0,3=29,18, DP=4,35; grupo todo-trans ácido retinoico 10=35,48, DP=8,14; grupo todo-trans ácido retinoico 50=30,31, DP=7,14 (p=0,85). CONCLUSÃO: Conclui-se que a exposição a diferentes doses de todo-trans ácido retinoico, em ratos, durante 30 dias, não exerce efeito sobre a resistência óssea, quando avaliada por ensaios biomecânicos.

Cortical and trabecular bone, bone mineral density, and resistance to ex vivo fracture are not altered in response to life-long vitamin A supplementation in aging rats

High vitamin A (VA) intakes have been correlated with increased risk of bone fracture. Over 50% of the U.S. adult population reports use of dietary supplements, which can result in VA intakes > 200% of the RDA. In this study, 2 experiments were designed to determine the effect of dietary VA on cortical and trabecular bone properties and resistance to ex vivo fracture. In Expt. 1, we investigated whether orally administered VA accumulates in bone. Seven-week-old rats were treated daily with VA (6 mg/d for 14 d). Total retinol increased in both the tibia and femur (P < 0.01). In Expt. 2, we conducted a longitudinal study in which rats were fed 1 of 3 levels of dietary VA (marginal, adequate, and supplemented, equal to 0.35, 4, and 50 μg retinol/g diet, respectively) from weaning until the ages of 2-3 mo (young), 8-10 mo (middle-age), and 18-20 mo (old). Tibial trabecular and cortical bone structure, bone mineral density, and resistance to fracture were measured using micro-computed tomography and material testing system analysis, respectively. The VA-marginal diet affected measures of cortical bone dimension, suggesting bone remodeling was altered. VA supplementation increased medullary area and decreased cortical thickness in young rats (P < 0.05), but these changes were not present during aging. VA supplementation did not affect resistance to fracture or bone mineral content in old rats. From these results, we conclude that VA-marginal status affects trabecular bone more than cortical bone, and VA supplementation at a moderate level over the lifetime is unlikely to increase the risk of age-related bone fracture in rats.

Nutrition and Bone: It is More than Calcium and Vitamin D

Unlike pharmacological agents that are taken for proscribed periods of time, food and nutrient intakes have the possibility of affecting bone health over the entire lifespan. While deficiencies or excesses of individual nutrients have been shown to affect bone, it is likely that individual foods or dietary patterns have important effects related to skeletal health. While biochemical mechanisms exist to relate a deficiency of vitamin K to altered bone metabolism, clinical trials related to supplementation of this nutrient have been confusing. It is likely that these disparate results are related to the fact that interactions of nutrients have not been considered or the possibility that suboptimal nutrient status is a marker of poor nutritional status. Vitamin A excess has been postulated to be related to high fracture risk; however, it is likely that retinol is not the best marker for the proposed interaction. Altering whole food patterns, such as the Dietary Approaches to Stop Hypertension diet, have demonstrated beneficial effects on bone metabolism. Individuals who select some vegetarian patterns may need to consider supplementation with nutrients such as calcium and protein. Future studies should center on whole food and dietary patterns and their relationship to bone metabolism and fracture risk.

Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases

BACKGROUND

Animal and physiological research as well as observational studies suggest that antioxidant supplements may improve survival.

OBJECTIVES

To assess the effect of antioxidant supplements on mortality in primary or secondary prevention randomised clinical trials.

SEARCH STRATEGY

We searched The Cochrane Library (Issue 3, 2005), MEDLINE (1966 to October 2005), EMBASE (1985 to October 2005), and the Science Citation Index Expanded (1945 to October 2005). We scanned bibliographies of relevant publications and wrote to pharmaceutical companies for additional trials.

SELECTION CRITERIA

We included all primary and secondary prevention randomised clinical trials on antioxidant supplements (beta-carotene, vitamin A, vitamin C, vitamin E, and selenium) versus placebo or no intervention. Included participants were either healthy (primary prevention trials) or had any disease (secondary prevention trials).

DATA COLLECTION AND ANALYSIS

Three authors extracted data. Trials with adequate randomisation, blinding, and follow-up were classified as having a low risk of bias. Random-effects and fixed-effect meta-analyses were performed. Random-effects meta-regression analyses were performed to assess sources of intertrial heterogeneity.

MAIN RESULTS

Sixty-seven randomised trials with 232,550 participants were included. Forty-seven trials including 180,938 participants had low risk of bias. Twenty-one trials included 164,439 healthy participants. Forty-six trials included 68111 participants with various diseases (gastrointestinal, cardiovascular, neurological, ocular, dermatological, rheumatoid, renal, endocrinological, or unspecified). Overall, the antioxidant supplements had no significant effect on mortality in a random-effects meta-analysis (relative risk [RR] 1.02, 95% confidence interval [CI] 0.99 to 1.06), but significantly increased mortality in a fixed-effect model (RR 1.04, 95% CI 1.02 to 1.06). In meta-regression analysis, the risk of bias and type of antioxidant supplement were the only significant predictors of intertrial heterogeneity. In the trials with a low risk of bias, the antioxidant supplements significantly increased mortality (RR 1.05, 95% CI 1.02 to 1.08). When the different antioxidants were assessed separately, analyses including trials with a low risk of bias and excluding selenium trials found significantly increased mortality by vitamin A (RR 1.16, 95% CI 1.10 to 1.24), beta-carotene (RR 1.07, 95% CI 1.02 to 1.11), and vitamin E (RR 1.04, 95% CI 1.01 to 1.07), but no significant detrimental effect of vitamin C (RR 1.06, 95% CI 0.94 to 1.20). Low-bias risk trials on selenium found no significant effect on mortality (RR 0.91, 95% CI 0.76 to 1.09).

AUTHORS' CONCLUSIONS

We found no evidence to support antioxidant supplements for primary or secondary prevention. Vitamin A, beta-carotene, and vitamin E may increase mortality. Future randomised trials could evaluate the potential effects of vitamin C and selenium for primary and secondary prevention. Such trials should be closely monitored for potential harmful effects. Antioxidant supplements need to be considered medicinal products and should undergo sufficient evaluation before marketing.

One is okay, more is better? Pharmacological aspects and safe limits of nutritional supplements

The use of vitamins, minerals and other supplements has increased considerably during recent years. In the National Diet and Nutrition Survey of British adults aged 19-64 years 40% of those surveyed were taking supplements. In 2005 sales of dietary supplements in the UK were approximately pound sterling 325.7 x 106 in 'bricks and mortar' shops (excluding health food shops). The physiological effects of vitamins and minerals in amounts approximating to the UK reference nutrient intake or the EU RDA are well understood in terms of reducing the risk of micronutrient deficiency. However, the effects of vitamins, minerals and other supplements in larger amounts have attracted much attention in recent decades, and these effects, some of which may be pharmacological, are not as well categorised. Some of these effects are beneficial, some are not. Although vitamins and minerals and other supplements are generally safe at higher doses, there are some safety issues that are relevant in the context of the wide availability of supplements without a doctor's prescription. Thus, several authorities throughout the world have established upper limits (UL) for the intake of vitamins and minerals, and the EU is in the process of setting maximum permitted levels (MPL) for vitamins and minerals in food supplements. The present paper discusses the potential benefits and safety issues relating to the use of supplements at doses higher than the RDA. The rationale for the establishment of UL is also discussed, explaining the differences between the values set by different authorities and the expected guidance and legislation from the European Commission on MPL for vitamins and minerals in food supplements.

Vitamin A: is it a risk factor for osteoporosis and bone fracture?

Results from observational studies of the association between vitamin A intake or serum concentration and bone mineral density or fracture are mixed. The inconsistencies may be due, in part, to difficulties in obtaining an accurate assessment of vitamin A intake or status. Serum retinol is a poor measure of vitamin A status because it is subject to homeostatic control. Stable-isotope-dilution methodology gives a validated assessment of the total-body and liver vitamin A stores and is recommended in future studies on vitamin A status and osteoporosis. The potential for exacerbating an already serious public health problem with intakes of vitamin A currently considered safe indicates further research into this matter is warranted.

Is vitamin A consumption a risk factor for osteoporotic fracture?

Severe vitamin A toxicity is known to have adverse effects on skeletal health. Studies involving animal models and case reports have documented that hypervitaminosis A is associated with bone resorption, hypercalcaemia and bone abnormalities. More recently, some epidemiological studies have suggested that high habitual intake of vitamin A could contribute to low bone mineral content and fracture risk. The evidence relating to the possible deleterious role of vitamin A in bone health is of variable quality and is potentially confounded by collinearity of nutrient intake and difficulties in assessing vitamin A exposure. Furthermore, because intake of vitamin A varies between studies it is not possible to define an intake threshold associated with harm.

Serum retinyl esters are not elevated in postmenopausal women with and without osteoporosis whose preformed vitamin A intakes are high

BACKGROUND

Recent observational studies suggest that preformed vitamin A (VA) intakes of 1500-2000 microg/d may increase the risk of osteoporosis and hip fracture. However, few studies have examined associations between biologic indicators of VA and osteoporosis.

OBJECTIVE

This study characterized VA intake, serum VA, and bone turnover markers in postmenopausal women with and without osteoporosis.

DESIGN

Bone density was measured by dual-energy X-ray absorptiometry. Subjects were separated into those with osteoporosis (n = 30) and those with normal bone density (n = 29). Women with osteopenia were excluded. Complete blood chemistries were obtained. Serum was analyzed for retinol, retinyl esters, and metabolites. Assays for 3 bone turnover markers were performed by using commercially available kits. Diet records were quantified. Logistic regression was used to test for an association between dietary and serum variables and osteoporosis.

RESULTS

Dietary VA did not differ significantly between the groups but was nearly twice the Recommended Dietary Allowance in both groups. Body mass index (BMI) and serum triacylglycerols were significantly lower in the osteoporosis group. Retinyl esters were not elevated in either group, but a trend existed for the association of serum retinyl esters as a percentage of total VA with osteoporosis (P = 0.070) after adjustment for BMI and triacylglycerols in the statistical model. Milk, fruit, and vegetable intakes were below the current recommendations.

CONCLUSIONS

Serum retinyl esters were not elevated in these postmenopausal women despite intakes of total VA that were nearly two-fold the Recommended Dietary Allowance. However, retinyl ester concentration (percentage of total VA) was marginally associated with osteoporosis and should be further investigated.

Possible contraindications and adverse reactions associated with the use of ocular nutritional supplements

The role of oxidation in the development of age-related eye disease has prompted interest in the use of nutritional supplementation for prevention of onset and progression. Our aim is to highlight possible contraindications and adverse reactions of isolated or high dose ocular nutritional supplements. Web of Science and PubMed database searches were carried out, followed by a manual search of the bibliographies of retrieved articles. Vitamin A should be avoided in women who may become pregnant, in those with liver disease, and in people who drink heavily. Relationships have been found between vitamin A and reduced bone mineral density, and beta-carotene and increased risk of lung cancer in smoking males. Vitamin E and Ginkgo biloba have anticoagulant and anti-platelet effects respectively, and high doses are contraindicated in those being treated for vascular disorders. Those patients with contraindications or who are considered at risk of adverse reactions should be advised to seek specialist dietary advice via their medical practitioner.

Vitamin A intake and osteoporosis: a clinical review

BACKGROUND

If osteoporosis is linked with vitamin A (Vit A) A consumption, millions of people could be affected.

METHODS

A MEDLINE search was performed with keywords retinol, beta-carotene, and osteoporosis.

RESULTS

Of 20 clinical studies, 3 were randomized controlled trials (RCTs), 14 were observational studies, and 3 were case reports. Most (8) observational studies were cross-sectional. Oral retinoyl palmitate (RP) in high doses induces fractures and radiographic osteoporosis in animals. Retinol intake from diet or supplements is negatively associated with lumbar, femoral neck, and trochanter bone mineral density (BMD). There is a graded increase in relative risk of hip fracture with increasing retinol intake, attributable primarily to retinol (either from diet or supplements) but not beta-carotene intake. Higher serum retinol levels are associated with higher risk of any fracture and with higher risk of hip fracture, whereas there is no evidence of harm associated with beta-carotene intake. The few RCTs involve serum markers of bone metabolism, not bone density or fracture outcomes. Observational studies are generally consistent in finding harm from either dietary or supplemental retinol intake on BMD and hip fracture risk. Total Vit A intake is more important than source in determining harm. Adverse effects may occur at a level of retinol intake that is only about twice the current recommendation for adult females.

CONCLUSIONS

It is not yet possible to set a specific level of retinol intake above which bone health is compromised. Pending further investigation, Vit A supplements should not be used with the express goal of improving bone health.

No effect of vitamin A intake on bone mineral density and fracture risk in perimenopausal women

In recent studies from Sweden and the United States, a high vitamin A intake has been associated with low bone mineral density (BMD) and increased fracture risk. In Sweden and the United States, food items such as milk and breakfast cereals are fortified with vitamin A, whereas in Denmark there is no mandatory fortification with vitamin A. In the present study, we investigated relations between vitamin A intake and BMD and fracture risk in a Danish population consuming mostly unfortified food items. Within a population-based cohort study in 2,016 perimenopausal women, associations between BMD and vitamin A intake were assessed at baseline and after 5-year follow-up. Moreover, associations between baseline vitamin A intake and 5-year changes in BMD were studied. Finally, fracture risk was assessed in relation to vitamin A intake. In our cohort, dietary retinol intake (0.53 mg/day) was lower than the intake reported in recent studies form Sweden (0.78 mg/day) and the United States (1.66 mg/day). Cross-sectional and longitudinal analyses showed no associations between intake of vitamin A and BMD of the femoral neck or lumbar spine. Neither did BMD differ between those 5% who had the highest, and those 5% who had the lowest, vitamin A intake. During the 5-year study period, 163 subjects sustained a fracture (cases). Compared to 978 controls, logistic regression analyses revealed no difference in vitamin A intake. Thus, in a Danish population, average vitamin A intake is lower than in Sweden and the United States and not associated with detrimental effects on bone.

An evidence-based approach for dietitian prescription of multiple vitamins with minerals

Dietitians working in hospitals are routinely involved in assessing energy and macronutrient (ie, protein, fat, carbohydrate) requirements of patients. However, complete nutritional therapy requires a comprehensive review of vitamin and mineral requirements. Scientific evidence for vitamin and mineral supplementation is primarily based on healthy, free-living people. This raises clinical challenges for dietitians working with patients whose vitamin and mineral requirements are impacted by various diseases, conditions, and medical treatment. Dietitians are the best-positioned health professionals to lead an evidence-based approach toward recommending vitamin and mineral supplements. The dietitians at the Toronto Rehabilitation Institute were authorized through a medical directive to prescribe multiple vitamins with minerals and to discontinue orders for unnecessary vitamin supplements. This is an ongoing, advanced practice initiative that focuses on the clinical efficacy for and safety of supplementation with multiple vitamins with minerals. It involves assessing the strength of evidence as it emerges in the literature, determining its relevance to specific patient populations in the practice setting and re-evaluating clinical practices for potential applications. When dietitians assume advanced practice initiatives, they are better equipped to deliver high-quality patient care. Simultaneously, state-of-the-art dietetic practice heightens dietitian recognition as a valuable member of the health care team.

Vitamin A supplementation and risk of skeletal fracture

Effects of toxic amounts of vitamin A include skeletal effects; from acute toxic exposure to chronic high-dose intake of vitamin A, these effects have led experts to speculate that long-term consumption of diets high in vitamin A (retinol) stimulates bone resorption and inhibits bone formation, and may contribute to osteoporosis and hip fractures.