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Information on the latest vitamin D news and research.

Find out more information on deficiency, supplementation, sun exposure, and how vitamin D relates to your health.

Vitamin D, vitamin A, and risk of hip fracture

Approximately 300,000 patients are hospitalized each year due to hip fractures in the United States. Hip fractures are very dangerous especially for elderly and frail patients. The risk of dying from the stress of the surgery and the injury in the first few days is high. Immobility subsequent to surgery increases that risk. Problems such as pressure sores, pneumonia, and blood clots are all increased by immobility. One out of five hip fracture patients dies within a year of their injury.

Over 90% of hip fractures are caused by falling, most often by falling sideways onto the hip. Treatment typically includes surgery and hospitalization, usually for about one week, and is frequently followed by admission to a nursing home and extensive rehabilitation. Up to one in four adults who lived independently before their hip fracture remains in a nursing home for at least a year after their injury. Medicare costs for hip fractures are around $2.9 billion per year.

Fracturing one’s hip may involve three separate problems.

  1. The first is that muscle strength often fails, causing the person to be too weak to keep from falling.
  2. Likewise, balance may be impaired leading to the fall.
  3. Third, the bones may be osteoporotic, or even osteomalatic (adult rickets), so a minor fall or minor trauma results in a fracture.

Vitamin D appears to help all three of these problems. I reviewed the evidence about vitamin D and muscle strength, as well as vitamin D and balance in my paper about vitamin D and athletic performance. Certainly most of the useful information about both was obtained by the Germans in the 1950s, when they studied the musculoskeletal effects of UVB radiation.

Cannell JJ, Hollis BW, Sorenson MB, Taft TN, Anderson JJ. Athletic performance and vitamin D. Med Sci Sports Exerc. 2009 May;41(5):1102-10.

Very recently, Dr. Barker at the Orthopedic Specialty Hospital in Murray Utah found that muscle strength in younger patients is related to vitamin D levels, but the association only held true for levels below 32 ng/ml. That is, levels higher than 32 ng/ml were not associated with any more muscle strength. They also found that vitamin D deficient patients had more inflammation.

Barker T, Martins TB, Hill HR, Kjeldsberg CR, Dixon BM, Schneider ED, Henriksen VT, Weaver LK. Circulating pro-inflammatory cytokines are elevated and peak power output correlates with 25-hydroxyvitamin D in vitamin D insufficient adults. Eur J Appl Physiol. 2013 Jan 6

Also, Dr. de Koning and colleagues of the University of Calgary recently found that 25(OH)D levels lower than 28 ng/ml inversely correlated with hip fractures in 254 elderly patients.

de Koning L, Henne D, Hemmelgarn BR, Woods P, Naugler C. Non-linear relationship between serum 25-hydroxyvitamin D concentration and subsequent hip fracture. Osteoporos Int. 2012 Dec 19.

However, beyond that they found a much more complicated relationship with 25(OH)D, with levels above 90 ng/ml and levels around 22 ng/ml having the lowest rate of hip fracture. I suspect the complicated relationship with higher levels may have been confounded by concomitant vitamin A intake. Excess vitamin A intake, common in many in North America, has been associated with fractures.

Barker ME, Blumsohn A. Is vitamin A consumption a risk factor for osteoporotic fracture? Proc Nutr Soc. 2003 Nov;62(4):845-50. Review.

A recent study also found a similar relationship between vitamin D, vitamin A and osteoporosis. Bone density measurements revealed that the risk of osteoporosis was 8 times higher in women with the highest retinol levels compared to the lowest levels. Women with low vitamin D levels had an even greater increased risk of osteoporosis when they had high retinol levels compared to low.

Mata-Granados JM, Cuenca-Acevedo JR, Luque de Castro MD, Holick MF, Quesada-Gómez JM. Vitamin D insufficiency together with high serum levels of vitamin A increases the risk for osteoporosis in postmenopausal women. Arch Osteoporos. 2013 Dec;8(1-2):124

What is a good strategy for avoiding hip fractures? One part of the puzzle seems to be getting both adequate vitamin D and avoiding excessive vitamin A. This is something I have always stood for and still do.

  About: John Cannell, MD

Dr. John Cannell is founder of the Vitamin D Council. He has written many peer-reviewed papers on vitamin D and speaks frequently across the United States on the subject. Dr. Cannell holds an M.D. and has served the medical field as a general practitioner, emergency physician, and psychiatrist.

7 Responses to Vitamin D, vitamin A, and risk of hip fracture

  1. laraup@salugenecists.com says:

    Where are you getting research showing most in the US have excessive vitamin A intake? The studies I have seen (and reported on in reviews of the research on Longevity Medicine Review) indicates just the opposite. Vitamins D and A work together to promote healthy immune function and bone. Research by George Leitz studies indicate that up to 68% of the population carries SNPs that greatly lessen their ability to convert beta-carotene to retinoic acid, leaving them vitamin A insufficient. I have discussed these studies at length on LMR @ http://www.lmreview.com/articles/view/common-genetic-variants-and-other-host-related-factors-greatly-increase-susceptibility-to-vitamin-a-deficiency/
    I would be very grateful for your citing the research that shows Americans are eating plenty of vitamin A rich foods (eg liver) and are sufficient in this nutrient.

  2. Rita and Misty says:

    Dear Laraup@salugenecists.com:

    Preformed Vitamin A is POISONOUS!!!

    Ever here the expression: “too much of a good thing?”

    That is the case with Preformed Vitamin A.

    Preformed Vitamin A is added to a variety of foods in the developed world and to specific foods in developing countries.

    Here in the United States, I would venture to guess it is literally impossible to be deficient in Preformed Vitamin A, and much more likely that we all are at toxicity level.

    If you add to this mix the Preformed Vitamin A found in a multivitamin, or in cod liver oil (CLO), you now have a recipe for a national health disaster.

    Preformed Vitamin A hinders Vitamin D’s ability to work successfully in our bodies.

    Again, I repeat: Preformed Vitamin a is POISONOUS. I’m not joking here. I am serious.

    Here’s the research to back up my words:
    (and thank goodness for VDC members that Dr. Cannell has done his research on this)

    There was an amazing paper published by the British Medical Journal…it was totally amazing because:
    • It studied more than 500,000 subjects
    • Had 56 (fifty-six) authors
    • It confirmed low vitamin D levels obtained in the past are a risk factor for developing colon cancer in the future!

    However, and I am quoting from the attached link to an excellent article written by Dr. Cannell:

    http://www.tbyil.com/Bell_Shaped_Curve.htm

    “The most remarkable part of the paper is that the 46 scientists minimized the true significance of their own research.

    They found that vitamin A, even in relatively low amounts, appears to thwart vitamin D’s association with reduced rates of colon cancer.

    Jenab M et al. Association between pre-diagnostic circulating vitamin D concentration and risk of colorectal cancer in European populations: a nested case-control study. BMJ 2010;340:b5500

    http://www.bmj.com/cgi/content/full/340/jan21_3/b5500? …

    This is a prospective nested case-controlled study, which means it uses subject’s vitamin D blood samples obtained and frozen in the past and then reviews their medical records into the future to see who gets colon cancer, comparing the study subjects to similar members of the group that did not get the illness. Dr. Mazda Jenab and his 45 colleagues from the International Agency for Research on Cancer confirmed that low vitamin D levels are a risk for colon cancer in a dose response manner; those with the highest levels were about twice as less likely to develop colon cancer compared to those with the highest levels.

    However, hidden on page eight is one sentence and a small table, which shows that the benefits of vitamin D are almost entirely negated in those with the highest vitamin A intake. And the retinol intake did not have to be that high in these older adults to begin to negate vitamin D’s effects, about 3,000 IU/day. Remember, young autistic children often take 3,500 IU of retinol a day in their powdered multivitamins, which doesn’t count any additional vitamin A given in high single doses.

    This is the largest study to date showing vitamin A blocks vitamin D’s effect and explains some of the anomalies in other papers on vitamin D and cancer.”

    From my own research regarding preformed Vitamin A and bone health, I have found four large, prospective, observational studies, conducted in Scandinavia and the United States, where the incidence of osteoporosis is high.

    These studies found associations between preformed vitamin A intake and hip fracture or osteoporosis. The studies differed in many design factors (eg, subject sex and age and years of follow-up), which makes direct comparisons difficult.

    Regardless, the findings generated much interest, because calcium intake is generally high in both these areas. It is interesting that the amount of dietary vitamin A associated with this effect was relatively low at 1500 RE, which is much lower than the amount traditionally associated with risk of toxicity and lower than the tolerable upper intake level (ie, 3000 RE), which is the highest amount thought to pose no risk of adverse health effects in the general population.

    These studies suggest that intakes much lower than 10 times the RDA, the amount conventionally thought to lead to toxicity, are needed to increase risk for osteoporosis—ie, ≈2× RDA.

    http://ajcn.nutrition.org/content/83/2/191.full

    To Sunny Days!
    Rita Celone Umile

  3. Gary says:

    Interesting comments from Rita. If preformed Vitamin A is indeed a poisen as you suggest. how do we explain the high intakes seen in the Eskimo with apparently no adverse effects.?I mean their intake would have been hugh.
    The Masai who take large amounts of fermented raw milk in there diets would have a very high intake of vitamin A also.
    Then the french diet high in cheese, butter and animal fats. High in vitamin A. But they had excellent health statistics. Note I added had as I am not so sure what more recent French health stats look like with more convenience foods added to diets.
    You must have some theory on this, or research that I would be interested in to help explain this conundrum!
    Sorry but I don’t buy your theory and would suggest from my clinical experience and the rates of chest infections we deal with that vitamin A deficiency is more the norm than not. Would be interested to know what others think on this.

  4. Rita and Misty says:

    Hi Gary,

    There is a theory that the Inuits, who don’t get that much sun exposure still have a darker skin because they get plenty of Vitamin D in one of the only food sources of it, fatty fish.

    It’s the fat in the fish that contains all the Vitamin D.

    When our ancestors moved north hundreds of thousands of years ago, we started to get less sunlight exposure and our skin became lighter to compensate.

    (If you are familiar with my previous posts, you’ll know that I am very concerned for people with darker skin pigmentation (skin level VI) living in northern climates. They are are at even greater risk of Vitamin D deficiency. This is a very serious public health issue…imo.)

    I understand your point regarding vitamin A consumption in the Eskimo diet…I am assuming that Eskimos ate the livers of these fatty fish, and liver contains high amount of A…

    My guess…and it is only a guess…is that the balance between these two vitamins, D & A, was favored toward D….after all, Mother Nature knows best, does she not?

    Now-a-days, the vast majority of us are Vitamin D deficient, due to lack of sun exposure, and lack of eating fatty fish as our ONLY food source….(breakfast, lunch, dinner).

    We are not at all…imo…Vitamin A deficient, as I mentioned in my previous post: Vitamin A is added to lots of foods and included in our multivitamins.

    See where I’m heading?

    No Vitamin D…and too much Vitamin A.

    The BALANCE is out-of-whack…it is unnatural.

    And it is a recipe for sickness in my opinion (yes, I know I have tons of opinions).

    Back in August 2012, Dr. Cannell wrote an excellent article on this very topic:
    (again, lucky for us he does research for us) :)

    Aboriginal Arctic populations: Vitamin D deficiency and disease risk
    Posted on August 1, 2012 by John Cannell, MD
    The incidence of cancer was exceptionally low among the Inuit and other Artic civilizations in older times, when they consumed traditional foods from the sea, especially whale blubber, which is very rich in vitamin D. However, their diet has changed dramatically in the last 50 years and their incidence of cancer, especially colorectal cancer, is now higher among the Inuit than in Whites living in the USA.
    In fact, Dr. Sangita Sharma and colleagues of University of Alberta report that, “Cancer mortality rates in Alaska are significantly higher than those in mainland United States.”
    Sharma S, Barr AB, Macdonald HM, Sheehy T, Novotny R, Corriveau A. Vitamin D deficiency and disease risk among aboriginal Arctic populations. Nutr Rev. 2011 Aug;69(8):468-78. doi: 10.1111/j.1753-4887.2011.00406.x. Review.
    Is it lack of vitamin D?

    This group of scientists think so and make several interesting points, including the fact that the few traditionally living Inuit still have lower rates of cancer compared to their Westernized brethren. Likewise, they make similar cases for fractures, diabetes, and infectious disease, all much higher among Westernized Inuit.
    Of course, the sun never gets very high in the sky in the Artic, even in the summer. However, the ozone hole, especially in the spring, allows more low hanging UVB than one would think to penetrate the atmosphere. Unfortunately, sunbathing is rare among the Inuit or the Alaskans.
    Alaskans should take 5,000 IU of vitamin D3 per day, while children need 1,000 IU per every 25 pounds of body weight, rounded up.

    http://blog.vitamindcouncil.org/2012/08/01/aboriginal-artic-populations-vitamin-d-deficiency-and-disease-risk/

  5. Gary says:

    Thanks for that Rita. Unfortunately still doesn’t in my opinion explain the supposed risks of high intake of Vitamin A. Fatty fish and seal meat etc would have been considereably higher in vitamin A than D. Possibly ten times greater.
    There must be something else going on that research isn’t picking up. I just don’t believe nature would have designed vitamin A to be as toxic as you believe.
    Come on Dr Cannell you must have some more to add. I am sure you will have had this one out with the Weston Price folk!

  6. Rita and Misty says:

    @Gary,

    I’ve been reading Dr. Cannell for some time now…and from reading his work I think he might say that vitamin A can reduce the effectiveness of vitamin D by inhibiting the binding of its active form to your DNA, effectively preventing its ability to regulate the expression of your vitamin D-responsive genes.

    But, this is only a guess on my part.

    To sunny days!
    Rita Celone

  7. This study showed that when measured by retinyl esters, 29% of the American population is subclincially toxic and 51% have excess vitamin A. Serum retinol is homostatically controlled and cannot be used to measure subclinical vitamin A toxicity.

    Cheng TY, Neuhouser ML. Serum 25-hydroxyvitamin D, vitamin A, and lung cancer mortality in the US population: a potential nutrient-nutrient interaction. Cancer Causes Control. 2012 Sep;23(9):1557-65.