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补钙:又一个神话在破灭

2018-07-04 唐金陵 检验医学网 检验医学网

曾经风靡世界的维生素C防治感冒无效,雌激素预防心脏病无效,维生素A预防癌症无效甚至增加死亡危险…… 一般健康老年人补充钙和维生素D预防骨折也无效,又一个神话在破灭。而且,这个结论是基于可靠的临床证据之上的。


作者:香港中文大学流行病与卫生统计学教授  唐金陵

曾经风靡世界的维生素C防治感冒无效,雌激素预防心脏病无效,维生素A预防癌症无效甚至增加死亡危险…… 一般健康老年人补充钙和维生素D预防骨折也无效,又一个神话在破灭。而且,这个结论是基于可靠的临床证据之上的。

补钙和补充维生素D的确可以提高骨质密度,预防骨质疏松。但是,预防骨质疏松最重要的目的在于预防摔倒时造成的骨折,尤其是股骨头部骨折。

2017年12月26日,美国医学会杂志(JAMA)发表了一篇随机对照试验(RCT)的系统综述,用大量可靠的证据说明,补钙和补充维生素D不能降低骨折的风险,而且很可能适得其反[1]。

但是,国内有权威专家发表的意见就有点儿含糊其词不明其意了[2]。

1)“类似的Meta分析早有发表,结果正的反的都有,结论一直不能统一,以前的这类Meta分析没能提供多大帮助,现在这个Meta分析也帮助不大。”

系统综述和Meta分析是总结和整合科学研究结果最可靠的方法,没有之一。2014年考科蓝的一篇随机对照试验的系统综述[3],以及2015年BMJ的系统综述[4],都不支持补钙有效,和JAMA这个研究的结论是一致的。这么多RCT的综合结果显示无效,误杀的可能性很小,即使真的有效,效果也小得没什么实际临床意义。更何况,如果补钙有什么作用,目前显示的是:补钙可能增加股骨头部骨折的风险。这是补钙的初衷,但结果则适得其反。

2)“主要原因是所有的研究都无法排除阳光的影响,这是维生素D很难做临床干预研究的主要原因,再加上研究对象的依从性差别以及检测方法缺乏标准化等等多种因素,对于维生素D补充治疗是否有效这一问题,通过这些观察是不可能得出一致结论的,现在没有结论,今后有结论的可能性也不会很大。”

纳入的研究都是随机对照试验,其他因素在治疗组和对照组是可比的,原始研究没有光照和其他因素的混杂,因此合并的结果也没有。光照可同时等量增加治疗组和对照组维生素D的生成并进而促进钙的吸收和利用,使补充钙和维生素D失去意义,正说明在晒足太阳基础上补充钙和维生素D没有意义。专家说“监测方法缺乏标准化”太笼统,但是骨折的确诊应该没有太大的技术问题。

面对基于如此大量可靠证据的否定结论,权威专家说永远也不会有结论,不知专家的用意何在。即使没有结论,是否也应该停止这些效果不明的补充剂呢!

3)“需结合基础研究、相关性研究以及干预性研究的结果来评价维生素D的作用。”

补充钙和维生素D无临床效果,无论基础研究显示的机理多么合理,都是忽悠,再美妙也不等于临床有效。临床效果才是最后的验证,而不是机理上的论证。还需要什么更好的“相关研究”评价吗?是干预性研究吗?这些RCT不就是最好的干预性研究吗!

另外,也有批评者用大型队列研究显示的补钙在骨质密度上的效果说事,是本末倒置的做法[5]。JAMA这篇文章总结的是几十个使用骨折作为结局的RCT。RCT存在混杂的可能性远远小于队列研究。骨折是评估补钙的终末硬结局指标,骨质密度是中间替代结局。因此,补钙在预防骨折上的临床意义也远远大于骨质密度的改善。

JAMA作者的“喜形于色”固然不招人喜欢,但这会反过来殃及原始的研究吗?JAMA发表的研究是严肃的,结论是谨慎的。而且,Meta分析进JAMA不容易,JAMA也是发Meta分析的老手,对中国来的Meta分析恐怕格外谨慎。这次JAMA会失手得如此不堪,连一个略通统计学的人就可以把它批得体无完肤?我怀疑。

我想如果我自己在JAMA上发了这篇文章,也会喜形于色吧,甚至开个派对庆祝一番。有几个不会呢?为什么不呢?众目睽睽之下,得意忘形,自吹自擂,固然不太好看,但这不能作为否定原JAMA文章的依据。

再者,如果这个系统综述的结论是错误的,我们一开始是如何知道补钙可以预防骨折的?我们是否有比JAMA这篇文章更好的方法和证据来否定(或肯定)这个结论?答案是:没有。

一个微效甚至无效的治疗,为什么在证据不足时就神话般高调登场?而且,补钙已成为一个庞大的商业概念。2013年钙剂全球年销售额相当于390亿人民币,美国2012年维生素D制剂的年销售额相当于48.6亿人民币[6]。今天,当有证据否定它时,有人如此恋恋不舍,其中的缘由不能不让人深思。

早先BMJ一篇文章指出:尽管缺乏对健康有益的证据,钙剂和维生素D补充剂仍然被广泛推荐用来预防和治疗骨质疏松症。但是,改变现状异常艰难,是因为相关企业、推荐机构、学术界之间错综复杂的关系[7]。

过去几十年证明了一条有关治疗的铁律:凡是争议不断的地方,要不效果很小,要不根本无效,甚至有害。有几个人会对白内障手术、抗生素、疫苗、麻醉、输血持有怀疑态度呢?

阳光、营养、运动都可以增加我们骨骼的硬度。但再硬的骨头也会折断。预防摔倒才是预防骨折的上策,不是补充钙和维生素D。

我们的健康经常是在自己手里,别让它完全成为别人赚钱的理据。

以上来源:港中大流行病与卫生统计学

争议

对 JAMA原文《社区居住老年人群中,钙剂/维生素D摄入对骨折发病率的关系:系统综述与Meta分析》的评论:

“文章是好文章,这一点不可否认,但其中存在局限性。”中山大学孙逸仙纪念医院骨外科教授丁悦指出,“骨折发生和补钙是两个话题,不能掺杂在一起论述。”论文以是否发生骨折来判断补钙和维D的效果,但其实骨折发生是多种因素结果,除了跟骨量、骨强度、肌肉力量等有关,还跟跌倒的风险等等有关。“对于50岁以上人群的来说,骨折不一定是骨质疏松引发的,也可能是意外导致。”

公开报道显示,赵嘉国医生也对自己论文引发的争议进行了回应。他在接受采访时表示,补钙和维生素D是否降低骨折风险其实是一个比较老的话题,在国际上已经发表了20余篇相关的Meta分析文章。此次的研究是基于RCT(随机对照)研究进行的荟萃分析,有33篇RCT纳入到了最终分析之中,其研究人群总计达5万多人。最终研究结果显示:对50岁以上的社区人群而言,额外补充钙和或补充维生素D不能降低其骨折风险。不过,他也指出,纳入的RCT研究人群主要限定为50岁以上的社区人群,并未区分对其是否诊断为骨质疏松人群进行进一步分析。“既往研究显示,对于长期居住养老机构的老人而言,补充钙和维生素D可能对降低骨折风险有益。这部分人群不包括在本研究范畴之内。”

以上来源:YuJinBio

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    2020-03-05 14825a3cm79暂无昵称

    就是钢也会折断 何况骨头 跟补钙有什么关系 增加骨密度是王道 这些哗众取宠的文章 不值得推荐

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=380107, encodeId=0ba238010ef0, content=就是钢也会折断 何况骨头 跟补钙有什么关系 增加骨密度是王道 这些哗众取宠的文章 不值得推荐, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=679c5272162, createdName=14825a3cm79暂无昵称, createdTime=Thu Mar 05 20:18:17 CST 2020, time=2020-03-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330518, encodeId=060633051826, content=谢谢了.学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=30331616752, createdName=txqjm, createdTime=Tue Jul 10 06:22:00 CST 2018, time=2018-07-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=329703, encodeId=e1a1329e031f, content=文笔还是比较犀利的, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLS3nbTc0lzBwDxSVnm5KA9vNmsZrjTSvKlld6teMf4RG4ZmZWRvC80GB7zl4TSib3BAoZgcCYpzxQ/132, createdBy=02681961038, createdName=若轩, createdTime=Fri Jul 06 09:26:54 CST 2018, time=2018-07-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=329665, encodeId=db34329665ec, content=学习了最新知识.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=aadd1680584, createdName=蔬菜, createdTime=Fri Jul 06 07:00:03 CST 2018, time=2018-07-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=329521, encodeId=1f9232952169, content=维生素C亲测有效, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e07793260, createdName=xchen855, createdTime=Thu Jul 05 14:09:27 CST 2018, time=2018-07-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=329408, encodeId=6aa732940801, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Thu Jul 05 06:43:58 CST 2018, time=2018-07-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=329375, encodeId=c3a33293e566, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Thu Jul 05 01:19:19 CST 2018, time=2018-07-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=329371, encodeId=bdd53293e1a1, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jul 05 00:52:23 CST 2018, time=2018-07-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=329349, encodeId=256b32934999, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1bb241978, createdName=phoebeyan520, createdTime=Thu Jul 05 00:02:24 CST 2018, time=2018-07-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=329346, encodeId=4bd632934653, content=科普科普, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=18741984753, createdName=smartxiuxiu, createdTime=Wed Jul 04 23:48:22 CST 2018, time=2018-07-04, status=1, ipAttribution=)]
    2018-07-10 txqjm

    谢谢了.学习

    0

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    2018-07-06 若轩

    文笔还是比较犀利的

    0

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    2018-07-06 蔬菜

    学习了最新知识.谢谢分享

    0

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    2018-07-05 xchen855

    维生素C亲测有效

    0

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    2018-07-05 张新亮1853311252142e2fm

    好文献学习了

    0

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    2018-07-05 1209e435m98(暂无昵称)

    学习了.谢谢分享

    0

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    2018-07-05 飛歌

    学习了很有用

    0

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    2018-07-05 phoebeyan520

    学习了谢谢分享

    0

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    2018-07-04 smartxiuxiu

    科普科普

    0

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