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not be considered as supportive for a relationship between either vitamin D or calcium and the health outcomes of diabetes or metabolic syndrome.

Additional Evidence from Randomized Controlled Trials

Two randomized trials were identified that evaluated the effect of vitamin D supplementation with or without supplemental calcium on markers of glucose tolerance as a primary outcome and four additional trials were identified that evaluated glucose metabolism as a secondary outcome. A trial in New Zealand that examined the effect of supplementation with 4,000 IU of vitamin D3 per day for 6 months on insulin resistance in non-diabetic overweight South Asian women found a significant improvement in insulin sensitivity compared with those in the placebo group after 6 months (von Hurst et al., 2010). Among women who had low serum 25OHD levels at the beginning of the study, those who achieved a serum 25OHD level above 80 nmol/L at 6 months had significant improvement in insulin sensitivity. In contrast, sub-analysis of data from the Randomised Evaluation of Calcium and/Or vitamin D (RECORD) trial examining the association between incidence of self-reported development of type 2 diabetes or initiation of treatment for type 2 diabetes and supplementation with 800 IU of vitamin D3 and 1,000 mg of calcium in an elderly population found no association (Avenell et al., 2009a). Zittermann et al. (2009), in a weight loss trial evaluating the effect of supplemental vitamin D on markers of CVD in overweight adults as a primary outcome, found no significant difference for an effect on glucose metabolism. Jorde et al. (2010), in a 1-year trial in Norway with overweight or obese subjects, found no change in measures of blood glucose in vitamin D–supplemented subjects compared with control subjects, but they did identify an unexpected and significant increase in systolic blood pressure in the supplemented group compared with controls. Without further analysis, however, it is not possible to determine whether the increase in blood pressure was related to 25OHD levels in blood. A trial in India evaluated the effect of short-term vitamin D supplementation on homeostasis model assessment and oral glucose insulin sensitivity in healthy, centrally obese men (Nagpal et al., 2009). In an intention-to-treat analysis, the difference was not significant. Overall, higher waist-to-hip ratios and lower baseline serum 25OHD levels were significant predictors of improvement in oral glucose insulin sensitivity. A posthoc analysis of a trial testing the effects of long-term supplementation with 700 IU of vitamin D and 500 mg of calcium daily on health, including associations between combined supplementation and changes in fasting glucose levels, found that subjects with impaired fasting glucose who followed the supplementation regimen for 3 years had a significantly lower rise in fasting glucose levels and less insulin resistance compared with



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