Annual injection of vitamin D and fractures of aged bones

New insights into the role of vitamin D and calcium in osteoporosis management: an expert roundtable discussion

BACKGROUND

Adequate vitamin D and calcium nutrition play a critical role in the maintenance of musculoskeletal health and are considered the first step in osteoporosis treatment.

ROUNDTABLE DISCUSSION

In February 2008 Merck Sharp & Dohme sponsored a 2-day, evidence-based expert panel on the benefits of vitamin D for the patient with osteoporosis and the role of vitamin D in combination with antiresorptive therapy for the management of osteoporosis. One of the primary objectives of the meeting was to review new data on the optimal serum 25-hydroxy vitamin D [25(OH)D] levels. The symposium was attended by 29 researchers and clinicians from Europe and the Middle East. The discussion focused on optimizing vitamin D and calcium nutrition and reducing falls and fractures in osteoporotic patients.

CONCLUSIONS

Current evidence and expert opinion suggests that optimal serum 25(OH)D concentrations should be at least 50 nmol/L (20 ng/mL) in all individuals. This implies a population mean close to 75 nmol/L (30 ng/mL). In order to achieve this level, vitamin D intake of at least 20 microg daily is required. There is a wider therapeutic window for vitamin D than previously believed, and doses of 800 IU per day, regardless of sun exposure, season or additional multivitamin use, appear to present little risk of toxicity. Apart from fracture and fall prevention, optimization of vitamin D status may also have additional general health benefits. Based on newly emerging data regarding calcium supplementation, and recommendations for increased vitamin D intake, the current recommendations for calcium intake in postmenopausal women may be unnecessarily high. In addition to vitamin D and calcium, treatment of patients with osteoporosis at high risk of fractures should also include pharmacologic agents with proven vertebral and non-vertebral fracture efficacy.

The role of calcium and vitamin D in the management of osteoporosis

The role of calcium and vitamin D supplementation in the treatment of osteoporosis has been extensively studied. The aim of this paper was to reach, where possible, consensus views on five key questions relating to calcium and vitamin D supplementation in the management of osteoporosis. Whereas global strategies that target supplementation to the general population could not be justified in terms of efficacy and health economics, there is a clearer rationale for supplementing patients who are at increased risk of osteoporosis and those who have developed osteoporosis, including those already taking other treatments for osteoporosis. The combination of vitamin D with calcium may be beneficial in terms of efficacy and, perhaps, for optimising adherence.

Mineral metabolism and aging: the fibroblast growth factor 23 enigma

PURPOSE OF REVIEW

The regulation of phosphate homeostasis was thought to be passively mediated by the calciotrophic hormones parathyroid hormone and 1,25(OH)2D3. This article summarizes the emerging trends that show an active regulation of phosphate homeostasis by fibroblast growth factor 23 (FGF-23) - a process fairly independent of calcium homeostasis - and how altered mineral ion metabolism may affect the aging process.

RECENT FINDINGS

A major breakthrough in FGF-23 biology has been achieved by the demonstration of strikingly similar physical/biochemical phenotypes of Fgf-23(-/-) and klotho hypomorph mice, which eventually led to the identification of klotho as a cofactor in FGF-23 and its receptor interactions. Furthermore, FGF-23 has emerged as a counter regulator of the renal 1alpha(OH)ase and sodium-phosphate cotransporter activities to modulate phosphate homeostasis. Finally, studies point towards a role of dentine matrix protein 1 in affecting phosphate homeostasis, in coordination with FGF-23.

SUMMARY

Recent mouse genetic studies have broadened our understanding of biochemical/molecular pathways involved in phosphate homeostasis, and linked FGF-23 to such regulation. Understanding the molecular interactions of essential calcium and phosphate regulators will enhance our knowledge of the coordinated regulation of mineral ion metabolism, and will help to redefine the molecular pathology of age-associated lesions accompanied by abnormal mineral ion metabolism such as vascular calcifications and osteoporosis.

Preventing fractures among older people living in institutional care: a pragmatic randomised double blind placebo controlled trial of vitamin D supplementation

INTRODUCTION

Osteoporotic fractures in older people are a major and increasing public health problem. We examined the effect of vitamin D supplementation on fracture rate in people living in sheltered accommodation.

METHODS

In a pragmatic double blind randomised controlled trial of 3 years duration, we examined 3,440 people (2,624 women and 816 men) living in residential or care home. We used four-monthly oral supplementation using 100,000 IU vitamin D(2) (ergocalciferol). As a main outcome measure, we used the incidence of first fracture using an intention to treat analysis. This was a multicentre study in 314 care homes or sheltered accommodation complexes in South Wales, UK.

RESULTS

The vitamin D and placebo groups had similar baseline characteristics. In intention-to-treat analysis, 205 first fractures occurred in the intervention group during a total of 2,846 person years of follow-up (7 fractures per 100 people per year of follow-up), with 218 first fractures in the control group over 2,860 person years of follow-up. The hazard ratio of 0.95 (95% confidence interval 0.79-1.15) for intervention compared to control was not statistically significant.

CONCLUSION

Supplementation with four-monthly 100,000 IU of oral vitamin D(2) is not sufficient to affect fracture incidence among older people living in institutional care.

Vitamin D and aging: old concepts and new insights

Aging is a complex biological process driven by a selective class of molecules and pathways that affect overall deterioration of physiological functions to increase the risk of age-related diseases. A role of vitamin D in mammalian aging is well documented. Since vitamin D has an essential role in bone formation and mineralization, its deficiency results in impaired bone mineralization, such as rickets in children, osteomalacia in adults and osteoporosis in the aged population. Vitamin D replacement therapy therefore is one of the most commonly prescribed treatments for the elderly. Recent studies using genetically altered mouse models, such as in Fgf-23(-/-) and klotho mutant mice, that exhibit altered mineral ion metabolism due to high vitamin D activities showed features of premature aging that include atherosclerosis, emphysema, osteopenia/osteoporosis, hypogonadism, soft tissue calcifications and generalized atrophy of organs; the pathologic effects of vitamin D in these mouse models are obvious, as diminution or genetic ablation of the vitamin D pathway ameliorated most of the above-mentioned phenotypes, by reversing mineral ion metabolism, and the resultant effect being prolonged survival of the mutant mice. These in vivo mouse studies, although subject to further molecular characterization, add new insights into the role of vitamin D in aging.

How to select the doses of vitamin D in the management of osteoporosis

The dose of vitamin D in the management of osteoporosis should be no less than 700-800 IU per day. An optimal dose of vitamin D should raise serum concentrations of 25(OH)D to the desirable range of at least 75 nmol/l. Higher intermittent oral doses of vitamin D may overcome low adherence. Vitamin D supplementation in the management of osteoporosis holds a significant public health potential because of its low cost, excellent tolerability, and combined musculo-skeletal benefits. Fall and fracture prevention with vitamin D is especially appealing in the treatment of older individuals at risk for fall-related fractures. However, bone density, strength, and function benefits with vitamin D include active and inactive subgroups of community-dwelling older men and women. Based on a recent expert panel and supportive evidence presented in this review, serum concentrations of at least 75 nmol/l 25(OH)D will be referred to as desirable. Today, desirable serum 25(OH)D levels of at least 75 nmol/l may only be reached in about one third of US older individuals and even fewer European older individuals. Two main factors discussed in this review may help public health efforts to ensure desirable vitamin D levels for fall and fracture prevention, including (1) a sufficient dose of vitamin D and (2) improved adherence to supplementation.

Vitamin D Deficiency and Secondary Hyperparathyroidism Among Patients with Chronic Kidney Disease

BACKGROUND

Chronic kidney disease (CKD) is associated with morbid complications that lead to high mortality and costs. Vitamin D deficiency and secondary hyperparathyroidism (SHPT) are frequent complications of CKD.

METHODS

We reviewed the current literature regarding the prevalence, diagnosis, complications, and management of vitamin D deficiency and SHPT among patients with CKD.

RESULTS

There is a high prevalence of vitamin D deficiency among adolescents and adults in the United States (age and gender dependent). Patients with CKD or those who are dialysis-dependent are much more likely to have low levels of vitamin D in comparison to those without kidney disease. In order to avoid significant complications including SHPT and musculoskelatal diseases, vitamin D needs to be measured routinely by primary care physicians and nephrologists. In the majority of CKD patients, SHPT is not diagnosed until late, leading to advanced cardiovascular and bone diseases.

CONCLUSIONS

In conclusion, current management of vitamin D deficiency and SHPT is suboptimal. Early diagnosis of vitamin D deficiency and SHPT are integral to optimal management of CKD, and additional research is needed in this area.

The role of dietary calcium in bone health

Approximately 99% of body Ca is found in bone, where it serves a key structural role as a component of hydroxyapatite. Dietary requirements for Ca are determined by the needs for bone development and maintenance, which vary throughout the life stage, with greater needs during the periods of rapid growth in childhood and adolescence, during pregnancy and lactation, and in later life. There is considerable disagreement between expert groups on the daily Ca intake levels that should be recommended, reflecting the uncertainty in the data for establishing Ca requirements. Inadequate dietary Ca in early life impairs bone development, and Ca supplementation of the usual diet for periods of ≤3 years has been shown to enhance bone mineral status in children and adolescents. However, it is unclear whether this benefit is long term, leading to the optimisation of peak bone mass in early adulthood. In later years inadequate dietary Ca accelerates bone loss and may contribute to osteoporosis. Ca supplementation of the usual diet in post-menopausal women and older men has been shown to reduce the rate of loss of bone mineral density at a number of sites over periods of 1–2 years. However, the extent to which this outcome reduces fracture risk needs to be determined. Even allowing for disagreements on recommended intakes, evidence indicates that dietary Ca intake is inadequate for maintenance of bone health in a substantial proportion of some population groups, particularly adolescent girls and older women.

The case for improving vitamin D status

Evidence from both physiological experiments and randomized trials demonstrates that elevating vitamin D status above levels prevailing in the North American and European adult populations improves calcium absorption and reduces fall risk and osteoporotic fractures. Additionally observational data suggest that raising vitamin D status protects against various cancers and autoimmune disorders as well. Hence a strong case can be made for immediate improvement in vitamin D status of the general population.

Diet, nutrition and the prevention of osteoporosis

Objective:

To review the evidence on diet and nutrition relating to osteoporosis and provide recommendations for preventing osteoporosis, in particular, osteopototic fracture.

Approach:

Firstly, to review the definition, diagnosis and epidemiology of osteoporosis, to discuss the difficulties in using bone mineral density to define osteoporosis risk in a world-wide context and to propose that fragility fracture should be considered as the disease endpoint. Secondly, to provide an overview of the scientific data, the strengths and weaknesses of the evidence and the conceptual difficulties in interpreting studies linking diet, nutrition and osteoporosis. The following were considered: calcium, vitamin D, phosphorus, magnesium, protein and fluorine. Other potential dietary influences on bone health were also discussed, including vitamins, trace elements, electrolytes, acid–base balance, phyto-oestrogens, vegetarianism and lactose intolerance.

Conclusions:

There is insufficient knowledge linking bone mineral status, growth rates or bone turnover in children and adolescents to long-term benefits in old age for these indices to be used as markers of osteoporotic disease risk. For adults, the evidence of a link between intakes of any dietary component and fracture risk is not sufficiently secure to make firm recommendations, with the exception of calcium and vitamin D. For other aspects of the diet, accumulating evidence suggests that current healthy-eating advice to decrease sodium intake, to increase potassium intake, and to consume more fresh fruits and vegetables is unlikely to be detrimental to bone health and may be beneficial.

Bone health

Much evidence indicates that both calcium and vitamin D are efficacious in protecting the skeleton, particularly when these 2 nutrients are used in combination. Each nutrient is necessary for the full expression of the effect of the other, and where their actions are independent, their effects on skeletal health are complementary. Nutrient status for both tends to be deficient in the adult population of the industrialized nations. Hence, supplementation or food fortification with both nutrients is appropriate and, given contemporary diets and sun exposure, probably necessary. Various meta-analyses, systematic evidence reviews, and controlled trials evaluating these 2 nutrients will be defective if they fail 1) to take into consideration the nearly universal need to augment the status of both nutrients in the populations studied rather than just one or the other, 2) to consider the threshold characteristics of both nutrients, and 3) to use the achieved serum 25-hydroxyvitamin D concentration as the independent variable for vitamin D effects (instead of oral vitamin D intake). Problems with adherence to a regimen of taking supplements daily make an appropriate fortification strategy the preferred option for improving the status of both nutrients.

RETRACTED: Etidronate for fracture prevention in amyotrophic lateral sclerosis: a randomized controlled trial

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Corresponding Author, Yoshihiro Sato, and the co-authors have been informed. Dr. Sato wishes to retract this article on the grounds that it contains fabricated clinical trial data, which he was responsible for producing. In addition, Dr. Sato claims he listed all of the named co-authors without their consent. The co-authors were therefore unaware of the presence of fabricated data in this publication and their participation in the publication. This retraction was initiated by Dr. Sato, and the Editor-in-Chief of Bone was informed by the author directly.

Longitudinal study of bone and calcium metabolism and fracture incidence in spinocerebellar degeneration

Little is known about bone and calcium metabolism and fracture incidence in spinocerebellar degeneration (SCD) despite frequent falls and immobilization. To address bone and calcium metabolism and fracture incidence in SCD, we conducted a 10-year prospective study in a cohort of adult patients with SCD. Bone mineral density (BMD) and serum levels of ionized calcium, parathyroid hormone, 25-hydroxyvitamin D, and pyridinoline cross-linked carboxy-terminal telopeptide of type I collagen (ICTP) were followed in 110 patients with SCD for 10 years. Age-matched healthy volunteers (n = 110) served as controls. At baseline, the SCD patients had a low BMD with high levels of serum ionized calcium and ICTP which correlated with the degree of immobilization (Barthel index). Over 10 years, serum 25-hydroxyvitamin D decreased to the osteomalacic level (<5 ng/ml), and calcium and ICTP further increased in accordance with a decreased Barthel index score. The BMD decreased by 15.2% in men and by 24.6% in women. The incidence of fractures in the patients was significantly higher as compared with the control group (men 8/49 vs. 1/42, p = 0.0428; women 16/49 vs. 2/48, p = 0.0026). Over 10 years, the BMD was significantly reduced in the SCD patients, particularly in women, which increased the risk of a fracture. Vitamin D deficiency due to sunlight deprivation, increased bone resorption due to immobilization, and frequent falls are probable causes of osteoporosis and fractures in these patients. Hypovitaminosis D and increased bone resorption may be corrected readily by the routine use of vitamin D supplements together with bisphosphonate.

Vitamin D supplementation and the prevention of fractures and falls: results of a randomised trial in elderly people in residential accommodation

OBJECTIVES

To determine whether vitamin D supplementation reduces the risk of fracture or falls in elderly people in care home accommodation.

DESIGN

A randomised controlled trial of cluster design.

SETTING AND SUBJECTS

223 Residential units (mainly identical 30-bedded units), within 118 homes for elderly people throughout Britain, with 3,717 participating residents (76% women, average age 85 years). The units provided mainly or entirely residential care (35% of residents), nursing care (42%) or care for elderly mentally infirm (EMI) residents (23%).

METHODS

Participants were randomly allocated by residential unit (cluster design) to a treated group offered ergocalciferol 2.5 mg every 3 months (equivalent to a daily dose of 1,100 IU), or to a control group. Fractures were reported by staff and confirmed in hospital, and routinely collected data on reported falls were obtained.

RESULTS

After median follow-up of 10 months (interquartile range 7-14 months), 64 (3.6%) of 1,762 vitamin D-treated residents and 51 (2.6%) of 1,955 controls had one or more non-vertebral fractures, and 24 (1.3%) and 20 (1.0%), respectively, had a hip fracture. The proportion reporting at least one fall was 44% in vitamin D-treated and 43% in control residents. The differences between the vitamin D and control groups were not statistically significant. The incidence of all non-vertebral fractures in the care homes (3.2% per year) and of hip fractures (1.1% per year) was low, similar to rates in elderly people in sheltered accommodation, and the pre-treatment serum 25-hydroxy vitamin D concentration was high [median 47 nmol/l, measured in a 1% (n = 18) sample].

CONCLUSIONS

We found no evidence that vitamin D prevents fractures or falls in elderly people in care home accommodation.

The role of vitamin D for bone health and fracture prevention

Vitamin D inadequacy is pandemic in adults. Vitamin D deficiency causes osteopenia, precipitates and exacerbates osteoporosis, causes the painful bone disease osteomalacia, and increases muscle weakness, which worsens the risk of falls and fractures. Vitamin D deficiency can be prevented by sensible sun exposure and adequate supplementation. Monitoring serum 25-hydroxyvitamin D is the only way to determine vitamin D status. Recent recommendations suggest that in the absence of sun exposure, adults should ingest 1000 IU of vitamin D3 per day. The ideal healthy blood level of 25-hydroxyvitamin D should be 30 to 60 ng/mL. Vitamin D intoxication occurs when 25-hydroxyvitamin D levels are greater than 150 ng/mL. Three recent reports suggesting that vitamin D and calcium supplementation does not decrease the risk of fracture will be put into perspective in light of the vast literature supporting increasing vitamin D and calcium intake as an effective method for decreasing risk of vertebral and nonvertebral fractures.

A system for improving vitamin D nutrition in residential care

OBJECTIVE

To assess the feasibility of administering an inexpensive preparation of vitamin D(3) 100 000 IU orally 3 monthly to aged-care residents.

DESIGN

Prospective, controlled open-label implementation trial.

SETTING

Residential aged care, November 2003 to May 2004 (primary study).

PARTICIPANTS

137 ambulant residents: 107 treated (mean age, 85 years; 79 were women), 30 untreated controls (mean age, 87 years; 22 were women).

INTERVENTIONS

Lactose microencapsulated vitamin D(3) 100 000 IU orally at baseline, then 3 monthly (three or more doses); untreated subjects were observed contemporaneously.

MAIN OUTCOME MEASURES

Serum levels of 25-hydroxyvitamin D [25(OH)D] at 6 months compared with baseline; acceptability of the program to residents and staff.

RESULTS

At baseline, 95% of residents assessed (n = 137) had serum 25(OH)D levels below the desirable range of 60-160 nmol/L. At 6 months, all treated residents (n = 98) achieved desired levels, with the mean (+/- SD) 25(OH)D level increasing from 36.4 +/- 12.6 nmol/L (range, 12-75 nmol/L) at baseline to 124.0 +/- 27.9 nmol/L (range, 68-244 nmol/L). In no resident did 25(OH)D approach toxic levels. The mean serum 25(OH)D level remained low in the control group (n = 27): 42.8 +/- 18.3 nmol/L (range, 18-98 nmol/L). The difference between the mean 25(OH)D levels of treatment and control groups at 6 months was 81.2 nmol/L (95% CI, 69.7-92.0 nmol/L). The cost of the supplement was $4 per resident per annum. Substudies showed mean trough serum 25(OH)D levels in the desired range at 3 months (n = 31), but below the desired range at 6 months (n = 50). Subjects given 3-monthly doses for up to 2 years maintained serum 25(OH)D levels within the desired range, with no trend toward undesirable accumulation (n = 11).

CONCLUSIONS

Vitamin D(3) 100 000 IU given orally 3 monthly is a practical, safe, effective and inexpensive way to meet the vitamin D(3) requirements of aged-care residents.

Cancer-treatment-induced bone loss, part 2

PURPOSE

The pathophysiology, frequency, sequelae, diagnosis, and treatment of cancer-treatment-induced bone loss (CTIBL) are discussed.

SUMMARY

CTIBL is a long-term complication associated with cancer therapies that can directly or indirectly affect bone metabolism. Although CTIBL can occur in any patient receiving a cancer therapy known to cause bone loss, CTIBL is most common in patients with breast or prostate cancer who receive chemotherapy, hormone therapy, or surgical castration, as these can cause hypogonadism and induce bone loss. CTIBL causes bone fragility and an increased susceptibility to fractures; therefore, prevention, early diagnosis, and treatment of CTIBL are essential to decrease the risk of fracture. Bone loss occurs more rapidly and tends to be more severe in patients with CTIBL compared with those with normal age-related bone loss. Fractures of the hip, vertebra, and wrist are the fractures most commonly associated with bone loss. CTIBL is diagnosed by measuring bone mass using bone densitometry. Treatment of CTIBL consists of changing diet and lifestyle such as optimizing calcium and vitamin D intake, exercising, modifying behaviors known to increase the risk of CTIBL and pharmacologic therapy with hormone replacement therapy (HRT), selective estrogen-receptor modifiers (SERMs), calcitonin, or a bisphosphonate.

CONCLUSION

Early identification and treatment of CTIBL are essential to prevent fractures. Patients should be instructed to optimize calcium and vitamin D intake, exercise regularly, and modify lifestyle behaviors known to cause bone loss. Patients with CTIBL should be treated with an oral or i.v. bisphosphonate; SERMs or HRT may be an option in some patients if contraindications do not exist.

The implications of a growing evidence base for drug use in elderly patients. Part 4. Vitamin D and bisphosphonates for fractures and osteoporosis

Fractures are common in elderly subjects, disabling and occasionally fatal. Their incidence increases exponentially with age, with the commonest affected sites being the wrist, vertebrae, hip and humerus. Of these, hip fractures are the most relevant in terms of morbidity and financial cost. The increase in fracture rate with age is believed to result predominantly from age-related increases in the incidence of osteoporosis and falls. This article reviews the evidence for the use of vitamin D and bisphosphonates for the prevention of bone fractures and osteoporosis in elderly patients.

Addressing the musculoskeletal components of fracture risk with calcium and vitamin D: a review of the evidence

Osteoporotic fractures are an extremely common and serious health problem in the elderly. This article presents the rationale for calcium and vitamin D supplementation in the prevention and treatment of osteoporotic fractures and reviews the literature evidence on the efficacy of this strategy. Two musculoskeletal risk factors are implicated in osteoporotic fractures in the elderly: the loss of bone mass due to secondary hyperparathyroidism and the increased propensity to falls. Calcium and vitamin D reverse secondary hyperparathyroidism with resultant beneficial effects on bone mineral density (BMD). Additionally, calcium and vitamin D supplementation significantly improves body sway and lower extremity strength, reducing the risk of falls. The effects of combined calcium and vitamin D on parathyroid function and BMD provide a strong rationale for the use of this therapy in the prevention and treatment of osteoporosis and osteoporotic fractures. There is general agreement that, in patients with documented osteoporosis, calcium and vitamin D supplementation should be an integral component of the management strategy, along with antiresorptive or anabolic treatment. Frail elderly individuals constitute another major target population for calcium and vitamin D because evidence from randomized studies in institutionalized elderly subjects demonstrates that these supplements reduce osteoporotic fracture risk, particularly in the presence of dietary deficiencies. However, the results of trials in community-dwelling subjects have been equivocal. Within the primary-care setting, further research is required to establish appropriate target subgroups for calcium and vitamin D supplementation; overall, the data are consistent with a benefit individuals with insufficient calcium and/or vitamin D, although patients with documented osteoporosis will derive further benefit in terms of fracture prevention from the addition of an antiresorptive agent.

The vitamin D questions: How much do you need and how should you get it?

UV radiation is a well-documented human carcinogen, indisputably linked to the current continued increased rate of skin cancer. UV radiation is also responsible for cutaneous synthesis of vitamin (vit) D3, a substance that is then sequentially hydroxylated in the liver and kidney to yield 1,25(OH)2 vit D, a hormone critical for calcium homeostasis and skeletal maintenance. Because the UV action spectra for DNA damage leading to skin cancer and for vit D photosynthesis are virtually identical, the harmful and beneficial effects of UV irradiation are inseparable. This has given rise to the argument that sun avoidance, with a goal of skin cancer prevention, may compromise vit D sufficiency. Public interest in this matter has been heightened in recent years by multiple studies correlating the level of 25-OH vit D, the readily measurable "storage" precursor form of the vit, with a variety of benefits separate from skeletal health. Although the studies are of variable quality and all alleged treatment benefits are based on dietary supplementation with vit D, not on increased sun exposure, they have been interpreted by some as support for advocating increased sun exposure of the public at large. The goal of this review is to provide a detailed, balanced, and referenced discussion of the complex literature underlying the current popular interest in vit D and sun exposure for the purpose of increasing vit D photosynthesis. We review the nomenclature, metabolism, and established functions of vit D; the evidence supporting the less well-established but purported vit D effects; the concept of vit D insufficiency; populations at risk for vit D deficiency; and finally the risk/benefit of obtaining vit D from cutaneous photosynthesis versus diet or supplementation.

Calcium, vitamin D and involutional osteoporosis

PURPOSE OF REVIEW

Previous studies suggest that combined calcium and vitamin D supplementation decreases the risk of fractures in older people, particularly those living in care homes, but trials of vitamin D alone in fracture prevention have generated inconsistent results. This review examines the physiological functions of calcium and vitamin D, and the contrasting views of what constitutes an adequate dietary calcium intake and vitamin D sufficiency in adults, and highlights the results of recent large studies of calcium and vitamin D supplementation.

RECENT FINDINGS

The RECORD study shows that calcium (1000 mg/day) and vitamin D (800 IU/day), either alone or in combination, are ineffective in the secondary prevention of osteoporotic fractures in older men and women living in the community. The Northern and Yorkshire Study also suggests that calcium (1000 mg/day) and vitamin D (800 IU/day) are of no benefit in the primary prevention of fractures in community-dwelling older women. Furthermore, the Wessex study demonstrated no reduction in fractures in older people living in the community treated with annual IM injections of vitamin D (300 000 IU).

SUMMARY

The latest studies highlight that vitamin D, either alone or in combination with calcium supplementation, is ineffective in the primary or secondary prevention of fractures in community-dwelling older people. In contrast, calcium and vitamin D supplementation prevents fractures in institutionalized elderly people, who commonly have vitamin D deficiency and secondary hyperparathyroidism.

Anti-resorptive therapy for the prevention of postmenopausal osteoporosis : when should treatment begin?

Osteoporosis is a condition associated with decreased bone strength and an increased fracture risk. It may be defined based on bone mineral density (BMD) with a T-score at the hip or spine of less than -2.5 standard deviations in young healthy individuals or from an osteoporotic fracture (i.e. a fracture occurring after low-energy trauma or no apparent trauma). Risk factors predisposing to fractures include: increasing age; female gender; low BMD; a prior fragility fracture; a family history of fragility fractures; low bodyweight; lack of estrogen in women (i.e. post menopause); corticosteroid use; smoking; a number of diseases; deficiency in calcium and vitamin D; an increased risk of falls (i.e. impaired vision); immobilization; and Caucasian race. The more risk factors that are present the higher the risk of fractures over the following 10 years. The need to initiate preventive therapy with anti-osteoporotic treatment increases steeply with the absolute fracture risk. Indications for referral for dual energy x-ray absorptiometry measurement of BMD include: age >65 years; age <65 years in postmenopausal women with any of the risk factors already mentioned; premature menopause (<45 years); prolonged amenorrhea (>1 year) in younger women; fragility fractures; and diseases or conditions known to lead to osteoporosis.Anti-resorptive therapies include calcium plus vitamin D, bisphosphonates (alendronate, etidronate, risedronate, ibandronate), selective estrogen receptor modulators (raloxifene), hormone replacement therapy, and calcitonin. Guidelines from several countries on when to initiate anti-resorptive therapy state that therapy may be started in patients with a prior fragility fracture (some guidelines state that in this situation no BMD measurements are necessary) or in patients with a T-score of less than -2.5 (some guidelines state that additional risk factors need to be present in this situation). Some guidelines state that anti-resorptive therapy may be initiated in patients with a T-score in the osteopenic range (from -1 to -2.5, i.e. not frank osteoporosis) in the presence of other risk factors. The cost effectiveness of anti-resorptive therapy increases with the absolute fracture risk. In some scenarios, treatment with bisphosphonates may be cost effective in a 50-year-old woman with an absolute hip fracture risk of >or=1.1% over the next 10 years.

Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis

BACKGROUND

Vitamin D and related compounds have been used to prevent fractures.

OBJECTIVES

To determine the effects of vitamin D or analogues, with or without calcium, in the prevention of fractures in older people.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group trials register, the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE, EMBASE, CINAHL, and reference lists of articles. Most recent search: March 2005.

SELECTION CRITERIA

Randomised or quasi-randomised trials comparing vitamin D or an analogue, alone or with calcium, against placebo, no intervention, or calcium, reporting fracture outcomes, in older people.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality, and extracted data. Data were pooled, where admissible, using the fixed-effect model, or random-effects model if the relative risks were heterogeneous.

MAIN RESULTS

Vitamin D alone showed no statistically significant effect on hip fracture (seven trials, 18,668 participants, RR 1.17, 95% CI 0.98 to 1.41), vertebral fracture (four trials, 5698 participants, RR (random effects) 1.13, 95% CI 0.50 to 2.55) or any new fracture (eight trials, 18,903 participants, RR 0.99, 95% CI 0.91 to 1.09). Vitamin D with calcium marginally reduced hip fractures (seven trials, 10,376 participants, RR 0.81, 95% CI 0.68 to 0.96), non-vertebral fractures (seven trials, 10,376 participants, RR 0.87, 95% CI 0.78 to 0.97), but there was no evidence of effect of vitamin D with calcium on vertebral fractures. The effect appeared to be restricted to those living in institutional care. Hypercalcaemia was more common when vitamin D or its analogues was given compared with placebo or calcium (14 trials, 8035 participants, RR 2.38, 95% CI 1.52 to 3.71). The risk was particularly high with calcitriol (three trials, 742 participants, RR 14.94, 95% CI 2.95 to 75.61). There was no evidence that vitamin D increased gastro-intestinal symptoms (seven trials, 10,188 participants, RR (random effects) 1.03, 95% CI 0.79 to 1.36) or renal disease (nine trials, 10,107 participants, RR 0.80, 95% CI 0.34 to 1.87).

AUTHORS' CONCLUSIONS

Frail older people confined to institutions may sustain fewer hip and other non-vertebral fractures if given vitamin D with calcium supplements. Effectiveness of vitamin D alone in fracture prevention is unclear. There is no evidence of advantage of analogues of vitamin D compared with vitamin D. Calcitriol may be associated with an increased incidence of adverse effects. Dose, frequency, and route of administration of vitamin D in older people require further investigation.

Annual intramuscular injection of a megadose of cholecalciferol for treatment of vitamin D deficiency: efficacy and safety data

AIM

To evaluate the efficacy and safety of an annual intramuscular injection of cholecalciferol for vitamin D deficiency.

DESIGN

Prospective open-label study.

PARTICIPANTS

Five men and 45 women (mean age 66.3 years) with vitamin D deficiency who were given a single therapeutic intramuscular injection of 600 000 IU (15 mg) cholecalciferol (vitamin D(3)).

OUTCOME MEASURES

Serum levels of calcium, creatinine, 25-hydroxyvitamin D(3) (25OHD(3)) and parathyroid hormone, as well as early morning 2-hour urine calcium/creatinine excretion index. Specimens were collected at baseline and after 4 and 12 months of therapy. Data are reported as mean +/- 1 SD.

RESULTS

Vitamin D deficiency was severe (< 12.5 nmol/L) in one participant, moderate (12.5-24 nmol/L) in 14, and mild (25-49 nmol/L) in 35. Twenty-four participants (48%) had secondary hyperparathyroidism. Following intramuscular cholecalciferol injection, serum 25OHD(3) levels normalised in all participants and remained above 50 nmol/L throughout the study. Serum 25OHD(3) levels were significantly higher at 4 months (114 +/- 35 nmol/L), and 12 months (73 +/- 13 nmol/L) compared with baseline (32 +/- 8 nmol/L) (P < 0.001), increasing by an average of 128% over the 12 months. There was a corresponding decrease in serum parathyroid hormone levels at 4 months (6 +/- 3 pmol/L) and at 12 months (5.2 +/- 3 pmol/L), with a 30% decrease at 12 months from baseline (7.4 +/- 4 pmol/L) (P < 0.01). Primary hyperparathyroidism was unmasked in one participant at 4 months and mild hypercalcaemia (serum calcium, < 2.70 mmol/L) was noted in two participants (4%) at 12 months. Serum creatinine levels remained normal in all participants throughout the study, while increases in 2-hour urine calcium/creatinine excretion index were seen in 10 participants (20%) at 12 months, three of whom had had elevated values at baseline.

CONCLUSIONS

Once-yearly intramuscular cholecalciferol injection (600 000 IU) is effective therapy for vitamin D deficiency. While this therapy appears to be safe, the potential for developing hypercalciuria needs to be examined in a large randomised controlled trial.

Vitamin D Supplementation in Older Women

BACKGROUND

The purpose of this study was to determine if vitamin D supplementation, 400-800 IU daily, could effectively treat vitamin D deficiency and insufficiency over 3 months.

METHODS

To test this hypothesis, we conducted a cross-sectional survey followed by a 3-month, open-label run-in phase prior to a randomized clinical trial. We enrolled 573 community-dwelling women age 65 or older, 373 of whom completed the run-in phase. All women received a daily multivitamin containing 400 IU of vitamin D and one to two calcium supplements containing 200 IU of vitamin D. We assessed bone mineral metabolism (including 25-hydroxyvitamin D and parathyroid hormone), markers of bone turnover, and bone mineral density.

RESULTS

Of the 553 screened participants who had baseline vitamin D levels available, 16% had vitamin D deficiency (serum vitamin D < 10 ng/ml) and 48% had vitamin D insufficiency (serum vitamin D between 10 and 20 ng/ml). Only 36% of participants had normal vitamin D levels (serum vitamin D > or = 20 ng/ml). Baseline vitamin D intake was negatively associated with serum parathyroid hormone (r = -0.29, p <.0001), and not associated with bone mineral density or bone resorption. Vitamin D deficiency was associated with decreased physical activity and slower gait. Of the 373 women who completed the run-in phase and received treatment with a multivitamin and vitamin D-containing calcium supplement, vitamin D deficiency decreased from 16% at baseline to 0% at 3 months, and vitamin D insufficiency decreased from 48% at baseline to 20% at 3 months (p <.001).

CONCLUSIONS

We conclude that vitamin D deficiency and insufficiency, which are common among ambulatory, community-dwelling elderly women, can be normalized in 80% of patients over 3 months with vitamin D supplementation of 400-800 IU/d.

Vitamin D and the elderly

This review summarizes current knowledge on vitamin D status in the elderly with special attention to definition and prevalence of vitamin D insufficiency and deficiency, relationships between vitamin D status and various diseases common in the elderly, and the effects of intervention with vitamin D or vitamin D and calcium. Individual vitamin D status is usually estimated by measuring plasma 25-hydroxyvitamin D (25OHD) levels. However, reference values from normal populations are not applicable for the definition of vitamin D insufficiency or deficiency. Instead vitamin D insufficiency is defined as the lowest threshold value for plasma 25OHD (around 50 nmol/l) that prevents secondary hyperparathyroidism, increased bone turnover, bone mineral loss, or seasonal variations in plasma PTH. Vitamin D deficiency is defined as values below 25 nmol/l. Using these definitions vitamin D deficiency is common among community-dwelling elderly in the developed countries at higher latitudes and very common among institutionalized elderly, geriatric patients and patients with hip fractures. Vitamin D deficiency is an established risk factor for osteoporosis, falls and fractures. Clinical trials have demonstrated that 800 IU (20 microg) per day of vitamin D in combination with 1200 mg calcium effectively reduces the risk of falls and fractures in institutionalized patients. Furthermore, 400 IU (10 microg) per day in combination with 1000 mg calcium or 100 000 IU orally every fourth month without calcium reduces fracture risk in individuals over 65 years of age living at home. Yearly injections of vitamin D seem to have no effect on fracture risk probably because of reduced bioavailability. Simulation studies suggest that fortification of food cannot provide sufficient vitamin D to the elderly without exceeding present conventional safety levels for children. A combination of fortification and individual supplementation is proposed. It is argued that all official programmes should be evaluated scientifically. Epidemiological studies suggest that vitamin D insufficiency is related to a number of other disorders frequently observed among the elderly, such as breast, prostate and colon cancers, type 2 diabetes, and cardiovascular disorders including hypertension. However, apart from hypertension, causality has not been established through randomized intervention studies. It seems that 800 IU (20 microg) vitamin D per day in combination with calcium reduces systolic blood pressure in elderly women.

Teenage girls and elderly women living in northern Europe have low winter vitamin D status

OBJECTIVE

To determine the vitamin D status (serum 25-hydroxyvitamin D; S-25OHD) in adolescent girls and elderly community-dwelling women living in four countries of northern Europe and to explain differences in S-25OHD concentrations between and within the countries.

DESIGN

A cross-sectional observational study conducted in a standardised way during February-March. S-25OHD was analysed by high-performance liquid chromatography. Vitamin D and calcium intake was calculated using a standardised food composition database.

SETTING

Denmark, Finland, Ireland, and Poland.

SUBJECTS

A total of 199 girls (mean (s.d.) age 12.6 (0.5) y) and 221 women (mean (s.d.) age 71.8 (1.4) y).

RESULTS

The median (inter quartiles) concentration of S-25OHD was 29.4 (20.3, 38.3) nmol/l for the girls and 40.7 (28.0, 54.2) nmol/l for the women. S-25OHD below 25 nmol/l was found in 37% of the girls and 17% of the women, and S-25OHD below 50 nmol/l was found in 92% of the girls and 37% of the women. Positive significant determinants for S-25OHD in girls were use of vitamin D supplements, and in women sun habits, dietary vitamin D intake, use of vitamin D and calcium supplements. Body mass index and smoking were negative determinants in women. For women predictors could explain the differences between countries (P(country) = 0.09, R(2) = 0.39), but for girls the difference remained significant even after including predictors (P(country) = 0.03, R(2) = 0.15).

CONCLUSION

Vitamin D status is low in northern Europe during winter. More than one-third of the adolescent girls have vitamin D status below 25 nmol/l and almost all are below 50 nmol/l. Two-thirds of the elderly community-dwelling women have vitamin D status below 50 nmol/l. Use of vitamin D supplements is a significant positive determinant for S-25OHD for both girls and women (P = 0.001).

SPONSORSHIP

The European Fifth Framework Programme (Contract No. QLK1-CT-2000-00623).

RETRACTED: Menatetrenone and vitamin D2 with calcium supplements prevent nonvertebral fracture in elderly women with Alzheimer's disease

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Corresponding Author, Yoshihiro Sato, and the co-authors have been informed. Dr. Sato wishes to retract this article on the grounds that it contains fabricated clinical trial data, which he was responsible for producing. In addition, Dr. Sato claims he listed all of the named co-authors without their consent. The co-authors were therefore unaware of the presence of fabricated data in this publication and their participation in the publication. This retraction was initiated by Dr. Sato, and the Editor-in-Chief of Bone was informed by the author directly.

The role of vitamin D in the prevention of osteoporosis

The need for vitamin D to prevent rickets was the drive for selection of lighter skin color in temperate climates. Anthropologists also know that as human populations developed more sedentary lifestyles, this coincided with a decline in bone quantity, quality, and fracture resistance. Since osteoporosis occurs after the reproductive years, there is no way that natural selection could have adapted our biology to prevent it. However, osteoporosis can be largely prevented by optimizing physical activity, and the vitamin D-related factors of environment, and nutrition. The role of vitamin D3 in osteoporosis is conclusively established from a very simple meta-analysis of the four randomized, placebo-controlled clinical trials into the effect of 20 microg (800 IU) per day. These have all demonstrated that this dose prevents approximately 30% of hip or non-vertebral fractures compared to placebo, in adults older than 65 years. Intakes less than this have never been found effective. The lowest average serum 25-hydroxyvitamin D concentration in any study demonstrating fracture reduction was 74 nmol/L. Thus, 25-hydroxyvitamin D levels in older adults should exceed this amount. The role of vitamin D supplementation is to provide humans with the nutrient in an amount closer to our species' biological norm. This amount of vitamin D results in the optimal function of many aspects of health, including balance and muscle strength that lessen the risk of fracture beyond what is possible via the quality and quantity of bone itself.

Vitamin D requirements: current and future

The requirements for vitamin D were last set in 1997 by the Food and Nutrition Board of the Institute of Medicine. Intakes were assumed to come from diet, and values were based on achievement of adequate vitamin D status and on observed values to prevent seasonal variations in parathyroid hormone concentrations. Serum 25-hydroxyvitamin D concentrations were considered the best indicator of vitamin D adequacy, because the production of 25-hydroxyvitamin D is not regulated. Normal ranges were obtained from reference populations, but the values varied widely with age and geographic region. Revised recommendations should take into consideration appropriate functional measures for multiple tissues and disease risks. Vitamin D-calcium interdependencies must be taken into account. Higher intakes of both vitamin D and calcium can reduce bone resorption, and higher concentrations of one nutrient might compensate for insufficiency in the other. Better ways to assess vitamin D (and calcium) inputs are needed. Food composition databases are incomplete for both vitamin D and calcium, especially in this era of food fortification, and are complicated by the poor quality control for vitamin D fortification. Upper levels of vitamin D intake were set at 50 microg/d (2000 IU/d) for all ages. Some individuals would require higher levels than these to achieve serum 25-hydroxyvitamin D concentrations for optimal calcium absorption. So much new information on vitamin D and health has been collected since the requirements were set in 1997 that this nutrient is likely the most in need of revised requirements.

Effect of oral vitamin D2 yearly bolus on hip fracture risk in elderly women: a community primary prevention study

BACKGROUND AND AIMS

Vitamin D deficiency is a well-known risk for hip fracture, and vitamin D insufficiency is so frequent in the elderly that population-wide preventive intervention would be useful. The objective of the study was to evaluate the efficacy of vitamin D bolus on hip fracture incidence in elderly women.

METHODS

All women aged > 65 years registered at Health District 20 of the Regione Veneto, Italy, were eligible for this quasi-experimental, prospective community intervention study. A vial containing 400,000 IU vitamin D2 (Ostelin 800, Teofarma, Italy) was offered for oral administration to all women in the winters of 2000-2001 and 2001-2002. The only exclusion criteria for treatment were age and gender, and the control group included women who did not participate in the Health District initiative. Analysis of hip fracture incidence was carried out for 4 years, from 1999 to 2002. Patients with incident hip fracture were identified as soon as they were admitted to one of the 3 hospitals of the health district and interviewed regarding their participation in the vitamin D preventive intervention program. In 120 of the women (age range 68-90 years), serum concentrations of 25-OH vitamin D were measured from October to June, both before and 1 and 4 months after vitamin D administration.

RESULTS

23,325 and 24,747 women received the vitamin D bolus during winters 2000-2001 and 2001-2002 respectively, i.e. 45-47% of eligible women. The proportion of women who accepted the bolus declined with advancing age, from 50-55% in women aged 60-70 years to 22-26% in those aged > 90 years. The two-year intervention on the community decreased the incidence of fracture by 10% (p = 0.050) in comparison with the previous two years. The age-adjusted risk reduction (RR) of hip fracture during 2001 and 2002 in women who had received vitamin D, with respect to women who had not, decreased by 17% (p = 0.056) and 25% (p = 0.005) respectively. The RR was considerably greater and statistically significant over both 2001 and 2002 in the cohort aged > 75 years. 25-OH vitamin D concentrations, in the subset of women in whom it was measured, rose significantly (p < 0.0001) by 9 ng/ml over 4 months after administration.

CONCLUSION

Despite several obvious limitations due to its nature, this study sufficiently documents that yearly vitamin D bolus supplements, given as primary prevention to elderly Caucasian women, may decrease the incidence of hip fracture. For its probable safety and excellent feasibility and cost-effectiveness, this primary intervention has a great potential for generalisability.

Understanding treatments for bone loss and bone metastases in patients with prostate cancer: a practical review and guide for the clinician

Prostate cancer patients are at risk for developing bone loss and bone metastases. Clinicians prescribing ADT should appreciate the potential effects of ADT on BMD as well as the morbidity and mortality that can result from osteoporotic fractures. Measures to address the evaluation of patients and when to treat patients with significant bone loss have been discussed. Bisphosphonates effectively prevent loss of BMD in prostate cancer patients. Treatment of prostate cancer patients with established bone metastases with zoledronic acid should be considered strongly based on the results of the Saad study and other studies of patients with bone metastases with other malignancies. Zoledronic acid is approved by the US FDA for use in men with metastatic hormone-refractory prostate cancer and in the European Union for any patient with bone metastases, including prostate cancer patients,because of the beneficial impact of zoledronic acid on skeletal-related events. There is no validated method to determine which patients might benefit most from bisphosphonate therapy in this setting. Many questions about the use of bisphosphonate therapy in men with prostate cancer must be addressed, both in terms of the use in bone loss and bone metastases. These questions include: What is the optimal timing of therapy? Which bisphosphonate is best? What is the best dose and dose schedule? Do bisphosphonates effectively decrease skeletal fracture rates in patients with osteoporosis? How long should patients receive therapy? Are bisphosphonate "holidays" warranted? What are the long-term skeletal and renal toxicities? Is there a role for sequencing bisphosphonate therapy either before or after chemotherapy? Is bisphosphonate therapy synergistic with certain chemotherapy or other bone-targeted therapies? Which patients are the most likely to benefit from bisphosphonate therapy? What are clinically significant endpoints of bisphosphonate trials in patients with metastatic disease? Does inhibiting bone turnover also inhibit formation of bone metastases? Preliminary work in these areas has been completed, but more questions than answers are available. Given the rising costs of health care, it is imperative that these questions be addressed to best use the health care dollar while offering high-risk patients the best available therapy. At present, no data suggest that bisphosphonates should be used routinely to prevent BMD loss in men with normal BMD or to prevent the development of bone metastases in men with biochemical relapse. Continuing trials may give us guidance in the future.

Are those in need taking dietary supplements? A survey of 21 923 adults

Many people take dietary supplements, but information on characteristics associated with their use is lacking. The relationship between lifestyle behaviours, morbidity and use of dietary supplements has not been examined and earlier studies have limited applicability to a general population. These issues were addressed in the current study. Information was obtained by postal questionnaire sent to a sample of the general population. The questionnaire was completed by 70.5 % of the sample (15 465 from a total sample of 21 923), with at least one-third (35.5 %) taking dietary supplements. In adjusted analyses, supplement users were more likely to be women, white, home-owners, non-smokers and physically active. Use of vitamin, mineral and/or antioxidant supplements was associated with eating more fruits and vegetables, and taking fish-oil supplements was associated with eating oil-rich fish. A history of CVD or risk factors for CVD reduced the risk of taking vitamins, minerals and/or antioxidants or fish-oil supplements. Those reporting musculoskeletal disorders such as arthritis were more likely to take fish-oil supplements For the first time, we have shown that dietary supplement use is related to different types of morbidity. In particular, people at risk of primary or secondary CVD seem less likely to use dietary supplements, despite possible benefits shown in clinical trials. Public health organisations need to develop guidelines for the public and health professionals regarding the uncontrolled use of dietary supplements in the community.

Why the optimal requirement for Vitamin D3 is probably much higher than what is officially recommended for adults

The physiologic range for circulating 25-hydroxyvitamin D3 [25(OH)D; the measure of Vitamin D nutrient status] concentration in humans and other primates extends to beyond 200 nmol/L (>80 ng/mL). This biologic "normal" value is greater than current population norms for 25(OH)D. Concentrations of 25(OH)D that correlate with desirable effects extend to at least 70 nmol/L, with no obvious threshold. Randomized clinical trials using 20 mcg (800 IU) per day of Vitamin D show that this suppresses parathyroid hormone, preserves bone mineral density, prevents fractures, lowers blood pressure and improves balance. Calcium absorption from diet correlates with 25(OH)D in the normal range. Health effects of Vitamin D beyond osteoporosis are mostly supported by the circumstantial evidence of epidemiologic studies and laboratory research. These include prevention of cancer and the autoimmune diseases, insulin-dependent diabetes and multiple sclerosis. One mcg per day of Vitamin D(3) (cholecalciferol) increases circulating 25(OH)D by about 1 nmol/L (0.4 ng/mL). A recommended dietary allowance (RDA) is the long-term daily intake level that meets the total requirements for the nutrient by nearly all healthy individuals (it would presume no sunshine). If 70 nmol/L is regarded as a minimum desirable target 25(OH)D concentration, then current recommendations of 15 mcg per day do not meet the criterion of an RDA.

Seasonal periodicity of serum vitamin D and parathyroid hormone, bone resorption, and fractures: the Geelong Osteoporosis Study

In this population-based study, seasonal periodicity was seen with reduced serum vitamin D, increased serum PTH, and increased bone resorption in winter. This was associated with an increased proportion of falls resulting in fracture and an increased risk of wrist and hip fractures.

INTRODUCTION

In a population of women who reside in a temperate climate and do not generally receive dietary vitamin D supplementation, we investigated whether seasonal vitamin D insufficiency is associated with increased risk of fracture.

MATERIALS AND METHODS

An observational, cross-sectional, population-based study set in southeastern Australia (latitude 38-39 degrees S). Participants were drawn from a well-defined community of 27,203 women >/=55 years old: 287 randomly selected from electoral rolls, 1635 with incident fractures, and 1358 presenting to a university hospital with falls. The main outcome measures were annual periodicities of ultraviolet radiation, serum 25-hydroxyvitamin D [25(OH)D], serum parathyroid hormone (PTH), serum C-telopeptide (CTx), BMD, falls, and fractures.

RESULTS

Cyclic variations in serum 25(OH)D lagged 1 month behind ultraviolet radiation, peaking in summer and dipping in winter (p < 0.001). Periodicity of serum PTH was the inverse of serum 25(OH)D, with a phase shift delay of 1 month (p = 0.004). Peak serum CTx lagged peak serum PTH by 1-2 months. In late winter, a greater proportion of falls resulted in fracture (p < 0.001). Seasonal periodicity in 439 hip and 307 wrist fractures also followed a simple harmonic model (p = 0.078 and 0.002, respectively), peaking 1.5-3 months after the trough in 25(OH)D.

CONCLUSIONS

A fall in 25(OH)D in winter is accompanied by increases in (1) PTH levels, (2) bone resorption, (3) the proportion of falls resulting in fracture, and (4) the frequency of hip and wrist fracture. Whether vitamin D supplementation in winter can reduce the population burden of fractures requires further investigation.

Hormonal fountains of youth

Any hope of a fountain of youth to stop people from getting older is a long way off, with science just beginning to understand the complex genetic, physical, and hormonal causes of aging. Clearly, modem research has demonstrated that the concept of a hormonal fountain of youth is predominantly mythology. The best evidence supporting use of hormonal replacement is vitamin D and estrogen replacement to prevent hip fractures. Other than that, treatment should be limited to hormone replacement in persons who have endocrine disease.

Calcium and vitamin D supplementation failed to improve bone mineral density in Indo-Asians suffering from hypovitaminosis D and secondary hyperparathyroidism

BACKGROUND

The association of low bone mineral density (BMD) in Asians with hypovitaminosis D (HD) and when complicated with secondary hyperparathyroidism (HD-SHPT) has been shown previously.

OBJECTIVE

Our aim was to study the effectiveness of calcium and vitamin D therapy in Indo-Asians with HD and HD-SHPT.

METHODS

One hundred forty-three patients attending our rheumatology clinic, including 97 (68%) with HD aged 48.9+/-11.6 years (86% female) and 46 (32%) with HD-SHPT aged 55.9+/-12.6 years (85% female), were recruited. Baseline investigations included routine biochemistry and 25-hydroxy vitamin D [25(OH)D], and parathyroid hormone (PTH) assays. Bone mineral densities (BMDs) of femoral neck, lumbar spine (LS), and distal radius (DR) were measured by dual energy X-ray absorptiometry. Patients were commenced on 1.0-1.25 g of calcium plus 400 IU of vitamin D. Blood tests were repeated at 6 and 12 months. Thirty-six patients with t scores of <-1 had their BMDs remeasured at 2 years. Unpaired t- and Mann-Whitney U tests were used in statistics. Results were considered significant at P< or =0.05.

RESULTS

Femur t and z scores failed to improve in either group. The reduction in LS t scores but not z scores was significant in both groups. Significant reductions in DR t and z scores occurred in the HD group only. Calcium and 25(OH)D increased significantly in both groups. Alkaline phosphatase and PTH were suppressed significantly only in HD-SHPT.

CONCLUSION

The failure of BMD to improve could be due to lack of compliance with medication between years 1 and 2, when most patients were under the supervision of primary care. To overcome this, we recommend continuance of blood monitoring at least once a year.

Management of vitamin d depletion in postmenopausal women

In the United States, the impact regarding the routine fortification of milk and other dairy products has been less than satisfactory in preventing vitamin D depletion in adults. As more individuals are being evaluated and treated for osteoporosis, it has become necessary to exclude vitamin D depletion as a cause, because of the likelihood that differences in vitamin D and calcium nutrition may modify the individual response to therapy. Increased prevalence of subclinical vitamin D depletion among vertebral and hip fracture patients and the beneficial effect of vitamin D therapy and calcium supplementation in preventing such fractures lend credence to this assumption. The prevalence of vitamin D depletion is increasing again, especially among older adults, precisely the group at greatest risk for osteoporotic fractures.

Dietary calcium and vitamin D intake in relation to osteoporotic fracture risk

The etiologic role of dietary calcium and vitamin D intake in primary prevention of osteoporotic fractures is uncertain, despite considerable research efforts. With the aim to examine these associations with an improved precision, we used data from a large population-based prospective cohort study in central Sweden. We estimated nutrient intake from a self-administered food-frequency questionnaire filled in by 60,689 women, aged 40-74 years at baseline during 1987-1990. During follow-up, we observed 3986 women with a fracture at any site and 1535 with a hip fracture. Rate ratio of fractures (RR) and 95% CI were estimated using Cox proportional hazards models. We found no dose-response association between dietary calcium intake and fracture risk. The age-adjusted RR of hip fracture was 1.01 (95% CI 0.96-1.06) per 300 mg calcium/day and the corresponding risk of any osteoporotic fracture was 0.99 (95% CI 0.96-1.03). Furthermore, women with an estimated calcium intake below 400 mg/day and those with a calcium intake higher than 1200 mg/day both had a similar age-adjusted hip fracture risk as those with intermediate calcium intakes: RR 1.07 (95% CI 0.92-1.24) and RR 1.00 (95% CI 0.79-1.27), respectively. Vitamin D intake was not associated with fracture risk. Furthermore, women in the highest quintiles compared to the lowest quintiles of both calcium and vitamin D intake had an age-adjusted RR of 1.02 for all fractures (95% CI 0.88-1.17). Dietary calcium or vitamin D intakes estimated at middle and older age do not seem to be of major importance for the primary prevention of osteoporotic fractures in women.

Effect of four monthly oral vitamin D3 (cholecalciferol) supplementation on fractures and mortality in men and women living in the community: randomised double blind controlled trial

OBJECTIVE

To determine the effect of four monthly vitamin D supplementation on the rate of fractures in men and women aged 65 years and over living in the community.

DESIGN

Randomised double blind controlled trial of 100 000 IU oral vitamin D3 (cholecalciferol) supplementation or matching placebo every four months over five years.

SETTING AND PARTICIPANTS

2686 people (2037 men and 649 women) aged 65-85 years living in the general community, recruited from the British doctors register and a general practice register in Suffolk.

MAIN OUTCOME MEASURES

Fracture incidence and total mortality by cause.

RESULTS

After five years 268 men and women had incident fractures, of whom 147 had fractures in common osteoporotic sites (hip, wrist or forearm, or vertebrae). Relative risks in the vitamin D group compared with the placebo group were 0.78 (95% confidence interval 0.61 to 0.99, P=0.04) for any first fracture and 0.67 (0.48 to 0.93, P=0.02) for first hip, wrist or forearm, or vertebral fracture. 471 participants died. The relative risk for total mortality in the vitamin D group compared with the placebo group was 0.88 (0.74 to 1.06, P=0.18). Findings were consistent in men and women and in doctors and the general practice population.

CONCLUSION

Four monthly supplementation with 100 000 IU oral vitamin D may prevent fractures without adverse effects in men and women living in the general community.

Vitamin D and bone health in postmenopausal women

Osteoporosis, a disease of increased skeletal fragility, is becoming increasingly common as the U.S. population ages. Adequate vitamin D and calcium intake is the cornerstone of osteoporosis prevention and treatment. Age-related changes in vitamin D and calcium metabolism increase the risk of vitamin D insufficiency and secondary hyperparathyroidism. Although longitudinal data have suggested a role of vitamin D intake in modulating bone loss in perimenopausal women, studies of vitamin D and calcium supplementation have failed to support a significant effect of vitamin D and calcium during early menopause. There is a clearer benefit in vitamin D and calcium supplementation in older postmenopausal women. Vitamin D intake between 500 and 800 IU daily, with or without calcium supplementation, has been shown to increase bone mineral density (BMD) in women with a mean age of approximately 63 years. In women older than 65, there is even more benefit with vitamin D intakes of between 800 and 900 IU daily and 1200-1300 mg of calcium daily, with increased bone density, decreased bone turnover, and decreased nonvertebral fractures. The decreases in nonvertebral fractures may also be influenced by vitamin D-mediated decreases in body sway and fall risk. There are insufficient available data supporting a benefit from vitamin D supplementation alone, without calcium, to prevent osteoporotic fracture in postmenopausal women.