Public health impact and cost-effectiveness of dairy products supplemented with vitamin D in prevention of osteoporotic fractures

Cost Effectiveness Analyses of Interventions for Osteoporosis in Men: A Systematic Literature Review

BACKGROUND

Osteoporosis is often considered to be a disease of women. Over the last few years, owing to the increasing clinical and economic burden, the awareness and imperative for identifying and managing osteoporosis in men have increased substantially. With the approval of agents to treat men with osteoporosis, more economic evaluations have been conducted to assess the potential economic benefits of these interventions. Despite this concern, there is no specific overview of cost-effectiveness analyses for the treatment of osteoporosis in men.

OBJECTIVES

This study aims (1) to systematically review economic evaluations of interventions for osteoporosis in men; (2) to critically appraise the quality of included studies and the source of model input data; and (3) to investigate the comparability of results for studies including both men and women.

METHODS

A literature search mainly using MEDLINE (via Ovid) and Embase databases was undertaken to identify original articles published between 1 January, 2000 and 30 June, 2022. Studies that assessed the cost effectiveness of interventions for osteoporosis in men were included. The Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases and the International Osteoporosis Foundation osteoporosis-specific guideline was used to assess the quality of design, conduct, and reporting of included studies.

RESULTS

Of 2973 articles identified, 25 studies fulfilled the inclusion criteria, classified into economic evaluations of active drugs (n = 8) or nutritional supplements (n = 4), intervention thresholds (n = 5), screening strategies (n = 6), and post-fracture care programs (n = 2). Most studies were conducted in European countries (n = 15), followed by North America (n = 9). Bisphosphonates (namely alendronate) and nutritional supplements were shown to be generally cost effective compared with no treatment in men over 60 years of age with osteoporosis or prior fractures. Two other studies suggested that denosumab was cost effective in men aged 75 years and older with osteoporosis compared with bisphosphates and teriparatide. Intervention thresholds at which bisphosphonates were found to be cost effective varied among studies with a 10-year probability of a major osteoporotic fracture that ranged from 8.9 to 34.2% for different age categories. A few studies suggested cost effectiveness of screening strategies and post-fracture care programs in men. Similar findings regarding the cost effectiveness of drugs and intervention thresholds in women and men were captured, with slightly greater incremental cost-effectiveness ratios in men. The quality of the studies included had an average score of 18.8 out of 25 (range 13-23.5). Hip fracture incidence and mortality risk were mainly derived from studies in men, while fracture cost, treatment efficacy, and disutility were commonly derived from studies in women or studies combining both sexes.

CONCLUSIONS

Anti-osteoporosis drugs and nutritional supplements are generally cost effective in men with osteoporosis. Screening strategies and post-fracture care programs also showed economic benefits for men. Cost-effectiveness and intervention thresholds were generally similar in studies conducted in both men and women, with slightly greater incremental cost-effectiveness ratios in men.

Analysis of the relationship between periodontitis and osteoporosis/fractures: a cross-sectional study

BACKGROUND

Chronic periodontitis is a multifactorial inflammatory disease resulting in patients exhibiting high levels of inflammatory factors causing systemic inflammatory bone destruction that may lead to osteoporosis development. The association between periodontitis and osteoporosis has been documented; however, the findings remain unclear. This study aimed to identify the association between periodontitis and osteoporosis using a cross-sectional study design and Korean Genome and Epidemiology Study (KoGES) health examinee data.

METHODS

This cross-sectional study used epidemiological data from the KoGES during 2004-2016. Of 125,324 participants (age, 40-79 years), 9969 with periodontitis and 115,332 controls (without periodontitis) were selected. We analyzed the history of osteoporosis and fractures of all participants. All participants were examined according to age, sex, income group, obesity, smoking habits, alcohol consumption, and food intake. To analyze the odds ratio (OR) of periodontitis for those with osteoporosis and fractures, a logistic regression model was used.

RESULTS

The adjusted odds ratio (aOR) of periodontitis for osteoporosis was 2.16 (95% confidence interval [CI], 2.01-2.31; P < 0.001). The aOR of periodontitis for any fracture was 1.54 (95% CI 1.46-1.62; P < 0.001).

CONCLUSION

Osteoporosis and fractures are associated with periodontitis. Performing regular oral hygiene and examinations of bone mineral density are recommended to prevent aggravation of osteoporosis and periodontitis.

Dietary Intake of Vitamin D from Dairy Products Reduces the Risk of Osteoporosis

Background: Vitamin D and calcium are important dietary compounds that affect bone mass, even if other minerals (potassium, zinc, etc.) and vitamins (A, C and K) are also involved. Vitamin D and certain minerals, in fact, play an important role in calcium homeostasis and calcium absorption. Hip fracture incidence is higher in Europe and the United States, where calcium is frequently included in the human diet; while the occurrence of these fractures is lower in developing countries, where diets are often poor in calcium. This condition is named the “calcium paradox”, and may be partially explained by phosphate toxicity, which can negatively affect mineral metabolism. It is important to maintain correct dietary calcium-phosphate balance in order to have a healthy life, reducing the risk of osteoporotic fractures in older people. Vitamin D can also act as a hormone; vitamin D2 (ergocalciferol) is derived from the UV-B radiation of ergosterol, the natural vitamin D precursor detected in plants, fungi, and invertebrates. Vitamin D3 (cholecalciferol) is synthesized by sunlight exposure from 7-dehydrocholesterol, a precursor of cholesterol that can also act as provitamin D3. Dietary intake of vitamin D3 is essential when the skin is exposed for short periods to ultraviolet B light (UV-B), a category of invisible light rays such as UV-A and UV-C. This can be considered the usual situation in northern latitudes during the winter season, or the typical lifestyle for older people and/or for people with very white delicate skin. The actual recommended daily intake of dietary vitamin D is strictly correlated with age, ranging from 5 μg for infants, children, teenagers, and adults—including pregnant and lactating women—to 15 μg for people over 65 years.

Dairy foods and bone health throughout the lifespan: a critical appraisal of the evidence

The consumption of high-Ca, high-protein dairy foods (i.e. milk, cheese, yogurt) is advocated for bone health across the lifespan to reduce the risk of low-trauma fractures. However, to date, the anti-fracture efficacy of dairy food consumption has not been demonstrated in randomised controlled trials but inferred from cross-sectional and prospective studies. The anti-fracture efficacy of dairy food consumption is plausible, but testing this requires a robust study design to ensure outcomes are suitably answering this important public health question. The evidence of skeletal benefits of dairy food consumption is equivocal, not because it may not be efficacious but because the study design and execution are often inadequate. The key issues are compliance with dietary intervention, dropouts, sample sizes and most importantly lack of deficiency before intervention. Without careful appraisal of the design and execution of available studies, precarious interpretations of outcomes may be made from these poorly designed or executed studies, without consideration of how study design may be improved. Dairy food interventions in children are further hampered by heterogeneity in growth: in particular sex and maturity-related differences in the magnitude, timing, location and surface-specific site of bone accrual. Outcomes of studies combining children of different sexes and maturity status may be masked or exaggerated by these differences in growth, so inaccurate conclusions are drawn from results. Until these critical issues in study design are considered in future dairy food interventions, the anti-fracture efficacy of dairy food consumption may remain unknown and continue to be based on conjecture.

European guidance for the diagnosis and management of osteoporosis in postmenopausal women

Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis.

INTRODUCTION

The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2013. This manuscript updates these in a European setting.

METHODS

Systematic reviews were updated.

RESULTS

The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; monitoring of treatment; assessment of fracture risk; case-finding strategies; investigation of patients; health economics of treatment. The update includes new information on the evaluation of bone microstructure evaluation in facture risk assessment, the role of FRAX® and Fracture Liaison Services in secondary fracture prevention, long-term effects on fracture risk of dietary intakes, and increased fracture risk on stopping drug treatment.

CONCLUSIONS

A platform is provided on which specific guidelines can be developed for national use.

Rationale and Plan for Vitamin D Food Fortification: A Review and Guidance Paper

Vitamin D deficiency can lead to musculoskeletal diseases such as rickets and osteomalacia, but vitamin D supplementation may also prevent extraskeletal diseases such as respiratory tract infections, asthma exacerbations, pregnancy complications and premature deaths. Vitamin D has a unique metabolism as it is mainly obtained through synthesis in the skin under the influence of sunlight (i.e., ultraviolet-B radiation) whereas intake by nutrition traditionally plays a relatively minor role. Dietary guidelines for vitamin D are based on a consensus that serum 25-hydroxyvitamin D (25[OH]D) concentrations are used to assess vitamin D status, with the recommended target concentrations ranging from ≥25 to ≥50 nmol/L (≥10-≥20 ng/mL), corresponding to a daily vitamin D intake of 10 to 20 μg (400-800 international units). Most populations fail to meet these recommended dietary vitamin D requirements. In Europe, 25(OH)D concentrations <30 nmol/L (12 ng/mL) and <50 nmol/L (20 ng/mL) are present in 13.0 and 40.4% of the general population, respectively. This substantial gap between officially recommended dietary reference intakes for vitamin D and the high prevalence of vitamin D deficiency in the general population requires action from health authorities. Promotion of a healthier lifestyle with more outdoor activities and optimal nutrition are definitely warranted but will not erase vitamin D deficiency and must, in the case of sunlight exposure, be well balanced with regard to potential adverse effects such as skin cancer. Intake of vitamin D supplements is limited by relatively poor adherence (in particular in individuals with low-socioeconomic status) and potential for overdosing. Systematic vitamin D food fortification is, however, an effective approach to improve vitamin D status in the general population, and this has already been introduced by countries such as the US, Canada, India, and Finland. Recent advances in our knowledge on the safety of vitamin D treatment, the dose-response relationship of vitamin D intake and 25(OH)D levels, as well as data on the effectiveness of vitamin D fortification in countries such as Finland provide a solid basis to introduce and modify vitamin D food fortification in order to improve public health with this likewise cost-effective approach.

Sunscreens block cutaneous vitamin D production with only a minimal effect on circulating 25-hydroxyvitamin D

A 50+ SPF sunscreen decreased significantly cutaneous vitamin D production following a single narrow-band (nb)UVB exposure, independently from the body surface area exposed. In contrast, the circulating 25(OH)D₃ levels were only minimally affected. It is probable that another endogenous source of precursors is selected when skin-originated precursors are lacking.

PURPOSE

Sunscreen use, highly advocated for preventing cutaneous carcinogenesis, is potentially leading to an aggravation of vitamin D deficiency with its consequences on bone health. The effect of sunscreens on circulating vitamin D levels remains debated. This study investigated the effect of sunscreen on cutaneous vitamin D production and circulating 25(OH)D₃ levels, according to different body surface areas (BSA).

METHODS

Vitamin D and 25(OH)D₃ levels were measured in four groups exposed to a single nbUVB exposure on 9% (group I: head and hands), 23% (group II: head, hands and arms), 50% (group III: head, hands, arms and legs) and 96% (group IV: total body) of the body surface without and with a 50+ sun protection factor sunscreen.

RESULTS

Sunscreen use decreased by 83, 88.3, 75.7 and 92.5% the cutaneous vitamin D production in groups I to IV, respectively, but only by 13.2, 10.5, 7.7 and 10.4% the values of circulating 25(OH)D_3, correspondingly.

CONCLUSIONS

Although a 50+ sunscreen decreases significantly cutaneous vitamin D production following a single nbUVB exposure, and independently from the BSA, the circulating 25(OH)D₃ levels were only minimally affected. This could be explained by a switch to another endogenous source of precursors. Short-term sunscreen use probably does not affect circulating vitamin D levels and hence does not increase the risk for osteoporosis. The effect of long-term sunscreen use remains however to be determined.

The projected public health and economic impact of vitamin D fortified dairy products for fracture prevention in France

BACKGROUND

There is a paucity of research that projects the public health and economic impact of healthcare interventions in the future. In this study, we aimed to estimate the public health and economic impact of vitamin D fortified dairy products for the years 2020, 2030, 2040, 2050 and 2060.

METHODS

We used a previously validated Markov microsimulation model that was designed to assess the public health and economic impact of dairy products for fracture prevention in the French general population aged over 60 years in the year 2015.

RESULTS

The expected benefit (in terms of fractures prevented) of the recommended intake of dairy products compared to the absence of appropriate intake is expected to increase by 63% in 2040 and by 85% in 2060. The cost per quality-adjusted life years gained of the appropriate intake of dairy products is expected to decrease from €58,244 in 2015 to €42,616 in 2060.

CONCLUSION

The potential public health and economic benefits of vitamin D fortified dairy products is expected to substantially increase in the future, especially in the population aged over 80 years. Decision makers should be aware of the current and future potential benefits of dairy products to protect bone fractures.

Risk of Deficiency in Multiple Concurrent Micronutrients in Children and Adults in the United States

Certain population sub-groups in the United States are vulnerable to micronutrient malnutrition. Nationally representative data from the National Health and Nutrition Examination Survey (NHANES) describing the biochemical status of vitamins A, B6, B12, C, D, E, folate, and anemia, were aggregated to determine the overall risk of multiple concurrent deficiencies in U.S. children and adults (n = 15,030) aged >9 years. The prevalence of deficiency risk according to socio-demographic, life-stage, dietary supplement use, and dietary adequacy categories was investigated. Thirty-one percent of the U.S. population was at risk of at least one vitamin deficiency or anemia, with 23%, 6.3%, and 1.7% of the U.S. population at risk of deficiency in 1, 2, or 3-5 vitamins or anemia, respectively. A significantly higher deficiency risk was seen in women (37%), non-Hispanic blacks (55%), individuals from low income households (40%), or without a high school diploma (42%), and underweight (42%) or obese individuals (39%). A deficiency risk was most common in women 19-50 years (41%), and pregnant or breastfeeding women (47%). Dietary supplement non-users had the highest risk of any deficiency (40%), compared to users of full-spectrum multivitamin-multimineral supplements (14%) and other dietary supplement users (28%). Individuals consuming an adequate diet based on the Estimated Average Requirement had a lower risk of any deficiency (16%) than those with an inadequate diet (57%). Nearly one-third of the U.S. population is at risk of deficiency in at least one vitamin, or has anemia.

Public health impact and economic evaluation of vitamin D-fortified dairy products for fracture prevention in France

The recommended intake of vitamin D-fortified dairy products can substantially decrease the burden of osteoporotic fractures and seems an economically beneficial strategy in the general French population aged over 60 years.

INTRODUCTION

This study aims to assess the public health and economic impact of vitamin D-fortified dairy products in the general French population aged over 60 years.

METHODS

We estimated the lifetime health impacts expressed in number of fractures prevented, life years gained, and quality-adjusted life years (QALY) gained of the recommended intake of dairy products in the general French population over 60 years for 1 year (2015). A validated microsimulation model was used to simulate three age cohorts for both women and men (60-69, 70-79, and >80 years). The incremental cost per QALY gained of vitamin D-fortified dairy products compared to the absence of appropriate intake was estimated in different populations, assuming the cost of two dairy products per day in base case.

RESULTS

The total lifetime number of fractures decreased by 64,932 for the recommended intake of dairy products in the general population over 60 years, of which 46,472 and 18,460 occurred in women and men, respectively. In particular, 15,087 and 4413 hip fractures could be prevented in women and men. Vitamin D-fortified dairy products also resulted in 32,569 QALYs and 29,169 life years gained. The cost per QALY gained of appropriate dairy intake was estimated at €58,244 and fall below a threshold of €30,000 per QALY gained in women over 70 years and in men over 80 years.

CONCLUSION

Vitamin D-fortified dairy products have the potential to substantially reduce the burden of osteoporotic fractures in France and seem an economically beneficial strategy, especially in the general population aged above 70 years.

Relevance of vitamin D in the pathogenesis and therapy of frailty

PURPOSE OF REVIEW

This article reviews recently published evidence regarding the role of vitamin D in the physiopathology of physical frailty in elderly populations and its role in the management of this geriatric condition.

RECENT FINDINGS

Some recent studies have found a low level of 25-hydroxyvitamin D, considered the best marker of vitamin D status, in frail individuals. All prospective studies consistently report that low vitamin D status is associated with an increased risk of becoming frail. Recent studies also suggest that the relationship between vitamin D status and frailty is largely mediated by the development of sarcopenia. Very few well designed randomized controlled trials are available that assess the effectiveness of vitamin D supplementation in the prevention or management of frailty. In the absence of specific guidelines, a minimal serum 25-hydroxyvitamin D level of 75 nmol/l is proposed for frail elderly patients by some scientific societies. The doses necessary to reach this target are between 800 and 2000 IU/day.

SUMMARY

Several studies suggest a potential effect of vitamin D on physical frailty but large clinical trials are lacking at this time to provide solid evidence of clinical benefit.

A scoping review of the public health impact of vitamin D-fortified dairy products for fracture prevention

PURPOSE

Dairy products are rich in nutrients that positively influence bone health and hence fracture risk, and have therefore been recommended and used for fracture prevention. To help decision makers to efficiently allocate scare resources, it is further important to assess the public health and economic impact of any health intervention. In recent years, several studies have been conducted to estimate the public health and/or economic impact of dairy products but no overview is currently available. This article aims therefore to summarize evidence and review articles that estimated the public health and/or economic impact of vitamin D-fortified dairy products for fracture prevention.

METHODS

A literature review was conducted using PubMed to identify original studies that assessed the public health and/or economic impact of dairy products (or of calcium/vitamin D supplementation) for fracture prevention up to January 15, 2017.

RESULTS

Seven articles were identified. Different strategies were used by the authors to model the economic/public health impact of dairy products. The four studies assessing the public health impact of dairy products revealed a substantial benefit in terms of fracture prevented, life years, disability-adjusted life years and/or quality-adjusted life years gained. Studies assessing the cost-effectiveness revealed that the use of dairy products is generally cost-effective in the general population aged above 70 years, and from the age of 60 years in populations at high risk of fractures.

CONCLUSION

This systematic review suggests that the use of dairy products could substantially reduce the burden of osteoporotic fractures and seem to be an economically beneficial strategy.

Phase IV randomized preference study in patients eligible for calcium and vitamin D supplementation

INTRODUCTION/OBJECTIVES

Preference for supplement formulation helps determine an individual's adherence to long-term medication and can improve clinical benefit for chronic illnesses such as osteoporosis. This study compared the preference, acceptability and tolerability of a reformulation of Calcichew D3 ¹ 500 mg/400 IU and Calcichew D3 500 mg/800 IU (Takeda UK Ltd, Wobrun Green, UK) with Adcal-D3 ² 500 mg/400 IU (ProStrakan Ltd, Galashiels, UK) and Kalcipos-D 500 mg/800 IU (Meda Pharmaceuticals Ltd, Bishop's Stortford, UK), respectively.

METHOD

This phase IV, randomized, open-label, two-period, cross-over study was conducted at nine sites in the UK and Germany. Eligible subjects (≥65 years requiring calcium/vitamin D supplementation for prevention/treatment of deficiencies, or ≥18 years requiring supplementation as an adjunct to osteoporosis treatment) were randomly assigned to one of two 2 week treatment sequences - Group 1: Calcichew D3 500/400 then Adcal-D3 500/400 (or vice versa), or Group 2: Calcichew D3 500/800 then Kalcipos-D 500/800 (or vice versa). After each treatment period, patients rated the treatment for acceptability using 100 mm visual analogue scales. After the second treatment period, patients indicated their treatment preference. The primary endpoint, the percentage of patients with a preference for each treatment, was analyzed with a logistic regression model.

RESULTS

Two hundred and seventy-six patients were randomly assigned by treatment sequence, 138 to each group. Preference questionnaires among patients who preferred Calcichew or comparator revealed the odds for patients preferring Calcichew 500/400 (77.6%) over Adcal-D3 was 3.46 ([95% CI 2.24, 5.36], p < 0.001) in Group 1, and Calcichew D3 500/800 (63.2%) over Kalcipos-D was 1.72 ([1.19, 2.47], p = 0.004) in Group 2. Adverse events were mostly gastrointestinal and were comparable between groups. The new formulation of Calcichew D3 is acceptable and consistent with its known tolerability profile.

CONCLUSIONS

In this short-term 30 day study, patients preferred Calcichew D3 500/400 and Calcichew D3 500/800 over respective comparators. A trend towards better compliance with Calcichew D3 preference observed in Group 1 warrants a longer term study to identify treatment compliance.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02457247.