Effects of a short-term vitamin D and calcium supplementation on body sway and secondary hyperparathyroidism in elderly women

Vitamin D for the Prevention of Disease: An Endocrine Society Clinical Practice Guideline

BACKGROUND

Numerous studies demonstrate associations between serum concentrations of 25-hydroxyvitamin D (25[OH]D) and a variety of common disorders, including musculoskeletal, metabolic, cardiovascular, malignant, autoimmune, and infectious diseases. Although a causal link between serum 25(OH)D concentrations and many disorders has not been clearly established, these associations have led to widespread supplementation with vitamin D and increased laboratory testing for 25(OH)D in the general population. The benefit-risk ratio of this increase in vitamin D use is not clear, and the optimal vitamin D intake and the role of testing for 25(OH)D for disease prevention remain uncertain.

OBJECTIVE

To develop clinical guidelines for the use of vitamin D (cholecalciferol [vitamin D3] or ergocalciferol [vitamin D2]) to lower the risk of disease in individuals without established indications for vitamin D treatment or 25(OH)D testing.

METHODS

A multidisciplinary panel of clinical experts, along with experts in guideline methodology and systematic literature review, identified and prioritized 14 clinically relevant questions related to the use of vitamin D and 25(OH)D testing to lower the risk of disease. The panel prioritized randomized placebo-controlled trials in general populations (without an established indication for vitamin D treatment or 25[OH]D testing), evaluating the effects of empiric vitamin D administration throughout the lifespan, as well as in select conditions (pregnancy and prediabetes). The panel defined "empiric supplementation" as vitamin D intake that (a) exceeds the Dietary Reference Intakes (DRI) and (b) is implemented without testing for 25(OH)D. Systematic reviews queried electronic databases for publications related to these 14 clinical questions. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology was used to assess the certainty of evidence and guide recommendations. The approach incorporated perspectives from a patient representative and considered patient values, costs and resources required, acceptability and feasibility, and impact on health equity of the proposed recommendations. The process to develop this clinical guideline did not use a risk assessment framework and was not designed to replace current DRI for vitamin D.

RESULTS

The panel suggests empiric vitamin D supplementation for children and adolescents aged 1 to 18 years to prevent nutritional rickets and because of its potential to lower the risk of respiratory tract infections; for those aged 75 years and older because of its potential to lower the risk of mortality; for those who are pregnant because of its potential to lower the risk of preeclampsia, intra-uterine mortality, preterm birth, small-for-gestational-age birth, and neonatal mortality; and for those with high-risk prediabetes because of its potential to reduce progression to diabetes. Because the vitamin D doses in the included clinical trials varied considerably and many trial participants were allowed to continue their own vitamin D-containing supplements, the optimal doses for empiric vitamin D supplementation remain unclear for the populations considered. For nonpregnant people older than 50 years for whom vitamin D is indicated, the panel suggests supplementation via daily administration of vitamin D, rather than intermittent use of high doses. The panel suggests against empiric vitamin D supplementation above the current DRI to lower the risk of disease in healthy adults younger than 75 years. No clinical trial evidence was found to support routine screening for 25(OH)D in the general population, nor in those with obesity or dark complexion, and there was no clear evidence defining the optimal target level of 25(OH)D required for disease prevention in the populations considered; thus, the panel suggests against routine 25(OH)D testing in all populations considered. The panel judged that, in most situations, empiric vitamin D supplementation is inexpensive, feasible, acceptable to both healthy individuals and health care professionals, and has no negative effect on health equity.

CONCLUSION

The panel suggests empiric vitamin D for those aged 1 to 18 years and adults over 75 years of age, those who are pregnant, and those with high-risk prediabetes. Due to the scarcity of natural food sources rich in vitamin D, empiric supplementation can be achieved through a combination of fortified foods and supplements that contain vitamin D. Based on the absence of supportive clinical trial evidence, the panel suggests against routine 25(OH)D testing in the absence of established indications. These recommendations are not meant to replace the current DRIs for vitamin D, nor do they apply to people with established indications for vitamin D treatment or 25(OH)D testing. Further research is needed to determine optimal 25(OH)D levels for specific health benefits.

A Systematic Review Supporting the Endocrine Society Clinical Practice Guidelines on Vitamin D

CONTEXT

Low vitamin D status is common and is associated with various common medical conditions.

OBJECTIVE

To support the development of the Endocrine Society's Clinical Practice Guideline on Vitamin D for the Prevention of Disease.

METHODS

We searched multiple databases for studies that addressed 14 clinical questions prioritized by the guideline panel. Of the 14 questions, 10 clinical questions assessed the effect of vitamin D vs no vitamin D in the general population throughout the lifespan, during pregnancy, and in adults with prediabetes; 1 question assessed dosing; and 3 questions addressed screening with serum 25-hydroxyvitamin D (25[OH]D). The Grading of Recommendations Assessment, Development and Evaluation approach was used to assess certainty of evidence.

RESULTS

Electronic searches yielded 37 007 citations, from which we included 151 studies. In children and adolescents, low-certainty evidence suggested reduction in respiratory tract infections with empiric vitamin D. There was no significant effect on select outcomes in healthy adults aged 19 to 74 years with variable certainty of evidence. There was a very small reduction in mortality among adults older than 75 years with high certainty of evidence. In pregnant women, low-certainty evidence suggested possible benefit on various maternal, fetal, and neonatal outcomes. In adults with prediabetes, moderate certainty of evidence suggested reduction in the rate of progression to diabetes. Administration of high-dose intermittent vitamin D may increase falls, compared to lower-dose daily dosing. We did not identify trials on the benefits and harms of screening with serum 25(OH)D.

CONCLUSION

The evidence summarized in this systematic review addresses the benefits and harms of vitamin D for the prevention of disease. The guideline panel considered additional information about individuals' and providers' values and preferences and other important decisional and contextual factors to develop clinical recommendations.

Effect of vitamin D supplementation or fortification on bone turnover markers in women: a systematic review and meta-analysis

Vitamin D is a vital indicator of musculoskeletal health, as it plays an important role through the regulation of bone and mineral metabolism. This meta-analysis was performed to investigate the effects of vitamin D supplementation/fortification on bone turnover markers in women. All human randomised clinical trials reported changes in bone resorption markers (serum C-terminal telopeptide of type-I collagen (sCTX) and urinary type I collagen cross-linked N-telopeptide (uNTX)) or bone formation factors (osteocalcin (OC), bone alkaline phosphatase (BALP) and procollagen type-1 intact N-terminal propeptide (P1NP)) following vitamin D administration in women (aged ≥ 18 years) were considered. Mean differences (MD) and their respective 95 % CI were calculated based on fixed or random effects models according to the heterogeneity status. Subgroup analyses, meta-regression models, sensitivity analysis, risk of bias, publication bias and the quality of the included studies were also evaluated. We found that vitamin D supplementation had considerable effect on sCTX (MD: -0·038, n 22) and OC (MD: -0·610, n 24) with high heterogeneity and uNTX (MD: -8·188, n 6) without heterogeneity. Our results showed that age, sample size, dose, duration, baseline vitamin D level, study region and quality of studies might be sources of heterogeneity in this meta-analysis. Subgroup analysis also revealed significant reductions in P1NP level in dose less than 600 μg/d and larger study sample size (>100 participants). Moreover, no significant change was found in BALP level. Vitamin D supplementation/fortification significantly reduced bone resorption markers in women. However, results were inconsistent for bone formation markers.

Effect of vitamin D, calcium, or combined supplementation on fall prevention: a systematic review and updated network meta-analysis

BACKGROUND

The association between vitamin D supplementation and the risk of falls in older adults has been controversial. This systematic review and network meta-analysis aims to assess the efficacy of vitamin D, calcium, and combined supplementation in the prevention of falls.

METHODS

Randomized controlled trials (RCTs) on the efficacy of vitamin D in fall prevention were systematically searched in PubMed, Embase, Cochrane Library, and Web of Science from inception to May 9, 2023. The network meta-analysis was performed using a random effects model in R4.1.3 and Stata15.0. Heterogeneity was evaluated by the I2 statistic, and publication bias was assessed using funnel plots, Begg's test, and Egger's tests. Data were pooled and expressed as relative risk (RR) and 95% confidence interval (CI).

RESULTS

A total of 35 RCTs involving 58,937 participants were included in this study, among which 11 RCTs (31.4%) applied calcium combined with vitamin D. There was low heterogeneity (I2 = 11%) among the included studies. Vitamin D supplementation at 800-1000 International Unit (IU)/d resulted in a lower risk of falls than placebo or no treatment (RR = 0.85, 95%CI: 0.74-0.95). In addition, 800-1000 IU/d of vitamin D with or without calcium were more effective in preventing falls than calcium alone. High-dose vitamin D (> 1000 IU/day) increased the risk of falls compared with 800-1000 IU/d of vitamin D. According to the subgroup analysis, daily administration of 800-1000 IU/d vitamin D was associated with a 22% reduction in the risk of falls (RR = 0.78, 95%CI:0.64-0.92), whereas intermittent vitamin D administration had no preventive effect. Furthermore, 800-1000 IU/d of vitamin D also significantly decreased the risk of falls in old adults with ≤ 50 nmol/L 25-hydroxyvitamin D [25(OH)D] (RR = 0.69, 95%CI:0.52-0.86) but not in individuals with > 50 nmol/L 25(OH)D.

CONCLUSION

Vitamin D supplementation at 800-1000 IU/d is associated with a lower risk of falls among older adults. 800-1000IU/d of vitamin D has a benefit on prevention of falls in population received daily dose regimens and in population with vitamin D deficiency.

Preoperative vitamin D supplementation is a cost-effective intervention in arthroscopic rotator cuff repair

BACKGROUND

This study investigates the potential role of preoperative 25(OH)D supplementation as a cost-effective strategy to decrease revision rotator cuff repair (RCR) rates and lower the total health care burden from patients undergoing primary arthroscopic RCR. Previous literature has emphasized the importance of vitamin D on bone health maintenance, soft tissue healing, and outcomes in RCR. Inadequate preoperative vitamin D levels may increase revision RCR rates following primary arthroscopic RCR. Although 25(OH)D deficiency is common in RCR patients, serum screening is not routinely performed.

METHODS

A cost-estimation model was developed to determine the cost-effectiveness of both preoperative selective and nonselective 25(OH)D supplementation in RCR patients in order to reduce revision RCR rates. Prevalence and surgical cost data were obtained from published literature through systematic reviews. Cost of serum 25(OH)D assay and supplementation were obtained from public-use data. Mean and lower and upper bounds of 1-year cost savings were calculated for both the selective and nonselective supplementation scenarios.

RESULTS

Preoperative 25(OH)D screening and subsequent selective 25(OH)D supplementation was calculated to result in a mean cost savings of $6,099,341 (range: -$2,993,000 to $15,191,683) per 250,000 primary arthroscopic RCR cases. Nonselective 25(OH)D supplementation of all arthroscopic RCR patients was calculated to result in a mean cost savings of $11,584,742 (range: $2,492,401-$20,677,085) per 250,000 primary arthroscopic RCR cases. Univariate adjustment projects that selective supplementation is a cost-effective strategy in clinical contexts where the cost of revision RCR exceeds $14,824.69 and prevalence of 25(OH)D deficiency exceeds 6.67%. Additionally, nonselective supplementation is a cost-effective strategy in clinical scenarios where revision RCR cost is ≥$4216.06 and prevalence of 25(OH)D deficiency is ≥1.93%.

CONCLUSIONS

This cost-predictive model promotes the role of preoperative 25(OH)D supplementation as a cost-effective mechanism to reduce revision RCR rates and lower the overall health care burden from arthroscopic RCR. Nonselective supplementation appears to be more cost-effective than selective supplementation, likely due to the lower cost of 25(OH)D supplementation compared to serum assays.

The Influences of Macronutrients on Bone Mineral Density, Bone Turnover Markers, and Fracture Risk in Elderly People: A Review of Human Studies

Osteoporosis is a health condition that involves weak bone mass and a deteriorated microstructure, which consequently lead to an increased risk of bone fractures with age. In elderly people, a fracture attributable to osteoporosis elevates mortality. The objective of this review was to examine the effects of macronutrients on bone mineral density (BMD), bone turnover markers (BTMs), and bone fracture in elderly people based on human studies. A systematic search was conducted in the PubMed®/MEDLINE® database. We included human studies published up to April 2023 that investigated the association between macronutrient intake and bone health outcomes. A total of 11 meta-analyses and 127 individual human studies were included after screening the records. Carbohydrate consumption seemed to have neutral effects on bone fracture in limited studies, but human studies on carbohydrates' effects on BMD or/and BTMs are needed. The human studies analyzed herein did not clearly show whether the intake of animal, vegetable, soy, or milk basic proteins has beneficial effects on bone health due to inconsistent results. Moreover, several individual human studies indicated an association between eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and osteocalcin. Further studies are required to draw a clear association between macronutrients and bone health in elderly people.

The Impact of Vitamin D Deficiency on Infants' Health

Vitamin D is an essential nutrient that plays a vital role in bone health and musculoskeletal development. The aim of this narrative review is to present up-to-date information about the impact of vitamin D deficiency (VDD) on the health status of infants in their first year of life. Vitamin D is indispensable for skeletal growth and bone health, and emerging research suggests that it may also have significant roles in maternal and fetal health. VDD affects a large proportion of infants according to current guidelines. However, its prevalence varies depending on geographic location, skin pigmentation, and the time of year. Based on current guidelines for normal vitamin D levels and recommended daily intake, studies suggest that VDD is a global health issue with potentially significant implications for those at risk, especially infants. Our understanding of the role of vitamin D has improved significantly in the last few decades. Systematic reviews and meta-analyses investigating the effect of vitamin D on preterm birth, low birth weight, anthropometric parameters, and health outcomes such as infectious diseases in infants, have found conflicting or inconsistent results. It is important to encourage further research to fill in these knowledge gaps and develop national or global strategies that ease the burden of VDD, especially in groups at risk.

The effectiveness of vitamin D3 supplementation in improving functional outcome of non-surgically treated symptomatic lumbar spinal stenosis: Randomized controlled clinical trial - Pilot study

BACKGROUND

Although vitamin D is one of the essential nutrients associated with musculoskeletal system function, there is no standard treatment method for vitamin D deficiency. This study aimed to investigate the effects of vitamin D supplementation on the improvement in symptoms, functional recovery of the spine, and changes in the quality of life in patients with spinal stenosis.

METHODS

In this prospective study, patients with spinal stenosis and serum 25-hydroxy vitamin D levels < 10 ng/mL were randomly assigned to a supplementation group (Group S) and a non-supplementation group (Group NS): 26 participants in Group S (16 females and 10 males) and 25 in Group NS (15 females and 10 males). The degree of lower back pain in both groups was assessed using the visual analog scale; spine function was assessed using the Oswestry disability index and Roland-Morris disability questionnaire; and patient quality of life was assessed using the 36-item short form health survey. We compared and analyzed the values that were measured at baseline, between 4 and 6 weeks (V1), 10 and 12 weeks (V2), and 22 and 26 weeks (V3).

RESULTS

No statistically significant difference was observed in lower back pain, spine function, or quality of life between both groups at baseline. In terms of lower back pain in V1, Group S scored 4.15 ± 3.12, while Group NS scored 5.64 ± 1.85 (P = .045). In V2, Group S scored 3.15 ± 2.38, while Group NS scored 4.52 ± 1.87 (P = .027). Moreover, in V3, Group S scored 3.58 ± 1.65, while Group NS scored 4.60 ± 1.68 (P = .033), indicating a statistically significant improvement in each period.

CONCLUSION

If a vitamin D deficiency that does not require surgical treatment exists in patients with lumbar spinal stenosis, high-dose vitamin D injections can improve lower back pain, which is the main symptom of lumbar spinal stenosis, as well as the functional outcomes of the spine and quality of life.

Brown Tumour in Chronic Kidney Disease: Revisiting an Old Disease with a New Perspective

Osteitis fibrosa cystica (OFC) and Brown Tumours are two related but distinct types of bone lesions that result from the overactivity of osteoclasts and are most often associated with chronic kidney disease (CKD). Despite their potential consequences, these conditions are poorly understood because of their rare prevalence and variability in their clinical manifestation. Canonically, OFC and Brown Tumours are caused by secondary hyperparathyroidism in CKD. Recent literature showed that multiple factors, such as hyperactivation of the renin-angiotensin-aldosterone system and chronic inflammation, may also contribute to the occurrence of these diseases through osteoclast activation. Moreover, hotspot KRAS mutations were identified in these lesions, placing them in the spectrum of RAS-MAPK-driven neoplasms, which were until recently thought to be reactive lesions. Some risk factors contributed to the occurrence of OFC and Brown Tumours, such as age, gender, comorbidities, and certain medications. The diagnosis of OFC and Brown Tumours includes clinical symptoms involving chronic bone pain and laboratory findings of hyperparathyroidism. In radiological imaging, the X-ray and Computed tomography (CT) scan could show lytic or multi-lobular cystic alterations. Histologically, both lesions are characterized by clustered osteoclasts in a fibrotic hemorrhagic background. Based on the latest understanding of the mechanism of OFC, this review elaborates on the manifestation, diagnosis, and available therapies that can be leveraged to prevent the occurrence of OFC and Brown Tumours.

Vitamin D Supplementation and Muscle Power, Strength and Physical Performance in Older Adults: A Randomized Controlled Trial

BACKGROUND

Low 25-hydroxyvitamin D (25[OH]D) concentrations (<30 ng/mL [<50 nmol/L]) have been associated with muscle weakness and impaired physical performance in observational studies. However, the effect of vitamin D supplementation on changes in muscle strength and physical performance in randomized controlled trials has been mixed.

OBJECTIVES

To determine the effect of daily vitamin D supplementation on leg power, strength, and physical performance in low-functioning older adults with 25(OH)D concentrations of 18 to <30 ng/mL.

METHODS

In this double-blind, randomized controlled trial, 136 low-functioning [Short Physical Performance Battery (SPPB) scores ≤10] adults aged 65-89 y with 25(OH)D concentrations of 18 to <30 ng/mL were randomly assigned to 2000 IU/d vitamin D3 or placebo for 12 mo. Lower-extremity leg power (primary outcome), leg and grip strength, SPPB, timed up and go (TUG), postural sway, and gait velocity and spatiotemporal parameters (secondary outcomes) were assessed at baseline, 4 and 12 mo. A subset (n = 37) also underwent a muscle biopsy at baseline and 4 mo and muscle fiber composition and contractile properties were assessed.

RESULTS

Participants' mean ± SD age and SPPB scores at baseline were 73.4 ± 6.3 y and 7.8 ± 1.8, respectively. Mean ± SD 25(OH)D concentrations at baseline and 12 mo were 19.4 ± 4.2 ng/mL and 28.6 ± 6.7 ng/mL in the vitamin D group and 19.9 ± 4.9 ng/mL and 20.2 ± 5.0 ng/mL in the placebo group for a mean ± SE difference of 9.1 ± 1.1 ng/mL (P < 0.0001). However, there were no differences in change in leg power, leg or grip strength, SPPB score, TUG, postural sway, or gait velocity and spatiotemporal parameters by intervention group over 12 mo or muscle fiber composition and contractile properties over 4 mo.

CONCLUSIONS

In low-functioning older adults with 25(OH)D concentrations of 18 to <30 ng/mL, randomization to 2000 IU/d vitamin D3 did not result in improvements in leg power, strength, or physical performance or muscle fiber composition and contractile properties. This trial was registered at clinicaltrials.gov as NCT02015611.

Is antenatal or early-life vitamin D associated with eczema or food allergy in childhood? A systematic review

OBJECTIVE

To summarise the associations between antenatal or early-life blood vitamin D and the development of eczema/food allergy in childhood.

DESIGN

A systematic review and meta-analyses were conducted to synthesize the published literature. Two reviewers independently performed the study selection and data extraction on Covidence. We assessed the risk of bias for observational studies by using the Newcastle-Ottawa Scale and the Cochrane Risk of Bias tool for clinical trials. The certainty of the evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

DATA SOURCES

We systematically searched PubMed and Embase from inception and April 2022.

ELIGIBILITY CRITERIA

Human studies that investigated prospective associations between antenatal or early-life blood vitamin D levels, dietary intake or supplementation and childhood eczema/food allergy.

RESULTS

Forty-three articles including six randomised controlled trials (RCTs) were included. Four RCTs of vitamin D supplementation during pregnancy showed no evidence of an effect on the incidence of eczema (pooled odds ratio [OR] = 0.85; 0.67-1.08, I2  = 6.7%, n = 2074). Three RCTs reported null associations between supplementation in pregnancy/infancy and food allergy. From six cohort studies, increasing cord blood vitamin D levels were associated with reduced prevalence of eczema at/close to age one (OR per 10 nmol/L increase = 0.89; 0.84-0.94, I2  = 0%, 2025 participants). We found no evidence of an association between maternal antenatal or infant vitamin D level or dietary intake and the development of food allergy or eczema in offspring.

CONCLUSIONS

We found an association between higher vitamin D levels in cord blood and reduced risk of eczema in cohort studies. Further trials with maternal and infant supplementation are needed to confirm if vitamin D supplementation can effectively prevent eczema or food allergy in childhood.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, No. CRD42013005559.

Effect of vitamin D3 vs. calcifediol on VDR concentration and fiber size in skeletal muscle

INTRODUCTION

This study sought to examine the effect of vitamin D₃ (VD₃) 3200 IU/d, calcifediol (HyD) 20mcg/d, or placebo on intramyonuclear vitamin D receptor (VDR) concentration, muscle fiber cross-sectional area (FCSA), and muscle satellite cell activation.

MATERIALS AND METHODS

It was conducted on a subset of the VD₃ (n = 12), HyD (n = 11), and placebo (n = 13) groups who participated in the 6-month randomized controlled HyD Osteopenia Study in postmenopausal women. Baseline and 6-month vastus lateralis muscle cross sections were probed for VDR, fiber type I and II, and PAX7 (satellite cell marker) using immunofluorescence.

RESULTS

Baseline mean ± SD age was 61 ± 4 years and serum 25-hydroxyvitamin D (25OHD) level was 55.1 ± 22.8 nmol/L. Baseline characteristics did not differ significantly by group. Six-month mean ± SD 25OHD levels were 138.7 ± 22.2 nmol/L (VD₃), 206.8 ± 68.8 nmol/L (HyD), and 82.7 ± 36.1 nmol/L (placebo), ANOVA P < 0.001. There were no significant group differences in 6-month change in VDR concentration (ANOVA P = 0.227). Mean ± SD percent 6-month changes in type I FCSA were 20.5 ± 32.7% (VD₃), - 6.6 ± 20.4% (HyD), and - 0.3 ± 14.0% (placebo, ANOVA P = 0.022). Type II FCSA or PAX7 concentration did not change significantly by group (all P > 0.358).

CONCLUSION

This study demonstrated no significant change in intramyonuclear VDR in response to either form of vitamin D vs. placebo. Type I FCSA significantly increased with VD₃, but not with HyD at 6 months. As type I fibers are more fatigue resistant than type II, enlargement in type I suggests potential for improved muscle endurance. Although HyD resulted in the highest 25OHD levels, no skeletal muscle benefits were noted at these high levels.

CLINICAL TRIAL

NCT02527668.

Effects of Vitamin D with Calcium and Associations of Mean 25-Hydroxyvitamin D Levels with 3-Year Change in Muscle Performance in Healthy Older Adults in the Boston STOP IT Trial

The purpose of this analysis was to assess whether (1) daily vitamin D₃ plus calcium supplementation vs. placebo or (2) the mean 25-hydroxyvitamin D [25(OH)D] level achieved during a 3-year trial was associated with muscle performance or balance in the Boston STOP IT study. Methods We conducted exploratory analyses in 386 men and women age 65 years and older who participated in the Boston STOP IT trial and had one or more muscle performance or balance assessments at baseline and 3 years. Participants were treated with 700 IU of vitamin D₃ plus 500 mg of calcium or with double placebo daily for 3 years. Plasma 25(OH)D was measured at baseline, 6, 12, 18, 24, and 36 months; muscle performance (timed walk, grip strength, and chair-rise) and two balance tests, the one-leg stand and tandem stand, were assessed at baseline and 3 years only. Results Supplementation with vitamin D3 and calcium had no favorable effect on any muscle performance measure. The 3-year mean 25(OH)D levels were 22.7 ± 6.3 (SD) in the placebo and 30.8 ± 7.5 ng/ml in the supplemented groups (p < 0.001). The 3-year mean 25(OH)D level was positively associated with change in one-leg stand time (p = 0.04), but not with the other measures. Conclusion Vitamin D3 and calcium supplementation had no favorable effect on muscle performance or balance in this relatively healthy older population. A higher 3-year mean 25(OH)D level may favor balance, as indicated by longer one-leg stand time, but this observation should be confirmed.

Role of vitamin D supplementation in the management of musculoskeletal diseases: update from an European Society of Clinical and Economical Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) working group

Vitamin D is a key component for optimal growth and for calcium-phosphate homeostasis. Skin photosynthesis is the main source of vitamin D. Limited sun exposure and insufficient dietary vitamin D supply justify vitamin D supplementation in certain age groups. In older adults, recommended doses for vitamin D supplementation vary between 200 and 2000 IU/day, to achieve a goal of circulating 25-hydroxyvitamin D (calcifediol) of at least 50 nmol/L. The target level depends on the population being supplemented, the assessed system, and the outcome. Several recent large randomized trials with oral vitamin D regimens varying between 2000 and 100,000 IU/month and mostly conducted in vitamin D-replete and healthy individuals have failed to detect any efficacy of these approaches for the prevention of fracture and falls. Considering the well-recognized major musculoskeletal disorders associated with severe vitamin D deficiency and taking into account a possible biphasic effects of vitamin D on fracture and fall risks, an European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) working group convened, carefully reviewed, and analyzed the meta-analyses of randomized controlled trials on the effects of vitamin D on fracture risk, falls or osteoarthritis, and came to the conclusion that 1000 IU daily should be recommended in patients at increased risk of vitamin D deficiency. The group also addressed the identification of patients possibly benefitting from a vitamin D loading dose to achieve early 25-hydroxyvitamin D therapeutic level or from calcifediol administration.

Analyzing the relationship between the vitamin D deficiency and COVID-19 mortality rate and modeling the time-delay interactions between body's immune healthy cells, infected cells, and virus particles with the effect of vitamin D levels

This paper presents some recent views on the aspects of vitamin D levels in relation to the COVID-19 infections and analyzes the relationship between the prevalence rates of vitamin D deficiency and COVID-19 death rates per million of various countries in Europe and Asia using the data from the PubMed database. The paper also discusses a new mathematical model of time-delay interactions between the body's immune healthy cells, infected cells, and virus particles with the effect of vitamin D levels. The model can be used to monitor the timely progression of healthy immune cells with the effects of the levels of vitamin D and probiotics supplement. It also can help to predict when the infected cells and virus particles free state can ever be reached as time progresses. The consideration of the time delay in the modeling due to effects of the infected cells or virus particles and the growth of healthy cells is also an important factor that can significantly change the outcomes of the body's immune cells as well as the infections.

Effect of Vitamin D Supplementation on Risk of Fractures and Falls According to Dosage and Interval: A Meta-Analysis

BACKGROUND

Although recent studies comparing various dosages and intervals of vitamin D supplementation have been published, it is yet to be elucidated whether there is an appropriate dose or interval to provide benefit regarding fracture risk. We aimed to assess the published evidence available to date regarding the putative beneficial effects of vitamin D supplements on fractures and falls according to various dosages and intervals.

METHODS

We performed a meta-analysis of randomized controlled studies reporting associations between vitamin D supplementation and the risks of fractures and falls in PubMed, EMBASE, and Cochrane library. Studies with supplements of ergocalciferol or calcitriol, those with a number of event ≤10, or those with a follow-up duration of less than 6 months were also excluded.

RESULTS

Thirty-two studies were included in the final analysis. Vitamin D supplementation with daily dose of 800 to 1,000 mg was associated with lower risks of osteoporotic fracture and fall (pooled relative risk [RR], 0.87; 95% confidence interval [CI], 0.78 to 0.97 and RR, 0.91; 95% CI, 0.85 to 0.98), while studies with <800 or >1,000 mg/day did not. Also, among intervals, daily administration of vitamin D was associated with the reduced risk of falls, while intermittent dose was not. Also, patients with vitamin D deficiency showed a significant risk reduction of falls after vitamin D supplementation.

CONCLUSION

Daily vitamin D dose of 800 to 1,000 IU was the most probable way to reduce the fracture and fall risk. Further studies designed with various regimens and targeted vitamin D levels are required to elucidate the benefits of vitamin D supplements.

Vitamin D Supplementation and Fractures in Adults: A Systematic Umbrella Review of Meta-Analyses of Controlled Trials

CONTEXT

The growing number of systematic reviews/meta-analyses (SR/MAs) on vitamin D (± calcium) for fracture prevention has led to contradictory guidelines.

OBJECTIVE

This umbrella review aims to assess the quality and explore the reasons for the discrepancy of SR/MAs of trials on vitamin D supplementation for fracture risk reduction in adults.

METHODS

We searched 4 databases (2010-2020), Epistemonikos, and references of included SRs/MAs, and we contacted experts in the field. We used A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR-2) for quality assessment. We compared results and investigated reasons for discordance using matrices and subgroup analyses (PROSPERO registration: CRD42019129540). We included 13 SR/MAs on vitamin D and calcium (Ca/D) and 19 SR/MAs on vitamin D alone, compared to placebo/control.

RESULTS

Only 2 from 10 SRs/MAs on Ca/D were of moderate quality. Ca/D reduced the risk of hip fractures in 8 of 12 SRs/MAs (relative risk [RR] 0.61-0.84), and any fractures in 7 of 11 SR/MAs (RR 0.74-0.95). No fracture risk reduction was noted in SRs/MAs exclusively evaluating community-dwelling individuals or in those on vitamin D alone compared to placebo/control. Discordance in results between SRs/MAs stems from inclusion of different trials, related to search periods and eligibility criteria, and varying methodology (using intention to treat, per-protocol, or complete case analysis from individual trials).

CONCLUSION

Ca/D reduces the risk of hip and any fractures, possibly driven by findings from institutionalized individuals. Individual participant data meta-analyses of patients on Ca/D with sufficient follow-up periods, and subgroup analyses, would unravel determinants for a beneficial response to supplementation.

Association Between Vitamin D Supplementation and Fall Prevention

BACKGROUND

Falls occur frequently among older individuals, leading to high morbidity and mortality. This study was to assess the efficacy of vitamin D in preventing older individuals from falling.

METHODS

We searched the PubMed, Cochrane Library, and EMBASE databases systematically using the keywords "vitamin D" and "fall" for randomized controlled trials (RCTs) comparing the effects of vitamin D with or without calcium supplements with those of a placebo or no treatment on fall incidence in adults older than 50 years. A meta-analysis was performed to calculate risk ratios (RRs), absolute risk differences (ARDs) and 95% CIs with random-effects models.

RESULTS

A total of 38 RCTs involving 61 350 participants fulfilled the inclusion criteria. Compared with placebo, high-dose vitamin D (≥ 700 IU) can prevent falls [RR, 0.87 (95% CI 0.79 to 0.96); ARD, -0.06 (95% CI, -0.10 to -0.02)]. Low-dose vitamin D (<700 IU) was not significantly associated with falls. Subgroup analysis showed that supplemental calcium, 25(OH) D concentration and frequency influenced the effect of vitamin D in preventing falls. Sensitivity analysis showed that vitamin D prevented falls, which was consistent with the primary analysis. In addition, the active form of vitamin D also prevented falls.

CONCLUSION

In this meta-analysis of RCTs, doses of 700 IU to 2000 IU of supplemental vitamin D per day were associated with a lower risk of falling among ambulatory and institutionalized older adults. However, this conclusion should be cautiously interpreted, given the small differences in outcomes.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier CRD42020179390.

Vitamin D supplementation reduces the risk of fall in the vitamin D deficient elderly: An updated meta-analysis

INTRODUCTION

Vitamin D supplementation has been widely recommended to prevent falls. However, considerable controversy exists regarding the association of such supplementation and fall risk. Previous meta-analyses yielded inconsistent results because of differences in the baseline of 25-hydroxyvitamin D [25(OH)D] and dose of vitamin D and use of vitamin D or in combination with calcium in different studies. Furthermore, some studies published recently were not included in the previous meta-analyses. Therefore, an updated and comprehensive meta-analysis is warranted.

METHODS

We systematically searched several literature databases including PubMed and the Embase from inception to September 2020. The protocol for this meta-analysis was registered with PROSPERO (CRD42021226380). Randomized clinical trials (RCTs) reporting the effect of vitamin D supplementation alone or with calcium on fall incidence were selected from studies. Qualitative and quantitative information was extracted; the random-effects model was conducted to pool the data for fall; statistical heterogeneity was assessed using the I² test and potential for publication bias was assessed qualitatively by a visual estimate of the funnel plot and quantitatively by calculation of the Begg's test and the Egger's test.

RESULTS

Of the citations retrieved, 31 eligible studies involving 57 867 participants met inclusion criteria, reporting 17 623 falls. A total of 21 RCTs of vitamin D alone and 10 RCTs of vitamin D plus calcium were included in the meta-analysis. The meta-analysis of 21 RCTs (51 984 participants) of vitamin D supplementation alone (daily or intermittent doses of 400-60 000 IU) did not show a reduced risk of falls (The risk ratio [RR] 1.00, 95% confidence intervals [CI] 0.95 to 1.05) compared to placebo or no treatment. Subgroup analyses showed that the baseline of serum 25(OH)D concentration less than 50 nmol/L resulted in a reduction of fall risk (RR 0.77, 95% CI 0.61 to 0.98). In contrast, the meta-analysis of 10 RCTs (5883 participants) of combined supplementation of vitamin D (daily doses of 700-1000 IU) and calcium (daily doses of 1000-1200 mg) showed a 12% reduction in the risk of fall (RR 0.88, 95% CI 0.80 to 0.97).

CONCLUSIONS

The combination of vitamin D and calcium have beneficial effects on prevention falls in old adults. Although vitamin D supplementation alone has no effect on fall risk in old adults with 25(OH)D levels higher than 50 nmol/L, vitamin D supplementation alone does have a benefit on prevention of falls in old adults with 25(OH)D levels lower than 50 nmol/L.

Updates on Osteoporosis in Men

Osteoporosis is less common in men than women; however, the mortality rate associated with major fragility fractures is higher in men. The diagnosis of osteoporosis is established by measurement of bone mineral density or by the presence of a fragility fracture, especially spine or hip fracture. However, many men at high risk of fracture will not meet the T-score criteria for osteoporosis, so fracture risk calculation, with a tool such as FRAX, should be performed. Bone-active agents should be prescribed for men at high risk of fracture to decrease fracture risk, and therapy must be individualized.

Natural medicine delivery from biomedical devices to treat bone disorders: A review

With an increasing life expectancy and aging population, orthopedic defects and bone graft surgeries are increasing in global prevalence. Research to date has advanced the understanding of bone biology and defect repair mechanism, leading to a marked success in the development of synthetic bone substitutes. Yet, the quest for functionalized bone grafts prompted the researchers to find a viable alternative that regulates cellular activity and supports bone regeneration and healing process without causing serious side-effects. Recently, researchers have introduced natural medicinal compounds (NMCs) in bone scaffold that enables them to release at a desirable rate, maintains a sustained release allowing sufficient time for tissue in-growth, and guides bone regeneration process with minimized risk of tissue toxicity. According to World Health Organization (WHO), NMCs are gaining popularity in western countries for the last two decades and are being used by 80% of the population worldwide. Compared to synthetic drugs, NMCs have a broader range of safety window and thus suitable for prolonged localized delivery for bone regeneration. There is limited literature focusing on the integration of bone grafts and natural medicines that provides detailed scientific evidences on NMCs, their toxic limits and particular application in bone tissue engineering, which could guide the researchers to develop functionalized implants for various bone disorders. This review will discuss the emerging trend of NMC delivery from bone grafts, including 3D-printed structures and surface-modified implants, highlighting the significance and potential of NMCs for bone health, guiding future paths toward the development of an ideal bone tissue engineering scaffold. STATEMENT OF SIGNIFICANCE: To date, additive manufacturing technology provids us with many advanced patient specific or defect specific bone constructs exhibiting three-dimensional, well-defined microstructure with interconnected porous networks for defect-repair applications. However, an ideal scaffold should also be able to supply biological signals that actively guide tissue regeneration while simultaneously preventing post-implantation complications. Natural biomolecules are gaining popularity in tissue engineering since they possess a safer, effective approach compared to synthetic drugs. The integration of bone scaffolds and natural biomolecules exploits the advantages of customized, multi-functional bone implants to provide localized delivery of biochemical signals in a controlled manner. This review presents an overview of bone scaffolds as delivery systems for natural biomolecules, which may provide prominent advancement in bone development and improve defect-healing caused by various musculoskeletal disorders.

Screening for Vitamin D Deficiency in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Low serum vitamin D levels have been associated with adverse clinical outcomes; identifying and treating deficiency may improve outcomes.

OBJECTIVE

To review the evidence about screening for vitamin D deficiency in adults.

DATA SOURCES

PubMed, EMBASE, the Cochrane Library, and trial registries through March 12, 2020; bibliographies from retrieved articles, outside experts, and surveillance of the literature through November 30, 2020.

STUDY SELECTION

Fair- or good-quality, English-language randomized clinical trials (RCTs) of screening with serum 25-hydroxyvitamin D (25[OH]D) compared with no screening, or treatment with vitamin D (with or without calcium) compared with placebo or no treatment conducted in nonpregnant adults; nonrandomized controlled intervention studies for harms only. Treatment was limited to studies enrolling or analyzing participants with low serum vitamin D levels.

DATA EXTRACTION AND SYNTHESIS

Two reviewers assessed titles/abstracts and full-text articles, extracted data, and assessed study quality; when at least 3 similar studies were available, meta-analyses were conducted.

MAIN OUTCOMES AND MEASURES

Mortality, incident fractures, falls, diabetes, cardiovascular events, cancer, depression, physical functioning, and infection.

RESULTS

Forty-six studies (N = 16 205) (77 publications) were included. No studies directly evaluated the health benefits or harms of screening. Among community-dwelling populations, treatment was not significantly associated with mortality (pooled absolute risk difference [ARD], 0.3% [95% CI, -0.6% to 1.1%]; 8 RCTs, n = 2006), any fractures (pooled ARD, -0.3% [95% CI, -2.1% to 1.6%]; 6 RCTs, n = 2186), incidence of diabetes (pooled ARD, 0.1% [95% CI, -1.3% to 1.6%]; 5 RCTs, n = 3356), incidence of cardiovascular disease (2 RCTs; hazard ratio, 1.00 [95% CI, 0.74 to 1.35] and 1.09 [95% CI, 0.68 to 1.76]), incidence of cancer (2 RCTs; hazard ratio, 0.97 [95% CI, 0.68 to 1.39] and 1.01 [95% CI, 0.65 to 1.58], or depression (3 RCTs, various measures reported). The pooled ARD for incidence of participants with 1 or more falls was -4.3% (95% CI, -11.6% to 2.9%; 6 RCTs). The evidence was mixed for the effect of treatment on physical functioning (2 RCTs) and limited for the effect on infection (1 RCT). The incidence of adverse events and kidney stones was similar between treatment and control groups.

CONCLUSIONS AND RELEVANCE

No studies evaluated the direct benefits or harms of screening for vitamin D deficiency. Among asymptomatic, community-dwelling populations with low vitamin D levels, the evidence suggests that treatment with vitamin D has no effect on mortality or the incidence of fractures, falls, depression, diabetes, cardiovascular disease, cancer, or adverse events. The evidence is inconclusive about the effect of treatment on physical functioning and infection.

Screening for Vitamin D Deficiency in Adults: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Vitamin D is a fat-soluble vitamin that performs an important role in calcium homeostasis and bone metabolism and also affects many other cellular regulatory functions outside the skeletal system. Vitamin D requirements may vary by individual; thus, no one serum vitamin D level cutpoint defines deficiency, and no consensus exists regarding the precise serum levels of vitamin D that represent optimal health or sufficiency.

OBJECTIVE

To update its 2014 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review on screening for vitamin D deficiency, including the benefits and harms of screening and early treatment.

POPULATION

Community-dwelling, nonpregnant adults who have no signs or symptoms of vitamin D deficiency or conditions for which vitamin D treatment is recommended.

EVIDENCE ASSESSMENT

The USPSTF concludes that the overall evidence on the benefits of screening for vitamin D deficiency is lacking. Therefore, the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults cannot be determined.

RECOMMENDATION

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults. (I statement).

Endocrine Challenges in Patients with Continuous-Flow Left Ventricular Assist Devices

Heart failure (HF) remains a leading cause of morbidity, hospitalization, and mortality worldwide. Advancement of mechanical circulatory support technology has led to the use of continuous-flow left ventricular assist devices (LVADs), reducing hospitalizations, and improving quality of life and outcomes in advanced HF. Recent studies have highlighted how metabolic and endocrine dysfunction may be a consequence of, or associated with, HF, and may represent a novel (still neglected) therapeutic target in the treatment of HF. On the other hand, it is not clear whether LVAD support, may impact the outcome by also improving organ perfusion as well as improving the neuro-hormonal state of the patients, reducing the endocrine dysfunction. Moreover, endocrine function is likely a major determinant of human homeostasis, and is a key issue in the recovery from critical illness. Care of the endocrine function may contribute to improving cardiac contractility, immune function, as well as infection control, and rehabilitation during and after a LVAD placement. In this review, data on endocrine challenges in patients carrying an LVAD are gathered to highlight pathophysiological states relevant to this setting of patients, and to summarize the current therapeutic suggestions in the treatment of thyroid dysfunction, and vitamin D, erythropoietin and testosterone administration.

Vitamin D supplementation associated with 12-weeks multimodal training in older women with low bone mineral density: A randomized double-blind placebo-controlled trial

OBJECTIVE

To evaluate the influence of vitamin D supplementation with a multimodal exercise program on postural balance and muscle strength in older women with low bone mineral density (BMD) and vitamin D insufficiency.

METHODS

12-week, randomized, double-blind, placebo-controlled clinical trial. Total of 422 subjects were screened for participation, and 46 met the inclusion criteria. Those were randomized into an experimental group (EG; n = 23) and control group (CG; n = 23). At the time of enrollment, all subjects had low BMD, vitamin D insufficiency, and were not practicing resistance exercise. Muscle strength assessments were performed by the 30-s sit to stand test; 15-steps climbing test; handgrip dynamometer and knee muscle strength using an isokinetic dynamometer at 60°/sec. Postural balance was clinically evaluated by the MiniBESTest and by a force platform. Dynamic balance was assessed by standing up from a chair and walk over a step, using also a force platform.

RESULTS

In the EG, vitamin D levels increased in the post-treatment period (P < 0.001) whereas in CG levels remained unchanged (P = 0.86). Both groups improved muscular strength in the dynamometry isokinetic test: flexors PT/BW - right (P < 0.02) and left side (P < 0.04). In the dynamic postural balance during the task to step up over: the Lift Up Left was better in the CG (P = 0.01); the Moment Time left was better in the CG (P = 0.01); the Impact index left was better in the EG (P = 0.01). The Mini-BESTest - both groups improved the postural balance test (P < 0.001).

CONCLUSION

Vitamin D supplementation associated with multimodal exercise program did not augment muscle strength adaptation or postural balance in older women with low bone mineral density and vitamin D insufficiency.

Vitamin D deficiency 2.0: an update on the current status worldwide

Vitamin D testing and the use of vitamin D supplements have increased substantially in recent years. Currently, the role of vitamin D supplementation, and the optimal vitamin D dose and status, is a subject of debate, because large interventional studies have been unable to show a clear benefit (in mostly vitamin D replete populations). This may be attributed to limitations in trial design, as most studies did not meet the basic requirements of a nutrient intervention study, including vitamin D-replete populations, too small sample sizes, and inconsistent intervention methods regarding dose and metabolites. Vitamin D deficiency (serum 25-hydroxyvitamin D [25(OH)D] < 50 nmol/L or 20 ng/ml) is associated with unfavorable skeletal outcomes, including fractures and bone loss. A 25(OH)D level of >50 nmol/L or 20 ng/ml is, therefore, the primary treatment goal, although some data suggest a benefit for a higher threshold. Severe vitamin D deficiency with a 25(OH)D concentration below <30 nmol/L (or 12 ng/ml) dramatically increases the risk of excess mortality, infections, and many other diseases, and should be avoided whenever possible. The data on a benefit for mortality and prevention of infections, at least in severely deficient individuals, appear convincing. Vitamin D is clearly not a panacea, and is most likely efficient only in deficiency. Given its rare side effects and its relatively wide safety margin, it may be an important, inexpensive, and safe adjuvant therapy for many diseases, but future large and well-designed studies should evaluate this further. A worldwide public health intervention that includes vitamin D supplementation in certain risk groups, and systematic vitamin D food fortification to avoid severe vitamin D deficiency, would appear to be important. In this narrative review, the current international literature on vitamin D deficiency, its relevance, and therapeutic options is discussed.

Effect of Vitamin D Supplementation on Bone Mineral Density in Rheumatoid Arthritis Patients With Osteoporosis

Objectives: To assess the effect of vitamin D supplementation on bone mineral density (BMD) in rheumatoid arthritis (RA) patients with osteoporosis and determine whether supplementation of more than 800 IU/day, which is the currently recommended dose, is beneficial.

Methods: RA patients with osteoporosis who received bisphosphonate were included. Patients were classified into four groups according to the dose of vitamin D supplementation (0, 400, 800, and ≥1,000 IU/day). Multivariable linear regression models were performed to evaluate the effect of each dose of vitamin D supplementation on 1-year% change of BMD.

Results: In total, 187 RA patients with osteoporosis were included. In the multivariate model adjusted for potential confounders, patients receiving vitamin D supplementation had a significantly higher increase in 1-year % change in lumbar spine BMD (400 IU/day: β = 2.51 [95% CI: 0.04–4.99], 800 IU/day: β = 2.90 [95% CI: 0.47–5.33], and ≥1,000 IU/day: β = 6.01 [95% CI: 3.71–8.32]) and femoral neck BMD (400 IU/day: β = 3.88 [95% CI: 1.83–5.94], 800 IU/day: β =4.30 [95% CI: 2.25–6.35], and ≥1,000 IU/day: β = 6.79 [95% CI: 4.87–8.71]) than those not receiving the supplementation. Notably, the ≥1,000-IU/day group had a significantly higher increase in 1-year % change in lumbar spine BMD (β = 3.11 [95% CI: 0.86–5.37]) and femoral neck BMD (β = 2.50 [95% CI: 0.63–4.36]) than the 800-IU/day group.

Conclusion: In RA patients with osteoporosis receiving bisphosphonates, vitamin D supplementation was associated with a higher increase in BMD. This effect was higher in the vitamin D supplementation dose of ≥1,000 IU/day than in 800 IU/day.

Vitamin D supplement on prevention of fall and fracture: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Vitamin D supplement is one of the current possible interventions to reduce fall and fracture. Despite having several studies on vitamin D supplement and fall and fracture reductions, the results are still inconclusive. We conducted a meta-analysis to examine the effect of vitamin D supplement in different forms and patient settings on fall and fracture.

METHODS

A systematic literature research was conducted in MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials to identify randomized controlled trials (RCTs) to compare the effects of vitamin D supplements on fall and fracture outcomes. Random-effect models were used to compute the weighted mean difference for continuous variables and the risk ratio for binary variables.

RESULTS

Forty-seven RCTs with 58,424 participants were identified reporting on fall outcome. Twenty-four of 47 studies with 40,102 subjects also reported fracture outcome. Major populations were elderly women with age less than 80 years. Overall, vitamin D supplement demonstrated a significant effect on fall reduction, RR = 0.948 (95% CI 0.914-0.984; P = .004, I = 41.52). By subgroup analyses, only vitamin D with calcium supplement significantly reduce fall incidence, RR = 0.881 (95% CI 0.821-0.945; P < .001, I = 49.19). Vitamin D3 supplement decreased incidence of fall but this occurred only when vitamin D3 was supplemented with calcium. Regarding fracture outcome, vitamin D supplement failed to show fracture lowering benefit, RR = 0.949 (95% CI 0.846-1.064; P = .37, I = 37.92). Vitamin D along with calcium supplement could significantly lower fracture rates, RR = 0.859 (95% CI 0.741-0.996; P = .045, I = 25.48).

CONCLUSIONS

The use of vitamin D supplement, especially vitamin D3 could reduce incidence of fall. Only vitamin D with calcium supplement showed benefit in fracture reduction.

A Review of Vitamin D in Spinal Surgery: Deficiency Screening, Treatment, and Outcomes

In this review, we discuss the demonstrated value of vitamin D in bone maintenance, fracture resistance, spinal health, and spine surgery outcomes. Despite this, the effect of vitamin D levels in spine surgery has not been well described. Through this review of literature, several conclusions were drawn. First, despite the fact that a high number of spine surgery patients are vitamin D deficient, screening is not commonly performed. Second, adequate vitamin D levels will not be achieved in a majority of these patients without supplementation. Last, inadequate vitamin D levels may increase the risk of pseudarthrosis. Given these findings, we suggest that many patients undergoing spinal surgery could be treated with vitamin D supplementation prior to surgery without the need for confirmatory testing for vitamin D deficiency. This is a more cost-effective method than screening all patients. However, future randomized trials and cost-effectiveness analyses are needed to determine the ultimate effects of vitamin D supplementation on clinical morbidity and surgical outcomes.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS-2020 UPDATE

Objective: The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs). Methods: Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols. Results: The Executive Summary of this 2020 updated guideline contains 52 recommendations: 21 Grade A (40%), 24 Grade B (46%), 7 Grade C (14%), and no Grade D (0%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 368 citations: 123 (33.5%) evidence level (EL) 1 (highest), 132 (36%) EL 2 (intermediate), 20 (5.5%) EL 3 (weak), and 93 (25%) EL 4 (lowest). New or updated topics in this CPG include: clarification of the diagnosis of osteoporosis, stratification of the patient according to high-risk and very-high-risk features, a new dual-action therapy option, and transitions from therapeutic options. Conclusion: This guideline is a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of post-menopausal osteoporosis. Abbreviations: 25(OH)D = 25-hydroxyvitamin D; AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; AFF = atypical femoral fracture; ASBMR = American Society for Bone and Mineral Research; BEL = best evidence level; BMD = bone mineral density; BTM = bone turnover marker; CI = confidence interval; CPG = clinical practice guideline; CTX = C-terminal telopeptide type-I collagen; DXA = dual-energy X-ray absorptiometry; EL = evidence level; FDA = U.S. Food and Drug Administration; FRAX® = Fracture Risk Assessment Tool; GI = gastrointestinal; HORIZON = Health Outcomes and Reduced Incidence with Zoledronic acid ONce yearly Pivotal Fracture Trial (zoledronic acid and zoledronate are equivalent terms); ISCD = International Society for Clinical Densitometry; IU = international units; IV = intravenous; LSC = least significant change; NOF = National Osteoporosis Foundation; ONJ = osteonecrosis of the jaw; PINP = serum amino-terminal propeptide of type-I collagen; PTH = parathyroid hormone; R = recommendation; ROI = region of interest; RR = relative risk; SD = standard deviation; TBS = trabecular bone score; VFA = vertebral fracture assessment; WHO = World Health Organization.

Exercise May Ameliorate the Detrimental Side Effects of High Vitamin D Supplementation on Muscle Function in Mice

Vitamin D is commonly prescribed to normalize deficiencies and to treat osteoporosis. However, the effect vitamin D supplements have on skeletal muscle health is equivocal. Although vitamin D is known to play a role in the various processes that maintain muscle integrity and function, recent studies utilizing high bolus dose vitamin D supplementation has demonstrated an increased risk of falls. Thus, the aim of this study was to investigate the effects of high vitamin D supplementation on skeletal muscle function with and without exercise enrichment. Four-week old C57BL/10 mice (n = 48) were separated into either normal vitamin D (1500 IU/kg diet; unsupplemented) or high vitamin D (20,000 IU/kg diet; supplemented) treatment groups. Each dietary group was further separated into interventional subgroups where mice either remained sedentary or received exercise-enrichment for 8 weeks in the form of voluntary running. Following the intervention period, whole body in vivo and ex vivo contractile analysis were performed. High vitamin D supplementation decreased force production in the slow-twitch soleus muscles of sedentary mice (p < .01); however, exercise normalized this effect. Eight weeks of exercise did not improve fatigue resistance of the extensor digitorum longus (EDL) or soleus muscles in unsupplemented mice, likely due to low levels of activation in these muscles. In contrast, fatigability was improved in the EDL (p < .01) and even more so in the soleus (p < .001) in the supplemented exercise-enriched group. Our data highlights that increasing vitamin D levels above normal reduces postural muscle force as seen in the soleus. Thus, unnecessary vitamin D supplementation may contribute to the increased risk of falls observed in some studies. Interestingly, when vitamin D supplementation was combined with exercise, force production was effectively restored, and fatigue resistance improved, even in muscles lowly activated. Regular exercise may modulate the effects of vitamin D on skeletal muscle, and be recommended for individuals receiving vitamin D supplements. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

Cholecalciferol or Calcifediol in the Management of Vitamin D Deficiency

Vitamin D deficiency is a global health problem due to its high prevalence and its negative consequences on musculoskeletal and extra-skeletal health. In our comparative review of the two exogenous vitamin D supplementation options most used in our care setting, we found that cholecalciferol has more scientific evidence with positive results than calcifediol in musculoskeletal diseases and that it is the form of vitamin D of choice in the most accepted and internationally recognized clinical guidelines on the management of osteoporosis. Cholecalciferol, unlike calcifediol, guarantees an exact dosage in IU (International Units) of vitamin D and has pharmacokinetic properties that allow either daily or even weekly, fortnightly, or monthly administration in its equivalent doses, which can facilitate adherence to treatment. Regardless of the pattern of administration, cholecalciferol may be more likely to achieve serum levels of 25(OH)D (25-hydroxy-vitamin D) of 30-50 ng/mL, an interval considered optimal for maximum benefit at the lowest risk. In summary, the form of vitamin D of choice for exogenous supplementation should be cholecalciferol, with calcifediol reserved for patients with liver failure or severe intestinal malabsorption syndromes.

Effects of Supplemental Vitamin D on Muscle Performance and Quality of Life in Graves' Disease: A Randomized Clinical Trial

Background: Vitamin D deficiency has been proposed to have a role in the development and course of Graves' disease (GD). Muscle weakness and quality of life (QoL) impairments are shared features of GD and vitamin D deficiency. We aimed at investigating whether vitamin D supplementation would improve restoration of muscle performance and thyroid-related QoL in GD and at describing the effect of anti-thyroid medication (ATD) on these outcomes. Methods: In a double-blinded clinical trial, hyperthyroid patients with a first-time diagnosis of GD were randomized to vitamin D 70 μg (2800 IU)/day or matching placebo as add-on to standard ATD. At baseline and after 3 and 9 months of intervention, we assessed isometric muscle strength, muscle function tests, postural stability, body composition, and QoL-impairment by using the ThyPRO questionnaire. Linear mixed modeling was used to analyze between-group differences. (The DAGMAR study clinicaltrials.gov ID NCT02384668). Results: Nine months of vitamin D supplementation caused an attenuation of muscle strength increment in all muscle measures investigated, significant at knee extension 60° where the increase was 24% lower (p = 0.04) in the vitamin D group compared with placebo. Compared with placebo, vitamin D supplementation tended to reduce gain of lean body mass (-24%, p = 0.08). Vitamin D supplementation significantly impeded alleviation of Composite QoL and the same trend was observed for the Overall QoL-Impact and Impaired Daily Life scales. In response to ATD, all measures improved significantly. The increase in muscle strength ranged from 25% to 40% (p_all < 0.001), and increment of lean body mass was 10% (p < 0.001). Large changes were observed in all QoL scales. Conclusions: Nine months of vitamin D supplementation caused unfavorable effects on restoration of muscle performance. In contrast, ATD treatment was associated with marked improvement in all measures of muscle performance and thyroid-related QoL. In patients with newly diagnosed GD, high-dose vitamin D supplementation should not be recommended to improve muscle function, but ATD is of major importance to alleviate muscle impairment.

Effect of Vitamin D Supplementation on Muscle Strength, Muscle Function, and Body Composition in Vitamin D-Deficient Middle-Aged Women

Sarcopenia is the loss of muscle strength and muscle mass with aging and is one of the major risk factors for metabolic diseases. Cross-sectional studies have shown that vitamin D is associated with sarcopenia in both men and women. We investigated the effect of vitamin D supplementation over 12 weeks on muscle strength, muscle function, and body composition in middle-aged women in randomized double-blind placebo-controlled trial format. This revealed a significant difference in serum 25-hydroxyvitamin D levels between the intervention and placebo groups. In addition, handgrip strength was improved, and the timed get up and go (TGUG) test and body fat content were decreased. This chapter presents a protocol for trial setup involving measurement of vitamin D levels, handgrip strength, the TGUT test, and body composition as readouts.

Effect of increased serum 25(OH)D and calcium on structure and function of post-menopausal women: a pilot study

The purpose was to determine if increasing serum 25(OH)D and calcium in postmenopausal women increased skeletal muscle size, strength, balance, and functional task performance while decreasing muscle fatigue. PCSA of the vastus lateralis increased and ascent of stairs time decreased after 6 months of increased serum 25(OH)D.

PURPOSE

The Institute of Medicine recommends ≥ 20 ng/ml of serum 25-hydroxyvitamin D [25(OH)D] for bone and overall health. Serum 25(OH)D levels have been associated with physical performance, postural sway, and falls. The purpose of this study was to determine if increasing postmenopausal women's serum 25(OH)D levels from 20-30 ng/ml to 40-50 ng/ml improved skeletal muscle size, strength, balance, and functional performance while decreasing skeletal muscle fatigue.

METHODS

Twenty-six post-menopausal women (60-85 years old) with baseline serum 25(OH)D levels between 20 and 30 ng/ml were recruited. Oral over-the-counter (OTC) vitamin D3 and calcium citrate were prescribed to increase subjects' serum 25(OH)D to levels between 40 and 50 ng/ml, serum calcium levels above 9.2 mg/dl, and PTH levels below 60 pg/ml, which were confirmed at 6 and 12 weeks. Outcome measures assessed at baseline and 6 months included muscle physiological cross-sectional area (PCSA), muscle strength, postural balance, time to perform functional tasks, and muscle fatigue. Repeated measures comparisons between baseline and follow-up were performed.

RESULTS

Nineteen subjects completed the study. One individual could not afford the time commitment for the repeated measures. Three individuals did not take their vitamin D as recommended. Two subjects were lost to follow-up (lack of interest), and one did not achieve targeted serum 25(OH)D. Vastus lateralis PCSA increased (p = 0.007) and ascent of stair time decreased (p = 0.042) after 6 months of increasing serum 25(OH)D levels from 20-30 ng/ml to 40-50 ng/ml. Isometric strength was unchanged. Anterior-posterior center of pressure (COP) excursion and COP path length decreased (p < 0.1) albeit non-significantly, suggesting balance may improve from increased serum 25(OH)D and calcium citrate levels.

CONCLUSIONS

Several measures of muscle structure and function were sensitive to elevated serum 25(OH)D and calcium levels indicating that further investigation of this phenomenon in post-menopausal women is warranted.

Effects of Elevated Parathyroid Hormone Levels on Muscle Health, Postural Stability and Quality of Life in Vitamin D-Insufficient Healthy Women: A Cross-Sectional Study

Independently of plasma 25-hydroxyvitamin D (P-25(OH)D) levels, elevated parathyroid hormone (PTH) levels may exert an adverse effect on muscle health, postural stability, well-being, and quality of life. Using a cross-sectional design, we investigated 104 healthy postmenopausal women with low P-25(OH)D (< 50 nmol/l) levels, who had either secondary hyperparathyroidism (SHPT) with elevated PTH levels (> 6.9 pmol/l, n = 52) or normal PTH levels (n = 52). The average PTH value in women with SHPT was 8.5 (interquartile range 7.5-9.7) pmol/l and 5.3 (4.4-6.3) pmol/l in women with normal PTH (p < 0.001). Plasma phosphate was significantly lower in women with SHPT than in women with normal PTH (1.01 ± 0.14 vs. 1.09 ± 0.13 mmol/l; p < 0.01). In the total cohort, average level of 25(OH)D were 38 (31-45) nmol/l, with no differences between groups. SHPT was associated with impaired muscle strength as assessed by both maximum muscle strength and maximum force production at knee flexion with the knee fixed at 60° and 90° (p_all < 0.05). Postural stability was impaired during semi tandem standing (p = 0.001). However, the two groups did not differ in terms of self-reported physical activity, muscle-related symptoms, quality of life, or lean muscle mass as assessed by dual-energy X-ray absorptiometry. Independently of 25(OH)D levels, mild to moderately elevated PTH levels are associated with adverse effects on muscle strength and postural stability. Why some individuals respond to vitamin D insufficiency with an elevated PTH and others do not need further elucidation, but elevated PTH itself seems to affect muscle function and postural stability.

Cross-sectional Study on Vitamin D Levels in Stress Urinary Incontinence in Women in a Tertiary Referral Center in India

OBJECTIVE

To assess the levels of vitamin D in patients with Stress Urinary Incontinence (SUI) in gynecology clinic of All India Institute of Medical Sciences, New Delhi.

MATERIALS AND METHODS

This is a cross sectional study on a total of 40 women presenting to gynecology outpatient department with stress urinary incontinence diagnosed by history and examination. The women were divided with moderate, severe and very severe SUI confirmed by incontinence severity index (ISI) and pad test. Vitamin D (serum 25 OH D) levels were measured in all cases by electrochemiluminenscene Immunoassay (ECLIA) using Roche Elecsys 2010 and levels of =30 ng/ml were taken as sufficient while levels between 20-30 ng/ml as insufficient and <20 ng/ml as deficient. Statistical analysis was performed using ANOVA test with P value of <0.05 taken as significant.

RESULTS

Mean age of patients was 41.6 years. Mean parity was 2.73 and mean duration of symptoms was 4.14 years. Vitamin D levels ranged between 6-38 ng/ml with mean being 17.15±8.1 ng/ml. Levels were deficient (<20 ng/ml) in 30 (75%) women, insufficient (20-30ng/ml) in 7 (17.5%) women and sufficient (>30ng/ml) in 3 (7.57%) women. There was no significant correlation between severely of SUI and levels of vitamin D with Vit D being 19.18±5.76 ng/ml in moderate SUI, 16.96±9.03 ng/ml in severe SUI and 13.60 ± 2.09 ng/ml in very severe SUI.

CONCLUSION

There was very high prevalence of vitamin D deficiency in SUI patients with 75% patients showing deficient levels and 17.5% showing insufficient levels in SUI patients. There is need to provide vitamin D supplementation in such women.

Serum 25(OH)D levels after oral vitamin D3 supplementation and UVB exposure correlate

BACKGROUND

The inter-individual variation in 25(OH)D₃ increase (Δ25(OH)D₃ ) after vitamin D₃ supplementation was determined and compared with the UVB irradiation response.

METHODS

Nineteen Danish participants received 85 μg vitamin D₃ (cholecalciferol) daily for nine weeks with regular serum 25(OH)D₃ measurements. These participants had three years earlier taken part in a 9-week controlled UVB study. The Δ25(OH)D₃ was not confounded by ambient UVB, BMI or ethnicity.

RESULTS

Δ25(OH)D₃ was 53 nmol L^-1 and almost identical to Δ25(OH)D₃ (52 nmol L^-1 ) after UVB. Δ25(OH)D₃ ranged from 17 to 91 nmol L^-1 (span 74 nmol L^-1 ) and was about half of that observed after UVB irradiation (span 136 nmol L^-1 ). The interquartile ranges for vitamin D₃ supplementation (38.8-71.4 nmol L^-1 , span: 32.6 nmol L^-1 ) and UVB irradiation (35.7-65.4 nmol L^-1 , span: 29.7 nmol L^-1 ) were similar indicating a comparable response of the two interventions. As the 25(OH)D₃ start levels (R²  = 0.398, P = 3.8 × 10^-3 ), 25(OH)D₃ end levels (R²  = 0.457, P = 1.5 × 10^-3 ) and Δ25(OH)D₃ (R²  = 0.253, P = 0.028) between both interventions were correlated, this suggested a possible common individual background for the variation. Four pigment SNPs influenced the variation in the vitamin D₃ -induced and UVB-induced Δ25(OH)D₃ . A combined model including the influence of these four SNPs and the 25(OH)D₃ start level explained 86.8% (P = 1.6 × 10^-35 ) of the individual variation after vitamin D₃ supplementation.

CONCLUSION

The inter-individual variation in the two interventions was comparable and had no common demographic but a partly common genetic background.

Vitamin D Status in Women with Pelvic Floor Disorders: A Meta-Analysis of Observational Studies

The current evidence regarding the association between vitamin D status and pelvic floor disorder (PFD) are inconclusive. This meta-analysis was aimed to summarize existing data demonstrating the association between Vitamin D status and PFD using published observational studies. All national and international databases including Web of Science, PubMed, Google Scholar, and Scopus were searched up until January 30, 2018, and related published studies retrieved for meta-analysis. The effect sizes of Vitamin D status were presented as standardized mean difference (SMD) with 95% confidence interval (CI), using random-effect models and inverse variance method. The Cochran Q statistic and I² tests were used to evaluate the heterogeneity across included studies. Seven studies with 3219 women were included our meta-analysis. There was heterogeneity existing among included studies (I² = 96.4%, P < 0.001), so a random-effect model was used. The findings of this meta-analysis revealed that the mean serum Vitamin D levels in women with PFD were significantly lower than healthy women (SMD −0.60; 95% CI, −1.06, −0.13; P = 0.01). This meta-analysis demonstrates lower levels of serum Vitamin D in women with PFD rather than healthy women. Additional prospective studies regarding the association between Vitamin D status and PFD are required to confirm our findings.

Modern India and the Tale of Twin Nutrient Deficiency-Calcium and Vitamin D-Nutrition Trend Data 50 Years-Retrospect, Introspect, and Prospect

Vitamin D and calcium are essential nutrients for bone health, to achieve peak bone mass and to preserve bone as age advances. A deficiency in these nutrients casts a long shadow in later life in the form of short/long latency diseases-rickets/osteomalacia/osteoporosis. There is scant review available about the trend of these nutrients in India. For over past half a century, the intake of dietary calcium, milk, milk products, and cereals has declined drastically in the background of upward revision of RDA/RDI in modern India. This is attributed to changing lifestyle, inadequate milk consumption across various socio-economic strata, and shift in dietary intake from cereals to rice and wheat. There is a clear rural-urban divide in consumption of milk, milk products and cereals, a change in dietary habits which magnify the calcium and vitamin D deficiency. Revisiting of RDA guidelines for calcium along with public health measures is required to tackle the morbidity arising due to the deficiency in these nutrients. Any measure to addresses this issue in isolation, without achieving the desired benefits, is a disservice to the population. Population based educational strategies, government measures, leveraging technology, adequate sun exposure and food fortification help in tackling the twin nutrient deficiencies in this diverse country.

High Postural Sway Is an Independent Risk Factor for Osteoporotic Fractures but Not for Mortality in Elderly Women

The aim of this prospective cohort study was to investigate the independent effect of postural sway on overall fracture and osteoporotic fracture risk after controlling for other established fracture risk factors. As a secondary outcome, mortality was also investigated. The study sample is a stratified random sample of 1568 women born between 1932 and 1941, residing in Kuopio province, eastern Finland. Fracture data were obtained through study questionnaires and verified through hospital records. Mortality data were verified through the National Registry. Using static posturography, postural sway was recorded for 1568 women at the fifth year of follow-up in 1994 through 1997. Mediolateral (ML), anteroposterior (AP), and total sway parameters were used for analysis. Mean follow-up time for any fractures, osteoporotic fractures, and mortality was 10.6, 11.4, and 17.5 years, respectively. After adjustment, subjects in the highest quartile of ML sway (HR, 2.0; 95% CI, 1.5 to 2.8) and total sway (HR, 1.6; 95% CI, 1.2 to 2.2) had a higher risk for any fracture. Osteoporotic fracture risk was also higher in the fourth quartile of ML sway (HR, 1.9; 95% CI, 1.1 to 3.0) and total sway (HR, 1.7; 95% CI, 1.0 to 2.8). The models were adjusted for fracture risk assessment tool risk factors and leg-extension strength. Further, women having both lowest bone density and highest postural sway were at 4.9 (95% CI, 2.6 to 9.5) times higher risk of overall fracture and 11.8 (95% CI, 2.7 to 51.3) times higher risk for osteoporotic fracture in comparison with subjects having highest bone density and lowest postural sway. The association between postural sway and mortality was not significant after adjustment. In conclusion, high postural sway is an independent risk factor for any fractures as well as for osteoporotic fractures. A combination of low bone density and high postural sway poses even higher fracture risk than either factor alone. Postural sway does not predict mortality independently. © 2019 American Society for Bone and Mineral Research.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS - 2016

ABBREVIATIONS

AACE = American Association of Clinical Endocrinologists AFF = atypical femur fracture ASBMR = American Society for Bone and Mineral Research BEL = best evidence level BMD = bone mineral density BTM = bone turnover marker CBC = complete blood count CI = confidence interval DXA = dual-energy X-ray absorptiometry EL = evidence level FDA = U.S. Food and Drug Administration FLEX = Fracture Intervention Trial (FIT) Long-term Extension FRAX_® = Fracture Risk Assessment Tool GFR = glomerular filtration rate GI = gastrointestinal HORIZON = Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly IOF = International Osteoporosis Foundation ISCD = International Society for Clinical Densitometry IU = international units IV = intravenous LSC = least significant change NBHA = National Bone Health Alliance NOF = National Osteoporosis Foundation 25(OH)D = 25-hydroxy vitamin D ONJ = osteonecrosis of the jaw PINP = serum carboxy-terminal propeptide of type I collagen PTH = parathyroid hormone R = recommendation RANK = receptor activator of nuclear factor kappa-B RANKL = receptor activator of nuclear factor kappa-B ligand RCT = randomized controlled trial RR = relative risk S-CTX = serum C-terminal telopeptide SQ = subcutaneous VFA = vertebral fracture assessment WHO = World Health Organization.

Status of Vitamin D and Parathyroid Hormone in Patients Scheduled to Undergo Orthopedic Fracture Management: A Case-Control Study

BACKGROUND

Vitamin D deficiency (VDD) is seen in all races, age groups, and ethnic backgrounds. VDD estimated to affect >1 billion people worldwide. The purpose of the present study is to characterize the extent of Vitamin D inadequacy and parathyroid hormone (PTH) levels among patients presenting to us for fracture management.

MATERIALS AND METHODS

A prospective case-control study was performed whereby serum Vitamin D levels and corresponding PTH levels were measured. The study subjects included patients >45 years of age irrespective of sex who presented with fracture as a result of trivial trauma. A total of 102 cases (34 intertrochanteric fracture, 66 fracture neck of femur, and 2 Colle's fracture) and 100 controls were included in the study.

RESULT

Average serum hydroxy-vitamin D and serum PTH of cases 15.8 ± 5.25 ng/mL and 91.15 ± 6.03 pg/mL, respectively. Average S.25-OH Vitamin D and serum PTH of controls was 25.49 ± 3.79 ng/mL and 23.46 ± 3.79 pg/mL, respectively. Eighty (78.4%) cases were in insufficient range (Vitamin D between 10-30 ng/mL), 16 (15.6%) were deficient (Vitamin D <10 ng/mL), and only 6 (5.8%) were sufficient (Vitamin D >30 ng/mL). While in controls, 28% had sufficient and 72% had insufficient Vitamin D levels. There was no deficient control. Serum PTH levels were significantly raised in cases when compared to controls consistent with secondary hyperparathyroidism.

CONCLUSION

This study gives us very important data regarding the prevalence of VDD and rise of PTH secondary to the former and this hormonal milieu in our body is an independent risk factor for increased incidence of fracture.

Effect of 800 IU Versus 2000 IU Vitamin D3 With or Without a Simple Home Exercise Program on Functional Recovery After Hip Fracture: A Randomized Controlled Trial

OBJECTIVES

To evaluate 2 simple strategies, vitamin D₃ and a home exercise program, in functional recovery during the first year after hip fracture.

DESIGN

Secondary analysis of a factorial clinical trial. Patients were randomly allocated to 800 IU (standard of care) or 2000 IU vitamin D₃ and a daily instruction of a simple home exercise program (SHEP) or standard physiotherapy alone during acute care.

SETTING AND PARTICIPANTS

Acute hip fracture patients aged ≥65 years, after hip fracture surgery, admitted to a large hospital in Zurich, Switzerland.

MEASURES

Three objective measures of lower extremity function were assessed at baseline and 6 and 12 months, with the Timed Up and Go test (TUG) as the primary endpoint, and knee flexor and extensor strength, and a self-reported physical function score (PF-10) as secondary endpoints. Linear mixed model regression analyses were based on intention to treat, adjusting for baseline function, time, age, sex, and baseline 25-hydroxyvitamin D level.

RESULTS

We enrolled 173 patients (79.2% women; mean age 84 years; 77.5% living at home). A significant interaction was found between vitamin D₃ dose and SHEP for TUG (P = .045). Thus, findings compared the standard of care reference arm with 800 IU vitamin D₃ without SHEP to 3 interventions arms (800 IU vitamin D₃+SHEP; 2000 IU vitamin D₃ without SHEP; 2000 IU vitamin D₃+SHEP). For TUG, over 12 months the 800 IU vitamin D₃+SHEP group performed significantly better than the standard-of-care group (13.8 vs 19.5 seconds; P = .01). Findings for knee flexor strength were in line with TUG results and approached significance (P = .07), whereas knee extensor strength and PF-10 did not differ by treatments.

CONCLUSIONS/IMPLICATIONS

For functional recovery after hip fracture, combining home exercise with 800 IU vitamin D₃ is superior to no home exercise or 2000 IU vitamin D₃. None of the interventions improved subjective physical functioning.

Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis

BACKGROUND

The effects of vitamin D on fractures, falls, and bone mineral density are uncertain, particularly for high vitamin D doses. We aimed to determine the effect of vitamin D supplementation on fractures, falls, and bone density.

METHODS

In this systematic review, random-effects meta-analysis, and trial sequential analysis, we used findings from literature searches in previously published meta-analyses. We updated these findings by searching PubMed, Embase, and Cochrane Central on Sept 14, 2017, and Feb 26, 2018, using the search term "vitamin D" and additional keywords, without any language restrictions. We assessed randomised controlled trials of adults (>18 years) that compared vitamin D with untreated controls, placebo, or lower-dose vitamin D supplements. Trials with multiple interventions (eg, co-administered calcium and vitamin D) were eligible if the study groups differed only by use of vitamin D. We excluded trials of hydroxylated vitamin D analogues. Eligible studies included outcome data for total or hip fractures, falls, or bone mineral density measured at the lumbar spine, total hip, femoral neck, total body, or forearm. We extracted data about participant characteristics, study design, interventions, outcomes, funding sources, and conflicts of interest. The co-primary endpoints were participants with at least one fracture, at least one hip fracture, or at least one fall; we compared data for fractures and falls using relative risks with an intention-to-treat analysis using all available data. The secondary endpoints were the percentage change in bone mineral density from baseline at lumbar spine, total hip, femoral neck, total body, and forearm.

FINDINGS

We identified 81 randomised controlled trials (n=53 537 participants) that reported fracture (n=42), falls (n=37), or bone mineral density (n=41). In pooled analyses, vitamin D had no effect on total fracture (36 trials; n=44 790, relative risk 1·00, 95% CI 0·93-1·07), hip fracture (20 trials; n=36 655, 1·11, 0·97-1·26), or falls (37 trials; n=34 144, 0·97, 0·93-1·02). Results were similar in randomised controlled trials of high-dose versus low-dose vitamin D and in subgroup analyses of randomised controlled trials using doses greater than 800 IU per day. In pooled analyses, there were no clinically relevant between-group differences in bone mineral density at any site (range -0·16% to 0·76% over 1-5 years). For total fracture and falls, the effect estimate lay within the futility boundary for relative risks of 15%, 10%, 7·5%, and 5% (total fracture only), suggesting that vitamin D supplementation does not reduce fractures or falls by these amounts. For hip fracture, at a 15% relative risk, the effect estimate lay between the futility boundary and the inferior boundary, meaning there is reliable evidence that vitamin D supplementation does not reduce hip fractures by this amount, but uncertainty remains as to whether it might increase hip fractures. The effect estimate lay within the futility boundary at thresholds of 0·5% for total hip, forearm, and total body bone mineral density, and 1·0% for lumbar spine and femoral neck, providing reliable evidence that vitamin D does not alter these outcomes by these amounts.

INTERPRETATION

Our findings suggest that vitamin D supplementation does not prevent fractures or falls, or have clinically meaningful effects on bone mineral density. There were no differences between the effects of higher and lower doses of vitamin D. There is little justification to use vitamin D supplements to maintain or improve musculoskeletal health. This conclusion should be reflected in clinical guidelines.

FUNDING

Health Research Council of New Zealand.

Effects of Vitamin D3 Supplementation on Muscle Strength, Mass, and Physical Performance in Women with Vitamin D Insufficiency: A Randomized Placebo-Controlled Trial

Vitamin D insufficiency and hyperparathyroidism have been associated with reduced muscle strength, physical performance, postural stability, well-being, and quality of life. In a double-blinded, randomized placebo-controlled trial, we aimed to investigate effects of vitamin D3 supplementation on above-mentioned outcomes in healthy community-dwelling postmenopausal women with plasma levels of 25-hydroxyvitamin D (25(OH)D) below < 50 nmol/l and high parathyroid hormone (PTH) levels. Participants (N = 81) were 1:1 treated with vitamin D3, 70 µg (2800 IU)/day or identical placebo for three months during wintertime (56°N). Vitamin D3 supplementation increased levels of 25(OH)D and 1,25(OH)₂D by 230% (95% CI 189 to 272)%, p < 0.001 and 58% (190 to 271%), p < 0.001, respectively, and reduced PTH by 17% (- 23 to - 11%), p < 0.001. Compared with placebo, vitamin D3 significantly reduced maximal handgrip strength by 9% (- 15 to - 3%; p < 0.01) and knee flexion strength by 13% (- 24 to - 2%; p = 0.02) and increased the time spent on performing the Timed Up and Go test by 4.4%; (0.1-8.6%; p < 0.05). Levels of physical activity, total lean body mass, appendicular lean mass index, postural stability, well-being, and quality of life did not change in response to treatment. Compared with placebo, a daily supplement with a relatively high dose of vitamin D3 had no beneficial effects on any outcomes. In some measures of muscle strength and physical performance, we even saw a small unfavorable effect. Our data call for caution on use of relatively high daily doses of vitamin D3 in the treatment of vitamin D insufficiency.

Assessment of research waste part 2: wrong study populations- an exemplar of baseline vitamin D status of participants in trials of vitamin D supplementation

BACKGROUND

Research waste can occur when trials are conducted in the wrong populations. Vitamin D deficient populations are most likely to benefit from vitamin D supplementation. We investigated waste attributable to randomised controlled trials (RCTs) of supplementation in populations that were not vitamin D deficient.

METHODS

In December 2015, we searched Pubmed, recent systematic reviews, and three trial registries for RCTs of vitamin D with clinical endpoints in adults, and 25-hydroxvitamin D (25OHD) survey data relevant to large (N ≥ 1000) RCTs. We investigated the proportion of RCTs that studied vitamin D deficient populations, temporal trends in baseline 25OHD, and whether investigators in large RCTs considered relevant 25OHD survey data or systematic reviews in their trial justifications.

RESULTS

Of 137 RCTs of vitamin D with clinical endpoints, 118 (86%) reported baseline mean/median 25OHD, which was < 25, 25-49, 50-74, and ≥ 75 nmol/L in 12 (10%), 62 (53%), 36 (31%), and 8 (7%) RCTs, respectively. In 70% of RCTs, baseline 25OHD was > 40 nmol/L. Baseline 25OHD increased over time. Before 2006, 38%, 62%, 0% and 0% of RCTs had baseline 25OHD < 25, 25-49, 50-74, and ≥ 75 nmol/L respectively; in 2011-15, the respective proportions were 9%, 49%, 37%, and 6%. Of 12 RCTs with baseline 25OHD < 25 nmol/L, 8 had neutral findings. Of 25 large RCTs (18 completed, 7 ongoing), 1 was undertaken in a vitamin D deficient population, 3 in vitamin D insufficient populations, and 17 had, or probably will have, baseline 25OHD > 40 nmol/L. 44% (8/18) of large completed RCTs cited relevant prior population 25OHD data, and only 3/10 (30%) relevant prior systematic reviews.

CONCLUSIONS

Up to 70% of RCTs of vitamin D with clinical endpoints, 71% of large completed RCTs, and 100% of ongoing large RCTs could be considered research waste because they studied cohorts that were not vitamin D deficient.

A randomized, controlled pilot study of the effects of vitamin D supplementation on balance in Parkinson's disease: Does age matter?

Objectives

To explore if short term, high dose vitamin D supplementation is safe and improves balance in persons with Parkinson's disease (PD).

Methods

A pilot randomized, double-blind intervention trial to measure the effects of 16 weeks of high dose vitamin D (10,000 IU/day) on balance as well as other motor and non-motor features of PD. We measured balance, gait, strength, falls, cognition, mood, PD severity, and quality of life before and after 16 weeks of high dose vitamin D supplementation or placebo. All participants also received 1000 mg calcium once daily.

Results

Fifty-one randomized participants completed sixteen weeks of high dose vitamin D supplementation or placebo. The intervention resulted in a rise in serum concentrations of vitamin D (25-OH) (30.2 ng/ml to 61.1 ng/ml) and was well tolerated with no serious adverse events. Serum vitamin D (25-OH) levels rose steadily and did not suggest a leveling off at the end of the 16 weeks. There was not an improvement in the primary endpoint, balance as measured by the Sensory Organization Test (p = 0.43). A post hoc analysis examining treatment effects in younger (ages 52–66) versus older (ages 67–86) participants found a significant improvement in the SOT of 10.6 points in the younger half of the cohort (p = 0.012).

Conclusions

Short term, high dose vitamin D supplementation appears safe in persons with PD, but did not significantly improve balance as measured with the Sensory Organization Test in this pilot study population. A post hoc analysis suggests that vitamin D may have potential for improving balance in a younger population with PD. High dose vitamin D supplementation in PD needs further study especially in light of new research suggesting that mega doses and even moderate doses (as low as 4000IU a day) may increase falls in an older populations.

Trial registration

ClinicalTrials.gov: NCT01119131.