Recommendations of the Brazilian Society of Endocrinology and Metabology (SBEM) for the diagnosis and treatment of hypovitaminosis D

The Role of Vitamin D in the Treatment of Carpal Tunnel Syndrome: Clinical and Electroneuromyographic Responses

Carpal tunnel syndrome (CTS) is the most common cause of peripheral compressive neuropathy and consists of compression of the median nerve in the wrist. Although there are several etiologies, idiopathic is the most prevalent origin, and among the forms of treatment for CTS, conservative is the most indicated. However, despite the high prevalence in and impact of this syndrome on the healthcare system, there are still controversies regarding the best therapeutic approach for patients. Therefore, noting that some studies point to vitamin D deficiency as an independent risk factor, which increases the symptoms of the syndrome, this study evaluated the role of vitamin D supplementation and its influence on pain control, physical examination and response electroneuromyography to conservative treatment of carpal tunnel syndrome. For this, the sample consisted of 14 patients diagnosed with CTS and hypovitaminosis D, who were allocated into two groups. The control group received corticosteroid treatment, while the experimental group received corticosteroid treatment associated with vitamin D. Thus, from this study, it can be concluded that patients who received vitamin D, when compared to those who did not receive it, showed improvement in the degree of pain intensity, a reduction in symptom severity and an improvement in some electroneuromyographic parameters.

Serum vitamin D and obesity among US adolescents, NHANES 2011-2018

Background and objectives

Childhood obesity is highly prevalent worldwide. We aimed to assess whether serum 25-hydroxyvitamin D was associated with general/central obesity among US adolescents, and further to explore the mediatory impact of homeostasis model assessment of insulin resistance (HOMA-IR) on this association.

Methods

This study is cross-sectional in design. Study adolescents were enrolled from the National Health and Nutrition Examination Survey (NHANES), 2011-2018. Serum 25-hydroxyvitamin D categories associated with general (indexed by body mass index) and central (indexed by waist circumference to height ratio) obesity were regressed. The possible mediatory effect of HOMA-IR on this association was explored. The nonlinear and dose-response association was examined by restricted cubic spline (RCS) test.

Results

Total 2,696 adolescents were eligible for inclusion, and the mean age of all adolescents was 15.4 years. Overall, the percentage of general and central obesity was 38.0% and 38.6%, respectively. Compared with adolescents with sufficient vitamin D, adolescent with deficient and insufficient vitamin D intake were associated with general obesity and central obesity; fully-adjusted OR for general obesity was 1.602 (95% CI: 1.161-2.211) and 1.659 (1.385-1.986), and fully-adjusted OR for central obesity was 2.025 (1.445-2.837) and 1.557 (1.287-1.884), respectively, while there was no observable significance in adolescents with possibly harmful vitamin D. The proportion mediated by HOMA-IR was estimated to be 31.7% for global obesity and 50.3% for central obesity (both P < 0.05). More stratified analyses were presented, and identified that the association with general obesity was particularly present among Mexican American, while with central obesity among Non-Hispanic Black adolescents.

Conclusions

Our findings indicate that deficient or insufficient 25-hydroxyvitamin D concentrations were associated with the significant risk of general and central obesity among US adolescents, and approximately 30% and 50%, respectively, of these associations were mediated by HOMA-IR.

A 12-Week Ballroom Dance Training Improves Physical Fitness Performance More Than Walking Training in Older Women, Regardless of Vitamin B12 or D Adequacy

AIM

This study aimed to compare the effects of Ballroom Dancing (BD) versus Walking Training (WT) on the physical fitness performance in physically independent older women with adequate or inadequate levels of vitamins B12 and D.

METHODS

Forty-three sedentary women aged 68.5 ± 6.5 years, were allocated to the BD (n = 23) or WT (n = 20) groups. They took part in a 12-week intervention, performed 3 times a week, for about 50 minutes with moderate effort intensity. Data were collected through Short Physical Performance Battery (SPPB), 6 minutes Walk Test (6MWT), Hand Grip Test (HGT), Isokinetic tests for lower limbs and blood tests to detect serum levels of vitamins B12 and D.

RESULTS

The BD group performed better after the intervention in relation to the WT in the Sit and Stand Test (SST) (BD pre = 3.1 score vs post = 3.8 score; WT pre = 2.8 score vs post = 3.4 score; P = .02) and in the Peak Torque 180° extension (PKTOQ 180° extension) (BD pre = 56.7 Nm vs post = 61.2 Nm, WT pre = 56.7 Nm vs post = 56.1; P < .01).

CONCLUSION

A time effect was observed in all other variables, with the exception of HGT. Both interventions improved physical fitness performance, regardless of the adequacy of vitamins B12 and D, but the older women from BD obtained significant improvements in more variables than the WT.

Vitamin D-associated genetic variants in the Brazilian population: Investigating potential instruments for Mendelian randomization

INTRODUCTION

Vitamin D is required for bone and mineral metabolism and participates in the regulation of the immune response. It is also linked to several chronic diseases and conditions, usually in populations of European descent. Brazil presents a high prevalence of vitamin D deficiency and insufficiency despite the widespread availability of sunlight in the country. Thus, it is important to investigate the role of vitamin D as a risk factor for disease and to establish causal relationships between vitamin D levels and health-related outcomes in the Brazilian population.

OBJECTIVE

To examine genetic variants identified as determinants of serum vitamin D in genome-wide association studies of European populations and check whether the same associations are present in Brazil. If so, these single nucleotide polymorphisms (SNPs) could be developed locally as proxies to use in genetically informed causal inference methods, such as Mendelian randomization.

MATERIALS AND METHODS

We extracted SNPs associated with vitamin D from the genomewide association studies catalog. We did a literature search to select papers ascertaining these variants and vitamin D concentrations in Brazil.

RESULTS

GC was the gene with the strongest association with vitamin D levels, in agreement with existing findings in European populations. However, VDR was the most investigated gene, regardless of its non-existing association with vitamin D in the genomewide association studies.

CONCLUSIONS

More research is needed to validate sound proxies for vitamin D levels in Brazil, for example, prioritizing GC rather than VDR.

Interaction between vitamin D level, antiseizure medications (ASM) and seizure control in epilepsy adult patients

OBJECTIVE

To investigate vitamin D levels and factors associated with seizure control in adult patients with epilepsy (APE).

METHOD

Cross-sectional study with APE in routine outpatient follow-up at a neurology clinic. Clinical variables, antiseizure medications (ASM) and vitamin D were investigated. Data were analyzed using the Chi2 or Fisher's exact tests, Mann-Whitney, Spearman's correlation coefficient, ROC curve and univariate and multiple logistic regression analysis.

RESULTS

Mean age was 46.5±15.1 years and disease duration was 27.5±17.0 years; 52.7% (n=49) of patients used one ASM and 47.3% (n=44) used≥2 ASM. There was a significant difference in the level of vitamin D according to the number of ASM and it was higher in patients who used a single ASM (26.02±10.22 versus 22.50±8.69; P=0.048). In the logistic regression, when vitamin D level was set at 20ng/mL, the chance of seizure control for patients using a single ASM was 6.99 times greater than for those using≥2 ASM. When vitamin D level was set at 40ng/mL, the number of ASM did not modify seizure control. There was no correlation between vitamin D and disease duration, patient age and age at the time of the first seizure. In the logistic regression, it was observed that satisfactory levels of vitamin D did not modify potential seizure control.

CONCLUSION

Thirty-three percent (33%) of patients presented with vitamin D deficiency (values below 20ng/mL) and 80% had vitamin D levels below what is recommended (30ng/mL). The use of ASM, when associated with different levels of vitamin D, modified the probability of seizure control in APE. Vitamin D levels and intrinsic epilepsy factors are associated with failure to effectively control seizures.

Vitamin D deficiency and hyperglycemia in male rotating shift workers: A disturbed circadian rhythms influence

BACKGROUND

Shift work is related to several negative impacts on the health of workers. This study aimed to evaluate the association between vitamin D deficiency (VDD) and hyperglycemia in shift workers.

METHODOLOGY

This cross-sectional study included male rotating shift workers in an iron ore extraction company. Participants were classified as VDD when 25(OH)D < 20 ng/mL for a healthy population and 25(OH)D < 30 ng/mL for groups at risk for VDD. Hyperglycemia was classified when fasting glucose ≥100 mg/dL or HbA1c ≥ 5.7%. Data were compared using chi-square analysis with Cramer's V as effect size, and Bonferroni correction. Multivariate logistic regression, from a model of determination, was performed to investigate whether VDD was associated with hyperglycemia.

RESULTS

The study evaluated 1411 workers, most workers were aged 30-39 years (53.2%), and 77.5% self-declared as black, brown, with up to complete high school (71.4%) and working alternate shifts for more than 5 years (76.1%). Regarding glucose and vitamin D, 32.0% and 29.1% of the workers had hyperglycemia and VDD, respectively. In multivariate analysis, controlled for confounding factors, workers with VDD had a 119% increased chance of hyperglycemia (OR: 2.19; IC95%: 1.56-3.08). Furthermore, vitamin D levels in distribution quintiles showed a dose-response gradient in relation to hyperglycemia, where increased vitamin D values were associated with a reduction in the occurrence of hyperglycemia.

CONCLUSION

Rotating shift workers with vitamin D deficiency are more likely to have hyperglycemia.

Lower 25-hydroxyvitamin D (25OHD) levels, diabetes and age are associated with foot and ankle fracture treatment complications

Objective

This study investigated the nutritional status, 25-hydroxyvitamin D (25OHD), albumin and risk factors associated with complications in patients with foot and ankle fragility fractures.

Subjects and methods

Prospective study, developed with patients who suffered fractures due to fragility of the foot and ankle (n = 108); the type of fractured bone, fracture mechanisms and classification were studied and also pseudoarthrosis, treatment, surgical dehiscence, anthropometry, 25OHD and albumin. The Chi-square or Fisher's exact test, Mann-Whitney and Kruskal-Wallis tests were used in the statistical analysis and the multiple logistic regression analysis was used to identify the risk factors associated with complications.

Results

The factors that, together, were associated with treatment complications were the level of 25OHD (p = 0.0055; OR = 0.868 [1,152]; 95% CI = 0.786; 0.959 [1.043;1.272]) and diabetes (p = 0.0034; OR = 30,181; 95% CI = 3.087; 295.036). The factors that, together, were associated with the presence of any complication, were age (p = 0.0139; OR = 1.058; 95% CI = 1.011; 1,106) and 25OHD level (p = 0.0198; OR = 0.917; 95% CI = 0.852; 0.986). There was a complication probability above 0.40 associated with lower 25OHD levels (values below 20 ng/mL) and older age (over 50 years).

Conclusion

Lower or abnormal levels of 25OHD were associated with pseudoarthrosis, and age and 25OHD were both risk factors for treatment complications in patients with foot and ankle fractures.

VDR, SOD-2, and CYP24A1 Gene Expression in Different Genotypes of BsmI SNP of the Vitamin D Receptor Gene in Individuals with Hypovitaminosis

BACKGROUND

Hypovitaminosis D is a public health problem due to its implications for various diseases. Vitamin D has numerous functions, such as modulating the metabolism of cellular tissues, and it is expressed through the vitamin D receptor (VDR) gene that may influence gene expression modulation, which plays an important role in vitamin D metabolism.

OBJECTIVE

To evaluate the effect of the genotypes of BsmI single nucleotide polymorphism (SNP) of the VDR gene on VDR, SOD2, and CYP24A1 gene expression in individuals with low serum vitamin D levels.

METHODS

This was a cross-sectional analytical study. After signing the informed consent form, individuals were invited to participate and answered a structured questionnaire with identification data. Blood was collected for biochemical analysis, and vitamin D was measured by chemiluminescence; BsmI polymorphism was determined using real-time polymerase chain reaction (PCR) assays with TaqMan allelic discrimination, and gene expression was conducted by qRT-PCR using QuantiFast SYBR® Green PCR Master Mix. Data were analyzed using the SPSS 20.0 software, and differences were considered significant at p < 0.05.

RESULTS

98 individuals with vitamin D ≤ 20 ng/dL were evaluated, and the BsmI SNP of the VDR gene showed CYP24A1 overexpression and low SOD2 expression.

CONCLUSION

BsmI SNP of the VDR gene can modulate the expression of the genes evaluated without interfering with serum levels.

Lower mean phosphate independently predicts mortality in critically ill patients: Results from a prospective cohort study

PURPOSE

To evaluate lower mean phosphate as a prognostic tool in critically ill patients.

METHODS

This is a prospective single-center cohort study including adult patients (> 18 years) with a length of intensive care unit (ICU) stay of at least 24 h. Phosphatemia was evaluated within 1 h of ICU admission and once daily. Mean phosphate, calculated by the simple arithmetic mean of daily phosphate measurements, was proposed and tested. Standard severity scores were applied. Multivariate and survival analyses were performed.

RESULTS

A total of 317 patients were included, of whom 111 (35%) presented hypophosphatemia. Hypophosphatemia associated with surgical conditions, nutritional therapy, hypovitaminosis D, hyperparathyroidism, mechanical ventilation (need and duration), and ICU and hospital length of stay were evaluated. Admission APACHE II and SOFA (ICU days 1, 3, and 7) scores and ICU and in-hospital mortality were greater in the hypophosphatemia group than control group. Higher APACHE II (RR: 1.1; 95%CI: 1.01-1.2; p = 0.045) and lower mean phosphate (RR: 0.02; 95%CI: 0.001-0.09; p = 0.044) independently predicted ICU and in-hospital mortality.

CONCLUSIONS

Hypophosphatemia is frequent in the ICU, and was associated with unfavorable outcomes. This study introduces the importance of longitudinal monitoring of phosphate levels, since lower mean phosphate is an independent predictor of mortality in critically ill patients.

Influence of hypovitaminosis D during pregnancy on glycemic and lipid profile, inflammatory indicators and anthropometry of pregnant and newborn

BACKGROUND & AIMS

Hypovitaminosis D currently represents a public health problem and is related to the emergence of chronic diseases. Furthermore, this vitamin deficiency has been associated with pregnancy complications, and it can also influence newborn's growth and development. The purpose of this review is to understand the effects of vitamin D nutritional status on women during pregnancy, as well as its impact on newborn's health.

METHODS

Review of observational studies, published between 2020 and 2021. The research was carried out in the following databases: Pubmed and SciELO. The search terms used to select the articles were: vitamin D, 25(OH)D, serum levels, pregnancy, lactation, gene expression, maternal results, complications, pre-eclampsia, obesity, gestational diabetes, and children. As inclusion criteria, were considered observational studies that addressed the topic and answered the review aims.

RESULTS

52 articles were identified and at the end of the selection process, 19 articles were considered, in which they met all the established eligibility criteria. According to the findings in this review, hypovitaminosis D is related to gestational diabetes, pre-eclampsia and gestational weight gain, changes in laboratory parameters as well as outcomes in newborns.

CONCLUSIONS

Hypovitaminosis D can adversely influence pregnancy and newborn's health, evidencing the need to assess the nutritional status of vitamin D, as well as the existence, or not, of a clinic during pregnancy. It is important that new scientific evidence is published to support this hypothesis.

Osteometabolic profile and bone mass in the transition phase: ethnic differences in Brazilians treated with somatropin during childhood

OBJECTIVE

The main growth hormone action is to promote linear growth increasing protein synthesis stimulation and osteoblastic activity. Peak bone mass extends from adolescence to 30 years of age. Several factors may influence this acquisition and prevent fracture risk in adulthood, such as genetic potential, GH, ethnicity, and lifestyle factors. This study aims to compare bone mass and osteometabolic profile of white and Afro-descendant Brazilian adolescents in the transition phase, who were treated with human recombinant growth hormone in childhood.

METHODS

The authors selected 38 adolescents from the Transition Outpatient Clinic of the University of São Paulo. Lumbar spine and total body bone mineral density (BMD) and bone mineral content (BMC), serum calcium, 25-OH-vitamin D and bone markers were analyzed at the rhGH withdrawal.

RESULTS

The mean age was 16.8 ± 1.6 years. There were 21 Afro-descendant and 17 whites. Thirty-four percent of the sample presented vitamin D insufficiency, 66% inadequate calcium intake and 44.7% physical inactivity. The Afro-descendants showed a lower lumbar spine and total body Z scores than those of the whites (p = 0.04 and p = 0.03, respectively), as well as their mean body weight (p = 0.03). There were no differences in the remaining osteometabolic parameters.

CONCLUSION

As most adolescents had vitamin D insufficiency, low calcium intake, and physical inactivity, calcium, and cholecalciferol supplementation and lifestyle changes should be encouraged. The Brazilian Afro-descendant may be a vulnerable group for low bone mass, requiring special strategies to increase bone accrual and body weight. More studies are necessary to compare ethnic differences in this population.

Is there a relationship between 25-hydroxyvitamin D (25[OH]D) levels and anthropometry in patients with epilepsy?

Introduction

Vitamin D Metabolites: Analytical Challenges and Clinical Relevance

Recent research activities have provided new insights in vitamin D metabolism in various conditions. Furthermore, substantial progress has been made in the analysis of vitamin D metabolites and related biomarkers, such as vitamin D binding protein. Liquid chromatography tandem mass spectrometric (LC-MS/MS) methods are capable of accurately measuring multiple vitamin D metabolites in parallel. Nevertheless, only 25(OH)D and the biologically active form 1,25(OH)2D are routinely measured in clinical practice. While 25(OH)D remains the analyte of choice for the diagnosis of vitamin D deficiency, 1,25(OH)2D is only recommended in a few conditions with a dysregulated D metabolism. 24,25(OH)2D, free and bioavailable 25(OH)D, and the vitamin D metabolite ratio (VMR) have shown promising results, but technical pitfalls in their quantification, limited clinical data and the lack of reference values, impede their use in clinical practice. LC-MS/MS is the preferred method for the measurement of all vitamin D related analytes as it offers high sensitivity and specificity. In particular, 25(OH)D and 24,25(OH)2D can accurately be measured with this technology. When interpreted together, they seem to provide a functional measure of vitamin D metabolism beyond the analysis of 25(OH)D alone. The determination of VDBP, free and bioavailable 25(OH)D is compromised by unresolved analytical issues, lacking reference intervals and insufficient clinical data. Therefore, future research activities should focus on analytical standardization and exploration of their clinical value. This review provides an overview on established and new vitamin D related biomarkers including their pathophysiological role, preanalytical and analytical aspects, expected values, indications and influencing conditions.

Treatment options in hypoparathyroidism

Hypoparathyroidism remains the single endocrine deficiency disease that is not habitually treated with the missing hormone. In this article, we aim to provide a review of the conventional approach and the novel therapies as well as an overview of the perspectives on the treatment of this rare condition. We conducted a literature review on the conventional therapy using vitamin D analogs and calcium salts, indications for thiazide diuretics and phosphorus binders, PTH analogs history and usage, and the drugs that are currently being tested in clinical trials. Conventional treatment involves calcium salts and vitamin D analogs. Thiazide diuretics can be used to reduce hypercalciuria in some cases. A low-phosphate diet is recommended, and phosphate binders are rarely needed. During pregnancy, a careful approach is necessary. The use of PTH analogs is a new approach despite the limitation of high cost. Studies have included modified PTH molecules, calcilytics, microencapsulation of human parathyroid cells, and allotransplantation.

Musculoskeletal effects of obesity and bariatric surgery – a narrative review

Obesity affects several areas of the human body, leading to increased morbidity and mortality and the likelihood of other diseases, such as type 2 diabetes mellitus, cardiovascular diseases and musculoskeletal disorders. These conditions predispose to bone fractures and sarcopenic obesity, defined by the presence of an obesity-associated decrease in muscle mass and strength. Both bone fragility and sarcopenic obesity disease are consequences of several factors, such as a low degree of chronic inflammation, insulin resistance, hormonal changes, nutritional deficiencies, ectopic fat deposits and sedentary lifestyle. The diagnosis of obesity-related musculoskeletal disorders is limited by the lack of sarcopenia criteria and lower accuracy of bone mineral density measurement by dual-energy X-ray absorptiometry in overweight people. Reducing body weight provides undeniable benefits to this population, however treating cases of severe obesity with bariatric surgery can cause even greater damage to bone and muscle health, especially in the long term. The mechanisms involved in this process are not yet fully understood, but factors related to nutrient malabsorption and mechanical discharge as well as changes in gut hormones, adipokines and bone marrow adiposity should be taken into account. Depending on the surgical technique performed, greater musculoskeletal damage may occur, especially in cases of malabsorptive surgeries such as Roux-en-Y gastric bypass, when compared to restrictive techniques such as sleeve gastrectomy. This difference is probably due to greater weight loss, nutrient malabsorption and important hormonal changes that occur as a consequence of the diversion of intestinal transit and loss of greater absorptive surface. Thus, people undergoing bariatric procedures, especially malabsorptive ones, should have their musculoskeletal health supervised to allow early diagnosis and appropriate therapeutic interventions to prevent osteoporotic fractures and preserve the functionality of the skeletal muscles.

Vitamin D metabolism and extraskeletal outcomes: an update

Vitamin D deficiency is a general health problem affecting individuals at all stages of life and on different continents. The musculoskeletal effects of vitamin D are well known. Its deficiency causes rickets, osteomalacia, and secondary hyperparathyroidism and increases the risk of fractures. Clinical and experimental evidence suggests that vitamin D performs multiple extraskeletal functions. Several tissues unrelated to calcium and phosphate metabolism express vitamin D receptor (VDR) and are directly or indirectly influenced by 1,25(OH)₂D (calcitriol). Some also express the enzyme 1 alpha-hydroxylase (CYP27B1) and produce 1,25(OH)₂D, inducing autocrine or paracrine effects. Among the pleiotropic effects of vitamin D are the regulation of cell proliferation and differentiation, hormone secretion, and immune function. In this review, we outline vitamin D physiology and the outcomes of recent large RCTs on its potential extraskeletal effects. Those studies exhibit a need for continued clinical analysis to elucidate whether vitamin D status can influence extraskeletal health. Longer longitudinal follow-up and standardized assays are crucial to better assess potential outcomes.

LC-MS/MS reduces interference by high levels of 25(OH)D and its metabolites on measured 1,25(OH)2D

BACKGROUND

High-dose vitamin D supplementation has been recommended as treatment to several conditions; however, potential side effects such as hypercalcemia should be considered, plus the fact that high levels of 25(OH)D may interfere with potential 1,25(OH)2D measurements. Our study compared two methods of measuring 1,25-dihydroxyvitamin D [1,25(OH)2D] in samples with 25-hydroxyvitamin D [25(OH)D] levels above 150 ng/mL (375 nmol/L).

METHODS

We studied serum samples referred to 25(OH)D and 1,25(OH)2D quantification. The concentrations of 25(OH)D and 1,25(OH)2D were measured using DiaSorin chemiluminescent assays (CLIA) in 213 samples (CLIA group), whereas in 357 samples 25(OH)D and 1,25(OH)2D were measured by DiaSorin CLIA and liquid chromatography-tandem mass spectrometry (LC-MS/MS), respectively (CLIA + MS group).

RESULTS

Median concentrations of 25(OH)D and 1,25(OH)2D in the CLIA group were 371 ng/mL (928 nmol/L, range 154-856 ng/mL) and 350 pg/mL (875 pmol/L, range 41-1280 pg/mL), respectively, and correlated significantly (Spearman correlation coefficient rs = 0.8469, P < 0.001). In the CLIA + MS group, the median concentrations of 25(OH)D and 1,25(OH)2D were, respectively, 344 ng/mL (860 nmol/L, range 152-756 ng/mL) and 56 pg/mL (140 pmol/L, range 17-151 pg/mL), and were not correlated (rs = 0.0218, P = 0.6811). No significant difference was found in calcium, creatinine, and PTH serum values between the groups.

CONCLUSION

Methods for measuring 1,25(OH)2D in patients with high levels of 25(OH)D may be susceptible to interference by 25(OH)D and its metabolites and should be validated carefully. In such cases, measurement of 1,25(OH)2D using LC-MS/MS is preferred.

Prevalence of Vitamin D and Calcium Deficiency and Insufficiency in Women of Childbearing Age and Associated Risk Factors: A Systematic Review and Meta-Analysis

Vitamin D deficiency and insufficiency as well as low serum calcium levels can trigger negative health outcomes in women of childbearing age. Therefore, we aimed to estimate the prevalence of serum vitamin D and calcium deficiencies and insufficiencies and associated risk factors in Brazilian women of childbearing age and to assess whether there are differences in prevalence according to regions of the country and the presence or absence of pregnancy. The systematic literature review was performed using the following databases: PubMed, LILACS, Embase, Scopus, and Web of Science. Cross-sectional, cohort, and intervention studies were included. Among pregnant women, the prevalence of vitamin D deficiency ranged from 0% to 27% and of vitamin D insufficiency from 33.9% to 70.4%. Among non-pregnant women, the prevalence of vitamin D deficiency ranged from 0% to 41.7% and of vitamin D insufficiency from 38.5% to 69.3%. We found a high prevalence of vitamin D deficiency and insufficiency in women of childbearing age, with insufficiency affecting more than half of these women. The highest prevalence of vitamin D deficiency and insufficiency was observed in the South region. It was not possible to assess the prevalence and factors associated with calcium deficiency.

Association between lower serum vitamin D (25-hydroxy-cholecalciferol) concentrations and cognitive impairment in older adults: data from a populational-based cohort study in a middle-income country

OBJECTIVE

To investigate the association between serum vitamin D (25-hydroxy-cholecalciferol) (25(OH)D) concentrations and cognitive impairment in older adults living in Southern Brazil.

DESIGN

Cross-sectional analysis using data from the second follow-up wave of the populational-based EpiFloripa Aging Cohort Study was collected in 2013-2014.

SETTING

Cognitive impairment was evaluated using the Mini-Mental State Examination (MMSE). Blood samples were collected to measure serum vitamin D concentrations using a chemiluminescent microparticle immunoassay. Vitamin D concentrations were distributed in quartiles (Q1: 4·0-20·7 ng/ml; Q2: 20·8-26·6 ng/ml; Q3: 26·7-32·0 ng/ml and Q4: 32·1-60·1 ng/ml), and its association with cognitive impairment was tested by crude and adjusted logistic regression (sociodemographic, behavioural and health aspects) using Q4 as a reference group.

PARTICIPANTS

200 men and 371 women aged 60 years or older participated in this study.

RESULTS

The prevalence of probable cognitive impairment was 21·7 %. Those without cognitive impairment had a higher mean of vitamin D serum concentrations (26·8 v. 24·6, P = 0·014). In the crude analysis, only individuals in Q2 of vitamin D presented an increased risk for probable cognitive impairment compared with Q4 (highest quartile) (OR 2·65, 95 % CI 1·46, 4·81), remaining significant in the adjusted analysis (OR 6·04, 95 % CI 2·78, 13·13). While Q1 (lowest quartile) was not associated in the crude analysis, but when adjusted, an increased risk of cognitive impairment was observed.

CONCLUSION

The lowest quartile of vitamin D was directly associated with probable cognitive impairment in older adults in Southern Brazil. More studies are needed to investigate whether maintaining adequate serum levels may represent a significant factor in preventing age-related neurological disorders as well as to verify the need for new cutoff points for this age group.

Effects of vitamin D supplementation on glycemic control of children and adolescents with type 1 diabetes mellitus: a systematic review

OBJECTIVES

To evaluate the effect of vitamin D supplementation on glycemic control in children and adolescents with T1DM.

CONTENT

A systematic search was conducted of the Medline/PubMed, Web of Science, Embase, BVS/Lilacs, Cochrane Library, Scopus, Cinahl, Food Science, and FSTA databases. Two reviewers independently extracted article data and assessed quality.

SUMMARY

A total of 1,613 eligible articles were retrieved, ten of which met the selection criteria: eight clinical trials, one retrospective cohort study, and one cross-sectional study. Regarding the cutoff points used to classify vitamin D status, most of the studies set deficiency at 25-hydroxyvitamin D <20 ng/mL, sufficiency at ≥30 ng/mL, and insufficiency as the interval between these values. Regarding intervention strategies, most used cholecalciferol for supplementation, but there was great variation in the dose and supplementation time. When evaluating the effect of vitamin D supplementation on HbA1c, a significant improvement in glycemic control was observed in 50% of the studies. However, only one of these studies was classified as being of positive methodological quality, with three having their quality classified as neutral and one as negative.

OUTLOOK

There is yet no consistent evidence on the effect of vitamin D supplementation on glycemic control as an adjuvant in the treatment of children and adolescents with T1DM.

Vitamin D Deficiency as a Possible Cause of Type 1 Diabetes in Children and Adolescents up to 15 Years Old: A Systematic Review

OBJECTIVE: To evaluate vitamin D ((25OH)D levels) deficiency as a possible cause in the development of DT1 in children and adolescents aged 0-15. METHODS: We searched PubMed/ Medline, EBSCO, and Cochrane Library to identify potentially eligible articles that examine whether low serum 25(OH)D levels are associated with subsequent development of DT1. All type of research designs, including randomized and non-randomized controlled trials, prospective and retrospective cohort studies, case- control and cross-sectional studies with subjects aged ≤15 years old were consider for inclusion. RESULTS: Seven original studies met the entry criteria. Most of these studies found up to 50% lower levels of vitamin D in children with DT1 compared to control group and a significant positive association between vitamin D levels and of the risk of developing DT1. Results of quality assessment demonstrated moderate to high quality of all the studies included. CONCLUSIONS: Vitamin D deficiency may be a possible cause in the development of DT1 in the early years of life and particularly in children with genetic predisposition, whilst the deficiency of vitamin D is a very common occurrence in patients with DT1. Further long-term studies on children are required to determine the role of vitamin D on DT1.

Vitamin D supplementation during pregnancy to prevent vitamin D deficiency in newborns: a systematic review and meta-analysis

Abstract Objectives: to assess the effects of vitamin D supplementation during pregnancy on the outcomes of vitamin D concentration in newborns, length at birth, overall health (Apgar), birth weight and maternal vitamin D concentration after childbirth. Methods: this research was conducted in the electronic databases of MEDLINE, LILACS, EMBASE and Cochrane Library until December 2020, using the terms “vitamin D”, “pregnancy”, “vitamin D deficiency”, “infant”, “newborn” and their synonyms. Randomized controlled trials were searched by evaluating the effects of maternal vitamin D supplementation in neonates. The data was analyzed on RevMan 5.4 software and the quality of evidence on GRADE. Results: the newborn’s overall health condition was presented as Apgar, with a mean difference (MD) of 0.15 (CI95%=0.06-0.25; p=0.002; I2=0%, two studies, 648 participants, moderate quality evidence) at the first minute and 0.11 (CI95%=0.04-0.17; p=0.001; I2=0%, two studies, 648 participants, moderate quality evidence) at the fifth minute. Significant effects were also presented at the length at birth considering any supplemented dose (MD=0.19; CI95%=0.08-0.30; p=0.0010; I2=0%, 1452 participants, low quality evidence) and birth weight in doses higher than 4000IU/day (MD=257.05 (CI95%=137.81-376.29; p<0.0001; I2=14%, 176 participants, moderate quality evidence). Conclusion: vitamin D supplementation during pregnancy improves serum 25 (OH) D concentration and suggests positive effects on overall health condition, length at birth and birth weight. PROSPERO CRD42017073292.

Deficiency and Insufficiency of Vitamin D in Women of Childbearing Age: A Systematic Review and Meta-analysis

OBJECTIVE

 To estimate the prevalence of inadequate vitamin D level and its associated factors for women of childbearing age in Brazil.

METHODS

 A systematic review was conducted (last updated May 2020). Meta-analyses were performed using the inverse-variance for fixed models with summary proportion calculation by Freeman-Tukey double arcsine. Reporting and methodological quality were assessed using the Joanna Briggs Institute tool for prevalence studies.

RESULTS

 Our review identified 31 studies, comprising 4,006 participants. All the studies had at least one weakness, mainly due to the use of convenience sampling and small sample size. The overall prevalence of vitamin D deficiency, insufficiency, and both deficiency and insufficiency were 35% (confidence interval, 95%CI: 34-37%), 42% (95%CI: 41-44%), and 72% (95%CI: 71-74%), respectively.

CONCLUSION

 Although the magnitude of the prevalence of inadequate levels of vitamin D is uncertain, the evidence suggests that presence of vitamin D deficiency or insufficiency in women of reproductive age can cause moderate to severe problems.

RISK FACTORS ASSOCIATED WITH FRACTURE OF THE LUMBOSACRAL SPINE AND ITS COMPROMISE IN THE QUALITY OF LIFE OF CIRRHOTICS

ABSTRACT Background Chronic hepatic disease is associated with osteoporosis, osteopenia or osteomalacia. Osteoporosis and fractures due to bone fragility present high prevalences and are more frequent in patients with liver cirrhosis than in the general population. The search for a diagnosis of osteopenia and osteoporosis in this population may allow early intervention and modify unfavorable outcomes. Objective To know the prevalence of osteopenia or osteoporosis and of fracture due to bone fragility in individuals with liver cirrhosis, the associated risk factors, and its compromise in their quality of life (QoL). Methods Observational, transversal study performed with 71 liver cirrhosis patients of the Hepatology Service of the Hospital de Base do Distrito Federal, Brasília, DF, Brazil, between July 2017 and December 2018. The patients were submitted to bone densitometry (DXA) of the lumbar spine and of the femoral neck, to x-ray of the lumbosacral spine and to the Chronic Liver Disease Questionnaire (CLDQ) for the evaluation of quality of life (QoL). The Fracture Risk Assessment (FRAX) major was calculated for patients >50 years old. The analyses were performed for the evaluation of the risk factors associated with lumbosacral spine fracture. Results The majority (62%) of the 71 evaluated patients was diagnosed with osteoporosis or osteopenia on DXA. Of the 44 patients with osteopenia or osteoporosis, 52.3% were female, with a mean age of 62.6±9.51 years old, with the majority (72.7%) being Child A, cirrhotics of alcoholic etiology (36.4%), and with an intermediate QoL according to the CLDQ (3.3). Regarding the patients with lumbosacral spine fracture, the mean age was 61.6±11.1 years old, 60% were female, most of them Child A (66.7%), of alcoholic etiology (46.7%), and with an intermediary QoL according to the CLDQ (3.5). The presence of osteopenia and/or osteoporosis was associated with lumbosacral fracture (P<0.001), without correlation with the other analyzed variables: age, body mass index, gender, presence and absence of ascites, Child-Pugh classification, vitamin D, calcium, and phosphorus serum concentration, cirrhosis etiology and FRAX major. Conclusion The prevalence of hepatic osteodystrophy was high, and the occurrence of lumbosacral spine fracture was more associated with osteoporosis and/or osteopenia among the cirrhotic patients studied. The QoL was intermediate and with no differences between cirrhotics with and without fracture.

Influence of Hypovitaminosis D on the Ocurrence of Fractures

Objective  To measure the levels of vitamin D in patients hospitalized for fractures and to evaluate its relationship with fractures.

Methods  A primary, analytical, cross-sectional, non-interventional, observational, controlled study was conducted in humans. The serum measurement of: vitamin D, parathyroid hormone (PTH), calcium, phosphorus, magnesium and albumin was performed in 49 patients who were consecutively hospitalized for surgery due to fracture(s) (study group), and in 50 patients without fractures, from the various outpatient clinics, and who underwent routine tests (control group).

Results  The mean level of 25-hydroxyvitamin D (25[OH]D) in patients with fractures was of 23.78 ± 8.01 ng/mL (61.22% of patients with fractures had hypovitaminosis D). The mean 25(OH)D of the control group was of 37.52 ± 9.21 ng/mL (10% of the patients had hypovitaminosis D). Most cases of hypovitaminosis (96%) did not course with secondary hyperparathyroidism (mean PTH = 41.80 ± 22.75 pg/mL).

Conclusion  Hypovitaminosis D was found in a significant percentage (61.22%) of the patients who suffered fractures. Further studies on the subject are needed to better understand the influence of hypovitaminosis D on the occurrence of fractures, as well as the benefits of vitamin D supplementation in these patients.

Vitamin D is associated with the hypertriglyceridemic waist phenotype in Brazilian children

BACKGROUND

Prevalence of cardiometabolic risk factors is increasing and vitamin D insufficiency/deficiency has become a worldwide public health problem, even in tropical countries. Therefore, we identified the prevalence of hypertriglyceridemic waist phenotype (HWP) and evaluate its relationship with vitamin D insufficiency/deficiency.

METHODS

A cross-sectional study with 378 children aged 8 and 9 enrolled in all urban schools in the city of Viçosa, MG, Brazil. Anthropometric measurements, body composition (dual energy X-ray absorptiometry), biochemical tests and clinical evaluation were performed. Poisson regression was used to analyze the association between vitamin D and HWP.

RESULTS

Prevalence of HWP was 16.4%. This prevalence was higher among children with vitamin D insufficiency and deficiency and in those with a greater number of other cardiometabolic risk factors. Multiple regression analysis showed that children with vitamin D insufficiency and deficiency had, respectively, prevalence 85% (95% CI: 1.03-3.30) and 121% (95% CI: 1.11-4.45) higher of HWP than the vitamin D sufficiency group.

CONCLUSION

Vitamin D insuffiency and deficiency were associated with a higher prevalence of HWP among children, regardless of the presence of other cardiometabolic risk factors, indicating an additional risk of inadequate vitamin D status to cardiometabolic health in childhood.

Cardiometabolic risk factors and hypovitaminosis D in adolescents with overweight from a sunny region in northeast Brazil: A cross-sectional study

BACKGROUND

obesity can influence vitamin D levels, which in turn might be associated with cardiometabolic risk factors.

OBJECTIVES

this study assessed the association between 25-hydroxyvitamin D [25(OH)D] levels and cardiometabolic risk factors in adolescents with overweight living in a region of northeastern Brazil.

MATERIAL AND METHODS

a cross-sectional study was carried out by non-probabilistic sampling in adolescents diagnosed with overweight or obesity. The subjects were divided according to their 25(OH)D status into two groups: sufficient vitamin D and hypovitaminosis D. Biodemographic, lifestyle, cardiometabolic, and biochemical factors were evaluated. A logistic regression model was applied to determine the predictors of hypovitaminosis D.

RESULTS

we found a high frequency of hypovitaminosis D (45.6 %) in adolescents. Weekly sun exposure was negatively associated with hypovitaminosis D (OR = 0.96; 95 % CI: 0.92-0.99), while significant positive associations were observed between hypovitaminosis D and blood pressure above the 95th percentile (OR = 4.00; 95 % CI: 1.19-13.37), body weight (OR = 1.04; 95 % CI: 1.01-1.07), and fasting insulin (OR = 1.13; 95 % CI: 1.05-1.22).

CONCLUSION

hypovitaminosis D showed a high prevalence in adolescents with overweight living in a sunny region of northeastern Brazil, and cardiometabolic risk factors such as systemic arterial hypertension, high body weight, and hyperinsulinemia are predictors of hypovitaminosis D.

Vitamin D recommendations in clinical guidelines: A systematic review, quality evaluation and analysis of potential predictors

BACKGROUND

Vitamin D has been widely promoted for bone health through supplementation and fortification of the general adult population. However, there is growing evidence that does not support these strategies. Our aim is to review the quality and recommendations on vitamin D nutritional and clinical practice guidelines and to explore predictive factors for their direction and strength.

METHODS

We searched three databases and two guideline repositories from 2010 onwards. We performed a descriptive analysis, a quality appraisal using AGREE II scores (Appraisal of Guidelines Research and Evaluation) and a bivariate analysis evaluating the association between direction and strength of recommendations, AGREE II domains' scores and pre-specified characteristics.

RESULTS

We included 34 guidelines, 44.1% recommended, 26.5% suggested and 29.4% did not recommend vitamin D supplementation. Guidelines that scored higher for "editorial independence" and "overall quality score" were less likely to recommend or suggest vitamin D supplementation (median 68.8 vs 35.4; P = .001 and 58.3 vs 37.5; P = .02). Guidance produced by government organisations and those that reported source of funding were associated with higher AGREE II scores. Unclear role of source of funding was associated with recommending or suggesting vitamin D supplementation (P = .034). Editorial independence was an independent predictor for recommending or suggesting vitamin D supplementation (OR 1.09; CI95% 1.02 to 1.16; P = .006).

CONCLUSIONS

Policymakers, clinicians and patients should be aware that lower quality guidelines and those reporting conflicts of interest are more likely to promote vitamin D supplementation. Guideline organisations should improve the quality of their recommendations' development and the management of conflicts of interest. Users and editors should be aware of these findings when using and appraising guidelines.

Vitamin D Supplementation and Sunlight Exposure on Serum Vitamin D Concentrations in 2 Parallel, Double-Blind, Randomized, Placebo-Controlled Trials

BACKGROUND

Vitamin D concentrations are a function of sunlight exposure and dietary intake. However, current dietary vitamin D recommendations do not consider differences in country-specific sunlight availability or spontaneous individual exposure.

OBJECTIVES

We aimed to investigate the effects of vitamin D supplementation and sunlight exposure on vitamin D concentrations in Brazilian women living in high compared with low latitudes.

METHODS

In 2 parallel, double-blind, randomized placebo-controlled trials, Brazilian women living in England (51°N) composed "without ultraviolet B (UVB) exposure" groups and those living in Brazil (16°S) composed the "with UVB exposure" groups (mean age, 31.39 ± 8.7 years). Participants received 15 μg cholecalciferol or placebo daily for 12 weeks during wintertime. Serum 25-hydroxyvitamin D [25(OH)D] concentrations, the primary outcome, were assessed by HPLC-MS/MS, vitamin D intakes were assessed by 4-day diet diaries, and sunlight exposure was assessed by UVB dosimeters. The effects of supplementation and UVB exposure were tested by the intention to treat with a linear mixed model.

RESULTS

The 25(OH)D concentrations increased in both supplemented groups [from 75.1 ± 22.0 to 84.8 ± 21.0 nmol/L (P = 0.004) in the group with UVB exposure; from 38.1 ± 15.9 to 55.1 ± 12.2 nmol/L (P < 0.001) in the group without UVB exposure], with no significant changes in either placebo group. Concentrations in both supplemented groups were higher than those in the placebo group without UVB exposure (P = 0.0002 in the group with UVB exposure; P = 0.0035 in the group without UVB exposure). Postintervention 25(OH)D concentrations were significantly affected by serum 25(OH)D concentrations at baseline (P < 0.0001) and by intervention (placebo or supplement; P > 0.0001), with a large effect size (Cohen's D = 0.768), but were not affected by UVB exposure (with or without; P = 0.1386), nor by the interaction between the intervention (placebo or supplement) and UVB exposure (with or without; P = 0.9845).

CONCLUSIONS

Moderate supplementation of 15 ug/d cholecalciferol, in accordance with current recommendations, supports an adequate vitamin D status in adult women, irrespective of latitude, and might concomitantly prevent an increase in parathyroid hormone. The Interaction Between Vitamin D Supplementation and Sunlight Exposure in Women Living in Opposite Latitudes (D-SOL) study was registered at clinicaltrials.gov as NCT03318029.

Osteoporosis Drug Treatment Update

The Brazilian population is aging and the prevalence of chronic degenerative diseases, including osteoporosis, is increasing. The diagnosis and treatment of osteoporosis have made significant advances in the last decade. The orthopedist and traumatologist can no longer be detained only in the surgical treatment of osteoporotic fracture. It is extremely important that we know: 1) what risk factors to evaluate, and the Fracture Risk Assesment Tool (FRAX) can be used; 2) which complementary tests should be requested, such as densitometry, radiography of the spine and pelvis, blood and urine tests, and even bone biopsy; 3) which supplements to use, such as calcium and magnesium, vitamins D and K; 4) which medications to prescribe, antiresorptives or trainers, therapeutic windows and adverse events.

The impact of visceral fat and levels of vitamin D on coronary artery calcification

OBJECTIVE

To evaluated calcification of the coronary arteries and its association with visceral fat and 25-hydroxyvitamin D (25(OH)D) serum levels.

METHODS

A cross sectional study involving 140 individuals without any previous diagnosis of cardiovascular disease. A biochemical analysis of vitamin D serum levels was carried out, as well as computed tomography to measure coronary artery calcium score and visceral adipose tissue.

RESULTS

The mean age of the individuals was 55.9 (±12.4). Coronary artery calcium was observed in 40.7% of the population. Vitamin D presented median serum levels of 30.4 ng/ml (IQ24.5-39.1), with 14,1 and 33.7% of the individuals presenting deficiency and insufficiency, respectively. In the univariate analysis, the calcium score was more prevalent in aged patients (p<0.01), in hypertensive individuals (p<0.01), in diabetics (p=0.02), and in those with a higher concentration of VAT (p=0.02). In the adjusted analysis, it was found that the highest concentration of VAT (OR: 4.0; 95%CI 1.4-11.7), hypertension (OR: 4.8; 95%CI 1.5-15.3), and age (OR: 10.4; 95%CI 3.9-27.6) were predictors of subclinical atherosclerosis, regardless of body mass index, diabetes, and 25OHD.

CONCLUSIONS

Excess visceral fat was associated with subclinical atherosclerosis, regardless of other risk factors for cardiovascular disease. Serum levels of 25OHD were not associated with CAD in its early stages.

Vitamin D and Cytokine Profiles in Patients With Systemic Sclerosis

INTRODUCTION

Hypovitaminosis D has been frequently described in systemic sclerosis (SSc). Cytokines are important mediators of tissue damage and clinical dysfunction in SSc and may be influenced by vitamin D levels.

OBJECTIVE

To evaluate the serum levels of vitamin D and its correlation with the clinical features and cytokine profiles in SSc patients.

METHODS

Case-control study, including 50 SSc patients and 35 healthy non matched controls. Serum levels of 25(OH) vitamin D were measured by chemiluminescence assay, and serum concentrations of interleukin 2 (IL-2), IL-4, IL-6, IL-10, tumor necrosis factor, and interferon γ were determined by flow cytometry.

RESULTS

Fourteen patients (28%) had diffuse cutaneous SSc, 94% were female, 80% European derived, with a mean age of 57.2 ± 12.8 years. The serum vitamin D levels in SSc patients were 23.9 ± 8.5 ng/mL and 30.2 ± 6.2 ng/mL in the control group (standardized mean difference -6.19; 95% confidence interval, -9.9 to -2.3; p = 0.002), despite the more frequent supplementation of vitamin D in SSc patients (p = 0.014). No significant associations were found among vitamin D concentrations and cytokine levels. Serum levels of IL-6 were significantly elevated in SSc patients (p = 0.024) and were positively correlated with the modified Rodnan skin score (rs = 0.291, p =0.041).

CONCLUSIONS

Despite lower vitamin D levels in SSc patients, there was no clear association with any cytokine. Serum levels of IL-6 were significantly elevated and positively correlated with the extent of skin involvement in SSc patients.

Reference values for free 25-hydroxy-vitamin D based on established total 25-hydroxy-vitamin D reference values

Measurements of total 25-hydroxyvitamin D (t25(OH)D) are currently primarily used to assess the vitamin D status. The lipophilic cell membrane can only be passed by the un-bound form of 25-hydroxyvitamin D: free 25-hydroxyvitamin D (f25(OH)D). It is thought that f25(OH)D does reflect its biological actions better than t25(OH)D. However, as of today, there are no established guidelines for the clinical use of f25(OH)D. We analysed 5060 patients with simultaneous measurements of free and total 25(OH). Linear regression was used to study the relationship between free 25(OH)D and total 25(OH)D. We reviewed and used the established t25(OH)D reference values and determined the slope of the relationship between them to calculate reference values for f25(OH)D. F25(OH)D and t25(OH)D showed a strong positive linear (r = 0.8395, p < 0.0001) correlation. The slope of the relationship was 0.2833 ± 0.00257. The recommended threshold level of f25(OH)D is 8.499 pg/mL, corresponding to a target concentration for t25(OH)D of at least 30 ng/mL considered as sufficient in most of the international vitamin D guidelines. The upper limit for vitamin D is less clear in the guidelines. Most experts favour an upper limit for t25(OH)D of 100 ng/mL. This is equivalent to 28.330 pg/mL f25OHD. We established based on international guidelines for t25(OH)D reference values for f25(OH)D that are urgently needed for clinical use of f25(OH)D. However, clinical studies with f25(OH)D to confirm our suggestions are needed but will take time.

Reasons to avoid vitamin D deficiency during COVID-19 pandemic

The effects of vitamin D on the musculoskeletal system are well established. Its deficiency causes osteomalacia, secondary hyperparathyroidism, and an increased risk for fractures and falls. However, clinical and experimental evidence points to extra-skeletal actions of vitamin D, including on immune and respiratory systems. Thus, during this COVID-19 pandemic, a possible deleterious role of vitamin D deficiency has been questioned. This paper aims to present a brief review of the literature and discuss, based on evidence, the role of vitamin D in the lung function and in the prevention of respiratory infections. Relevant articles were searched in the databases MEDLINE/PubMed and SciELO/LILACS. The mechanisms of vitamin D action in the immune system response will be discussed. Clinical data from systematic reviews and meta-analyses show benefits in the prevention of respiratory infections and improvement of pulmonary function when vitamin D-deficient patients are supplemented. At the time of writing this paper, no published data on vitamin D supplementation for patients with COVID-19 have been found. Vitamin D supplementation is recommended during this period of social isolation to avoid any deficiency, especially in the context of bone outcomes, aiming to achieve normal values of 25(OH)D. The prevention of respiratory infections and improvement of pulmonary function are additional benefits observed when vitamin D deficiency is treated. Thus far, any protective effect of vitamin D specifically against severe COVID-19 remains unclear. We also emphasize avoiding bolus or extremely high doses of vitamin D, which can increase the risk of intoxication without evidence of benefits.

Moderator role of vitamin D concentrations on the association between metabolic syndrome and C-reactive protein among adults

OBJECTIVE

To evaluate the association between MetS, its components and insulin resistance (IR) with 25(OH)D and hsCRP. The moderator role of 25(OH)D in the association of MetS, its diagnostic components and IR with hsCRP were also explored.

METHODS

A cross-sectional study (2014/2015) with a population-based cohort in Southern Brazil (n = 605). Metabolic syndrome (MetS) diagnosis was defined based on the Joint Interim Statement, while the Homeostasis Model Assessment of insulin resistance (IR) (HOMA-IR) was used for determining IR. Serum concentrations of 25-hydroxy vitamin D [25(OH)D] (ng/mL) and high sensitivity C-reactive protein (hsCRP) (mg/L) were evaluated following standard protocols. 25(OH)D was categorized as sufficiency (>30 ng/mL), insufficiency (20-30 ng/mL) or deficiency (<20 ng/mL) to test its moderator role. Multiple linear regression was used to test the associations. The results were adjusted for possible confounders.

RESULTS

Hypertriglyceridemia and IR were associated with lower 25(OH)D concentrations. However, except for systolic blood pressure, other MetS components and IR were associated with higher hsCRP. The association between elevated waist circumference (WC) and hsCRP was moderated by the 25(OH)D concentrations. The hsCRP median concentrations were more than two times higher among those with elevated WC and 25(OH)D insufficiency or deficiency. In this study, inadequate concentrations of 25(OH)D increased the adverse relationship between elevated WC and inflammation. 25(OH)D concentrations could be incorporated into the clinical protocols for monitoring individuals with abdominal obesity to identify those at a higher risk of complications.

EFFECTS OF VITAMIN D SUPPLEMENTATION DURING PREGNANCY ON NEWBORNS AND INFANTS: AN INTEGRATIVE REVIEW

OBJECTIVE

To identify the effects of vitamin D supplementation during pregnancy on newborns and infants.

DATA SOURCES

The present study is an integrative review of literature based on clinical trials published in journals indexed in the PubMed and Web of Science databases. Two searches were carried out, starting with the association (and) of the health term "vitamin D" with "pregnancy". In the search for information, selection criteria were established, and there was no language limitation and year of publication.

DATA SYNTHESIS

The final selection resulted in 44 clinical trials, most of which were randomized and double blind, which were carried out in outpatient clinics, referral hospitals and universities, mainly in Europe. The samples studied were predominantly of newborns. In these 44 trials, 23 types of different doses of vitamin D during pregnancy, with different doses, regimens and times of use, and 14 different outcomes were studied in newborns (NB) and infants. Of the 44 studies performed, 35 showed statistically significant beneficial effects of vitamin D supplementation during pregnancy on newborns and infants compared to control groups.

CONCLUSIONS

Vitamin D supplementation during pregnancy for at least three months before delivery has the potential of positively influencing calcium metabolism, physical growth and immune system development in newborns and infants. However, there is insufficient knowledge to define the optimal dose and to guarantee the absence of possible long-term adverse effects.

Vitamin D deficiency in children and adolescents with obesity: a meta-analysis

OBJECTIVE

To evaluate the prevalence of vitamin D deficiency in obese children and adolescents when compared to eutrophic controls.

METHODS

Systematic review with meta-analysis covering studies with patients aged 0-18 years old diagnosed with obesity and vitamin D deficiency and control group of eutrophic patients. The studies were retrieved in the PubMed, Embase, and LILACS databases in December 2019. The search used the terms "obesity" in combination with "pediatric population" and "vitamin D".

RESULTS

Through the search 3155 articles were retrieved; and after analysis, 20 studies were selected according to the study objectives. A total of 24,600 children and adolescents were included. Through meta-analysis, the relative risk for the association between obesity and vitamin D deficiency in the pediatric population was 1.41 (95% CI: 1.26-1.59) (I² = 89%, p < 0.01).

CONCLUSION

Children and adolescents with obesity have higher risk of vitamin D deficiency.

Serum 25-hydroxyvitamin D concentration among users of a referral outpatient unit for vascular diseases and associated factors

OBJECTIVE

Assess serum 25-hydroxyvitamin D (25OHD) concentration and associated factors among users of a referral outpatient unit for vascular diseases in Southern Brazil.

DESIGN

Cross-sectional study conducted for almost one year, from March 2016 to January 2017. The serum vitamin D level was determined biochemically and classified as: sufficient (>50 nmol/L), insufficient (30-50 nmol/L) and deficient (<30 nmol/L). Associations were tested through multiple linear regression.

SETTING

At a reference outpatient clinic specialized in vascular diseases located in a southern Brazilian medium-sized city (latitude 29°S).

SUBJECTS

Consecutive sample of 133 individuals of both sexes, aged at least 40 years.

RESULTS

The mean serum 25OHD concentration was 54.9 ± 25.9 nmol/L (57.7 ± 27.9 nmol/L for men; 52.2 ± 24.2 nmol/L for women, p = 0.267). A total of 12.8% of the participants had vitamin D deficiency and 32.3% had insufficiency. Regarding the total sample, variables associated to the serum 25OHD concentration were: age (β = -0.55; CI95% -0.95; -0.17), sun exposure (β = 1.22; CI95% 0.32; 2.10) and vitamin D intake (β = 7.29; CI95% 2.10; 12.48). Among men, a significant association was observed for age (β = -0.82; CI95% -1.47; -0.17, p = 0.015) and borderline for sun exposure (β = 1.22; CI95% 0.32; 2.10, p = 0.053). Among women, only vitamin D intake was significantly associated with serum concentration of this vitamin (β = 8.74; CI95% 1.32; 16.17, p = 0.022).

CONCLUSION

Although the mean 25OHD concentration was greater than 50 nmol/L, about 45% of this consecutive sample presented poor vitamin D nutritional status. Unadjusted for seasonality, factors associated with serum 25OHD concentration were age and sun exposure among men and vitamin D intake among women.

Sun-induced production of vitamin D3 throughout 1 year in tropical and subtropical regions: relationship with latitude, cloudiness, UV-B exposure and solar zenith angle

This study evaluated the differences in vitamin D₃ synthesis in two different latitudes throughout 1 year using an in vitro model, which simulates cutaneous vitamin D photoproduction. Borosilicate ampoules containing 7-dehydrocholesterol (7-DHC) were exposed to sunlight hourly throughout the daylight hours, 1 day per month for a year, in Fortaleza (latitude 03° 43' 01" S-LAT3° S) and Sao Paulo (latitude 23° 32' 53" S-LAT23° S). Later, vitamin D₃ and photoisomers of 7-DHC (tachysterol and lumisterol) were measured by a high-performance liquid chromatography system (HPLC). Vitamin D synthesis weighted UV radiation (UVBVitD) and solar zenith angle (SZA) were calculated during the same periods for both latitudes. Vitamin D₃ synthesis occurred throughout the year in both locations, as expected in latitudes lower than 35°. Median of photoconversion to vitamin D₃ through the year was higher in LAT3°S [median (IQR): LAT 3°S 4.1% (6.0); LAT 23°S 2.9% (4.5); p value = 0.020]. Vitamin D₃ production strongly correlated with UV-B (LAT3° S, r = 0.917; p < 0.0001 and at LAT23° S, r = 0.879; p < 0.0001) and SZA (LAT3° S, r = - 0.924; p < 0.0001 and in LAT23°S, r = - 0.808; p < 0.0001). Vitamin D₃ production starts later in LAT23° S, especially in winter. Lowest percentages were observed in June in both cities, although, compared to LAT3° S, in LAT 23° S the conversion was over 50% lower in the winter period. Cloudiness impaired photoproduction of Vitamin D₃ even in summer months in both latitudes. Our results provide data to help guide medical recommendations for sensible sun exposure to promote the cutaneous production of vitamin D₃ at different latitudes, seasonality, time of day and cloudiness status in Brazil.

Does the relationship between 25-hydroxyvitamin D status and bone mass vary according to skin color in adults? Results of a Brazilian population-based study

Skin color has been indicated as an important factor in determining serum concentrations of 25-hydroxyvitamin D [25(OH)D], and consequently bone health. However, studies are controversial and scarce for mixed populations.

PURPOSE/INTRODUCTION

To analyze the association of 25(OH)D with bone mineral content (BMC) and bone mineral density (BMD); and to investigate the presence of interaction with skin color in Brazilian adults.

METHODS

This is a cross-sectional, population-based study conducted with adult individuals (20-59 years) of both genders. Bone health was assessed by dual energy radiological absortometry. Vitamin D status was measured using serum 25(OH)D. Skin color and other variables in the adjusted model were collected using a questionnaire and anthropometric assessment. Associations and interactions were evaluated using linear regression models stratified according to gender.

RESULTS

Non-white men with vitamin D deficiency (< 20.0 ng/mL) have less bone mass than those with insufficiency and sufficiency for the femoral neck and hip sites. According to the adjusted regression analysis, the deficient status of 25(OH)D in men was associated with worse bone health for the lumbar spine sites (β = - 0.1; p = 0.006), femoral neck (β = - 0.08; p = 0.006), and hip (β = - 0.08; p = 0.009). No statistically significant associations were observed between 25(OH)D and bone health in women. In addition, no statistical interaction was identified between skin color and vitamin D status in relation to bone health (p > 0.05 for all tests) in either gender and for all bone sites evaluated.

CONCLUSION

Deficient vitamin D status is associated with lower bone mass in adults with differences observed according to gender, but not according to skin color.

Potential immunomodulatory effects of vitamin D in the prevention of severe coronavirus disease 2019: An ally for Latin America (Review)

Currently, the world is under a pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), responsible for coronavirus disease 2019 (COVID-19). This disease is characterized by a respiratory syndrome that can progress to an acute respiratory distress syndrome. To date, limited effective therapies are available for the prevention or treatment of COVID-19; therefore, it is necessary to propose novel treatment options with immunomodulatory effects. Vitamin D serves functions in bone health and has been recently reported to exert protective effects against respiratory infections. Observational studies have demonstrated an association between vitamin D deficiency and a poor prognosis of COVID-19; this is alarming as vitamin D deficiency is a global health problem. In Latin America, the prevalence of vitamin D deficiency is unknown, and currently, this region is in the top 10 according to the number of confirmed COVID-19 cases. Supplementation with vitamin D may be a useful adjunctive treatment for the prevention of COVID-19 complications. The present review provides an overview of the current knowledge of the potential immunomodulatory effects of vitamin D in the prevention of COVID-19 and sets out vitamin D recommendations for the Latin American population.

Effects of a Single Oral Megadose of Vitamin D3 on Inflammation and Oxidative Stress Markers in Overweight and Obese Women: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

AIM

The study aimed to evaluate the effects of vitamin D3 (VD3) supplementation on inflammation and oxidative stress markers in overweight and obese women with deficiency or insufficiency of vitamin D.

METHODS

Twenty-nine overweight or obese women who had a deficiency or insufficiency of vitamin D were placed into two groups according to VD3 intervention. Patients in the supplemented group received a single oral megadose of VD3 (VD3, n=14). Patients in placebo group received a single oral identical capsule without vitamin D (placebo, n = 15). Anthropometric and biochemical variables were assessed at baseline and after 4-weeks intervention.

RESULTS

Anthropometric variables (waist circumference, waist-hip ratio, waist-height ratio and body mass index) were similar between groups (p > 0.05). VD3 supplementation increased the serum levels of 25-hydroxyvitamin D (p=0.000), malondialdehyde (p=0.021) and C-reactive protein (p=0.043) in overweight and obese women. Additionally, VD3 supplementation reduced the serum levels of aspartate aminotransferase (AST, p=0.035), alanine aminotransferase (ALT, p<0.0001) in overweight and obese women. Despite this, the serum levels of parathyroid hormone (PTH), fasting glucose (FG), and alpha-1- acid glycoprotein (A1GPA), total antioxidant capacity (TAC) were similar between groups.

CONCLUSION

In summary, a single oral megadose of VD3 increased 25-hydroxyvitamin D serum levels but did not improve oxidative stress and inflammation markers.

Effect of Hypovitaminosis D on Lipid Profile in Hypothyroid Patients in Saudi Arabia

Background

Hypothyroidism is believed to be associated with dyslipidemia and is considered a risk factor for the development of atherosclerotic cardiovascular diseases (ASCVD). Vitamin D, due to its steroid hormone action, retains cell function and controls the metabolism of lipids. Therefore, the present study was carried out to show the association of the risk factors of ASCVD and deficiency of thyroid hormones and vitamin D levels since no previous studies have been performed on Saudi patients before. Methodology. A retrospective cohort study was carried out on 400 hypothyroid patients. Medical records of those patients were followed up and were classified as normal and hypothyroid patients according to their thyroid-stimulating hormone levels. TSH, vitamin D, and lipid profiles were determined using the ELISA technique.

Result

Total cholesterol, triglyceride, and low-density lipoprotein cholesterol levels were significantly higher in hypothyroid patients than those in the normal group. We have found a significant correlation between TSH levels and the risk factors of ASCVD (total cholesterol, triglycerides, and LDL-C). Moreover, a significant correlation between vitamin D levels and the risk factors of ASCVD (total cholesterol, triglycerides, and LDL-C) has been found. In addition, there is a correlation between deficiency of Vit D and low-TSH levels (95% CI 1.092-4.05) indicating a higher risk for the development of ASCVD among those patients.

Conclusion

Hypothyroid and vitamin D-deficient patients must be screened regularly at an early stage to predict and also to prevent cardiovascular diseases. Moreover, an adequate supply of vitamin D and TH should be given to those patients to prevent cardiovascular diseases at an early stage.

The evident and the hidden factors of vitamin D status in older people during COVID-19 pandemic

Purpose

Considering the COVID-19 pandemic, vitamin D is a target of research and speculation. Lockdown or home isolation reduces sunlight exposition and increases the risk of vitamin D deficiency. Special attention is needed for older people at risk of both severe forms of COVID-19 and vitamin D deficiency. This review aims to highlight the association of vitamin D and COVID-19 in two instances, the direct influence of vitamin D on the immune system, and the indirect risks for other vitamin D deficiency-related diseases, such as musculoskeletal properties in older persons.

Methods

We performed a narrative review.

Results

Whether vitamin D deficiency is associated with COVID-19 poor prognosis, and if vitamin D supplementation may improve the post-infection outcomes is still unclear. In any case, the pandemic generates indirect burden, such as the sequence: home isolation, low sunlight exposition, vitamin D deficiency, and fragility fractures.

Conclusion

Therefore, it is time to debate how to optimize vitamin D status in older people, especially during the COVID-19 pandemic.

The relationship between vitamin D deficiency and oxidative stress can be independent of age and gender

Abstract. The active vitamin D (1,25(OH)2D) acts through a nuclear receptor to perform several functions in cellular metabolism. 1,25(OH)2D participates directly in calcium homeostasis, regulates the immune system, nervous system, blood pressure, insulin secretion, among others. Vitamin D deficiency could also be associated with several diseases and increased cellular oxidative damage. The present study aimed to investigate whether lipid peroxidation and/or protein oxidation are affected by vitamin D deficiency and whether sunlight exposure/diet, gender, and age might influence this relationship. Vitamin D concentrations were obtained from the Heart Hospital database and a questionnaire was applied among the 212 participants. We used the inactive vitamin D (25(OH)2) in the analyses since 1,25(OH)2D has a short half-life and a low blood concentration. Lipid peroxidation and protein oxidation analyses were performed using spectrophotometry. Multivariate analyses suggested the participation of vitamin D deficiency (<30 ng/mL) and sunlight/diet in oxidative stress (p <0.05; R2 MDA: 0.562; R2 CG: 0.429). Multiple linear regression test show that the age and gender of patients are not interfering in the analyses (p>0.05). Therefore, we suggest that the relationship between vitamin D deficiency and oxidative stress can be independent of age and gender.

Vitamin D status and prevalence of hypovitaminosis D in different genders throughout life stages: A Brazilian cross-sectional study

OBJECTIVES

To evaluate the mean concentration of 25-hydroxivitamin D [25(OH) D] and prevalence of hypovitaminosis D in individuals residing in Rio de Janeiro, Brazil.

METHODS

The data of 80,000 consecutive individuals who had 25(OH) D measurements performed by electrochemiluminescence between 1/2/2018 and 2/5/2018 were selected. Patients who reported the use of therapies/supplements were excluded. Levels of 25(OH) D ≥20 ng/mL (ages <60 years) and ≥30 ng/mL (ages ≥60 years) were considered adequate.

RESULTS

We analyzed the data of 24,074 individuals (1-95 years old, 64.7% female). Descriptive curves showed that, in both sexes, the mean values of 25(OH) D decreased from the first years of life until adolescence, then slightly increased, and then tended to stabilize during adulthood. Levels of 25(OH) D <20 ng/mL were observed in 6% of girls versus 3.6% of boys and in 13.6% of adolescent girls versus 12.6% of adolescent boys and 11% of adults. The percentage of seniors with serum levels of 25(OH) D <20 ng/mL was 13.6% in women and 12.7% in men; 53.2% of women and 50.6% of men had levels <30 ng/mL.

CONCLUSIONS

Mean 25(OH) D values were higher in children and lower in adolescents and women. Approximately 90% of non-seniors and presumably healthy residents of the urban metropolitan region of Rio de Janeiro presented satisfactory levels of 25(OH) D during the summer months; however, in over half of the elderly, the serum concentrations of 25(OH) D were inadequate. Therefore, strategies for the prevention of hypovitaminosis D should be considered in the senior population.

Vitamin D status and predictors of 25-hydroxyvitamin D levels in patients with heart failure living in a sunny region

Introduction

Aims: hypovitaminosis D has frequently been identified in patients with heart failure (HF). However, few studies have been conducted in regions with high solar incidence. Therefore, this study aimed to evaluate vitamin D status and predictors of 25-hydroxyvitamin D (25(OH)D) levels in patients with HF living in a sunny region (5 °- 6 °S). Methods: this cross-sectional study enrolled 70 patients with HF. Biodemographic, clinical, biochemical, dietary, and sun exposure data were collected, and 25(OH)D levels were measured. Results: the mean 25(OH)D level was 40.1 (12.4) ng/mL, and 24.3 % (95 % CI: 14.2-33.8) of patients with HF had hypovitaminosis D (25(OH)D < 30 ng/mL). Female patients (p = 0.001), those with ischemic etiology (p = 0.03) and those with high parathyroid hormone levels (> 67 pg/mL) (p = 0.034) were more likely to present hypovitaminosis D. Higher 25(OH)D levels were observed in men than in women (β = 7.78, p = 0.005) and in patients with HF in New York Heart Association (NHYA) functional class I when compared to those in class III/IV (β = 8.23, p = 0.032). Conclusions: the majority of patients with HF had sufficient 25(OH)D levels. Sex and functional classification were identified as independent predictors of 25(OH)D levels. These results highlight the need for increased monitoring of vitamin D status among female patients with heart failure and those with more severe symptoms.

Acute and long-term kidney function after parathyroidectomy for primary hyperparathyroidism

Background

In kidney transplant patients, parathyroidectomy is associated with an acute decrease in renal function. Acute and chronic effects of parathyroidectomy on renal function have not been extensively studied in primary hyperparathyroidism (PHPT).

Methods

This retrospective cohort study included 494 patients undergoing parathyroidectomy for PHPT. Acute renal changes were evaluated daily until day 4 post-parathyroidectomy and were stratified according to acute kidney injury (AKI) criteria. Biochemical assessment included serum creatinine, total and ionized calcium, parathyroid hormone (PTH), and 25-hydroxyvitamin D (25OHD). The estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI equation. We compared preoperative and postoperative renal function up to 5 years of follow-up.

Results

A total of 391 (79.1%) patients were female, and 422 (85.4%) were non-African American. The median age was 58 years old. The median (first and third quartiles) preoperative serum creatinine, PTH and total calcium levels were 0.81 mg/dL (0.68–1.01), 154.5 pg/mL (106–238.5), and 10.9 mg/dL (10.3–11.5), respectively. The median (first and third quartiles) preoperative eGFR was 86 mL/min/1.73 m² (65–101.3). After surgery, the median acute decrease in the eGFR was 21 mL/min/1.73 m² (p<0.0001). Acutely, 41.1% of patients developed stage 1 AKI, 5.9% developed stage 2 AKI, and 1.8% developed stage 3 AKI. The acute eGFR decrease (%) was correlated with age and PTH, calcium and preoperative creatinine levels in univariate analysis. Multivariate analysis showed that the acute change was related to age and preoperative values of ionized calcium, phosphorus and creatinine. The change at 12 months was related to sex, preoperative creatinine and 25OHD. Permanent reduction in the eGFR occurred in 60.7% of patients after an acute episode.

Conclusion

There was significant acute impairment in renal function after parathyroidectomy for PHPT, and almost half of the patients met the criteria for AKI. Significant eGFR recovery was observed during the first month after surgery, but a small permanent reduction may occur. Patients treated for PHPT seemed to present with prominent renal dysfunction compared to patients who underwent thyroidectomy.

CASE-CONTROL STUDY ON VITAMIN D STATUS IN CHILDREN AND ADOLESCENTS WITH EOSINOPHILIC ESOPHAGITIS

BACKGROUND

Vitamin D is an essential fat-soluble steroid hormone and vitamin D deficiency is a global public health problem especially among children and adolescents. Factors such as the low intake of vitamin D-rich food sources, poor absorption and less exposure to the sun influence this outcome. Vitamin D has an anti-inflammatory effect in the body by promoting regulatory T cell differentiation as well as recovering T helper 17 cell response and secretion of anti-inflammatory cytokines. Eosinophilic esophagitis (EoE) is a chronic disease, histologically characterized by predominantly eosinophilic inflammation. The most common therapeutic approaches are allergen-eliminating diets, such as excluding cow's milk, egg, soy, wheat, peanuts and seafood, or more specific dietary restrictions.

OBJECTIVE

To verify the serum levels of vitamin D in children and adolescents with eosinophilic esophagitis on a restricted food diet and to analyze their association with nutritional status, consumption of different food sources, exposure to the sun and skin color.

METHODS

Case-control study conducted in the city of Campinas-SP, Brazil, in which included patients were aged 2 to 18 years old, and those diagnosed with eosinophilic esophagitis was referred to as the case group (n=15), meanwhile a control group (n=17) was also formed. Epidemiological data, nutritional status, data on vitamin D intake (24-hour recall - performed only by EoE patients - and self-reported intake of vitamin D food sources: milk and dairy products, canned tuna and sardines, Bull's liver, chicken eggs - applied in both groups), and daily time of sun exposure (≥30 min or ≤30 min) were recorded. The samples were collected for serum levels of 25-hydroxy-vitamin D, where sufficiency levels >30 ng/mL were considered, insufficiency 21 to 30 ng/mL, deficiency <20 ng/mL.

RESULTS

There was a higher frequency of vitamin D insufficiency/ deficiency in the Eosinophilic Esophagitis group (P=0.035), even with longer sun exposure (P= 0.035). Skin color was not associated with lower levels of vitamin D in both groups studied. No difference was found in nutritional status between the groups.

CONCLUSION

The present study demonstrated a higher frequency of inadequate/ deficient levels of vitamin D in children and adolescents with EoE on a restricted diet. When necessary, serum levels should be investigated and correct exposure to the sun should be encouraged, with special attention to the recommended guidelines, time spent in the sun and the appropriate clothing for correct absorption. Since exposure for more than 30 minutes in the sun does not appear to have provided a protective effect in the EoE group, even in a region with high levels of solar radiation. There was a significant difference only in the consumption of cow's milk between the case and control groups, demonstrating the low adherence to the restriction diet by the case group. No association was found between serum 25 hydroxyvitamin D levels and nutritional status. Moreover, no association regarding the adequate or inadequate status of 25 hydroxyvitamin D and the consumption vitamin D-rich foods was identified. Multicentered studies with a larger number of cases should be performed to assess serum 25 hydroxyvitamin D levels and associated factors in pediatric patients with EoE.