Prevalence of vitamin D depletion among subjects seeking advice on osteoporosis: a five-year cross-sectional study with public health implications

Prevalence and Associated Factors of Vitamin D Deficiency in High Altitude Region in Saudi Arabia: Three-Year Retrospective Study

Background

Vitamin D has many functions in the human body, and its deficiency is associated with skeletal and non-skeletal diseases. Vitamin D deficiency (blood level of 25 (OH) vitamin D < 20 ng/mL) has been reported worldwide, including Kingdom of Saudi Arabia (KSA). Its prevalence and associated factors vary according to KSA region. Therefore, this study aimed to explore the prevalence and risk factors of vitamin D deficiency in the Taif region of KSA.

Methods

This retrospective study included patients who attended outpatient clinics at the Alameen General Hospital from 2019 to 2021. Demographic, clinical, and laboratory data were collected using a hospital software system.

Results

The study included 2153 patients and vitamin D deficiency was diagnosed in 900 (41.8%) of whom were diagnosed with vitamin D deficiency. It was more common in males (P=0.021), younger age (<0.001), and in patients without comorbidities. There was a positive correlation between 25 (OH) vitamin D levels and blood cholesterol, high-density lipoprotein, calcium, and vitamin B12 levels. In the binary logistic regression analysis, age was the most significant predictor (P<0.001), followed by the absence of thyroid disease (P=0.012) and asthma (P=0.030).

Conclusion

Vitamin D deficiency is common in the Saudi population despite sunny weather in KSA. It is more prevalent among males, younger individuals, and those without comorbidities such as thyroid diseases and asthma.

In Vitro Non-Genomic Effects of Calcifediol on Human Preosteoblastic Cells

Several recent studies have demonstrated that the direct precursor of vitamin D₃, the calcifediol [25(OH)D₃], through the binding to the nuclear vitamin D receptor (VDR), is able to regulate the expression of many genes involved in several cellular processes. Considering that itself may function as a VDR ligand, although with a lower affinity, respect than the active form of vitamin D, we have assumed that 25(OH)D₃ by binding the VDR could have a vitamin’s D₃ activity such as activating non-genomic pathways, and in particular we selected mesenchymal stem cells derived from human adipose tissue (hADMSCs) for the in vitro assessment of the intracellular Ca²⁺ mobilization in response to 25(OH)D₃. Our result reveals the ability of 25(OH)D₃ to activate rapid, non-genomic pathways, such as an increase of intracellular Ca²⁺ levels, similar to what observed with the biologically active form of vitamin D₃. hADMSCs loaded with Fluo-4 AM exhibited a rapid and sustained increase in intracellular Ca²⁺ concentration as a result of exposure to 10⁻⁵ M of 25(OH)D₃. In this work, we show for the first time the in vitro ability of 25(OH)D₃ to induce a rapid increase of intracellular Ca²⁺ levels in hADMSCs. These findings represent an important step to better understand the non-genomic effects of vitamin D₃ and its role in endocrine system.

The role of vitamin D and vitamin D deficiency in orthopaedics and traumatology-a narrative overview of the literature

Vitamin D is considered to play an important role in musculoskeletal health. It’s classical function is the regulation of calcium and phosphate homeostasis, thus ensuring a balanced bone metabolism that is characterised by an equal amount of bone resorption and bone formation. In the past decades, a plethora of pre-clinical and clinical studies reporting on potential health-beneficial properties of vitamin D have emerged. Moreover, there is an abundance of reports highlighting vitamin D deficiency and insufficiency in patients with almost innumerable diseases. Further, it is estimated that more than one billion people globally are affected by insufficient vitamin D levels. As such, research on vitamin D has been particularly popular over the past years. In orthopaedics and traumatology, most studies describe favourable effects of vitamin D in general. However, the relative importance of vitamin D is oftentimes debated. In this narrative review of the literature, we consider first, the properties of vitamin D and how vitamin D, vitamin D deficiency and the vitamin D receptor (VDR) impact on musculoskeletal health. Secondly, we provide an overview of studies reporting the prevalence of vitamin D deficiency in traumatology and diverse orthopaedic diseases including bone oncology. Lastly, we emphasise recent findings and touch on future perspectives in vitamin D research.

Effect of vitamin D nutrition on disease indices in patients with primary hyperparathyroidism

In patients with primary hyperparathyroidism, the size of the adenoma is a major determinant of biochemical indices, disease severity, and manner of presentation. However, the large variation in adenoma weight, both within and between populations and a steady decline in parathyroid adenoma weights over time remain largely unexplained. Based on the results in a small number of patients almost two decades ago we proposed that vitamin D nutritional status of the patient explains both the disease manifestations and much of the variation in adenoma size. Accordingly, we examined the relationship between vitamin D nutrition, as assessed by serum levels of 25-hydroxyvitamin D, and parathyroid gland weight, the best available index of disease severity, in a large number of patients (n = 440) with primary hyperparathyroidism. A significant inverse relationship was found between serum 25-hydroxyvitamin D level and log adenoma weight (r = -0.361; p < 0.001). Also, the adenoma weight was significantly related directly to serum PTH, calcium, and alkaline phosphatase as dependent variables. In patients with vitamin D deficiency (defined as serum 25-hydroxyvitamin D levels 15 ng/mL or lower), gland weight, PTH, AP, and adjusted calcium were each significantly higher than in patients with 25-hydroxyvitamin D levels of 16 ng/mL or higher, but serum 1,25-dihydroxyvitamin D levels were similar in both groups. We interpret this to mean that suboptimal vitamin D nutrition stimulates parathyroid adenoma growth by a mechanism unrelated to 1,25-dihydroxyvitamin D deficiency. We conclude that variable vitamin D nutritional status in the population may partly explain the differences in disease presentation.

An in vitro Experimental Insight into the Osteoblast Responses to Vitamin D3 and Its Metabolites

BACKGROUND

25-hydroxyvitamin D3 (25[OH]VD3) has recently been found to be an active hormone. Its biological actions are also demonstrated in various cell types. However, the precise influences of vitamin D3 (VD3) and its metabolites (25[OH]VD3, 1α,25-dihydroxyvitamin D3 [1α,25-(OH)2VD3]) on the osteoblast differentiation remain largely unknown. In this work, we investigated the effects of VD3 and its metabolites in different concentrations on the early and later osteoblast differentiation and biomineralization.

METHODS

We first used quantitative real-time polymerase chain reaction (RT-qPCR) to evaluate the responsiveness of osteoblasts to VD3, 25(OH)VD3 or 1α,25-(OH)2VD3. We also evaluated the proliferation, differentiation and biomineralization of osteoblast at different time points via cell counting kit-8 assay and the analysis of osteogenic markers.

RESULTS

The experimental results confirmed that osteoblasts could be responsive to 25(OH)VD3 and 1α,25-(OH)2VD3 but could not directly metabolize VD3 and 25(OH)VD3. Only 200 nmol/L VD3 significantly promoted osteoblast proliferation, while 25(OH)VD3 and 1α,25-(OH)2VD3 did not show obvious actions. Moreover, the early osteogenic markers were increased by 25(OH)VD3 and 1α,25-(OH)2VD3 in a dose-dependent manner. More importantly, only 25(OH)VD3 had accelerated the gene and protein expressions of osteocalcin and the biomineralization level of osteoblasts.

CONCLUSIONS

Our findings provide reliable evidence that 25(OH)VD3 at 100-200 nmol/L can induce the early and later osteoblast differentiation and biomineralization for clinical bone tissue engineering.

Change in serum level of vitamin D and associated factors at early phase of bone healing among fractured adult patients at University of Gondar teaching hospital, Northwest Ethiopia: a prospective follow up study

Introduction

Currently, Vitamin D deficiency is a major public health problem and it affects more than one billion people worldwide. Vitamin D is crucial for bone mineralization and ossification. Patients with fractures need Vitamin D for the healing of their fractured bone. The current study was carried out to determine if there is change in the serum level of Vitamin–D associated with factors at early phase of fractured bone healing (ossification) process among adult fractured patients at University of Gondar teaching hospital, Northwest Ethiopia.

Methods

This facility-based prospective follow up study was conducted from March to June 2016. Data was collected by an interviewer, and pretested and structured questionnaires were used. Biological samples were collected to determine the serum level of vitamin–D in all subjects. In addition, X–Ray findings were used to determine the early phase of bone healing process. Data was entered into EPI INFO version 3.5.3 and analyzed using the Statistical Package for Social Sciences (SPSS) version 20. Both bivariate and multivariate logistic regression analysis was done to screen for factors associated with decreased serum levels of Vitamin–D. In the Multivariate regression analysis, those variables which had a P–value of <0.05 were considered as independently associated with change in serum level of Vitamin–D.

Results

A total of 118 adult patients with fractures participated in this study. The prevalence of patients’ with decreased serum levels of vitamin–D at post-test was 63.6% [95% CI; (0.551–0.720)]. Inadequate intake of milk and milk products in the 1st week of fracture [AOR = 95%CI: 0.20 (0.05–0.90)], Poor Dietary Diversity Score [AOR = 95% CI: 29.1 (2.27–371.65)], and ossified bone [AOR =95% CI: 4.10 (1.12–14.95)] showed statistically significant association with decreased serum level of Vitamin–D.

Conclusion and recommendations

Decreased serum level of Vitamin–D at early phase of fractured bone healing process was found in the majority of patients (>63%) raising concern for Vitamin D deficiency to be a significant public health problem in the study population. It was statistically associated with: poor dietary diversity score, in adequate intake of milk and milk products in the 1^stone week of fracture and ossified (healed) bone. Introducing hospital based Vitamin–D supplementation and integrated with health and nutritional education is a vital intervention needed to improve serum levels of Vitamin–D.

25-Hydroxyvitamin D3 induces osteogenic differentiation of human mesenchymal stem cells

25-Hydroxyvitamin D₃ [25(OH)D₃] has recently been found to be an active hormone. Its biological actions are demonstrated in various cell types. 25(OH)D₃ deficiency results in failure in bone formation and skeletal deformation. Here, we investigated the effect of 25(OH)D₃ on osteogenic differentiation of human mesenchymal stem cells (hMSCs). We also studied the effect of 1α,25-dihydroxyvitamin D₃ [1α,25-(OH)₂D₃], a metabolite of 25(OH)D₃. One of the vitamin D responsive genes, 25(OH)D₃-24-hydroxylase (cytochrome P450 family 24 subfamily A member 1) mRNA expression is up-regulated by 25(OH)D₃ at 250-500 nM and by 1α,25-(OH)₂D₃ at 1-10 nM. 25(OH)D₃ and 1α,25-(OH)₂D₃ at a time-dependent manner alter cell morphology towards osteoblast-associated characteristics. The osteogenic markers, alkaline phosphatase, secreted phosphoprotein 1 (osteopontin), and bone gamma-carboxyglutamate protein (osteocalcin) are increased by 25(OH)D₃ and 1α,25-(OH)₂D₃ in a dose-dependent manner. Finally, mineralisation is significantly increased by 25(OH)D₃ but not by 1α,25-(OH)₂D₃. Moreover, we found that hMSCs express very low level of 25(OH)D₃-1α-hydroxylase (cytochrome P450 family 27 subfamily B member 1), and there is no detectable 1α,25-(OH)₂D₃ product. Taken together, our findings provide evidence that 25(OH)D₃ at 250-500 nM can induce osteogenic differentiation and that 25(OH)D₃ has great potential for cell-based bone tissue engineering.

A Survey of Vitamin D Status in Patients with Degenerative Diseases of the Spine

STUDY DESIGN

Descriptive cross-sectional study.

PURPOSE

To determine the prevalence of vitamin D deficiency in patients with degenerative diseases of the spine about to undergo spinal surgery and the relations between such deficiency and potential risk factors.

OVERVIEW OF LITERATURE

Vitamin D has a major role in musculoskeletal system health maintenance. Recently, studies on degenerative diseases of the spine have shown a high prevalence of vitamin D deficiency in patients undergoing spine surgery.

METHODS

Serum levels of 25(OH)D were determined by an electrochemiluminescence detection assay. The other variables were determined through relevant questionnaires, and the data was analyzed through analysis of variance, t-test, chi-square and multivariate logistic regression analysis.

RESULTS

A total of 110 patients were enrolled in the study. The mean serum level of 25(OH)D was 27.45±18.75 ng/mL, and 44.5% of patients showed vitamin D deficiency (25(OH)D<20 ng/mL), with an additional 17.3% of patients having a serum level of 25(OH)D that was insufficient (20≤25(OH)D<30 ng/mL). The prevalence of vitamin D deficiency was significantly higher in the younger age group compared to the older age group (p<0.001) and the ones without a history of taking vitamin D supplements (p=0.013). Compared to men, women showed significantly higher levels of vitamin D (p=0.029).

CONCLUSIONS

A high prevalence of vitamin D deficiency is seen in patients with degenerative diseases of the spine. On the other hand, the conventional risk factors such as old age or female sex alone did not seem to be sufficient in determining the likelihood of deficiency. Thus, it is recommended that vitamin D deficiency prevention strategies comprise a broader spectrum of the population through which such degenerative diseases and their consequences may be prevented or delayed.

High prevalence of hypovitaminosis D in Mexicans aged 14 years and older and its correlation with parathyroid hormone

A sample of 585 healthy subjects 14 years and older was studied to estimate the status of 25-hydroxyvitamin D (25(OH)D) and its correlation with parathyroid hormone in healthy Mexicans. In 43.6 % of the sample, levels of vitamin D were below 20 ng/mL and showed an inverse relationship with parathyroid hormone (PTH; p < 0.01).

PURPOSE

The purpose of the present study was to estimate the status of 25-hydroxyvitamin D (25(OH)D) and its correlation with parathyroid hormone in healthy Mexicans.

METHODS

A cross-sectional study of 585 healthy subjects 14 years and older was carried out. A questionnaire including all relevant demographics, medical history, and lifestyle factors was applied by trained interviewers. Morning fasting blood was collected in all subjects for estimation of 25(OH)D using liquid chromatography-tandem mass spectrometry and PTH hormone-intact molecule by RIA.

RESULTS

Of the group of 585 subjects, 54.1 % were women; the sample was divided in three age groups (14-29, 30-50, and >51). Only 9.6 % of the total sample had levels of 25(OH)D above 30 ng/mL; 46.8 % were between 20 and 29 ng/mL, and 43.6 % were below 20 ng/mL. Regarding PTH, a three-phase model was identified using regression smoothing scatterplot (LOESS), with two thresholds of 25(OH)D of 19 and 29 ng/mL. Phase 1 (25(OH)D <19 ng/mL) showed an inverse relationship with PTH (p < 0.01); phases 2 and 3 showed no significant relationship.

CONCLUSION

Our results show that 43.6 % of the Mexicans in this study have deficient concentration levels of vitamin D. The cutoff point of 20 ng/mL of 25(OH)D established by the Institute of Medicine has a biological and statistically significant relationship with PTH levels in the Mexican population, independently of principal confounding factors. Like many other countries, Mexico could be included in the global epidemic of hypovitaminosis D.

The prevalence of vitamin D deficiency in patients with vertebral fragility fractures

Hypovitaminosis D has been identified as a common risk factor for fragility fractures and poor fracture healing. Epidemiological data on vitamin D deficiency have been gathered in various populations, but the association between vertebral fragility fractures and hypovitaminosis D, especially in males, remains unclear. The purpose of this study was to evaluate serum levels of 25-hydroxyvitamin D (25-OH D) in patients presenting with vertebral fragility fractures and to determine whether patients with a vertebral fracture were at greater risk of hypovitaminosis D than a control population. Furthermore, we studied the seasonal variations in the serum vitamin D levels of tested patients in order to clarify the relationship between other known risk factors for osteoporosis and vitamin D levels. We measured the serum 25-OH D levels of 246 patients admitted with vertebral fractures (105 men, 141 female, mean age 69 years, sd 8.5), and in 392 orthopaedic patients with back pain and no fractures (219 men, 173 female, mean age 63 years, sd 11) to evaluate the prevalence of vitamin D insufficiency. Statistical analysis found a significant difference in vitamin D levels between patients with vertebral fragility fracture and the control group (p = 0.036). In addition, there was a significant main effect of the tested variables: obesity (p < 0.001), nicotine abuse (p = 0.002) and diabetes mellitus (p < 0.001). No statistical difference was found between vitamin D levels and gender (p = 0.34). Vitamin D insufficiency was shown to be a risk factor for vertebral fragility fractures in both men and women.

Cite this article: Bone Joint J 2015;97-B:89–93.

Bone mineral density status in urolithiasis patients with vitamin D inadequacy followed at a tertiary stone centre

INTRODUCTION

We assessed abnormalities in bone mineral density (BMD) and the risk of hip and major osteoporotic fractures in urolithiasis patients with vitamin D inadequacy (VDI) followed at a tertiary stone centre.

METHODS

Stone-free patients with VDI were invited to undergo dual-energy x-ray absorptiometry (DXA) scans to assess for BMD abnormalities at the femoral neck and lumbar spine. The World Health Organization's validated Fracture Risk Assessment Tool (FRAX) was used to calculate the risk of hip and major osteoporotic fractures within 10 years. Patients with primary hyperparathyroidism or hypercalcemia were excluded.

RESULTS

In total, 50 consecutive patients were included between June 2011 and August 2012, including 26 (52%) males. The median age was 51 years and the median 25-hydroxyl vitamin D (25[OH] D) was 18.8 ng/mL. Thirty patients (60%) had abnormal T-scores on DXA studies. This decreased to 22 (44%) when age-matched Z-scores were used; 36% had osteopenia and 8% had osteoporosis. Femoral neck and lumbar spines were affected in 24% and 32% of patients, respectively. Recurrent stone-formers had significantly lower BMD when compared with first-time stone formers. Median serum 25(OH)D was comparable between patients with normal and abnormal DXA scans (18.6 vs. 18.8 ng/mL; p = 0.91). Five patients (10%) were at high risk (≥3%) of hip fractures within 10 years.

CONCLUSION

A high prevalence of abnormal DXA scans was found in urolithiasis patients with VDI, including 5 patients (10%) at high risk of hip fractures. Future studies need to assess the economic impact of obtaining DXA scans on urolithiasis patients with VDI, especially in recurrent stone-formers.

Changes in the serum level of vitamin d during healing of tibial and femoral shaft fractures

BACKGROUND

Several systemic factors and hormones are thought to regulate the fracture healing process. Vitamin D has emerged as a compound or hormone that actively participates in the regulation of calcium homeostasis and bone metabolism.

OBJECTIVES

The aim of this study is to determine the serum changes in the level of vitamin D during the acute healing period of tibial and femoral shaft fractures.

PATIENTS AND METHODS

This cross-sectional study included of 73 patients with tibial and femoral shaft fractures referred to the Poursina Hospital between February 2011 and February 2012. Changes in the serum levels of vitamin D were assessed three times in a period of three weeks (at the first visit, end of first week, and end of the third week). Variables such as age, gender, fractured bone, concomitant fracture of tibia and fibula, type of fracture, time of measurement and serum levels of 25-hydroxyvitamin D were assessed. All statistical analyses were performed using the SPSS software.

RESULTS

Forty tibial fractures and 33 femoral fractures were recorded. Mean vitamin D levels at the time of admission, after one week and at the end of the third week for the 73 participants included in the study were 39.23, 31.49, and 28.57 ng/mL, respectively. The overall reduction of vitamin D level was significantly more evident in the first week versus the following (P < 0.0001).

CONCLUSIONS

Serum levels of vitamin D in patients with tibial or femoral fractures were reduced during the curative period of the fracture. This can be related the role of vitamin D in the formation and mineralization of the callus. Patients with tibial or femoral shaft fractures may benefit from the administration of vitamin D supplements during the fracture healing process.

Vitamin D insufficiency in patients with acute hip fractures of all ages and both sexes in a sunny climate

OBJECTIVES

To determine the incidence of vitamin D deficiency in patients with hip fractures of all ages who live in the southwest United States.

DESIGN

Retrospective comparative study.

SETTING

Two level 2 trauma centers and 2 community hospitals in San Diego, CA.

PATIENTS/PARTICIPANTS

Four hundred forty-eight patients who sustained a hip fracture from December 2010 to December 2011 and a control group of 1091 patients who underwent elective primary total hip or knee surgery during the same time period.

MAIN OUTCOME MEASUREMENTS

Serum 25-hydroxyvitamin D (25(OH)D) levels.

RESULTS

The mean 25(OH)D level for both the Hip Fracture (26.38 ng/mL) and Total Joint (29.92 ng/mL) Groups showed vitamin D insufficiency, with the Hip Fracture Group having lower levels (P < 0.05). More patients in the Hip Fracture Group were deficient or insufficient (65.8% vs. 54.0%, P < 0.05). Patients aged 71 years or older were more deficient or insufficient in the Hip Fracture Group than in the Total Joint Group (66.7% vs. 47.13%, P < 0.05). There was no difference when comparing males versus females (P > 0.05). Females in the Hip Fracture Group were more deficient or insufficient (67.3% vs. 54.3%, P < 0.05) than in the Total Joint Group.

CONCLUSIONS

The majority of patients aged 18 years or older of both sexes with hip fractures had vitamin D insufficiency and those aged 71 years or older had significantly lower 25(OH)D levels than a control group of total joint patients.

LEVEL OF EVIDENCE

Prognostic level III. See Instructions for Authors for a complete description of levels of evidence.

[Vitamin D insufficiency and deficiency: epidemiology, measurement, prevention and treatment]

Vitamin D has been traditionally considered as important for skeletal health. However, during the past decade, numerous research findings have revealed that vitamin D may have beneficial effects on extraskeletal tissues as well. Vitamin D deficiency is now recognized as a worldwide issue. The prevalence of vitamin D deficiency or insufficiency depends on the threshold used to define vitamin D deficiency or insufficiency. However, whatever the threshold (20, 30 or 40 ng/mL), the prevalence is high in France as elsewhere. Vitamin D status is now based on the measurement of 25-hydroxyvitamin D [25(OH)D] concentration. This assay does not seem justified in most situations encountered in clinical practice, and its overprescription generates a significant cost to public health. This is why Official Clinical Societies try to define: (a) target populations for which a determination is required (every situation in which the therapeutic goal requires an optimal serum 25(OH)D level for an appropriate medical care) and which require specific treatment; (b) target populations for which the risk of deficit is important (due to insufficient daily intake) and may benefit from preventive pharmaceutical supplementation without prior testing (infants, pregnant women, patients over 65...).

The effect of endogenous parathyroid hormone in iliac bone structure and turnover in healthy postmenopausal women

Little is known about the effect of endogenous parathyroid hormone (PTH) on the skeleton in postmenopausal women without hyperparathyroidism. In this study, the effects of PTH on bone were investigated in iliac crest biopsies obtained from 37 healthy white postmenopausal women aged 50-73 years. The results showed that neither cancellous nor cortical bone structure changed with serum PTH levels. In cancellous bone, bone formation (wall thickness, osteoid surface, osteoblast surface, mineralizing surface, and mineral apposition rate) and turnover (bone formation rate at the surface, volume levels, and activation frequency) variables increased with increasing serum PTH levels (all p < 0.05) in univariate analysis. Multiple linear regressions, adjusted for serum 25-OHD, calcium, alkaline phosphatase, age, and BMI, showed that serum PTH level was independently associated with wall thickness, osteoid surface, osteoblast surface, mineralizing surface, and bone formation rate (all p < 0.05). In cortical bone, no histomorphometric variable was correlated with PTH levels. On the endosteal surface, some of the bone formation (osteoid surface, osteoblast surface, mineralizing surface) and turnover (bone formation rate at the bone surface levels and activation frequency) variables were positively correlated with PTH levels (all p < 0.05). None of these variables could be independently predicted by PTH status. We conclude that in healthy postmenopausal women endogenous PTH has a positive effect on bone formation on the cancellous surface. The effects of PTH on the endosteal surface are probably confounded by other factors.

Is there an epidemic vitamin D deficiency in German orthopaedic patients?

BACKGROUND

Vitamin D plays an essential role in bone health and muscle function. Some studies have shown a widespread rate of vitamin D deficiency in the general population, but few have reported on the vitamin D status of orthopaedic patients.

QUESTIONS/PURPOSES

We investigated (1) the extent of hypovitaminosis D in orthopaedic patients, (2) seasonal variations in vitamin D levels, and (3) possible risk factors for insufficient vitamin D levels.

METHODS

Vitamin D levels in 1119 patients consecutively admitted to an orthopaedic surgery department in 2011 were measured. To investigate the correlation between climate factors and vitamin D levels, the sunshine hours for each month in 2011 were collected by Deutscher Wetterdienst (the German weather service) in the region where most tested patients lived. The prevalence of normal (> 30 ng/mL), insufficient (20-30 ng/mL), and deficient (< 20 ng/mL) 25-hydroxyvitamin D levels was determined. Univariate and multivariate analyses were used to assess risk factors for insufficient vitamin D levels.

RESULTS

Overall, 84% of patients had insufficient levels of vitamin D and 60% were vitamin D deficient. Only 15% were in the target range of 30 to 60 ng/mL. The prevalence of low vitamin D levels was greater during winter and months with fewer sunshine hours. Vitamin D levels did not vary according to age, sex, and disease. Individuals with obesity, hypertension, and osteoporosis were more likely to have low vitamin D levels compared with their healthy counterparts.

CONCLUSIONS

There is an alarmingly high rate of hypovitaminosis D and vitamin D deficiency among orthopaedic patients in this region of Germany, whose latitude (50° N) is approximately the same as those of Vancouver (49°, 15' N) and Paris (48°, 51' N). Given the well-known effects on bone metabolism and muscle health, low vitamin D levels may negatively affect patients. Screening and treating hypovitaminosis D appears to be important in this patient population.

Vitamin d status and spine surgery outcomes

There is a high prevalence of hypovitaminosis D in patients with back pain regardless of whether or not they require surgical intervention. Furthermore, the risk of hypovitaminosis D is not limited to individuals with traditional clinical risk factors. Vitamin D plays an essential role in bone formation, maintenance, and remodeling, as well as muscle function. Published data indicate that hypovitaminosis D could adversely affect bone formation and muscle function in multiple ways. The literature contains numerous reports of myopathy and/or musculoskeletal pain associated with hypovitaminosis D. In terms of spinal fusion outcomes, a patient may have a significant decrease in pain and the presence of de novo bone on an X-ray, yet their functional ability may remain severely limited. Hypovitaminosis D may be a contributing factor to the persistent postoperative pain experienced by these patients. Indeed, hypovitaminosis D is not asymptomatic, and symptoms can manifest themselves independent of the musculoskeletal pathological changes associated with conditions like osteomalacia. It appears that vitamin D status is routinely overlooked, and there is a need to raise awareness about its importance among all healthcare practitioners who treat spine patients.

25 hydroxyvitamin D serum levels influence adequate response to bisphosphonate treatment in postmenopausal osteoporosis

It remains unclear whether vitamin D sufficiency optimizes response to bisphosphonate (BP) treatment in postmenopausal osteoporosis. We evaluated the role and possible mechanisms of vitamin D in adequate response to standard BP treatment for postmenopausal osteoporosis.

METHODS

We included 120 postmenopausal osteoporotic women (aged 68 ± 8 years) receiving BP (alendronate or risedronate) at their annual follow-up, performing complete anamnesis, including treatment adherence, use of vitamin D supplements, and previous falls and fractures during the last year. We analyzed the evolution of bone mineral density (BMD) during this period and serum PTH and 25 hydroxyvitamin D (25(OH)D) and urinary NTx levels. Patients were classified as inadequate responders to antiosteoporotic treatment based on BMD loss>2% and/or the presence of fragility fractures during the last year.

RESULTS

Thirty percent of patients showed inadequate response to BP treatment, with significantly lower levels of 25(OH)D (22.4 ± 1.3 vs. 26.6 ± 0.3 ng/ml, p=0.01), a higher frequency of 25(OH)D levels<30 ng/ml (91% vs. 69%, p=0.019) and higher urinary NTx values (42.2 ± 3.9 vs. 30.9 ± 2.3 nM/mM, p=0.01). Patients with 25(OH)D>30 ng/ml had a greater significant increase in lumbar BMD than women with values <30 ng/ml (3.6% vs. 0.8%, p<0.05). The probability of inadequate response was 4-fold higher in patients with 25(OH)D<30 (OR, 4.42; 95% CI, 1.22-15.97, p=0.02).

CONCLUSIONS

Inadequate response to BP treatment is frequent in postmenopausal women with osteoporosis as is vitamin D insufficiency, despite vitamin D supplementation. Maintenance of 25(OH)D levels >30 ng/ml is especially indicated for adequate response to BP treatment.

Vitamin D levels in post-menopausal Korean women with a distal radius fracture

INTRODUCTION

The purpose of this study was to investigate serum levels of vitamin D in post-menopausal Korean women with a distal radius fracture (DRF) and to determine if there is any association between vitamin D levels and bone-related variables such as bone mineral densities (BMDs), serum parathyroid hormone (PTH) levels and several bone turnover markers.

MATERIALS AND METHODS

The data of 104 postmenopausal women surgically treated for a distal radius fracture (DRF group) and 107 age-matched control patients without a fracture (control group) were compared. Serum vitamin D levels (25-hydroxycholecalciferol, 25(OH)D(3)) were compared between the groups with consideration of age and seasonal variations. BMDs, serum PTH and several bone turnover markers, including serum osteocalcin, C-telopeptide and urine N-telopeptide, were measured and analysed to find any association with vitamin D levels.

RESULTS

The mean 25(OH)D(3) level was significantly lower in the DRF group compared to the control group (p < 0.001). In particular, patients in their sixth and seventh deciles in the DRF group had significantly lower 25(OH)D(3) levels than patients in the control group (p = 0.001 and 0.013, respectively). When seasonal variation was considered, significant differences of 25(OH)D(3) levels were found between the groups in autumn and winter. Hip BMDs were significantly lower in the DRF group than in the control group, and there was a positive correlation between serum 25(OH)D(3) levels and hip BMDs. Bone turnover markers were not significantly different between the two groups, although serum PTH levels were marginally higher in the DRF group (p = 0.08).

CONCLUSIONS

Post-menopausal Korean women with a DRF were found to have significantly lower serum vitamin D levels than the control group, and vitamin D levels were particularly lower in women in their sixth and seventh deciles who may be a good target group for prevention of future fractures. Future investigation should focus on determining whether vitamin D supplementation can be helpful in preventing future fractures in patients with a DRF.

The impact of vitamin D status on periodontal surgery outcomes

Vitamin D regulates calcium and immune function. While vitamin D deficiency has been associated with periodontitis, little information exists regarding its effect on wound healing and periodontal surgery outcomes. This longitudinal clinical trial assessed outcomes of periodontal surgery and teriparatide administration in vitamin-D-sufficient and -insufficient individuals. Forty individuals with severe chronic periodontitis received periodontal surgery, daily calcium and vitamin D supplements, and self-administered teriparatide or placebo for 6 wks to correspond with osseous healing time. Serum 25(OH)D was evaluated at baseline, 6 wks, and 6 mos post-surgery. Clinical and radiographic outcomes were evaluated over 1 yr. Placebo patients with baseline vitamin D deficiency [serum 25(OH)D, 16-19 ng/mL] had significantly less clinical attachment loss (CAL) gain (-0.43 mm vs. 0.92 mm, p < 0.01) and probing depth (PPD) reduction (0.43 mm vs. 1.83 mm, p < 0.01) than vitamin-D-sufficient individuals. Vitamin D levels had no significant impact on CAL and PPD improvements in teriparatide patients at 1 yr, but infrabony defect resolution was greater in teriparatide-treated vitamin-D-sufficient vs. -deficient individuals (2.05 mm vs. 0.87 mm, p = 0.03). Vitamin D deficiency at the time of periodontal surgery negatively affects treatment outcomes for up to 1 yr. Analysis of these data suggests that vitamin D status may be critical for post-surgical healing. (ClinicalTrials.gov number, CT00277706).

The biology and pathology of vitamin D control in bone

Vitamin D is a steroid pro-hormone, whose active metabolite binds the vitamin D receptor (VDR) which, in turn, binds to DNA sequences on target genes as a heterodimer with the retinoid-X receptor, resulting in regulation of gene expression. The vitamin D pro-hormone can be synthesized in the skin, in response to ultraviolet radiation; however, dietary sources have become increasingly important as a result of cultural changes over the past few centuries. Based on its initial discovery as an anti-rachitic factor, studies of the role of vitamin D and its receptor have largely focused on the skeleton. Investigations into the pathophysiologic basis and therapeutic responses of skeletal disorders associated with impaired vitamin D action have led to the identification of the molecular pathways involved in hormone activation and regulation of gene expression by the liganded VDR. These studies have also demonstrated that the skeletal actions of the VDR and its ligand are largely redundant if normal mineral ion homeostasis can be maintained by other means. However, investigations in animal models with tissue-specific ablation of the VDR or the enzyme required for hormone activation have demonstrated novel actions in skeletal tissues. The active vitamin D metabolite has been shown to have both paracrine and endocrine actions in other tissues as well.

Hypovitaminosis D in patients scheduled to undergo orthopaedic surgery: a single-center analysis

BACKGROUND

Vitamin D is essential for optimal bone health and muscle function. An alarmingly high rate of vitamin-D deficiency in the general population has been reported recently. The purpose of the present study was to characterize the extent of low serum levels of vitamin D among orthopaedic surgery patients.

METHODS

We performed a retrospective chart review of 723 patients who were scheduled for orthopaedic surgery between January 2007 and March 2008. Preoperative serum 25-hydroxyvitamin D (25[OH]D) levels were measured. The prevalence of normal (≥32 ng/mL), insufficient (<32 ng/mL), and deficient (<20 ng/mL) vitamin-D levels was determined. Logistic regression was used to assess risk factors for insufficient (<32 ng/mL) 25(OH)D levels.

RESULTS

Overall, 43% of all patients had insufficient serum vitamin-D levels, and, of these, 40% had deficient levels. Among the orthopaedic services, the highest rates of low serum vitamin-D levels were seen in the trauma and sports services, in which the rates of abnormal (insufficient and deficient) vitamin-D levels were 66% and 52%, respectively. The lowest rate of abnormal vitamin-D levels was seen in the metabolic bone disease service. Patients between the ages of fifty-one and seventy years were 35% less likely to have low vitamin-D levels than patients between the ages of eighteen and fifty years (p = 0.018). The prevalence of low vitamin-D levels was significantly higher in men (p = 0.006). Individuals with darker skin tones (blacks and Hispanics) were 5.5 times more likely to have low vitamin-D levels when compared with those with lighter skin tones (whites and Asians) (p < 0.001).

CONCLUSIONS

The prevalence of low serum levels of vitamin D among patients undergoing orthopaedic surgery is very common. Given the importance of vitamin D in musculoskeletal health, such low levels may negatively impact patient outcomes.

Effect of a single oral dose of 600,000 IU of cholecalciferol on serum calciotropic hormones in young subjects with vitamin D deficiency: a prospective intervention study

CONTEXT

Effects of vitamin D repletion in young people with low vitamin D status have not been investigated so far.

OBJECTIVE

We evaluated the effect of a single massive dose of cholecalciferol on calcium metabolism at 3, 15, and 30 d, compared to baseline.

DESIGN AND SETTING

We conducted a prospective intervention study in an ambulatory care setting.

PARTICIPANTS

Forty-eight young subjects with vitamin D deficiency participated in the study.

INTERVENTION

A single oral dose of 600,000 IU of cholecalciferol was administered to each subject.

MAIN OUTCOME MEASURES

We evaluated serum changes of 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D, calcium, and PTH induced by a single load of cholecalciferol.

RESULTS

The 25(OH)D level was 15.8 ± 6.5 ng/ml at baseline and became 77.2 ± 30.5 ng/ml at 3 d (P < 0.001) and 62.4 ± 26.1 ng/ml at 30 d (P < 0.001). PTH levels concomitantly decreased from 53.0 ± 20.1 to 38.6 ± 17.2 pg/ml at 3 d and to 43.4 ± 14.0 pg/ml at 30 d (P < 0.001 for both). The trends were maintained in a subgroup followed up to 90 d (P < 0.001). Mean serum Ca and P significantly increased compared to baseline, whereas serum Mg decreased at 3 d. 1,25-Dihydroxyvitamin D significantly increased from 46.8 ± 18.9 to 97.8 ± 38.3 pg/ml at 3 d (P < 0.001) and to 59.5 ± 27.3 pg/ml at 60 d (P < 0.05).

CONCLUSIONS

A single oral dose of 600,000 IU of cholecalciferol rapidly enhances 25(OH)D and reduces PTH in young people with vitamin D deficiency.

Elevated 1, 25-dihydroxyvitamin D levels are associated with protracted treatment in sarcoidosis

BACKGROUND

Active vitamin D metabolite, 1, 25-dihydroxyvitamin D, has pleomorphic effects on both innate and acquired immunity. Sarcoid granuloma derived 1, 25-dihydroxyvitamin D leads to hypercalcemia, but the association of 1, 25-dihydroxyvitamin D with the clinical phenotype of the disease is currently unknown.

OBJECTIVE

To determine the relationship between serum 1, 25-dihydroxyvitamin D levels and the degree of sarcoidosis disease chronicity.

DESIGN

Serum 1, 25-dihydroxyvitamin D levels were measured and associated with sarcoidosis activity and phenotypes as assessed by Sarcoidosis Severity Score and Sarcoidosis Clinical Activity Classification respectively.

RESULTS

Fifty nine patients were recruited with 44% having a sub-acute onset, and the chronic disease phenotype. There was no significant difference in serum 1, 25-dihydroxyvitamin D levels by chest radiograph stage (p = 0.092) nor did the levels correlate with the Sarcoidosis Severity Score (r = -0.16; p = 0.216). Serum 1, 25-dihydroxyvitamin D levels were associated with patients requiring repeated regimens of systemic immunosuppressive therapy or >1 year of therapy (SCAC Class 6). Increasing quartiles of serum 1, 25-dihydroxyvitamin D level was associated increased odds of the chronic phenotype (OR 1.82, 95% CI, 1.11, 2.99, p = 0.019). The majority (71%) of the patients with levels >51 pg/mL required chronic immunosuppressive therapy as defined by SCAC class 6.

CONCLUSIONS

In patients with sarcoidosis, elevated 1, 25-dihydroxyvitamin D levels are associated with chronic treatment needs.

Determinants of 25-hydroxyvitamin D levels in African-American and Caucasian male veterans

SUMMARY

Among 307 males seen in VA Medical Center, independent determinants (p < 0.01 for all) of serum 25-hydroxyvitamin D [25(OH)D] levels included race, vitamin D supplements, BMI, dietary calcium intake and smoking, but not age. Negative association between 25(OH)D and parathyroid hormone (PTH) was similar for Caucasian and African-American men.

INTRODUCTION

In this prospective cohort study, we examined determinants of serum 25-hydroxyvitamin D [25(OH)D] levels and the relationship between 25(OH)D and PTH levels and body mass index (BMI).

METHODS

Male veterans (n = 307) were recruited at a VA Medical Center. Serum levels of PTH and 25(OH)D were obtained. Surveys and chart reviews were completed. Vitamin D insufficiency was defined as 25(OH)D <30 ng/ml. Univariate and multivariate regression analyses were performed.

RESULTS

Among 232 African-American (AA) men (mean +/- SD), 25(OH)D level (21.4 +/- 10.4 ng/ml) was lower and prevalence of insufficiency (80%) was higher than among 75 Caucasians (C; 28.5 +/- 11.1 ng/ml and 53%, respectively, p < 0.01 for both). In multivariate regression analysis, independent determinants (p < 0.01 for all) of 25(OH)D levels included AA race, vitamin D supplements, BMI, dietary calcium intake, and smoking. Despite lower 25(OH)D levels in African-Americans, PTH levels were similar to those seen in Caucasians. There was a significant (p < 0.02) negative linear association between 25(OH)D and PTH in African-American (r(2) = 0.05) and Caucasian (r(2) = 0.08) men, and there was no difference between the slopes of the relationship.

CONCLUSIONS

25(OH)D levels are determined by modifiable risk factors such as vitamin D supplementation in both AA and C males. The negative association between 25(OH)D and PTH is similar between the two races.

Effects of vitamin D insufficiency on bone mineral density in African American men

In African American men serum, 25-hydroxyvitamin D (25-OHD) was below 30 ng/ml in 89% of subjects. In overall group, there was no correlation between 25-OHD and bone mineral density (BMD). A subgroup analysis of subjects with 25-OHD <or=15 ng/ml showed that serum 25-OHD was positively associated with BMD.

INTRODUCTION

This study examined the effects of low serum 25-hydroxyvitamin D (25-OHD) on bone mineral density (BMD) in African American (AA) men from the general medicine clinic at an inner city Veteran Administration medical center.

METHODS

The data for 112 AA males who had both 25-OHD levels and BMD of spine and hip were extracted and analyzed using SAS software.

RESULTS

AA men were aged 38 to 85 years, with mean age of 62 years. Levels of 25-OHD ranged from 4 to 45 ng/ml, with mean 17.5 ng/ml, 24% and 89% of the subjects had 25-OHD below 10 and 30 ng/ml, respectively. In the overall group, there was no correlation between 25-OHD and BMD at any site. In a subgroup analysis of subjects with 25-OHD <or=15 ng/ml, in multiple adjusted models, 25-OHD was positively associated with BMD of spine (r = 0.26, p = 0.05), total hip (r = 0.27, p < 0.05), ward's triangle (r = 0.25, p = 0.05), and trochanter (r = 0.30, p < 0.05).

CONCLUSIONS

The negative effect of vitamin D insufficiency on bone was observed only at very low levels of 25-OHD, suggesting that AA male skeleton is relatively resistant to the effects of secondary hyperparathyroidism.

Diagnosis of asymptomatic primary hyperparathyroidism: proceedings of the third international workshop

OBJECTIVE

Asymptomatic primary hyperparathyroidism (PHPT) is a common clinical problem. The purpose of this report is to guide the use of diagnostic tests for this condition in clinical practice.

PARTICIPANTS

Interested professional societies selected a representative for the consensus committee and provided funding for a one-day meeting. A subgroup of this committee set the program and developed key questions for review. Consensus was established at a closed meeting that followed. The conclusions were then circulated to the participating professional societies.

EVIDENCE

Each question was addressed by a relevant literature search (on PubMed), and the data were presented for discussion at the group meeting.

CONSENSUS PROCESS

Consensus was achieved by a group meeting. Statements were prepared by all authors, with comments relating to accuracy from the diagnosis subgroup and by representatives from the participating professional societies.

CONCLUSIONS

We conclude that: 1) reference ranges should be established for serum PTH in vitamin D-replete healthy individuals; 2) second- and third-generation PTH assays are both helpful in the diagnosis of PHPT; 3) DNA sequence testing can be useful in familial hyperparathyroidism or hypercalcemia; 4) normocalcemic PHPT is a variant of the more common presentation of PHPT with hypercalcemia; 5) serum 25-hydroxyvitamin D levels should be measured and, if vitamin D insufficiency is present, it should be treated as part of any management course; and 6) the estimated glomerular filtration rate should be used to determine the level of kidney function in PHPT: an estimated glomerular filtration rate of less than 60 ml/min.1.73 m2 should be a benchmark for decisions about surgery in established asymptomatic PHPT.

Closing the gap: bone health education in orthopaedic practice

Bone health education in an orthopaedic office and hospital setting is uncommon, yet essential. Many benefits are possible for patients by preventing future fractures and improving quality of life in those afflicted with osteoporosis and osteopenia. Ninety percent of hip fractures are due to osteoporosis; only stroke occupies more hospital bed days than hip fracture each year. Clinical time constraints, physician unawareness, cost-effectiveness, and patient noncompliance include some of the obstacles to education. Orthopaedic nurses can be a vital part of the challenging solution to removing barriers and bridging the educational gap for physicians and patients.

Short and long-term variations in serum calciotropic hormones after a single very large dose of ergocalciferol (vitamin D2) or cholecalciferol (vitamin D3) in the elderly

CONTEXT

In humans, few studies have compared the potencies of ergocalciferol and cholecalciferol in improving and maintaining vitamin D status.

OBJECTIVE

Our objective was to evaluate the effects of a single very large dose of both calciferols on serum changes of 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D [1,25(OH)(2)D], ionized calcium, and parathyroid hormone (PTH) at baseline, and at 3, 7, 30, and 60 d.

DESIGN

This was a prospective randomized intervention study.

SETTING

The study was performed in a nursing home residence.

PARTICIPANTS

A total of 32 elderly female patients (age range 66-97 yr), with vitamin D deficiency was included in the study.

INTERVENTION

Participants were randomized into four groups of eight to receive a single dose of 300,000 IU ergocalciferol or cholecalciferol by oral (os) or im route.

RESULTS

25(OH)D levels sharply increased at d 3 only when vitamins were given os. The 30-d basal difference in serum 25(OH)D was significantly greater after cholecalciferol os administration (47.8 +/- 7.3 ng/ml) compared with other forms (D(3) im: 15.9 +/- 11.3; D(2) os: 17.3 +/- 4.7; D(2) im: 5 +/- 4.4; all P < 0.001). The area under the curve (AUC) of the serum 25(OH)D against time (AUC(60)) was: D(3) os, 3193 +/- 759 ng x d/ml vs. D(2) os, 1820 +/- 512, P < 0.001; and D(3) im, 1361 +/- 492 vs. D(2) im, 728 +/- 195, P < 0.01. 25(OH)D significantly influences PTH levels at 3 (P < 0.03), 7 (P < 0.01), 30 (P < 0.01), and 60 d (P < 0.05). At 60 d, the form of vitamin (cholecalciferol) significantly lowers PTH levels (P = 0.037).

CONCLUSIONS

Cholecalciferol is almost twice as potent as ergocalciferol in increasing serum 25(OH)D, when administered either by mouth or im. 25(OH)D plays a role in modulating serum PTH.