High prevalence of low femoral bone mineral density in elderly women living in nursing homes or community-dwelling: a plausible role of increased parathyroid hormone secretion

Prevalence of vitamin D inadequacy in European women aged over 80 years

Inadequate vitamin D status is associated with secondary hyperparathyroidism and increased bone turnover and bone loss, which in turn increases fracture risk. The objective of this study is to assess the prevalence of inadequate vitamin D status in European women aged over 80 years. Assessments of serum 25-hydroxyvitamin D levels (25(OH)D) were performed on 8532 European women with osteoporosis or osteopenia of which 1984 were aged over 80 years. European countries included in the study were: France, Belgium, Denmark, Italy, Poland, Hungary, United Kingdom, Spain and Germany. Two cut-offs of 25(OH)D inadequacy were fixed: <75 nmol/L (30 ng/ml) and <50 nmol/L (20 ng/ml). Mean (SD) age of the patients was 83.4 (2.9) years, body mass index was 25.0 (4.0) kg/m(2) and level of 25(OH)D was 53.3 (26.7) nmol/L (21.4 [10.7] ng/ml). There was a highly significant difference of 25(OH)D level across European countries (p<0.0001). In these women aged over 80 years, the prevalence of 25(OH)D inadequacy was 80.9% and 44.5% when considering cut-offs of 75 and 50 nmol/L, respectively. In the 397 (20.0%) patients taking supplemental vitamin D with or without supplemental calcium, the mean serum 25(OH)D level was significantly higher than in the other patients (65.2 (29.2) nmol/L vs. 50.3 (25.2) nmol/L; P<0.001). This study indicates a high prevalence of vitamin D (25(OH)D) inadequacy in old European women. The prevalence could be even higher in some particular countries.

Genetic analysis of recently identified osteoporosis susceptibility genes in southern Chinese

CONTEXT

Fifty-six genomic loci recently were identified as associated with bone mineral density (BMD) in a large meta-analysis study of mainly European-descent subjects. Circulating factors related to calcium and phosphate metabolism, eg, serum levels of calcium, phosphate, vitamin D metabolites, PTH, and alkaline phosphatase (ALP), may affect bone turnover and metabolism.

OBJECTIVE AND DESIGN

We aimed to investigate the effects of these reported variants, as well as their interactions with 5 studied circulating factors, on BMD in a southern Chinese prospective cohort (n = 2670). The identified interactions were further replicated in an independent cohort of 800 Chinese females.

RESULTS

Approximately half (n = 27) of the reported variants were successfully replicated in our sample of southern Chinese individuals. We further demonstrated a significant interaction between MARK3 and serum ALP levels (Pmeta = 9.89 ×10(-6)); the effect of MARK3 rs11623869 on BMD was stronger in the presence of high serum levels of ALP. In addition, several interactions between other genes and circulating factors were suggested.

CONCLUSIONS

Our study has provided an independent replication of associations between several reported loci and BMD in a large sample of southern Chinese individuals. These replicated loci may represent osteoporosis susceptibility genes in both Chinese and European-descent populations. Furthermore, we have shown that serum ALP levels modified the association of MARK3 with BMD. Understanding the mechanisms of the interactions between BMD-related loci and circulating factors may help to determine the pathogenesis of susceptibility to osteoporosis and could have implications for clinical care.

Prevalence of vitamin D insufficiency and low bone mineral density in elderly Thai nursing home residents

Background

Numerous emerging data from research on osteoporosis among Asians found differences from Caucasians. Therefore, the aim of this study was to determine the prevalence of vitamin D insufficiency and osteoporosis in elderly participants from two nursing homes in Thailand, a country located near the equator.

Methods

The subjects of this cross-sectional study comprised 93 elderly Thai women who were living in institutional long-term nursing homes for the aged. Demographic data, daily food and calcium intake, physical activity, and sunlight exposure were measured. Lumbar spine and femoral neck bone mineral density (BMD) and biochemical levels including serum 25 hydroxyvitamin D [25(OH)D] and bone turnover markers were assessed. Vitamin D insufficiency was defined as 25(OH)D level < 70 nmol/l.

Results

The mean age of subjects was 75.2 ± 6.0 (SD) years. Dietary calcium intake was low (322 ± 158 mg/day) The mean 25(OH)D level was 64.3 ± 14.9 nmol/L and the prevalence of vitamin D insufficiency was 38.7% (95% CI: 28.8%, 49.4%). There was no correlation between serum 25(OH)D concentrations and age (r = −.11, p = 0.3). The mean BMD of lumbar spine and femoral neck were 0.92 ± 0.19 and 0.65 ± 0.10 g/cm², respectively. Nearly a half of the subjects had osteopenia (44.1%, 95% CI: 33.8%, 54.8%) and osteoporosis (47.3%, 95% CI: 36.9%, 57.9%). Circulating C-terminal telopeptide of type I collagen (CTx) level correlated significantly with both lumbar spine (r = −0.26, p = 0.01) and femoral neck BMD (r = −0.25, p = 0.02).

Conclusions

More than one-third of Thai elderly women residing in nursing homes had vitamin D insufficiency. Almost all nursing home residents had osteoporosis and/or osteopenia.

Nutritional and biochemical parameters associated with 6-year change in bone mineral density in community-dwelling Japanese women aged 69 years and older: The Muramatsu Study

OBJECTIVE

Predictors of bone loss in elderly Asian women have been unclear. This cohort study aimed to assess lifestyle, nutritional, and biochemical predictors of bone loss in elderly Japanese women.

METHODS

Subjects included 389 community-dwelling women aged 69 y and older from the Muramatsu cohort initiated in 2003; follow-up ended in 2009. We obtained data on physical characteristics, osteoporosis treatment (with bisphosphonates or selective estrogen receptor modulators), physical activity, calcium intake, serum 25-hydroxyvitamin D, undercarboxylated osteocalcin, serum albumin, and bone turnover markers as predictors. The outcome was a 6-y change in forearm BMD (ΔBMD). Osteoporosis treatment was coded as 0 for none, 1 for sometimes, and 2 for always during the follow-up period. Stepwise multiple linear regression analysis was used to identify independent predictors of ΔBMD.

RESULTS

Mean age of the subjects was 73.3 y. Mean values of ΔBMD and Δweight were -0.019 g/cm(2) (-5.8%) and -2.2 kg, respectively. Stepwise multiple linear regression analysis revealed baseline BMD (β = -0.137, P < 0.0001), osteoporosis treatment (β = 0.0068, P = 0.0105), serum albumin levels (β = 0.0122, P = 0.0319), and Δweight (β = 0.0015, P = 0.0009) as significant independent predictors of ΔBMD. However, none of the other nutritional or biochemical indices were found to be significant predictors of ΔBMD.

CONCLUSIONS

Our findings indicate that adequate general nutrition and appropriate osteoporosis medication, rather than specific nutritional regimens, may be effective in preventing bone loss in elderly women.

Vitamin D insufficiency: a risk factor to vertebral fractures in community-dwelling elderly women

OBJECTIVE

To determine the risk factors for the presence of moderate/severe vertebral fracture, specifically 25-hydroxyvitamin D (25-OHD).

STUDY DESIGN

Cross-sectional study conducted for 2 years in the city of São Paulo, Brazil including community-dwelling elderly women.

METHODS

Bone mineral density (BMD), serum 25-OHD, intact parathyroid hormone (iPTH), calcium and estimated glomerular filtration rate (eGFR) were examined in 226 women without vertebral fractures (NO FRACTURE group) and 189 women with at least one moderate/severe vertebral fracture (FRACTURE group). Vertebral fracture assessment (VFA) was evaluated using both the Genant semiquantitative (SQ) approach and morphometry.

RESULTS

Patients in the NO FRACTURE group had lower age, increased height, higher calcium intake, and higher BMD compared to those patients in the FRACTURE group (p<0.05). Of interest, serum levels of 25-OHD in the NO FRACTURE group were higher than those observed in the FRACTURE group (51.73 nmol/L vs. 42.31 nmol/L, p<0.001). Reinforcing this finding, vitamin D insufficiency (25-OHD<75 nmol/L) was observed less in the NO FRACTURE group (82.3% vs. 93.65%, p=0.001). After adjustment for significant variables within the patient population (age, height, race, calcium intake, 25-OHD, eGFR and sites BMD), the logistic-regression analyses revealed that age (OR=1.09, 95% CI 1.04-1.14, p<0.001) femoral neck BMD (OR=0.7, 95% CI 0.6-0.82, p<0.001) and 25-OHD <75 nmol/L (OR=2.38, 95% CI 1.17-4.8, p=0.016) remains a significant factor for vertebral fracture.

CONCLUSION

Vitamin D insufficiency is a contributing factor for moderate/severe vertebral fractures. This result emphasizes the importance of including this modifiable risk factor in the evaluation of elderly women.

Comparative 25-OH-vitamin D level in institutionalized women older than 65 years from two cities in Spain and Argentina having a similar solar radiation index

OBJECTIVE

The present study evaluated and compared vitamin D nutritional status and calcium-phosphorus metabolism in institutionalized women >65 y from two cities that have a similar sun irradiation index (heliophany).

METHODS

The study was carried out in women living in similar social-status institutions from geographic cities having a similar solar radiation index (Lleida, Spain, n=49, and suburban Buenos Aires, Argentina [BA], n=48) at the end of summer.

RESULTS

Fish consumption was higher in the Lleida group, as was red-meat consumption in the BA group. In both groups mean calcium intake was 800 mg/d. The daily intake of vitamin D was higher in the BA group (P<0.001). A total of 90% in Lleida and 86% in BA had 25-hydroxyvitamin D (25OHD) levels <20 ng/mL. A significant inverse correlation between individual 25OHD and parathyroid hormone (PTH) levels was observed in the two groups of women (r=-0.329, P=0.035). PTH levels >100 pg/mL were found in 24% and 20% of women in Lleida and BA, respectively. There was a marked increase in carboxy-terminal telopeptide cross-links of type I collagen levels and a decrease in 25OHD with an increase in PTH levels (P<0.05). Conversely, bone alkaline phosphatase increased significantly only when the PTH concentration duplicated the reference range.

CONCLUSION

Even at the end of summer, vitamin D deficiency/insufficiency was prevalent in the two studied institutionalized elderly women. In the narrow range of the dietary calcium intake (close to 800 mg/d) of both studied groups, secondary hyperparathyroidism was absent when 25OHD levels were >17 ng/dL, indicating changes in the regulation control of serum PTH and consequently the changes in this threshold. As a result, vitamin D deficiency must be reversed to avoid the increment in bone turnover and to ensure the endocrine and paracrine functions of vitamin D for overall health and well-being.

Highest prevalence of vitamin D inadequacy in institutionalized women compared with noninstitutionalized women: a case-control study

The reduced capacity of older skin to synthesize vitamin D(3) under the influence of ultraviolet light makes older persons at risk of vitamin D deficiency. The risk could even be increased in institutionalized persons owing to their lower sunshine exposure. It has been reported that an inadequate vitamin D level is associated with secondary hyperparathyroidism, increased bone turnover, and bone loss, which increase fracture risk. The objective of this study was to assess the prevalence of inadequate serum vitamin D levels in institutionalized, postmenopausal, osteoporotic women. Assessment of 25-hydroxyvitamin D [25(OH)D] was performed in 445 institutionalized, osteoporotic women from nine countries (Australia, Belgium, France, Germany, Hungary, Italy, Poland, Spain and UK). For each institutionalized woman, three age-matched, noninstitutionalized, osteoporotic controls were also included. Four cutoffs of 25(OH)D inadequacy were fixed: less than 80, less than 75, less than 50 and less than 30 nmol/l. Mean age was 79.7 years (standard deviation [SD] = 5.8) for the institutionalized women and 79.5 years (SD = 5.5) for the noninstitutionalized women (p = 0.45). Significantly fewer institutionalized women received vitamin D supplements (13.2 vs 24.0%; p < 0.0001). In women without vitamin D supplements, the level of 25(OH)D was significantly lower in institutionalized women (56.9 [SD = 23.9] nmol/l) compared with noninstitutionalized women (63.2 [SD = 22.0] nmol/l; p < 0.0001). In institutionalized women (without vitamin D supplements), the prevalence of 25(OH)D inadequacy was 10.4, 41.2, 80.3 and 84.2% when considering cutoffs of 80, 75, 50 and 30 nmol/l, respectively. In the control group, the prevalence was 2.7, 22.9, 74.4 and 81.7%, respectively. The prevalence of vitamin D inadequacy was significantly higher in institutionalized women when considering the 75, 50 and 30 nmol/l cutoffs but not when considering the 80 nmol/l cutoff. This study highlights a high prevalence of vitamin D inadequacy in institutionalized, osteoporotic women. Compared with age-matched osteoporotic controls, the prevalence of severe vitamin D inadequacy was substantially more important in institutionalized women. We believe that a greater awareness of the importance of vitamin D inadequacy is needed in order to address this public health problem.

Rapid correction of low vitamin D status in nursing home residents

This prospective study finds that ergocalciferol 50,000 IU three times weekly for four weeks effectively and safely corrects vitamin D inadequacy in nursing home residents.

INTRODUCTION

Low vitamin D status is common among nursing home residents and contributes to bone loss, falls and fractures. The objective of this study was to evaluate the efficacy and safety of short course, high dose, oral vitamin D(2) (ergocalciferol) treatment.

METHODS

This prospective study included 63 nursing home residents. The 25 with low vitamin D status (serum 25(OH)D < or = 25 ng/ml) received oral ergocalciferol 50,000 IU three times weekly for four weeks; the others received no change to their routine care. Serum total 25(OH)D, 25(OH)D(2), 25(OH)D(3), calcium, parathyroid hormone (PTH), bone turnover markers and neuro-cognitive assessments were obtained at baseline and four weeks.

RESULTS

Mean total 25(OH)D concentration increased (p < 0.0001) from 17.3 to 63.8 ng/ml in the treated group and remained unchanged in the comparison group. Serum 25(OH)D(3) remained stable in the comparison group, but declined (p < 0.0001) with D(2) treatment from 15.4 to 9.1 ng/ml. Serum PTH trended down in the treatment group (p = 0.06). No treatment-induced improvement in ambulation, cognition or behavior was observed. No hypercalcemia or other adverse effects were observed with ergocalciferol treatment.

CONCLUSION

Four weeks of oral vitamin D(2) supplementation effectively and safely normalizes serum 25(OH)D in nursing home residents.

Vitamin D inadequacy in French osteoporotic and osteopenic women

OBJECTIVE

Studies have shown that low serum vitamin D levels are associated with secondary hyperparathyroidism, which decreases bone strength and increases fracture risk, most notably after 50 years of age. The objective of this study was to evaluate the vitamin D status of postmenopausal women in France.

METHODS

We conducted a cross-sectional observational study of 1292 menopausal women with osteoporosis or osteopenia. The age range was 52-94 years. Serum 25-OH-vitamin D was assayed in each patient. Based on data in the literature, we used four 25-OH-D cutoffs to define vitamin D deficiency: 30, 50, 75, and 80 nmol/L (<12, <20, <30, and <32 ng/ml).

RESULTS

Mean serum 25-OH-D was 51.5+/-26.1 nmol/L (about 20.6+/-10.4 ng/ml). In the 343 (26.5%) patients taking supplemental vitamin D with or without supplemental calcium, the mean serum 25-OH-D level was significantly higher than in the other patients (65.0+/-26.0 ng/ml vs. 46.6+/-18.6 ng/ml; P<0.001). In the subgroup not taking vitamin D supplements, the prevalence of vitamin D deficiency was 27.3%, 54.1%, 89.9%, and 93.2% with the 30, 50, 75, and 80 nmol/L cutoffs, respectively. The mean 25-OH-D level varied across seasons (P<0.001), with the highest value being obtained in summer (53.4+/-18.7 nmol/L; about 21.3+/-7.5 ng/ml).

CONCLUSION

Vitamin D deficiency is common among postmenopausal women with osteoporosis or osteopenia in France.

Prevalence of vitamin D inadequacy in European postmenopausal women

OBJECTIVE

Inadequate vitamin D level is associated with secondary hyperparathyroidism and increased bone turnover and bone loss, which in turn increases fracture risk. The objective of this study is to assess the prevalence of inadequate serum vitamin D levels in postmenopausal European women. There are no clear international agreements on what constitutes a level of vitamin D inadequacy, but recent publications suggest that the circulating level of vitamin D should be over 80 nmol/L or at least between 50 and 80 nmol/L.

MATERIAL AND METHODS

Assessment of 25-hydroxyvitamin D [25(OH)D] was performed in 8532 European postmenopausal women with osteoporosis or osteopenia. European countries included France, Belgium, Denmark, Italy, Poland, Hungary, United Kingdom, Spain and Germany. Two cut-offs of 25(OH)D inadequacy were fixed : < 80 nmol/L and < 50 nmol/L.

RESULTS

Mean (SD) age of the patients was 74.2 (7.1) years, body mass index was 25.7 (4.1) kg/m(2). Level of 25(OH)D was 61.0 (27.2) nmol/L. There was a highly significant difference of 25(OH)D level across European countries (p < 0.0001). The lowest level of 25(OH)D was found in France [51.5 (26.1) nmol/L] and the highest in Spain [85.2 (33.3) nmol/L]. In the whole study population, the prevalence of 25(OH)D inadequacy was 79.6% and 32.1% when considering cut-offs of 80 and 50 nmol/L, respectively and when considering patients aged less than 65 years, the prevalence reached 86% (cut-off of 80 nmol/L) and 45% (cut-off of 50 nmol/L).

CONCLUSION

This study indicates a high prevalence of vitamin D [25(OH)D] inadequacy in European postmenopausal women. The prevalence could be even higher in some particular countries. A greater awareness of the importance of vitamin D inadequacy is needed to address this public health problem.

Vitamin D inadequacy in Belgian postmenopausal osteoporotic women

BACKGROUND

Inadequate serum vitamin D [25(OH)D] concentrations are associated with secondary hyperparathyroidism, increased bone turnover and bone loss, which increase fracture risk. The objective of this study is to assess the prevalence of inadequate serum 25(OH)D concentrations in postmenopausal Belgian women. Opinions with regard to the definition of vitamin D deficiency and adequate vitamin D status vary widely and there are no clear international agreements on what constitute adequate concentrations of vitamin D.

METHODS

Assessment of 25-hydroxyvitamin D [25(OH)D] and parathyroid hormone was performed in 1195 Belgian postmenopausal women aged over 50 years. Main analysis has been performed in the whole study population and according to the previous use of vitamin D and calcium supplements. Four cut-offs of 25(OH)D inadequacy were fixed : < 80 nmol/L, <75 nmol/L, < 50 nmol/L and < 30 nmol/L.

RESULTS

Mean (SD) age of the patients was 76.9 (7.5) years, body mass index was 25.7 (4.5) kg/m2. Concentrations of 25(OH)D were 52.5 (21.4) nmol/L. In the whole study population, the prevalence of 25(OH)D inadequacy was 91.3 %, 87.5 %, 43.1 % and 15.9% when considering cut-offs of 80, 75, 50 and 30 nmol/L, respectively. Women who used vitamin D supplements, alone or combined with calcium supplements, had higher concentrations of 25(OH)D than non-users. Significant inverse correlations were found between age/serum PTH and serum 25(OH)D (r = -0.23/r = -0.31) and also between age/serum PTH and femoral neck BMD (r = -0.29/r = -0.15). There is a significant positive relation between age and PTH (r = 0.16), serum 25(OH)D and femoral neck BMD (r = 0.07). (P < 0.05)Vitamin D concentrations varied with the season of sampling but did not reach statistical significance (P = 0.09).

CONCLUSION

This study points out a high prevalence of vitamin D inadequacy in Belgian postmenopausal osteoporotic women, even among subjects receiving vitamin D supplements.

Calcium and vitamin D in the prevention and treatment of osteoporosis - a clinical update

Combined calcium and vitamin D supplementation is an essential component of the management of osteoporosis, supported by a strong scientific rationale. The types of individuals who should receive calcium and vitamin D supplements are those: (i) patients with documented osteoporosis receiving antiresorptive or anabolic treatment; (ii) patients receiving glucocorticoids; and (iii) individuals with or at high risk of calcium and/or vitamin D insufficiencies, in particular older women and men. This article describes the evidence base that supports targeting these groups. Benefits are most apparent when 800 IU day(-1) vitamin D is complemented with a dose of 1000-1200 mg day(-1) elemental calcium. Compliance is also key to optimizing clinical efficacy.

Risk factors of osteoporosis in institutionalized older Thai people

INTRODUCTION

There are very few published studies on osteoporosis among the institutionalized elderly in Asian countries, where the incidence of osteoporosis is increasing rapidly. Our objectives were to determine both the prevalence and risk factors of osteoporosis, as assessed by calcaneal bone mineral density (BMD) measurements, in a Thai nursing home.

METHODS

Activities of daily living, the Mini-Mental State Examination, blood chemistry, body composition analysis, calcaneal quantitative ultrasound (QUS) and serum C-terminal telopeptides of type I collagen (serum beta-CTx) were assessed in 108 older people living in the largest nursing home for the elderly in Bangkok. Calcaneal BMD was measured by dual-energy X-ray absorptiometry (DXA).

RESULTS

The prevalence of osteoporosis, as defined by a calcaneal BMD T-score <1.6, was 79.6%. The prevalence of low bone mass, as defined by a T-score of broadband ultrasound attenuation <1.0, was 80.6%. The prevalence of osteoporosis detected by these two methods was not significantly different (p=1.00). The prevalence of increased bone turnover [with the cutoff point being the mean + 2 standard deviation (SD) of the serum beta-CTx level of a sex- and age-matched control group] was 13.9%. In multiple linear regression analysis, five risk factors -- serum beta-CTx, mental health, mobility index, height and lean body mass -- were able to predict calcaneal BMD at a coefficient of determination R(2)) of 0.54.

CONCLUSIONS

These results indicate the importance of mental health and self-care ability as factors associated with osteoporosis. Increased bone turnover was also a significant risk factor of low bone mass. Calcaneal QUS was a useful screening tool for diagnosing osteoporosis in this population and was comparable to calcaneal DXA.

The direct and indirect costs of the chronic management of osteoporosis: a prospective follow-up of 3440 active subjects

INTRODUCTION

The objective of this study was to estimate the direct and indirect costs attributable to osteoporosis (OP) from a societal and a payer's perspective among active subjects living in Belgium and employed in the public workforce.

MATERIALS AND METHODS

A cohort of 3440 subjects employed by the Liege City Council was followed for 6 months. The City Council employees were invited to fill a monthly log of the data related to their utilization of health resources (contacts with health professionals, medical examinations, drug use,...) due to OP. Information on work disability (number of days of sick leave) and on informal care (number of days off work incurred by active subjects in helping relatives or friends suffering from OP) was also collected.

RESULTS

Of those asked to participate in the study, 1,811 subjects filled in at least one questionnaire. The mean duration of follow-up was 3.46 months. Self-reported prevalence of OP at inclusion was 5.3%. OP subjects were significantly older (52.7+/-6.1 years) than normal subjects (45.5+/-9.8 years) (p<0.05) and included more women (85.3 vs. 55.9%). Direct costs came to 44.6 euros per OP patient-month: 10.9 euros was spent on contact with health professionals, 19.0 euros on medical examinations, 12.1 euros on drugs and 2.6 euros on hospitalizations. During this 6-month study, a total of 140 days of sick leave was recorded (mean: 0.4 per OP patient-month). From a payer's perspective, this loss in productivity yielded a mean cost of 34.05 euros per OP patient-month. A mean number of days off work of 0.018 per active subject-month, attributable to informal care, was recorded. These days of inactivity represented, for the employer, a mean cost of 1.8 euros per active subject-month.

CONCLUSION

The results of this survey of a large sample of active subjects confirm that OP-related expenditures, both for medical care and for loss of productivity, are significant.

The need for clinical guidance in the use of calcium and vitamin D in the management of osteoporosis: a consensus report

A European Union (EU) directive on vitamins and minerals used as ingredients of food supplements with a nutritional or physiological effect (2002/46/EC) was introduced in 2003. Its implications for the use of oral supplements of calcium and vitamin D in the prevention and treatment of osteoporosis were discussed at a meeting organized with the help of the World Health Organization (WHO) Collaborating Center for Public Health Aspects of Rheumatic Diseases (Liège, Belgium) and the support of the WHO Collaborating Center for Osteoporosis Prevention (Geneva, Switzerland). The following issues were addressed: Is osteoporosis a physiological or a medical condition? What is the evidence for the efficacy of calcium and vitamin D in the management of postmenopausal osteoporosis? What are the risks of self-management by patients in osteoporosis? From their discussions, the panel concluded that: (1) osteoporosis is a disease that requires continuing medical attention to ensure optimal therapeutic benefits; (2) when given in appropriate doses, calcium and vitamin D have been shown to be pharmacologically active (particularly in patients with dietary deficiencies), safe, and effective for the prevention and treatment of osteoporotic fractures; (3) calcium and vitamin D are an essential, but not sufficient, component of an integrated management strategy for the prevention and treatment of osteoporosis in patients with dietary insufficiencies, although maximal benefit in terms of fracture prevention requires the addition of antiresorptive therapy; (4) calcium and vitamin D are a cost-effective medication in the prevention and treatment of osteoporosis; (5) it is apparent that awareness of the efficacy of calcium and vitamin D in osteoporosis is still low and further work needs to be done to increase awareness among physicians, patients, and women at risk; and (6) in order that calcium and vitamin D continues to be manufactured to Good Manufacturing Practice standards and physicians and other health care professionals continue to provide guidance for the optimal use of these agents, they should continue to be classified as medicinal products.

The relationship between vitamin D and parathyroid hormone: calcium homeostasis, bone turnover, and bone mineral density in postmenopausal women with established osteoporosis

It is evident from several studies that not all patients with hypovitaminosis D develop secondary hyperparathyroidism. What this means for bone biochemistry and bone mineral density (BMD) remains unclear. The aim of this study was to investigate the effects of hypovitaminosis D (defined as a 25OHD < or = 30 nmol/l) and patients with a blunted PTH response (defined arbitrarily as a PTH within the standard laboratory reference range in the presence of a 25OHD < or = 30 nmol/l) in comparison to patients with hypovitaminosis D and secondary hyperparathyroidism (defined arbitrarily as a PTH above the standard laboratory reference range in the presence of a 25OHD < or = 30 nmol/l) and vitamin D-replete subjects (25OHD > 30 nmol/l). Four hundred twenty-one postmenopausal women (mean age: 71.2 years) with established vertebral osteoporosis were evaluated by assessing mean serum calcium, 25OHD, 1,25(OH)2D, bone turnover markers, and BMD. The prevalence of hypovitaminosis D was 39%. Secondary hyperparathyroidism was found in only one-third of these patients who maintained calcium homeostasis at the expense of increased bone turnover relative to the vitamin D-replete subjects (bone ALP mean difference: 43.9 IU/l [95% CI: 24.8, 59.1], osteocalcin: 1.3 ng/ml [95% CI: 1.1, 2.5], free deoxypyridinoline mean difference: 2.6 nmol/nmol creatinine [95% CI: 2.5, 4.8]) and bone loss (total hip BMD mean difference: 0.11 g/cm2 [95% CI: 0.09, 0.12]). Patients with hypovitaminosis D and a blunted PTH response were characterized by a lower serum calcium (mean difference: 0.07 mmol/l [95% CI: 0.08, 0.2]), a reduction in bone turnover (bone ALP mean difference: 42.4 IU/l [95% CI: 27.8, 61.9], osteocalcin: 1.6 ng/ml [95% CI: 0.3, 3.1], free-deoxypyridinoline mean difference: 3.0 nmol/nmol creatinine [95% CI: 1.9, 5.9]), but protection in bone density (total hip BMD mean difference: 0.10 g/cm2, [95% CI: 0.08, 0.11]) as compared to those with hypovitaminosis D and secondary hyperparathyroidism. This study identifies a distinct group of patients with hypovitaminosis D and a blunted PTH response who show a disruption in calcium homeostasis but protected against PTH-mediated bone loss. This has clinical implications with respect to disease definition and may be important in deciding the optimal replacement therapy in patients with hypovitaminosis D but a blunted PTH response.

Low bone density and abnormal bone turnover in patients with atherosclerosis of peripheral vessels

Patients with vascular calcifications often have low bone mineral density (BMD), but it is still uncertain if osteoporosis and peripheral vascular disease (VD) are interrelated and linked by a common pathomechanism. Moreover, data on bone turnover in patients with advanced atherosclerosis are lacking. We measured BMD by dual-energy X-ray absorptiometry (DXA) and quantitative bone ultrasound (QUS), as well as the serum levels of osteocalcin (OC), bone-specific alkaline phosphatase (BAP), osteoprotegerin (OPG) and its ligand RANKL, and the urinary concentration of the C-terminal telopeptides of type I collagen (CrossLaps), in 36 patient (20 male and 16 female) with serious atherosclerotic involvement of the carotid and/or femoral artery to investigate the underlying mechanism of vascular and osseous disorders. Thirty age-matched and gender matched healthy individuals served as controls. After adjustment for age, BMD was significantly reduced at the lumbar spine in 23/36 (63%) patients (mean T score -1.71+/-1.42) and at the proximal femur in 34/36 (93%) patients (neck mean T score -2.5+/-0.88). Ten patients (27%) had abnormal QUS parameters. Gender and diabetes had no effect on the relationship between vascular calcification and bone density at any site measured. VD subjects had OC and BAP serum levels lower than controls (13.3+/-3.1 vs 27.7+/-3.3 ng/ml, P<0.01, and 8.4+/-2.3 vs 12.5+/-1.4 microg/l, P<0.01, respectively). Urinary CrossLaps excretion was not significantly different in patients with VD and in controls (257.9+/-138.9 vs 272.2+/-79.4 micro g/mmol Cr, respectively). Serum OPG and RANKL levels were similar in patients and in controls (3.5+/-1.07 vs 3.4+/-1.05 pmol/l, and 0.37+/-0.07 vs 0.36+/-0.06 pmol/l, respectively). We proved high occurrence of osteoporosis in VD, with evidence of age and gender independence. Negative bone remodelling balance would be a consequence of reduced bone formation, with no apparent increased activation of the OPG-RANKL system.

Hypovitaminosis D and hyperparathyroidism in physically inactive elderly Japanese living in nursing homes: relationship with age, sunlight exposure and activities of daily living

BACKGROUND AND AIMS

The purposes of this study were to investigate the prevalences of hypovitaminosis D and hyperparathyroidism in physically inactive elderly people living in Japanese nursing homes and determine any correlations with demographic, environmental and/or life-style factors.

METHODS

We targeted 220 elderly people living in nursing homes for the physically disabled in Japan. Of these, 133 (women, 113; men, 20) subjects who agreed and met our inclusion criteria were studied. The average age of the subjects was 84.6 years (SD 8.2). Serum 25-hydroxyvitamin D3 (25[OH]D3), intact parathyroid hormone (intact PTH), creatinine, and albumin concentrations were measured in each subject. Total hours of sunshine during the previous 5 weeks, activities of daily living (ADL) levels, and dietary vitamin D intake were also measured. ADL levels were evaluated using the Physical Self-Maintenance Scale (5-point scale). The examinations were performed between October and December, 1999.

RESULTS

The average concentrations of serum 25(OH)D3 and intact PTH were 29.9 nmol/L (SD 13.1) and 5.04 pmol/L (SD 2.27), respectively. The prevalences of hypovitaminosis D (25[OH]D3<30 nmol/L) and hyperparathyroidism (intact PTH>6.90 pmol/L) were 77/133 (57.9%) and 21/133 (15.8%), respectively. Serum 25(OH)D3 concentrations were positively associated with hours of sunshine (R2=0.371, p<0.001) and serum albumin concentrations (R2=0.086, p<0.001), but not with age (p=0.075) or total ADL score (p=0.527). A negative association between serum intact PTH and 25(OH)D3 levels was found in subjects who were 80 years or older (p<0.001) but not in subjects under the age of 80 years.

CONCLUSIONS

Hypovitaminosis D and hyperparathyroidism are commonly seen in elderly Japanese with low ADL levels. Hypovitaminosis D seems to adversely affect PTH levels, especially in the very elderly.

Administration of a supplement containing both calcium and vitamin D is more effective than calcium alone to reduce secondary hyperparathyroidism in postmenopausal women with low 25(OH)vitamin D circulating levels

BACKGROUND AND AIMS

Supplementation of postmenopausal women with calcium alone or calcium-vitamin D association was suggested to have positive effects on bone turnover and bone density, as well as to lower fracture incidence. The beneficial effect appears to be mediated by a reduction in parathyroid hormone secretion. Our aim was to compare the respective efficacy of calcium and calcium-vitamin D supplements in reducing serum parathyroid hormone levels in postmenopausal women with prevalent low 25(OH)vitamin D levels.

METHODS

One hundred consecutive ambulatory postmenopausal women with serum 25(OH)vitamin D levels below 18 ng/mL were included in a randomized, prospective, open label study. For a duration of 90 days, the women were randomly assigned to a daily supplementation of either one tablet of calcium gluconolactate and carbonate (500 mg calcium), or one powder-pack of an association of calcium carbonate (500 mg calcium), citric acid (2.175 gr) and cholecalciferol (200 IU). Changes observed during the 90 days of the study in circulating PTH levels were the primary endpoint, while changes in serum 25(OH)D levels were assessed as secondary endpoint.

RESULTS

A significant difference was observed between the calcium-vitamin D (CaD) and the calcium (Ca) only groups for changes occurring during the 90 days of the study in PTH (-14.5+/-40% and +2.5+/-46%) (p=0.009) and 25(OH)D (+67+/-77% and +18+/-55%) (p<0.001) circulating levels. PTH changes between baseline and day 90 were significant in the CaD group, but not in the Ca group. The odds ratio for a patient in group Ca to experience an absolute (<12 ng/mL) deficiency in circulating 25(OH)vitamin D levels, compared to a group CaD patient was statistically increased (OR: 3.22, 95% CI: 1.33-7.80).

CONCLUSIONS

Our results support the recommendation of supplementing postmenopausal women with low circulating levels of 25(OH)vitamin D with a combination of calcium and vitamin D, rather than with calcium alone.

The contribution of nutritional factors to osteopenia in the elderly

Calcium and vitamin D deficiency increase age-related bone loss by causing secondary hyperparathyroidism. Reduced endogenous vitamin D synthesis exacerbates the problem of dietary deficiency and involves elderly people living in their own homes, who are just as much at risk as those living in institutionalized care. The effects of secondary hyperparathyroidism may be offset by hypercalcaemia of the increased bone turnover of immobility, which has a direct adverse effect on the skeleton causing osteoporosis. Active vitamin D analogues are effective in suppressing secondary hyperparathyroidism caused by vitamin D deficiency. However, simple deficiency is optimally treated with parent vitamin D, which has a greater safety margin than active vitamin D therapy (1,25 dihydroxyvitamin D), which requires close monitoring in the elderly.