Lack of association between vitamin D levels and bone mineral density in patients with multiple sclerosis

Body Composition and Its Outcomes and Management in Multiple Sclerosis: Narrative Review

Background: There is emerging interest in obesity and its prevalence, outcomes, and management in people with multiple sclerosis (MS). Body mass index (BMI) is the traditional marker of obesity in MS, whereas body composition, inclusive of specific body tissue compartments (e.g., fat, bone, and muscle), is often overlooked despite its relevance. Objective: This narrative review (a) underscored the use and utility of dual-energy X-ray absorptiometry (DEXA) as an accurate and reliable measure of body composition; (b) thematically analyzed and synthesized the current evidence regarding body composition (using DEXA); and (c) determined gaps to be addressed in future research. Methods: The structure and reporting of this narrative review followed the guiding criteria outlined in the Scale for the Assessment of Narrative Review Articles (SANRA). The relevant literature for this narrative review was identified via a PubMed search utilizing combined search terms such as 'body composition' and 'multiple sclerosis'. The identified research was then organized by the authors into major themes and sub-themes. The articles described within the narrative review were based on saturation of the identified themes and sub-themes. Results: Three major themes were identified, namely (1) comparison of body composition between people with MS and non-MS controls (2 meta-analyses); (2) examination of the relationships between body composition and a range of outcomes (14 cross-sectional studies); and (3) interventions that report and/or target body composition in MS (11 clinical trials). Conclusions: This narrative review mapped the existing evidence regarding body composition in MS, and posits body composition as a novel, informative, and targeted concept for this population. The narrative review underscores the importance of randomized controlled trials that focus on body composition as a significant and modifiable outcome. Such research could improve the understanding of obesity and poor body composition in MS and identify useful clinical recommendations for diagnosis and management.

Bone loss and fracture in people with multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

People with multiple sclerosis (PwMS) exhibit reduced bone mineral density (BMD) across several anatomical regions. Studies have indicated that PwMS are at a heightened risk of fractures due to decreased BMD and increased prevalence of osteopenia and osteoporosis. This study aimed to investigate the prevalence and risk of osteopenia, osteoporosis, and fracture among PwMS.

METHODS

Relevant studies were identified through comprehensive searches of databases (PubMed/MEDLINE, Scopus, Embase, and Web of Science) from January 1, 2000, to January 21, 2024. R software version 4.4.0 and random-effects models were employed to estimate the pooled prevalence, odds ratio (OR), and risk ratio (RR) of osteopenia, osteoporosis, and fracture among PwMS, along with their respective 95 % confidence intervals (CIs).

RESULTS

From a total of 2039 articles, 51 studies with 1,503,785 PwMS met our inclusion criteria. The pooled prevalence of osteopenia, osteoporosis, and overall fracture among PwMS was 41.41 % (95 % CI: 36.14% to 46.69 %, I2=97 %), 14.21 % (95 % CI: 10.75 % to 17.68 %, I2=99 %), and 12.84 % (95 % CI: 8.49 % to 17.19 %, I2 = 100 %), respectively. The likelihood of osteopenia (OR=2.02, 95 % CI: 1.46 to 2.8, p-value<0.01, I2=17 %) and osteoporosis (OR=1.71, 95 % CI: 1.27 to 2.31, p-value<0.01, I2=74 %), as well as the probability of overall fracture (RR=1.86, 95 % CI: 1.61 to 2.14, p-value<0.01, I2=74 %) were significantly higher in PwMS than healthy controls (HCs).

CONCLUSION

PwMS were at a substantially increased risk of developing osteopenia (2-fold), osteoporosis (1.7-fold), and overall fractures (1.9-fold). Well-designed studies are needed to explore these associations further.

Screening for osteoporosis in people with MS: A new risk score

BACKGROUND

Due to the demographic development and improved treatment options, the role of comorbidities is of increasing importance in the medical care of people with MS (pwMS). A higher risk of osteoporosis is well known in chronic autoimmune diseases, and is also described in MS. While there are several screening guidelines in the elderly or in patients with rheumatoid arthritis, there are no generally accepted recommendations when to perform bone mineral testing in pwMS under the age of 65 years. We aimed to determine risk factors of osteoporosis in pwMS and to develop a risk score which can be applied in daily clinical routine.

METHODS

Densitometry (hip and lumbar spine) was performed in 159 pwMS aged ≤65 years and in 81 age- and sex-matched healthy controls (HC). Osteoporosis was defined according to WHO criteria as a bone density 2.5 standard deviation or more below the mean of young adults. Risk factors were identified by logistic regression analysis.

RESULTS

Osteoporosis occurred more frequently in postmenopausal pwMS and male pwMS as compared to HC. Besides age, sex, menopausal status in females, body-mass-index and smoking, a higher degree of disability - as assessed by the Expanded Disability Status Scale - was identified as MS specific risk factor for osteoporosis, whereas the cumulative glucocorticoid dose was not associated with osteoporosis risk. Based on these risk factors, we developed an MS-specific risk score which allows to estimate the individual probability of osteoporosis.

CONCLUSION

This risk score enables individual screening recommendation for pwMS and, subsequently, early prevention of osteoporosis which probably should result in reduction of fractures and morbidity.

The prevalence of osteoporosis/osteopenia in patients with multiple sclerosis (MS): a systematic review and meta-analysis

BACKGROUND

The prevalence of osteoporosis is reported differently. We designed this systematic review and meta-analysis to estimate pooled prevalence of osteoporosis and osteopenia in patients with MS.

METHODS

Independently, two researchers searched PubMed, Scopus, EMBASE, Web of Science, and google scholar along with gray literature (conference abstracts and references of the references) up to March 2021. We collected data regarding first author, country of origin, number of enrolled patients, number cases with osteoporosis/ osteopenia, mean age, F/M ratio, mean EDSS, and mean duration of the disease.

RESULTS

Literature search revealed 847 articles and 658 remained after deleting duplicates. Finally, 29 original articles and 6 conference papers remained for meta-analysis. A total of 13,906 patients were evaluated. The pooled prevalence of osteoporosis was 17% (95% CI: 14-20%) (I² = 90.4%, p < 0.001). The pooled prevalence of osteopenia was 43% (95% CI: 35-51%) (I² = 97.9%, p < 0.001).

CONCLUSION

Osteoporosis/osteopenia should be considered in patients with MS.

Determinants of low bone mineral density in people with multiple sclerosis: Role of physical activity

BACKGROUND

People with multiple sclerosis (PwMS) have reduced bone mineral density (BMD), but the causes are unclear. Some factors that may cause reduced BMD in PwMS have been understudied, including physical activity, inflammation, cortisol, symptomatic fatigue, and depression. The aim of this study was to investigate factors that may uniquely contribute to reduced BMD in PwMS as compared to people without MS. We hypothesized that physical activity would be the primary determinant of low BMD in PwMS, with additional contributions from inflammation and sympathetic nervous system activation.

METHODS

We tested 23 PwMS (16 women; median EDSS: 2) and 22 control participants (16 women). BMD was measured from the femoral neck and lumbar spine with dual x-ray absorptiometry. Disability was measured with the Expanded Disability Status Scale, and functional capacity was measured with the Multiple Sclerosis Functional Composite. Questionnaires measured symptomatic fatigue and depression. A blood draw was used to measure calcium, phosphate, vitamin D, N-terminal telopeptide, osteopontin, and cytokine markers of inflammation. Physical activity was measured with accelerometry. Salivary cortisol and cardiac heart rate variability also were obtained. All outcome variables were compared between groups with independent samples t-tests. Variables that were different between groups and significantly correlated (Pearson product-moment) with femoral neck BMD, were included in a theoretical model to explain femoral neck BMD. The expected direction of relations in the theoretical model were developed based upon the results of previous research. A Bayesian path analysis was used to test the relations of predictive variables with femoral neck BMD and interrelations among predictive variables, as detailed in the theoretical model.

RESULTS

PwMS had lower BMD at the femoral neck than controls (p = =0.04; mean difference: -0.09; 95% CI: -0.2, -0.004; Cohen's d = =0.65), and there was a smaller, statistically non-significant difference in BMD at the lumbar spine (p = =0.07; mean difference: -0.08; 95% CI: -0.17, 0.007; Cohen's d = =0.59). PwMS also had lower functional capacity (p ≤ 0.001; Cohen's d = =1.50), greater fatigue (p<0.001; Cohen's d = =1.88), greater depression (p<0.001; d = =1.31), and decreased physical activity (p = =0.03; Cohen's d = =0.62). Using path analysis to test our theoretical model, we found that disability (standardized estimate= -0.17), physical activity (standardized estimate=0.39), symptomatic fatigue (standardized estimate= -0.36), depression (standardized estimate= -0.30), and inflammatory markers (standardized estimate=0.27) explained 51% of the variance in femoral neck BMD. Inflammatory markers were also predictive of disability (standardized estimate=0.44) and physical activity (standardized estimate= -0.40). Symptomatic fatigue and depression were correlated (r = =0.64).

CONCLUSION

Physical activity, symptomatic fatigue, depression, disability, and inflammation all contributed independently to decreased femoral neck BMD in PWMS. Bone metabolism in PwMS is complex. Efforts to increase physical activity and address symptomatic fatigue and depression may improve bone mineral density in PwMS. Future research should investigate the mechanisms through which symptomatic fatigue and depression contribute to reduced BMD in PwMS.

Assessment of Biochemical and Densitometric Markers of Calcium-Phosphate Metabolism in the Groups of Patients with Multiple Sclerosis Selected due to the Serum Level of Vitamin D3

Background

In addition to the widely known effect of vitamin D₃ (vitD₃) on the skeleton, its role in the regulation of the immune response was also confirmed.

Aim

The assessment of biochemical and densitometric markers of calcium-phosphate metabolism in the groups of patients with relapsing-remitting multiple sclerosis (RRMS) selected due to the serum level of vitamin D₃.

Methods

The concentrations of biochemical markers and indices of lumbar spine bone densitometry (DXA) were determined in 82 patients divided into vitamin D₃ deficiency (VitDd), insufficiency (VitDi), and normal vitamin D₃ level (VitDn) subgroups.

Results

The highest level of the parathyroid hormone (PTH) and the highest prevalence of hypophosphatemia and osteopenia were demonstrated in VitDd group compared to VitDi and VitDn. However, in VitDd, VitDi, and VitDn subgroups no significant differences were observed in the levels of alkaline phosphatase (ALP) and ionized calcium (Ca²⁺) and in DXA indices. A negative correlation was observed between the level of vitamin D₃ and the Expanded Disability Status Scale (EDSS) in the whole MS group. The subgroups were significantly different with respect to the EDSS scores and the frequency of complaints related to walking according to the EQ-5D.

Conclusions

It is necessary to assess calcium-phosphate metabolism and supplementation of vitamin D₃ in RRMS patients. The higher the clinical stage of the disease assessed with the EDSS, the lower the level of vitamin D₃ in blood serum. Subjectively reported complaints related to difficulties with walking were reflected in the EDSS in VitDd patients.

Risk Factors, Epidemiology and Treatment Strategies for Metabolic Bone Disease in Patients with Neurological Disease

Metabolic bone disease is a major public health concern, especially when it manifests as hip fracture which carries significant morbidity and mortality. Individuals with neurological disease are at higher risk of osteopenia, osteoporosis and fragility fracture compared to age-matched controls, yet this is under-appreciated by these patients. Clinician attention to this topic is therefore of importance and should address the bone health of men as well as women, a group in whom it may be an under-recognised problem. Evidence for optimal management of bone health in neurological disease remains to be defined, but a growing literature provides some useful guidance. This review focuses on two conditions, multiple sclerosis and Parkinson's disease, where research has been active over recent years. In neuroinflammation, shared immunological pathways between bone and brain are a current domain of interest and it will be intriguing to interrogate the action of emerging immunotherapies on these dual compartments.

Lack of Association between Pulse Steroid Therapy and Bone Mineral Density in Patients with Multiple Sclerosis

Multiple sclerosis (MS) has been associated with reduced bone mineral density (BMD). The purpose of this study was to determine the possible factors affecting BMD in patients with MS. We included consecutive 155 patients with MS and 90 age- and sex-matched control subjects. Patients with MS exhibited significantly lower T-scores and Z-scores in the femoral neck and trochanter compared to the controls. Ninety-four (61%) patients had reduced bone mass in either the lumbar spine or the femoral neck; of these, 64 (41.3%) had osteopenia and 30 (19.4%) had osteoporosis. The main factors affecting BMD were disability, duration of MS, and smoking. There was a negative relationship between femoral BMD and EDSS and disease duration. No association with lumbar BMD was determined. There were no correlations between BMD at any anatomic region and cumulative corticosteroid dose. BMD is significantly lower in patients with MS than in healthy controls. Reduced BMD in MS is mainly associated with disability and duration of the disease. Short courses of high dose steroid therapy did not result in an obvious negative impact on BMD in the lumbar spine and femoral neck in patients with MS.

Prevalence and risk factors of low bone mineral density in patients with multiple sclerosis

OBJECTIVES

To determine the prevalence and risk factors of low bone mineral density (BMD) in patients with multiple sclerosis (MS).

METHODS

Patients with MS who had undergone a BMD evaluation via dual-energy X-ray absorptiometry (DXA) between January 2010 and December 2013 were included in the study. Descriptive data, BMD values, and risk factors for osteoporosis along with the details regarding MS, such as age at onset, duration of disease, clinical type of MS, expanded disability status scale (EDSS) scores, and lifetime steroid intake were obtained from the medical record database and telephone interview.

RESULTS

The study group comprised 67 patients with a mean age of 41.1 ± 10.2 years. Of the patients, 20.9% revealed low BMD for chronological age. Vitamin D insufficiency (25(OH)D < 20  ng/ml) rate was 86.6%. Comorbidity and EDSS scores of patients with low BMD were significantly higher than those of the remaining patients (P = 0.000 and P = 0.015, respectively). Neck BMD was inversely correlated with comorbidity score, disease duration, relapse number, and lifetime steroid intake (r = - 0.270, r = - 0.263, r = - 0.359, and r = - 0.314, respectively).

CONCLUSION

The current study revealed that low BMD and vitamin D insufficiency were common in patients with MS. Longer disease duration, higher comorbidity score, and severe disability level led to lower BMD values. In conclusion, it is of paramount importance for clinicians to pay more attention on bone health in MS and to tailor preventative measures meticulously.

Short-term, high-dose glucocorticoid treatment does not contribute to reduced bone mineral density in patients with multiple sclerosis

Background:

Patients with multiple sclerosis (MS) are at increased risk of reduced bone mineral density (BMD). A contributing factor might be treatment with high-dose glucocorticoids (GCs).

Objectives:

The objective of this paper is to assess bone mass in patients with MS and evaluate the importance of short-term, high-dose GC treatment and other risk factors that affect BMD in patients with MS.

Methods:

A total of 260 patients with MS received short-term high-dose GC treatment and had their BMD measured by dual x-ray absorptiometry. BMD was compared to a healthy age-matched reference population ( Z-scores). Data regarding GCs, age, body mass index (BMI), serum 25(OH)D, disease duration and severity were collected retrospectively and analysed in a multiple linear regression analysis to evaluate the association between each risk factor and BMD.

Results:

Osteopenia was present in 38% and osteoporosis in 7% of the study population. Mean Z-score was significantly below zero, indicating a decreased BMD in our MS patients. Multiple linear regression analysis showed no significant association between GCs and BMD. In contrast, age, BMI and disease severity were independently associated with both lumbar and femoral BMD.

Conclusion:

Reduced BMD was prevalent in patients with MS. GC treatment appears not to be the primary underlying cause of secondary osteoporosis in MS patients.

Contribution of vitamin D insufficiency to the pathogenesis of multiple sclerosis

The contribution of vitamin D insufficiency to the pathogenesis of multiple sclerosis (MS) is reviewed. Among the multiple recently discovered actions of vitamin D, an immunomodulatory role has been documented in experimental autoimmune encephalomyelitis and in humans. This action in the peripheral immune system is currently the main known mechanism through which vitamin D might influence MS, but other types of actions could be involved within the central nervous system. Furthermore, vitamin D insufficiency is widespread in temperate countries and in patients with MS at the earliest stages of the disease, suggesting that the deleterious effects related to vitamin D insufficiency may be exerted in these patients. In fact, many genetic and environmental risk factors appear to interact and contribute to MS. In genetics, several human leukocyte antigen (HLA) alleles (more particularly HLA-DRB1*1501) could favour the disease whereas some others could be protective. Some of the genes involved in vitamin D metabolism (e.g. CYP27B1) also play a significant role. Furthermore, three environmental risk factors have been identified: past Epstein-Barr virus infection, vitamin D insufficiency and cigarette smoking. Interactions between genetic and environmental risk or protective factors may occur during the mother's pregnancy and could continue during childhood and adolescence and until the disease is triggered in adulthood, therefore possibly modulating the MS risk throughout the first decades of life. Furthermore, some clinical findings already strongly suggest that vitamin D status influences the relapse rate and radiological lesions in patients with MS, although the results of adequately powered randomized clinical trials using vitamin D supplementation have not yet been reported. While awaiting these incontrovertible results, which might be long in coming, patients with MS who are currently in vitamin D insufficiency should be supplemented, at least for their general health status, using moderate doses of the vitamin.

Investigation of the relationship between vitamin D and bone mineral density in newly diagnosed multiple sclerosis

The aim of this study was to investigate the relationship between vitamin D and bone mineral density in newly diagnosed multiple sclerosis (MS) and to compare results with data from healthy controls. A total of 60 subjects, including 30 patients with MS, newly diagnosed and untreated (18 females, 12 males, at 18-40 years of age) and 30 healthy controls (20 female, 10 male) were enrolled in this study. Bone mineral density (BMD) of the lumbar spine and left femoral neck region were measured by dual-energy X-ray absorptiometry (DEXA). Serum levels of 25-hydroxyvitamin D (25OHD) were measured by chemiluminescence microparticle immunoassay (CMIA) on the Architect-i2000(®) (Abbott) system. 25OHD levels of MS patients were significantly lower than in controls. 25OHD levels were 27.2 ± 14.1 ng/ml in MS patients and 42.6 ± 8.8 ng/ml in controls (p = 0.001). Twenty-six (86.6 %) of our patients had a reduced BMD in lumbar spine or femoral neck region; of these 24 patients (80 %) had osteopenia and 2 patients (6.6 %) had osteoporosis. Interestingly, there was no significant correlation between 25OHD and BMD in lumbar spine and femoral neck region (r = 0.454, p = 0,074; r = 0.636, p = 0.082). Interestingly, a significant reduction of bone density in female MS patients was observed. In our study, 25OHD deficiency and lower BMD appeared in newly diagnosed multiple sclerosis. This is compatible with shared etiologic or pathogenic factors in MS and osteopenia/osteoporosis, and calls for an active approach to optimize bone health in early stages of MS.

Bone turnover and metabolism in patients with early multiple sclerosis and prevalent bone mass deficit: a population-based case-control study

Background

Low bone mass is prevalent in ambulatory multiple sclerosis (MS) patients even shortly after clinical onset. The mechanism is not known, but could involve shared etiological risk factors between MS and low bone mass such as hypovitaminosis D operating before disease onset, or increased bone loss after disease onset. The aim of this study was to explore the mechanism of the low bone mass in early-stage MS patients.

Methodology/Principal Findings

We performed a population-based case-control study comparing bone turnover (cross-linked N-terminal telopeptide of type 1 collagen; NTX, bone alkaline phosphatase; bALP), metabolism (25-hydroxy- and 1, 25-dihydroxyvitamin D, calcium, phosphate, and parathyroid hormone), and relevant lifestyle factors in 99 patients newly diagnosed with clinically isolated syndrome (CIS) or MS, and in 159 age, sex, and ethnicity matched controls. After adjustment for possible confounders, there were no significant differences in NTX (mean 3.3; 95% CI −6.9, 13.5; p = 0.519), bALP (mean 1.6; 95% CI −0.2, 3.5; p = 0.081), or in any of the parameters related to bone metabolism in patients compared to controls. The markers of bone turnover and metabolism were not significantly correlated with bone mass density, or associated with the presence of osteoporosis or osteopenia within or between the patient and control groups. Intake of vitamin D and calcium, reported UV exposure, and physical activity did not differ significantly.

Conclusions/Significance

Bone turnover and metabolism did not differ significantly in CIS and MS patients with prevalent low bone mass compared to controls. These findings indicate that the bone deficit in patients newly diagnosed with MS and CIS is not caused by recent acceleration of bone loss, and are compatible with shared etiological factors between MS and low bone mass.

Bone health and multiple sclerosis

People with multiple sclerosis (MS) have many reasons to have low bone mineral density and an increased fracture risk. Osteoporosis is a major cause of morbidity and mortality, and is more common in people with MS than the general population. A number of studies have examined the relationship between multiple sclerosis and reduced bone mineral density. In this topical review we seek to address the risk of low bone mineral density, osteoporosis and fractures associated with MS, and make practical suggestions as to how this pertinent issue may be approached in clinical practice.

Obstructive sleep apnea and bone mineral density in obese patients

CONTEXT

Obesity and its co-morbidities may adversely affect bone mineral density (BMD). Obstructive sleep apnea (OSA) is a major complication of obesity. To date, the effects of OSA on BMD in obese patients have been poorly studied.

OBJECTIVE

To examine whether the severity of OSA independently correlates with BMD in obese patients.

METHODS

One hundred and fifteen obese subjects with OSA (Apnea/Hypopnea Index [AHI] ≥5 events per hour) were included in the study. BMD was measured at lumbar spine, total hip, and femoral neck by dual energy X-ray absorptiometry. Body mass index, lean mass, and representative measures of metabolic syndrome (waist circumference, fasting plasma glucose, blood pressure, HDL-cholesterol, triglycerides) and inflammation (ESR, CRP, fibrinogen) were also evaluated.

RESULTS

BMD did not differ among obese individuals regardless of OSA severity. Correlation coefficient analysis for all the covariates showed a lack of association between AHI and BMD that was strongly influenced by age and weight.

CONCLUSION

Our study does not support an independent association between AHI and BMD in obese patients. Controlled studies involving a greater number of patients are warranted.