Vitamin D insufficiency in older female community-dwelling acute hospital admissions and the response to supplementation

Adequate Dietary Intake and Vitamin D Supplementation: A Study of Their Relative Importance in Determining Serum Vitamin D and Ferritin Concentrations during Pregnancy

Vitamin D is essential for human health. However, it is not clear if vitamin D supplementation is necessary for all pregnant women. This study examines the relative importance of dietary patterns and vitamin D supplementation frequency in determining serum 25-hydroxyvitamin D (25(OH)D) and ferritin concentrations among pregnant women in Hong Kong, China. A total of 572 healthy women were recruited from antenatal clinics at 25–35 weeks pregnant. Participants completed an electronic version of the food frequency questionnaire and a web questionnaire on supplement use. Their blood samples were tested for serum 25(OH)D and ferritin. The associations of dietary patterns and vitamin D supplementation frequency with serum 25(OH)D and ferritin concentrations were analyzed using moderated hierarchical regression. Two dietary patterns were identified. The adequate dietary intake was characterized by the high probability of meeting recommended daily food group servings, whereas the inadequate dietary intake was characterized by inadequate consumption of vegetables, fruits, meat, fish, and eggs, or alternatives. The association between adequate dietary intake and serum ferritin concentrations was independent of vitamin D supplementation frequency (β = 0.05, p = 0.035), but dietary patterns interacted with vitamin D supplementation frequency to determine serum 25(OH)D concentrations (β = −13.22, p = 0.014). The current study presents evidence on the relative importance of dietary patterns and vitamin D supplementation in maintaining sufficient vitamin D and iron in pregnancy. Antenatal nutrition counselling services should be provided to pregnant women who show signs of inadequate dietary intake.

Vitamin D Status of Adults in the Community, in Outpatient Clinics, in Hospital, and in Nursing Homes in the West of Ireland

BACKGROUND

Approximately 1 billion people worldwide have Vitamin D deficiency. The aim of this study was to compare Vitamin D status and serum 25-hydroxyvitamin D (25(OH)D) concentrations among adults sampled in the community, in outpatient clinics, as hospital inpatients and in nursing homes in the West of Ireland. The secondary aim was to determine the associations between length of hospital stay (inpatients) at the time of serum 25(OH)D sampling and Vitamin D status.

METHODS

A cross-sectional study was carried out. Patients who had serum 25(OH)D analysis carried out in Galway University Hospitals (January 2011-December 2015) were identified following interrogation of the electronic laboratory data system. Baseline demographics, location, and date of sample collection were recorded. Vitamin D deficiency was defined as a serum 25(OH)D concentration <25 nmol/L.

RESULTS

In total, 24,302 patient samples were eligible for inclusion: community 15,319; outpatient clinics 6,371; inpatients 2,339; and nursing home residents 273. Vitamin D deficiency was more common in nursing home residents than inpatients, or those sampled in outpatient clinics or in the community (42% vs 37% vs 17% vs 13%; p < .001). Inpatients sampled further into their hospital stay (≥3 days) had greater Vitamin D deficiency than inpatients sampled on 0-2 days (p = .007). Season (p < .001), sex (p < .001), and age (p < .001) were associated with 25(OH)D concentrations. Vitamin D deficiency was more common in Winter/Spring, in males, and in those aged ≥80 years.

CONCLUSIONS

Nursing home residents and inpatients are at the highest risk for Vitamin D deficiency. Season, sex, age, and day of hospital stay on which serum 25(OH)D concentrations were sampled were associated with Vitamin D status.

Higher risk of vitamin D insufficiency/deficiency for rural than urban dwellers

There are many risk factors for Vitamin D deficiency. This study aimed to compare the Vitamin D status and serum 25(OH)D concentrations of adults living in an urban area to adults living in a rural area in the West of Ireland (latitude 53.27° North). A cross-sectional retrospective analysis of clinical records was performed. Following interrogation of the electronic laboratory information system, individuals who had serum 25(OH)D concentrations measured at Galway University Hospitals between January 2011 and December 2015 were identified. Clinical demographics, setting and date of sampling were recorded. In total, 17,590 patients (urban n = 4,824; rural n = 12,766) were eligible for inclusion. Serum 25(OH)D concentrations were lower among rural compared to urban dwellers irrespective of season (spring p < 0.001, summer p = 0.009, autumn p = 0.002, winter p < 0.001). There was a significant difference in Vitamin D status between urban and rural dwellers in three of the four seasons: spring- deficiency: 16%-v-23%, insufficiency: 39%-v-43%, sufficiency: 45%-v-35% (p < 0.001); autumn- deficiency: 11%-v-10%, insufficiency: 30%-v-35%, sufficiency: 59%-v-56% (p = 0.01); winter- deficiency: 23%-v-25%, insufficiency: 35%-v-42%, sufficiency: 41%-v-33% (p < 0.001). Serum 25(OH)D concentrations were higher and the prevalence of deficiency lower in urban/rural females compared to urban/rural males (p < 0.001). Serum 25(OH)D concentrations increased sequentially from the 18-39 year age group to the 60-69 year age group in both urban (p < 0.001) and rural (p < 0.001) dwellers and then decreased progressively as age increased to ≥90 years. The odds of Vitamin D deficiency increased with age, lower daily sunshine hours, male gender, rural address and season.

COVID-19: the older adult and the importance of vitamin D sufficiency

In December 2019, in Wuhan, China, the novel coronavirus ‘severe acute respiratory syndrome 2’ (SARS-CoV-2) was discovered as the cause of a pneumonia-like illness and subsequently named coronavirus disease 2019 (COVID-19). COVID-19 spread and is now a global pandemic. With few exceptions, countries in the Northern hemisphere have higher mortality rates from COVID-19. This may be due to an increased prevalence of older people in Northern Europe at higher risk of having cardio-pulmonary and metabolic comorbidities as well as hypovitaminosis D. With increasing age, immunosenescence and ‘inflammaging’ lead to impaired and maladaptive immune responses to SARS-CoV-2 infections, contributing to the enhanced prevalence of severe COVID-19 in older patients. The association of ageing with increased vitamin D deficiency, which is associated with cardiovascular risk factors and disease and worse prognosis in COVID-19 infection, is discussed. Considerable experimental evidence demonstrates the immuno-modulatory properties of vitamin D, in particular, its role in regulating and suppressing the inflammatory cytokine response to viral respiratory infections links the importance of vitamin D sufficiency as a potential protective factor in COVID-19. There is an urgent need for prospective randomised studies to examine whether hypovitaminosis D correlates with severity of COVID-19 disease and the actual benefit of repletion. Moreover, given what has been described as a ‘pandemic of vitamin D deficiency’, especially in Europe, and in the context of the SARS-CoV-2 contagion, the authors support the call for public health doctors and physicians, with support from Governments, to prioritise and strengthen recommendations on vitamin D intake and supplementation.

A review of vitamin D insufficiency and its management: a lack of evidence and consensus persists

Vitamin D deficiency is the most common nutritional deficiency worldwide, however uncertainty persists regarding the benefits of vitamin D supplementation. Vitamin D is essential for calcium homeostasis, and has been linked to falls and fractures in older people. There are numerous risk factors for vitamin D deficiency, chief among them old age. Studies of vitamin D supplementation have given mixed signals, but over all there is evidence of benefit for those with risk factors for deficiency. International guidelines recommend vitamin D target levels of >25 to >80 nmol/l, best achieved by a daily dose of 800-1000 IU. Large bolus doses should be avoided. There are still unanswered questions regarding vitamin D supplementation and target levels. There is need for well designed and powered trials to achieve consensus.

Awareness of medical students about vitamin D deficiency at Ahfad University for women, Sudan

Vitamin D deficiency is not only associated with rickets and osteomalacia, but also with several chronic diseases, such as cancer, ischaemic heart disease, and type 1and 2 diabetes mellitus. Worldwide, an estimated one billion people suffer from vitamin D deficiency. The prevalence of this problem is unknown in Sudan due to scarcity of research in this particular area of concern. The present study aimed to assess the awareness of vitamin D deficiency through the knowledge of the importance of vitamin D, the link to diseases, vitamin D resources and the importance of dietary supplements, in addition to assessing the sun exposure habits in a sample of female Sudanese medical students. It is a descriptive cross-sectional community-based study, conducted at Ahfad University for Women, Omdurman, Sudan. More than half (56 %) of the participants were aged 21-25 years and 30% were in the second academic class. The majority of the participants were aware of the importance of vitamin D; however, the awareness of relating it to the chronic diseases was poor. Overall, 61.9% declared that vitamin D supplementation is important, and sun exposure habits were good (64.5% didn't use sunblock and 87.6% get exposed for more than 10 minutes/day). There was significant association between the age categories and exposure to the sun without sunblock on a daily basis (p value = 0.007).

Vitamin D Deficiency and Insufficiency Prevalence in the West of Ireland - A Retrospective Study

OBJECTIVES

Vitamin D plays an important role in calcium homeostasis and is essential for normal bone growth and remodeling. Previous studies of acutely ill and institutionalized older women in Galway revealed that vitamin D insufficiency is extremely common. We aimed to evaluate age and gender-related rates of vitamin D insufficiency and deficiency in adult patients attending their General Practitioners in the same region.

DESIGN

A retrospective cohort study.

SETTING

General practices in Galway, a city located on the west coast of Ireland, latitude 53.17 North.

PARTICIPANTS

A total of 15,708 consecutive blood samples from adults attending their General Practitioners between January 2013 and December 2014 were sent to the Clinical Biochemistry Laboratory in the University Hospital Galway for vitamin D level testing. 73% were from women.

INTERVENTION

Data were collected and grouped according to age, sex and season. Vitamin D levels (25OHD) were categorised into deficiency (<25nmol/L), insufficiency (25-50nmol/L) and sufficiency ( >50nmol/L).

MEASUREMENTS

Median and interquartile range were reported as vitamin D levels were not normally distributed. Descriptive statistics were performed using STATA/MP 13.1 for Mac.

RESULTS

While vitamin D levels were sufficient in 56.4% (n=8,496), they were insufficient in 32.4% (n=4,891) and deficient in 11.2% (n=1,691). Of the deficient group, 19%( 325) had levels <15nmol/L consistent with profound deficiency. Men were more likely than women to be deficient (12% (n=489) vs. 10.9% (n=1,202)) and insufficient (38.0% (n=1,550) vs. 30.4% (n=3,341)) (p<0.01). Highest rates of deficiency were seen in those 81-97 years (19.4% (n=136)) and 18-40 years (13.8% (n=543)), the former group showing less seasonal variation.

CONCLUSION

Overall prevalence of insufficiency is similar to those in national and European studies published recently. However, there is a high possibility that those most vulnerable to vitamin D deficiency were underrepresented in this cohort, when results from previous studies in the same region are considered. Further prospective studies are needed to guide treatment with supplementation of vitamin D for appropriate subgroups.

Factors Affecting 25-Hydroxyvitamin D Concentration in Response to Vitamin D Supplementation

Sun exposure is the main source of vitamin D. Due to many lifestyle risk factors vitamin D deficiency/insufficiency is becoming a worldwide health problem. Low 25(OH)D concentration is associated with adverse musculoskeletal and non-musculoskeletal health outcomes. Vitamin D supplementation is currently the best approach to treat deficiency and to maintain adequacy. In response to a given dose of vitamin D, the effect on 25(OH)D concentration differs between individuals, and it is imperative that factors affecting this response be identified. For this review, a comprehensive literature search was conducted to identify those factors and to explore their significance in relation to circulating 25(OH)D response to vitamin D supplementation. The effect of several demographic/biological factors such as baseline 25(OH)D, aging, body mass index(BMI)/body fat percentage, ethnicity, calcium intake, genetics, oestrogen use, dietary fat content and composition, and some diseases and medications has been addressed. Furthermore, strategies employed by researchers or health care providers (type, dose and duration of vitamin D supplementation) and environment (season) are other contributing factors. With the exception of baseline 25(OH)D, BMI/body fat percentage, dose and type of vitamin D, the relative importance of other factors and the mechanisms by which these factors may affect the response remains to be determined.

The effect of vitamin D supplementation on arterial stiffness in an elderly community-based population

Vitamin D deficiency may lead to impaired vascular function and abnormalities in central arterial stiffness. We compared the effects of two different doses of vitamin D3 on arterial stiffness in an elderly population with deficient serum 25-hydroxy-vitamin D levels. A total of 119 known vitamin D deficient (<50 nmol/L) subjects were randomized to receive either 50,000 international units (IU) or 100,000 IU single intramuscular vitamin D3. In the group that received 100,000 IU vitamin D, median pulse wave velocity decreased from 12.2 m/s (range, 5.1-40.3 m/s) to 11.59 m/s (range, 4.3-14.9 m/s) after 8 weeks (P = .22). A mean decrease of 3.803 ± 1.7 (P = .032) in augmentation index (a measure of systemic stiffness) was noted. Only 3/51 (5.8%) who received 100,000 IU vitamin D reached levels of sufficiency (>75 nmol/L). A significant decrease in augmentation index was seen in the group that received 100,000 IU vitamin D. Serum levels of 25-hydroxy-vitamin D were still deficient at 8 weeks in the majority of patients, which may be attributable to impaired bioavailability.

Additive effects of nutritional supplementation, together with bisphosphonates, on bone mineral density after hip fracture: a 12-month randomized controlled study

Background

After a hip fracture, a catabolic state develops, with increased bone loss during the first year. The aim of this study was to evaluate the effects of postoperative treatment with calcium, vitamin D, and bisphosphonates (alone or together) with nutritional supplementation on total hip and total body bone mineral density (BMD).

Methods

Seventy-nine patients (56 women), with a mean age of 79 years (range, 61–96 years) and with a recent hip fracture, who were ambulatory before fracture and without severe cognitive impairment, were included. Patients were randomized to treatment with bisphosphonates (risedronate 35 mg weekly) for 12 months (B; n=28), treatment with bisphosphonates along with nutritional supplementation (40 g protein, 600 kcal daily) for the first 6 months (BN; n=26), or to controls (C; n=25). All participants received calcium (1,000 mg) and vitamin D3 (800 IU) daily. Total hip and total body BMD were assessed with dual-energy X-ray absorptiometry at baseline, 6, and 12 months. Marker of bone resorption C-terminal telopeptide of collagen I and 25-hydroxy vitamin D were analyzed in serum.

Results

Analysis of complete cases (70/79 at 6 months and 67/79 at 12 months) showed an increase in total hip BMD of 0.7% in the BN group, whereas the B and C groups lost 1.1% and 2.4% of BMD, respectively, between baseline and 6 months (P=0.071, between groups). There was no change in total body BMD between baseline and 12 months in the BN group, whereas the B group and C group both lost BMD, with C losing more than B (P=0.009). Intention-to-treat analysis was in concordance with the complete cases analyses.

Conclusion

Protein-and energy-rich supplementation in addition to calcium, vitamin D, and bisphosphonate therapy had additive effects on total body BMD and total hip BMD among elderly hip fracture patients.

Vitamin D supplementation versus combined calcium and vitamin D in older female patients - an observational study

BACKGROUND

In most developed countries overt vitamin D deficiency, characterized by rickets or osteomalacia, is now uncommon. However, subclinical vitamin D insufficiency is extremely common and may contribute to the development of skeletal and non-skeletal problems. Standard practice involves supplementation with a combination of vitamin D and calcium although the benefit of adding calcium to vitamin D supplements has not been fully established and may reduce adherence due to its bulky and chalky consistency.

PURPOSE OF STUDY

To compare the effects of vitamin D alone versus vitamin D/calcium supplements on vitamin D levels, bone profile and parathyroid hormone level.

POPULATION

Older (> 65 years) female patients living in the community and long term care institutions.

INTERVENTIONS

Either 800 iu of vitamin D3 or a composite supplement of 800 iu vitamin D3 and 1000 mg calcium were given to patients in an open-labelled observational study. Serum 25-hydroxy-vitamin D, parathyroid hormone, calcium, phosphate and alkaline phosphatase levels were assessed at baseline and after 3 months of treatment.

RESULTS

Serum 25-hydroxy-vitamin D levels rose from baseline levels of 25 ± 16 to 79 ± 16 in those treated with vitamin D alone and from 35 ± 24 nmol/L to 70 ± 24 nmol/L in those treated with vitamin D and calcium. Serum PTH levels fell by similar amounts in both groups. In both community dwellers and institutionalised patients, those treated with vitamin D alone were at least as likely to achieve normalisation of serum vitamin D levels as those on combined calcium/vitamin D treatment.

CONCLUSION

Vitamin D alone appears as effective as combined calcium/vitamin D treatment in restoring serum vitamin D levels in older community dwelling and institutionalised patients. A prospective randomised trial would help confirm these findings.

Impact of oral vitamin D supplementation on serum 25-hydroxyvitamin D levels in oncology

BACKGROUND

Serum 25-hydroxyvitamin D [25(OH)D] is the major circulating form of vitamin D and a standard indicator of vitamin D status. Emerging evidence in the literature suggests a high prevalence of suboptimal vitamin D (as defined by serum 25(OH)D levels of <32 ng/ml) as well as an association between lower serum levels and higher mortality in cancer. We investigated the effect of oral vitamin D supplementation as a means for restoring suboptimal levels to optimal levels in cancer.

METHODS

This is a retrospective observational study of 2198 cancer patients who had a baseline test prior to initiation of cancer therapy at our hospital to evaluate serum 25(OH)D levels between Jan 08 and Dec 09 as part of their initial nutritional evaluation. Patients with baseline levels of < = 32 ng/ml (n = 1651) were considered to have suboptimal serum 25(OH)D levels and were supplemented with 8000 IU of Vitamin D3 (four 2000 IU D3 capsules) daily as part of their nutritional care plan. The patients were retested at their first follow-up visit. Of 1651 patients, 799 were available for follow up assessment. The mean serum 25(OH)D levels were compared in these 799 patients across the 2 time points (baseline and first follow-up) using paired sample t-test. We also investigated the factors associated with response to vitamin D supplementation.

RESULTS

Of 2198 patients, 814 were males and 1384 females. 1051 were newly diagnosed and treated at our hospital while 1147 were diagnosed and treated elsewhere. The mean age at presentation was 55.4 years. The most common cancer types were breast (500, 22.7%), lung (328, 14.9%), pancreas (214, 9.7%), colorectal (204, 9.3%) and prostate (185, 8.4%). The mean time duration between baseline and first follow-up assessment was 14.7 weeks (median 10.9 weeks and range 4 weeks to 97.1 weeks). The mean serum 25(OH)D levels were 19.1 ng/ml (SD = 7.5) and 36.2 ng/ml (SD = 17.1) at baseline and first follow-up respectively; p < 0.001. Patients with prostate and lung cancer had the highest percentage of responders (70% and 69.2% respectively) while those with colorectal and pancreas had the lowest (46.7% each). Similarly, patients with serum levels 20-32 ng/ml at baseline were most likely to attain levels > 32 ng/ml compared to patients with baseline levels < 20 ng/ml.

CONCLUSIONS

The response to supplementation from suboptimal to optimal levels was greatest in patients with prostate and lung cancer as well as those with baseline levels between 20-32 ng/ml. Characteristics of non-responders as well as those who take longer to respond to supplementation need to be further studied and defined. Additionally, the impact of improved serum 25(OH)D levels on patient survival and quality of life needs to be investigated.

The tolerability and biochemical effects of high-dose bolus vitamin D2 and D3 supplementation in patients with vitamin D insufficiency

OBJECTIVES

To investigate the practicality and tolerability of high-dose intramuscular (i.m.) vitamin D2 or oral vitamin D3 replacement in vitamin D-insufficient patients, and to evaluate the biochemical efficacy of each formulation.

METHODS

Sixty-nine patients with vitamin D insufficiency [25-hydroxyvitamin D (25(OH)D) <40 nmol/L] were recruited from the Rheumatology Outpatient Department of St George's Hospital, London. In study 1, 50 patients received 300 000 IU i.m. vitamin D2 (ergocalciferol). In study 2, 19 patients received 300 000 IU oral vitamin D3 (cholecalciferol) under observation. Biochemical response was measured at baseline, and at 12 and 24 weeks.

RESULTS

Bolus i.m. vitamin D2 or oral vitamin D3 was well tolerated. The change from baseline in serum 25(OH)D was significantly greater at 6 and 12 weeks in study 2 (p<0.0001 and <0.0001, respectively). In study 1, a modest increase in mean serum 25(OH)D at 6, 12, and 24 weeks was observed but no patients achieved a serum 25(OH)D concentration > or = 50 nmol/L. PTH remained elevated in 42% of patients with secondary hyperparathyroidism at 12 weeks. In study 2, 100% and 89% of patients had serum 25(OH)D>50 nmol/L at 6 and 12 weeks, respectively. All patients with elevated baseline PTH were fully suppressed at 12 weeks. No cases of hypercalcaemia were observed in either group.

CONCLUSION

The 300 000-IU bolus of vitamin D2 or D3 was practical, well tolerated, and safe. Vitamin D3 had greater potency than equimolar vitamin D2, with a higher, sustained serum 25(OH)D response and efficacious PTH suppression. To adequately treat vitamin D insufficiency we would recommend administering 300,000 IU oral vitamin D3 approximately three times per year.

Supplements of 20 microg/d cholecalciferol optimized serum 25-hydroxyvitamin D concentrations in 80% of premenopausal women in winter

The serum 25-hydroxyvitamin D [25(OH)D] response to daily supplementation with 20 microg cholecalciferol (D3) during winter in predominantly white premenopausal women living in Maine was measured and the effects of body composition and hormonal contraceptive use on baseline serum 25(OH)D concentrations and the response to supplementation were examined. A total of 112 women (22.2 +/- 3.7 y old) received placebo from March 2005 until September 2005 when they were randomized to receive either placebo or 20 microg/d D3 through February 2006. Eighty-six women completed the study. Actual mean D3 content of the supplements was 22 microg per capsule. In February 2005 the serum 25(OH)D concentration was 62.0 +/- 23.4 nmol/L (mean +/- SD). Serum 25(OH)D concentrations increased by 35.3 +/- 23.2 nmol/L from February 2005 to February 2006 in the treatment group, significantly more than the 10.9 +/- 16.9 nmol/L increase in the placebo group. Treatment group, magnitude of summer increase in 25(OH)D, estrogen dose, and baseline serum 25(OH)D concentrations, but not body fat, were significant predictors of the 1-y change in 25(OH)D concentrations used to assess the magnitude of the response to supplementation. Daily supplementation with 20 microg D3 during winter achieved optimal 25(OH)D concentrations (> or = 75 nmol/L) in 80% of participants, indicating that this dose is adequate to optimize vitamin D status in most young women in Maine.

Hypovitaminosis D in internal medicine inpatients

Some studies have suggested that hypovitaminosis D may be a consequence of protein-calorie malnutrition. This study assessed both the relationship between vitamin D status, malnutrition, calcium and phosphorus metabolism indices and the importance attached by internists to these alterations. There were 239 patients admitted to an internal medicine division who underwent examinations to assess nutritional state, liver and renal function, and bone metabolism. At the end of the study, the clinical data included in the discharge letter, the treatment prescribed, and the diagnosis assigned to patients on their hospital discharge form were collected. Hypovitaminosis D was found in 72% and hypoalbuminemia in 34.3% of patients. Subjects with hypovitaminosis were generally older and had lower albumin levels than those with mild or no hypovitaminosis. 25-Hydroxyvitamin D was inversely related with parathyroid hormone and directly related with albumin. Alterations of calcium and phosphorus metabolism were present in 55.6% and recorded by the division's physicians for only 13.53% of patients, of whom 72.37% were not specifically treated. There is a direct correlation between 25-hydroxyvitamin D and albumin levels. The high incidence and the metabolic consequence of hypovitaminosis D and of protein-calorie malnutrition is significantly underestimated and undertreated by physicians.