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JJordan ordan OOsteoporosis steoporosis CCenterenter
Jordan HospitalJordan Hospital
Why Vitamin D is important for Bone
health?Basel Masri, MD
Consultant Rheumatologist
Al-Najah University9 October 2009
Nablus - Palestine
Jordanian Osteoporosis Prevention Society
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Vitamin D fat soluble prohormone
necessary for bone health, it controls
absorption of calcium from the intestines
and its use in bone mineralization
two important representatives:
Vitamin D2 found in plants considerably less potent than
Vitamin D3 naturally occurring form in humans
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Sources of Vitamin D (1)
*Sold in the United States, Canada, Argentina (optional), Brazil, Guatemala, Honduras, Mexico, Philippines (optional), and Venezuela
Adapted from Holick MF; Allain TJ, Dhesi J; Webb AR et al; Reid IR et al; Matsuoka LY et al; Holick MF; Lips P; Macleod CC et al; Omdahl JL et al; Chen TC et al; Holick MF et al; Heaney RP; Segal E et al; Webb AR et al; Faulkner H et al; Roche Vitamins Europe Ltd.
Known as the Sunshine VitaminSunlight Exposure provides 90% of vitamin
D for the body’s daily requirement
Vitamin D production is affected by: season duration and body-surface of exposure sunscreen use and skin pigmentation
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Sources of Vitamin D (2)
*Sold in the United States, Canada, Argentina (optional), Brazil, Guatemala, Honduras, Mexico, Philippines (optional), and Venezuela
Adapted from Holick MF; Allain TJ, Dhesi J; Webb AR et al; Reid IR et al; Matsuoka LY et al; Holick MF; Lips P; Macleod CC et al; Omdahl JL et al; Chen TC et al; Holick MF et al; Heaney RP; Segal E et al; Webb AR et al; Faulkner H et al; Roche Vitamins Europe Ltd.
Endogenous productionAbility of skin, liver and Ability of skin, liver and kidneys to form and process kidneys to form and process vitamin Dvitamin D
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Sources of Vitamin D (3)
*Sold in the United States, Canada, Argentina (optional), Brazil, Guatemala, Honduras, Mexico, Philippines (optional), and Venezuela
Adapted from Holick MF; Allain TJ, Dhesi J; Webb AR et al; Reid IR et al; Matsuoka LY et al; Holick MF; Lips P; Macleod CC et al; Omdahl JL et al; Chen TC et al; Holick MF et al; Heaney RP; Segal E et al; Webb AR et al; Faulkner H et al; Roche Vitamins Europe Ltd.
Dietary intake 10% onlyMinor source of vitamin D, providing 100 IU/dayVitamin D is rare in foods other than fatty fish, eggs, and supplemented dairy products*Even vitamin D–fortified dairy products may not contain level indicated on labelVitamin D can be supplied by multivitamins and supplementsSupplements containing vitamin D alone are not readily availablePatient compliance with supplementation therapy is inconsistent
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Diseases and Conditions that Vitamin D Helps Prevention
Rickets
Osteomalacia
Osteoporosis
Hyperparathyroism
Internal cancers
Multiple sclerosis
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Other Diseases that UVB /Vitamin D Helps Prevention Muscle pain, weakness Progression of rheumatoid and osteo-arthritis Type 1 diabetes mellitus in infancy Type 2 diabetes mellitus Body, brain disorders during fetal development Irritable bowel syndrome, Crohn’s disease High blood pressure, heart disease Tuberculosis
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Reasons for High Prevalence of Vitamin D Inadequacy in Postmenopausal Women
Adapted from Allain TJ, Dhesi J Gerontology 2003;49:273–278; Holick MF Am J Clin Nutr 1994;60:619–630; Lips P. In: Advances in Nutritional Research, Vol 9. New York: Plenum Press, 1994:151–165; Webb AR et al Am J Clin Nutr 1990;51:1075–1081; Holick MF et al Lancet 1989;2:1104–1105; MacLaughlin J, Holick MF J Clin Invest 1985;76:1536–1538.
Lack of sunlight exposure
Poor nutrition
Less efficient synthesis of vitamin D in the skin
Lower amount of vitamin D precursor 7-
dehydrocholesterol in the skin
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Levels of Serum 25(OH)D
Deficiency is <10 ng/ml (25 nmol/L)
Insufficiency is between 10 and 30 ng/ml (25-75 nmol/L)
Below 16 ng/ml (40 nmol/L), circulating 1,25(OH)D levels fall
For bone health and other conditions, optimal level is up to 36 ng/ml (90 nmol/L); 40 ng/ml (100 nmol/L) for those over the age of 70 years
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How Much Vitamin D is Required?
Present-day guidelines: 400 I.U./day for young & middle-aged persons
600 I.U./day for those around 50-70 years of age
and 800 I.U. for those over the age of 70 years
These guidelines were developed a number of years ago and are based on developing and maintaining strong bones
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How Much Solar UVB Exposure?
Michael Holick, MD, PhD, Boston University, author of The UV Advantage, now estimates that one needs to expose 25% of the body to midday solar radiation, 2-3 times a week, during summer, to produce the amount of vitamin D considered optimal
This is for light-skinned individuals; darker skinned ones need more exposure
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Consequences of SubclinicalVitamin D Inadequacy
Adapted from Parfitt AM et al Am J Clin Nutr 1982;36:1014–1031; Allain TJ, Dhesi J Gerontology 2003;49:273-278; Holick MF Osteoporos Int 1998;8(suppl 2):S24–S29; DeLuca HF Metabolism 1990;39(suppl 1):3–9.
• Calcium absorption
• PTH
• Bone mineral density
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Why Vitamin D is important for Osteoporosis Assessment
Epidemiological studies showed worldwide inadequacy in Vitamin D particularly in postmenopausal women
FiJoNOR survey
Others surveys
patients insufficient in Vitamin D show lower improvement with anti-resorptives drugs like bisphosphonates
Evidence suggests that vitamin D inadequacy Evidence suggests that vitamin D inadequacy increases risk of fracture
PTH=parathyroid hormone
Adapted from Parfitt AM et al Am J Clin Nutr 1982;36:1014–1031; Allain TJ, Dhesi J Gerontology 2003;49:273–278; LeBoff MS et al JAMA 1999;281:1505–1511; Bettica P et al Osteoporos Int 1999;9:226–229; Lips P et al J Clin Endocrinol Metab 2001;86:1212–1221; van der Wielen RPJ et al Lancet 1995;346:207–210.
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First Jordanian National
Osteoporosis Record FiJoNOR
Vitamin D Data
FiJoNOR B. Masri, E. Azar, A. Faqih (JOPS)
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FiJoNOR Population Distribution
Distribution of female population
153175
135157
97
72
32
0
40
80
120
160
200
20-29 30-39 40-49 50-59 60-69 70-79 80-89Num
ber o
f wom
en
Total of 821 randomized femalesMean age of menopause (48.5)
FiJoNOR B. Masri, E. Azar, A. Faqih (JOPS)
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Vitamin D levels in entire sample
135
273
413
0
50
100
150
200
250
300
350
400
450
123
No
. o
f w
om
en
< 10ng/ml 10-20 ng/ml > 20 ng/ml
50.3%33.5% 16.2%
NormalInsufficiencyDeficiency
FiJoNOR B. Masri, E. Azar, A. Faqih (JOPS)
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Vit. D Covered (760) vs non-covered (61)
18.95
13.02
0.002.004.006.008.00
10.0012.0014.0016.0018.0020.00
Not Covered Covered
Vit
. D (
ng
/ml)
FiJoNOR B. Masri, E. Azar, A. Faqih (JOPS)
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Vit. D vs Socioeconomic status
13.27 13.42
14.69
10.00
11.00
12.00
13.00
14.00
15.00
1 2 3
Low Medium High
Vit.
D (n
g/m
l)
FiJoNOR B. Masri, E. Azar, A. Faqih (JOPS)
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Prevalence of Vitamin D Inadequacy in Postmenopausal Women Treated for Osteoporosis in North America
Pre
vale
nce
, %
(±
95%
CI)
<20 <25<9 <15 <300
10
20
30
40
50
60
18.2%
35.5%
1.1%
8.1%
52.0%
Cutoff points for 25(OH)D concentration (ng/ml)
CI=confidence interval
Adapted from Holick MF et al J Clin Endocrinol Metab 2005;90:3215–3224.
N=1536
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Prevalence of Vitamin D Inadequacy (<30 ng/ml), by Age Group, in Postmenopausal
Women Treated for Osteoporosis
p=0.015 for test of trend
Adapted from Holick MF et al. Poster presented at ASBMR, October 1–5, 2004, Seattle, WA, USA.
Pre
vale
nce
(%
)
0
20
40
60
80
71–80
53.0%(n=558)
57.6%(n=245)
81–9051–60
50.7%(n=229)
61–70
48.0%(n=488)
>90
73.3%(n=15)
Age category
N=1536
In an epidemiologic study conducted in North America (N=1536)In an epidemiologic study conducted in North America (N=1536)
A high prevalence of vitamin D inadequacy was seen across all age groupsA high prevalence of vitamin D inadequacy was seen across all age groups
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53.4%
71.4%63.9%
60.3%57.7%
81.8%
Prevalence of Vitamin D Inadequacy (<30 ng/ml), by Region, in Postmenopausal Women with Osteoporosis
Pre
vale
nce
(%
)
0
10
30
40
60
80
90
LatinAmerica
AsiaAll Australia Europe
Regions
N=2589
MiddleEast
50
70
20
In a cross-sectional observational international studyIn a cross-sectional observational international study
A high prevalence of vitamin D inadequacy was seen across all geographic A high prevalence of vitamin D inadequacy was seen across all geographic regionsregions
Adapted from Lips P et al. Poster presented at ASBMR, September 23–27, 2005, Nashville, TN, USA.
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Vitamin D Supplementation Decreases Fracture Risk
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Muscle
Falls
Bone Density
Fracture
The neglected role of „Muscle“ in the pathogenesis of Osteoporosis
Osteoporosis(Immobil.-induced Opo.)
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Muscle
FallsBone Density
Fractures
Active Vitamin D reduces the risk of osteoporotic fractures by a dual effect
Vitamin D
+
+
Osteoporosis
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In a clinical studyVitamin D Supplementation Decreases Fracture Risk
Adapted from Trivedi D et al BMJ 2003;326:469.
Fra
ctu
re r
elat
ive
risk
(hip
, wri
st, f
ore
arm
, sp
ine)
–33%
Untreated(n=1341)
Treated(n=1345)
p=0.02
0.0
0.2
0.4
0.6
0.8
1.0
1.2 Five-year randomized,
double-blind, controlled trial
N=2686
Age 65–85 years
Vitamin D = 100,000 IU
once every four months
(equivalent to 800 IU/day)
Men and women living
in the community
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Effect of Vitamin D and Calcium Supplementation on Risk of Falling
Adapted from Bischoff HA et al J Bone Miner Res 2003;18:343–351.
Calcium only
(n=44)
Calcium + vitamin D
(n=45)
Fal
l ris
k
0.0
0.2
0.4
0.6
0.8
1.0
1.2
–49%
Reduction in falls
p=0.01
122 women Age: 63–99 years Randomized, double-blind,
controlled trial:Calcium 1200 mg/day Calcium 1200 mg/day
+ vitamin D 800 IU/day 12-week duration Mean serum 25(OH)D
12 ng/ml at baseline Women living in long-term
care units
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Summary I
Vitamin D inadequacy is widespread in postmenopausal women
Postmenopausal women have difficulty getting enough Vitamin D:
Formation and processing of vitamin D may be impaired Exposure to sunlight may be limited Dietary sources provide little vitamin D Patient compliance with vitamin D supplementation is inconsistent
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Summary II
Vitamin D is essential for calcium absorption. Adequate calcium absorption prevents secondary hyperparathyroidism and limits bone resorption
Vitamin D supplementation has been shown to reduce the risk of fracture and falls and improves lower extremity function in the elderly
Vitamin optimize antiresorptive drugs efficacy specially Bisphosphonates