J O P S J J ordan ordan O O steoporosis steoporosis C C enter enter Jordan Hospital Jordan Hospital Why Vitamin D is important for Bone health? Basel Masri, MD Consultant Rheumatologist Al-Najah University 9 October 2009 Nablus - Palestine Jordanian Osteoporosis Prevention Soci
J ordan O steoporosis C enter Jordan Hospital. Why Vitamin D is important for Bone health?. Basel Masri, MD Consultant Rheumatologist. J ordanian O steoporosis P revention S ociety. Al-Najah University 9 October 2009 Nablus - Palestine. Vitamin D. fat soluble prohormone - PowerPoint PPT Presentation
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Vitamin D2 found in plants considerably less potent than
Vitamin D3 naturally occurring form in humans
JOPS
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
JOPS
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
JOPS
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
JOPS
Diseases and Conditions that Vitamin D Helps Prevention
Rickets
Osteomalacia
Osteoporosis
Hyperparathyroism
Internal cancers
Multiple sclerosis
JOPS
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
JOPS
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
JOPS
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
JOPS
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
JOPS
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
JOPS
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
JOPS
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.
JOPS
First Jordanian National
Osteoporosis Record FiJoNOR
Vitamin D Data
FiJoNOR B. Masri, E. Azar, A. Faqih (JOPS)
JOPS
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)
JOPS
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)
JOPS
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)
JOPS
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)
JOPS
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
JOPS
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
JOPS
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.
JOPS
Vitamin D Supplementation Decreases Fracture Risk
JOPS
Muscle
Falls
Bone Density
Fracture
The neglected role of „Muscle“ in the pathogenesis of Osteoporosis
Osteoporosis(Immobil.-induced Opo.)
JOPS
Muscle
FallsBone Density
Fractures
Active Vitamin D reduces the risk of osteoporotic fractures by a dual effect
Vitamin D
+
+
Osteoporosis
JOPS
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
JOPS
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,
+ 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
JOPS
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
JOPS
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