j ordan o steoporosis c enter jordan hospital

JOPS

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

JOPS

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

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,

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

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

Vitamin optimize antiresorptive drugs efficacy specially Bisphosphonates