expert opinion

Case for Vitamin D – Reducing Fractures in the European Population

March 30, 2011

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Prof. Dr. med. Heike A. Bischoff-Ferrari, Centre on Aging and Mobility, University of Zurich, Dept. of Rheumatology, University Hospital Zurich, Switzerland.

“From 2008 to 2050, both in the US and in Europe, the number of seniors age 65 and older is expected to more than double, and seniors age 85 and older to more than triple (1, 2). As a consequence the number of people with age-related chronic diseases, such as osteoporosis, will rise markedly. Close to 75% of hip and non-hip fractures occur among seniors age 65 and older (3), and by 2050 the worldwide incidence in hip fractures is expected to increase by 240% among women and 310% among men (4). The consequences of hip fractures are severe: 50% of seniors have permanent functional disabilities, up to 30% require long-term nursing home care, and 10% to 20% die within one year (5–8). Beside the personal burden, hip fractures account for substantial health care expenses (9) that have been estimated to more than double between 1990 and 2020 (8).

At present, there is strong evidence that a causal link exists between sufficient vitamin D supplementation a reduction of falls and fractures, in all an estimated 20% curtailment of broken bones could be seen – including those at the hip – in all subgroups of the senior population (10, 11). Based on this evidence, the IOF (International Osteoporosis Foundation) recommends 800 IU vitamin D for all individuals age 60 years and older in their 2010 Position Statement on Vitamin D. Also in 2010, the Institute of Medicine (12) identified vitamin D supplementation as a strategy to improve bone health in all ages, with their recommendations of 600 IU vitamin D per day for children and all adults up to age 69 years, and 800 IU per day for those 70 years and older. Further, the 2011 assessment of the Agency for Healthcare Research and Quality (AHRQ) for the U.S. Preventive Services Task Force (13), the 2010 American Geriatric Society/British Geriatric Society Clinical Practice Guideline (14), and to the 2010 assessment by the IOF (15) all identified vitamin D as an effective intervention to prevent falling in older adults.

Unique to vitamin D is its benefits for both muscle and bone. As for effective fracture prevention in advanced age, fall prevention is paramount. Based on data from double-blind randomized controlled trials, fall and fracture prevention improves with higher 25(OH)D levels: with at least 60 nmol/l needed for fall prevention (11), and at least 75 nmol/l needed for reducing the risk of hip and any non-vertebral fractures (10, 16). Thus, as established at the 2010 Hearing on Vitamin D at the European Parliament, it is of concern that today less than 50% of the European adult population reaches 50 nmol/l 25(OH)D and less than 30% reaches the 75 nmol/l threshold for fracture prevention (17).

Most vulnerable to low 25(OH)D levels are senior adults, as their skin is less capable of producing vitamin D with exposure to sun light. Additionally, seniors tend to avoid direct sunshine; plus, independent of age, Europe on the whole does not get sufficient sun exposure for vitamin D production between the months of November to April. Further, natural nutritional sources of vitamin D are rare, largely limited to fatty fish.

Given vitamin D’s potential as a supplement for fracture and fall reduction, public health strategies must be put into place to address the burden of osteoporosis in an aging European population. With growing data that support a benefit of vitamin D also on general health, this may be even more meaningful.”

Brussels, Belgium, March 2011

References

  1. Spencer G. Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1995 to 2050. http://wwwcensusgov/prod/1/pop/p25-1130pdf 1996; U.S. Department of Commerce Economics and Statistics Administration, Bureau of the consensus.
  2. EUROSTAT. New European Population projections 2008-2060. http://wwwaalianceeu/public/news/eurostat-new-european-population-projections-2008-2060 2008.
  3. Melton L. J. et al. Fracture incidence in Olmsted County, Minnesota: comparison of urban with rural rates and changes in urban rates over time. Osteoporos Int. 1999; 9:29–37.
  4. Gullberg B. et al. World-wide projections for hip fracture. Osteoporos Int. 1997; 7:407–413.
  5. Cummings S. R. et al. Epidemiology of osteoporosis and osteoporotic fractures. Epidemiol Rev. 1985; 7:178–208.
  6. Bischoff-Ferrari H. A. et al. A higher dose of vitamin D is required for hip and non-vertebral fracture prevention: A pooled participant-based meta-analysis of 12 double-blind RCTs. Abstract and oral presentation at the American Society of Bone and Mineral Research Meeting in Toronto, Canada, October 14-19, 2010.
  7. Penrod J. D. et al. The association of race, gender, and comorbidity with mortality and function after hip fracture. J Gerontol A Biol Sci Med Sci. 2008; 63:867–872.
  8. Cummings S. R. et al. The future of hip fractures in the United States. Numbers, costs, and potential effects of postmenopausal estrogen. Clin Orthop Relat Res. 1990; 252:163–166.
  9. Burge R. et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res. 2007; 22:465–475.
  10. Bischoff-Ferrari H. A. et al. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med. 2009; 169:551–561.
  11. Bischoff-Ferrari H. A. et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ. 2009; 339:b3692.
  12. Institute of Medicine. Dietary Reference Ranges for Calcium and Vitamin D.http://wwwiomedu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/Report-Briefaspx2010.
  13. Michael Y. L. et al. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive services task force. Ann Intern Med. 2010; 153:815–825.
  14. 2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons.
  15. Dawson-Hughes B. et al. IOF position statement: vitamin D recommendations for older adults. Osteoporos Int. 2010; 21(7):1151–1154.
  16. Bischoff-Ferrari H. A. et al. Benefit-risk assessment of vitamin D supplementation. Osteoporos Int. 2010; 21:1121–1132.
  17. European Parliament Hearing on Vitamin D. 2010. http://www.cpme.be/news_eunews.php?id=1119.