AAOS Bulletin - December, 2005

Expert panel issues guidelines on Vitamin D and bone health

Addressing the issue of vitamin D deficiency

A panel of osteoporosis experts from the National Osteoporosis Foundation, the American Medical Women’s Association (AMWA) and the AAOS has issued physician recommendations to generate greater understanding of the role of vitamin D in bone health in women and men over 50. The guidelines call for an increase over the currently recommended level of vitamin D intake and encourage individualized treatment for patients.

More than 70 percent of women ages 51-70 and nearly 90 percent of women over age 70 are not getting the recommended adequate intake of vitamin D, according to an 2004 analysis based on the Third National Health and Nutrition Examination Survey. Vitamin D deficiency has been linked to osteoporosis, a condition that affects more than 10 million Americans and threatens 34 million others.

“We agreed that there is a need for increased awareness of the role of vitamin D in osteoporosis treatment,” said Felicia Cosman, MD, clinical director of the National Osteoporosis Foundation, associate professor of clinical medicine at Columbia University School of Medicine and chair of the expert panel. “These recommendations will serve to call attention to the prevalence of vitamin D deficiency and help ensure that patients, particularly women and men over 50, receive optimal care.”

The panel outlined the following action points regarding vitamin D and its role in bone health for physicians treating women and men over 50, including:

• Optimum treatment for bone health should be individualized and may include a combination of exercise, healthy diet, vitamin D and calcium supplements, and potentially, prescription medications.

• Women and men over age 50 receiving treatment for osteoporosis need to receive adequate vitamin D. Supplements are recommended as one of the best sources of vitamin D.

• Current daily vitamin D intake requirements for women and men over 50 should be increased to 800-1,000 International Units (IU).

“The recommendations we provided are designed as a guide for primary care physicians and specialists and are sufficient for most patients,” said AAOS fellow Kimberly J. Templeton, MD, associate professor of orthopaedic surgery at the Kansas University Medical Center. “However, some patients, after discussion with their physicians, may need to obtain a blood test to determine their vitamin D adequacy. Vitamin D deficiency should ultimately be treated on a patient-by-patient basis.” Dr. Templeton, who served on the panel, added: “I encourage people to speak to their physicians about whether vitamin D supplementation may be appropriate.”

Obtaining adequate levels of Vitamin D

Vitamin D is produced in the body after exposure to ultraviolet-B (UVB) rays. Individuals can obtain more than 90 percent of vitamin D through sun exposure, but the panel agreed that this is becoming increasingly difficult as a result of the wide use of sunscreen and protective clothing, due to concerns about skin cancer and other skin diseases, aging and geographic limitations.

Vitamin D is also found naturally in a limited number of foods, such as fatty fish, and in certain fortified foods such as milk, orange juice and ready-to-eat cereal. However, many of these foods are not part of most people’s diets or must be consumed in large volumes to meet the requirement. Therefore, supplements are recommended as a major source of vitamin D for many older Americans.

In using supplements, the panel advised that physicians should help their patients choose the supplement that is right for them by explaining the medical terms associated with the different forms of vitamin D.

Vitamin D in bone health

Vitamin D plays an important role in building and maintaining healthy bones by promoting calcium absorption. Suboptimal levels of vitamin D are associated with reduced calcium absorption, bone loss and an increased risk for osteoporosis. The first-ever report on Bone Health and Osteoporosis: A Report of the Surgeon General (2004) listed vitamin D, calcium and physical activity as the three key elements to maintaining optimal bone health.

Based on relevant clinical practice experience and involvement in various research that highlights the role of vitamin D in bone health, the panel concluded that it is important that vitamin D be considered in patients being treated for osteoporosis and other bone diseases.

AAOS members can provide patients and referring physicians with more information on the role of vitamin D in bone health by referring them to the osteoporosis center on the AAOS patient education Web site, Your Orthopaedic Connection.

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