Aileen Burford-Mason, PhD, President, Holistic Health Research Foundation of Canada, Toronto, ON.

Accumulated research evidence suggests that vitamin D deficiency or insufficiency has profound implications for health and well-being, compromising immune responses and increasing the risk for osteoporosis, arthritis, diabetes, depression, cancer, and cardiovascular disease. Older adults, especially those who are housebound, are at increased risk for vitamin D deficiency. In addition to sun avoidance and the use of sunscreen, age, ethnicity, and obesity are risk factors for vitamin D deficiency. This article discusses the use of serum 25-hydroxyvitamin D to assess vitamin D needs and outlines current recommendations on appropriate interventions to improve vitamin D status in older adults.
Key words: vitamin D, older adults, supplements, UVB exposure, immunity.

Cathy R. Kessenich, DSN, ARNP, Professor of Nursing, University of Tampa, Tampa, FL, USA.
Darlene A. Higgs, RN, BSN, Nurse Practitioner Student, University of Tampa, Tampa, FL, USA.

Osteoporosis is a major cause of health problems in residents of long-term care facilities. It often results in bone fracture, causing poor quality of life and a national financial burden. As the population ages, the incidence of osteoporosis and its consequences increase. It is essential to employ fracture-prevention strategies that have proven most beneficial in long-term care settings and those tailored to promote adherence among older adults. This article reviews osteoporotic treatment appropriate for individuals in long-term care, including treatment through pharmacology, nutritional support, fall prevention, and hip fracture prevention.
Key words: osteoporosis, long-term care, hip protectors, fall prevention, vitamin D.

With osteoporosis fractures increasing in prevalence worldwide, the prevention of fractures has become a major economic and social burden. In addition, nations with poorer health care systems in Asia, Africa, and Latin America are facing aging populations, making the development of affordable preventative therapy especially important.

Supplemental calcium, either alone or in combination with Vitamin D, has been suggested as an inexpensive treatment for the prevention of osteoporotic bone loss and fractures. Data from clinical trials have resulted in inconsistent results regarding the efficacy of this treatment in preventing bone loss and fracture. Tang et al. have synthesized a meta-analysis of randomized trials in which calcium, or calcium in combination with vitamin D, was used to prevent osteoporotic fracture and bone loss in adults over 50 years of age in an effort to offer a comprehensive review of all the relevant evidence.¹

Their findings supported the use of calcium and vitamin D supplementation. When data were pooled, it was revealed that supplementation had resulted in a reduction of 12% in bone fractures of all types (risk ratio 0.88, 95% CI 0.83-0.95; p=0.0004), and a 0.54% decrease in bone mineral density loss (0.35-0.73; p<0.0001) at the hip and 1.19% (0.76-1.61%; p<0.0001) in the spine.

The authors conclude that the evidence supports the use of calcium, or calcium in combination with vitamin D supplementation, as preventative therapy for osteoporosis in adults over 50 years of age. In addition, they suggest a minimum dosage of 1200 mg for calcium and 800 IU of vitamin D for optimal therapeutic effect.

Reference

1. Tang BM, Eslick GD, Nowson C, et al. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet 2007;370:657-66.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Susan J. Whiting, PhD, College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK.
Hassanali Vatanparast, MD, College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK.

This review describes the current state of knowledge in nutritional interventions in osteoporosis, using the Osteoporosis Society of Canada’s (OSC) 2002 clinical practice guidelines for the diagnosis and management of osteoporosis as a basis. Nutrients important for osteoporosis are calcium, vitamin D, protein, sodium, caffeine, and isoflavones. These recommendations are updated and other nutrients and food components, not covered in the OSC 2002 report, are described. As a single nutrient approach is no longer warranted, we discuss how the Dietary Approaches to Stop Hypertension (DASH) diet can be used to provide appropriate intakes of many key nutrients for persons with, or at risk of, osteoporosis.
Key words: DASH diet, calcium, vitamin D, protein, osteoporosis.

3 Supplementation For Primary Prevention of Fractures
A Review of the Literature

Ryan Foster, MD, Department of Medicine, University of Toronto, Toronto, ON.

Matthew T. Oughton, MD, Department of Medicine, McGill University, Montreal, PQ.

Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Staff Physician, Department of Medicine, University Health Network, Toronto, ON.

Fractures are a significant cause of morbidity and mortality in older adults. Previous studies indicated that fracture prevention with vitamin D supplementation, with or without calcium, was achievable only in limited populations. The most recent trial in this field, a randomized, placebo-controlled study by Trivedi, et al., found that large vitamin D doses given every four months are effective for primary prevention of fractures in the community-based older population. This study is critically reviewed in the context of previous studies, and recommendations are made about the role of calcium and vitamin D supplementation in fracture prevention.
Key words: osteoporosis, fracture prevention, vitamin D, calcium, supplementation.

Heike A. Bischoff, MD, MPH, Robert B. Brigham, Arthritis and Musculoskeletal Diseases Clinical Research Center, Brigham and Women's Hospital and Division on Aging, Harvard Medical School; Boston, MA, USA.

There is increasing evidence that vitamin D supplementation may improve musculoskeletal function and prevent falls in older persons at risk for vitamin D deficiency. One basic concept appears to be the direct effect of vitamin D on muscle strength. Highly specific receptors for 1,25-dihydroxyvitamin D are expressed in human muscle tissue and it has been suggested that these nuclear receptors promote protein synthesis in the presence of 1,25-dihydroxyvitamin D, eventually leading to improved strength.
Key words: vitamin D, muscle strength, function, elderly, falls.