1. A High Prevalence of Vitamin D Inadequacy in a Minimal Trauma Fracture Population A High Prevalence of Vitamin D Inadequacy in a Minimal Trauma Fracture Population C. Simonelli, 1 JA Morancey, 1 L Swanson, 1 KK Kileen, 1 KA Grimm, 1 T Weiss, 2 Y-T Chen 2 1 HealthEast Medical Research Institute, St. Paul, MN, USA, 2 Merck & Co., West Point, PA, USA BACKGROUND  To determine the prevalence of vitamin D inadequacy, as determined by serum level of 25 hydroxyvitamin D [25 (OH)D], in a population of adults hospitalized with non-traumatic fractures.  Study population: Patients age 50 years and older who were hospitalized for a fracture between 8/1/01 and 1/31/02 in a single health system in Minnesota –Patients were excluded if they had a high impact trauma, metastatic cancer diagnosis, or were non-communicative or failed to consent  Data Collection on admission –Demographics, medical and lifestyle information by chart review or patient self-report Gender, age, ethnicity, admitting fracture site, BMD testing Vitamin D and calcium supplementation, multivitamin intake, exercise, diet Osteoporosis medication use: none, estrogen, alendronate, risedronate, etidronate, raloxifene, calcitonin –Laboratory testing within 48 hours of hospitalization Vitamin D, parathyroid hormone, creatinine, calcium, albumin, alkaline phosphatase, protein electrophoresis OBJECTIVE METHODS  Results may not be applicable to other populations: –All patients from a single healthcare organization in the Midwest at latitude of 42 degrees –Small sample size –Older population –Lack of ethnic minorities  Variation in serum 25(OH)D assays may confound the diagnosis of vitamin D inadequacy across studies 1  Persistence and compliance of vitamin D use can not be examined due to the lack of information on the frequency and duration of vitamin D supplementation 1. Binkley, et al. JCEM 2004;89:3152-7  97% of hospitalized fracture patients had serum vitamin D [25(OH)D] levels < 30 ng/mL  Half had little or no vitamin D supplementation  Serum vitamin D levels did not differ by age, sex, or use of osteoporosis medications on admission  Patients taking at least 400 IU of vitamin D daily in supplement form had higher mean serum vitamin D levels than those that did not  Nearly all patients in this study hospitalized for fracture had serum vitamin 25(OH)D inadequacy, even those who were considered taking moderate (> 400 IU) daily supplementation of vitamin 25(OH)D.  Significant opportunity exists to ensure adequate and persistent vitamin 25(OH)D intake in patients at risk for fracture. CONCLUSION SUMMARY POSSIBLE LIMITATIONS Serum Vitamin D Assessment  Blood specimens collected during hospitalization within 48 hours of admission  Serum 25-hydroxyvitamin D [25 (OH)D] levels were performed using Diasorin 25-hydroxyvitamin D radioimmunoassay kit (RAI) – With reference sub range of 8-30 ng/mL determined by wintertime in Rochester, MN  Blood specimens were analyzed by Mayo Clinic, Rochester, MN  Results of 25(OH)D levels available for 78 of 82 patients identified for the study  Various cut points of serum 25(OH)D were used to define prevalence of vitamin D inadequacy: (< 9 ng/mL,< 15 ng/mL, < 25 ng/mL, < 30 ng/mL) Vitamin D, Calcium, and Multivitamin Supplementation  Vitamin D, calcium, and multivitamin use on admission was collected by patient self-report: - Vitamin D (IU/day): none, 200, 400, 800 - Calcium (mg/day): none, < 500, 501-750, 751-1000 - Multivitamin use: no, yes  Daily dose of vitamin D was calculated by adding the reported dosage of vitamin D use and 400 IU/day if patient reported taking multivitamin Daily Vitamin D Supplementation & Multivitamin Intake on Admission (n=78) N (%) Vitamin D only14 (18%) 200 IU7 (9%)  400 IU7 (9%) Multivitamin only*36 (46%) Vitamin D  400 IU39 (50%) and/or multivitamin* *Assumes 400 IU vitamin D in multivitamin Mean Vitamin D [25(OH)D] Mean (SD) ng/mL Overall14.2 (6.6) Sex Women14.1 (6.7) Men14.3 (6.4) Age < 8016.6 (7.4) 80+13.9 (6.1) Osteoporosis medication usage Yes15.3 (3.9) No14.0 (6.9) Vitamin D supplementation 400 IU/day* Yes16.4 (6.9) No11.9 (5.5) Mean 25(OH)D levels not statistically different by gender, age, or osteoporosis medication use *p=0.002 RESULTS Characteristics of Study Population on Admission N (%) Female61 (78%) Caucasian77 (99%) Age 50-7929 (37%) Age 80-9949 (63%) Hip Fracture64 (82%) Osteoporosis Medication10 (12%) Calcium supplementation27 (35%)  500 mg/day *N=78 Cutoff points for Serum-25(OH)D (ng/mL) Prevalence of Vitamin D Inadequacy by Vitamin D Supplementation Status * ≥ 400 IU/day including vitamin D obtained by multivitamin ** 35 patients reported no daily vitamin D or multivitamin supplementation, while 4 reported vitamin D supplementation of ≤ 200 IU/day but no multivitamin intake Cutoff points for Serum-25(OH)D (ng/mL) Percent 0 20 40 60 80 100 <9<15<20<25<30 Vit D ≥ 400 IU (n=39)* Vit D < 400 IU (n=39)** Cutoff points for Serum-25(OH)D (ng/mL) Percent Age 50-79 (n=29) Age 80+ (n=49) 0 20 40 60 80 100 <9<15<20<25<30 N=78 Prevalence of Vitamin D Inadequacy Prevalence of Vitamin D Inadequacy by Age Group Percent 20.5 52.5 80.8 96.297.4 0 10 20 30 40 50 60 70 80 90 100 <9<15<20<25<30  Vitamin D is essential for the management of osteoporosis to prevent fractures.  Vitamin D plays a critical role in: –Ensuring dietary calcium absorption –Normal mineralization of bone –Prevention of osteomalacia and secondary hyperparathyroidism  The ideal serum vitamin D level is unknown; however > 30 ng/mL is considered optimal 1  The prevalence of vitamin D inadequacy is not known in patients hospitalized for fractures – a population that is at very high risk for subsequent fractures 1. Heaney, et al. J Am Nutr 2003;22:142-146