OSTEOPOROSIS IS the most common human metabolic

Transcription

1 JOURNAL OF BONE AND MINERAL RESEARCH Volume 16, Number 8, American Society for Bone and Mineral Research Relation Between Vitamin D Insufficiency, Bone Density, and Bone Metabolism in Healthy Postmenopausal Women PEDRO MEZQUITA-RAYA, 1 MANUEL MUÑOZ-TORRES, 1 JUAN DE DIOS LUNA, 2 VICTORIA LUNA, 1 FRANCISCA LOPEZ-RODRIGUEZ, 1 ELENA TORRES-VELA, 1 and FERNANDO ESCOBAR-JIMÉNEZ 1 ABSTRACT Although only few postmenopausal women exhibit biochemical signs of hypovitaminosis D, vitamin D insufficiency has been shown to have adverse effects on bone metabolism and could be an important risk factor for osteoporosis and fracture. We determined serum levels of 25-hydroxyvitamin D [25(OH)D], intact parathyroid hormone (ipth), bone turnover markers, dietary calcium intake, and bone mineral density (BMD; measured by dual X-ray absorptiometry) in 161 consecutive ambulatory women, healthy except for osteoporosis, referred to a bone metabolic unit. The prevalence of vitamin D insufficiency [25(OH)D < 15 ng/ml] was 39.1%. 25(OH)D was lower in the osteoporotic subjects ( ng/ml vs ng/ml; p < 0.001). After controlling for all other variables, lumbar spine (LS) BMD was found to be significantly associated with 25(OH)D, body mass index (BMI), and years after menopause (YSM) (R ; p < 0.001). For femoral neck (FN), significant independent predictors of BMD were YSM, BMI, ipth, and 25(OH)D (R ; p < 0.001). The probability of meeting osteoporosis densitometric criteria was higher in the vitamin D insufficiency group (odds ratio [OR], 4.17, ) after adjusting by YSM, BMI, ipth, and dietary calcium intake. Our study shows that vitamin D insufficiency in an otherwise healthy postmenopausal population is a common risk factor for osteoporosis associated with increased bone remodeling and low bone mass. (J Bone Miner Res 2001;16: ) Key words: vitamin D insufficiency, osteoporosis, bone mineral density, bone turnover, postmenopausal women INTRODUCTION OSTEOPOROSIS IS the most common human metabolic bone disorder. It has been defined as a disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. (1,2) It is an important public health issue in postmenopausal women and if untreated, more than half of white women will experience fractures during their lifetime. Normal bone metabolism depends on the presence of appropriate repletion of vitamin D. The importance of vitamin D insufficiency is related primarily to bone integrity. Although only few patients with osteoporosis exhibit obvious biochemical signs of hypovitaminosis D, vitamin D insufficiency has been shown to have adverse effects on calcium metabolism, osteoblastic activity, matrix ossification, bone mineral density (BMD), and bone remodeling. (3 6) Determination of serum 25-hydroxyvitamin D [25(OH)D] is the most clinically reliable indicator of vitamin D status. Thus, low serum 25(OH)D concentration is associated with secondary hyperparathyroidism, increased bone turnover, reduced BMD, and increased risk of osteoporotic fractures. (4 6) In addition, administration of vitamin D to the elderly slows bone turnover, increases 1 Bone Metabolic Unit, Endocrinology Division, University Hospital San Cecilio, Granada, Spain. 2 Biostatistics Department, School of Medicine, Granada, Spain. 1408

2 VITAMIN D INSUFFICIENCY IN POSTMENOPAUSAL WOMEN 1409 BMD, and can reduce the rates of fragility fractures. (7) However, although previous studies have established the importance of vitamin D insufficiency in selected groups at risk (8 10) such as elderly patients who are housebound, living in a nursing home, or general medical inpatients, the role of this disorder on bone metabolism and postmenopausal bone loss is still controversial. (11 14) Therefore, we assessed the relationships between vitamin D insufficiency, parathyroid hormone (PTH) concentrations, BMD, and biochemical markers of bone turnover in a healthy (except for osteoporosis), communitydwelling, ambulatory postmenopausal women. MATERIALS AND METHODS Study subjects From November 1998 to April 1999, 363 Spanish women were referred by general practitioners to our unit for osteoporosis screening in Granada, Spain (latitude N and longitude 3 35 W). The study was approved by the Investigation Committee of the University Hospital San Cecilio. At the clinic, detailed medical histories and biochemical studies were performed to identify any causes for low BMD. After giving informed consent, 161 postmenopausal women were recruited. All were white; ambulatory; in good health except for osteoporosis; had normal values for serum calcium and phosphorus; and did not present renal, hepatic, gastrointestinal, or thyroid diseases or any other secondary causes for low BMD or serum vitamin D levels. None of them had been treated with calcium supplements, vitamin D preparations, hormone therapy, antiresorptive therapy, thiazides, steroids, or other medications that might affect BMD or vitamin D metabolism. Assessment of dietary calcium intake Dietary calcium intake was assessed by a detailed weekly food-frequency interview performed by a single expert dietitian. Each subject was asked to indicate the type and quantity of all food and drink consumed over a 1-week period and the dietary calcium content was calculated using a local food composition table. (15) They were entered in a database and analyzed by a single trained operator using a computer program to obtain the average daily intake of calcium. Bone density measurements and radiography BMD was measured by dual-energy X-ray absorptiometry (Hologic QDR 1000 ; Hologic, Inc., Waltham, MA, USA) at lumbar spine (LS) and femoral neck (FN). The in vivo precision (CV) was better than 2% at both sites of measurement. A total of 2552 healthy normal subjects (1331 females and 1221 males) served to establish the mean BMD in the healthy Spanish population and to calculate the T score (number of SDs of the patient s value from the mean of young control population) and Z score for each BMD measurement (number of SDs of the patient s value from the mean control population in a 5-year-age band). The characteristics of this reference population have been described previously. (16) According to the World Health Organization (WHO) criteria, (17) we considered osteoporosis when the LS and/or FN T score was equal or below 2.5 SD. Vertebral fractures, calcifications, or other significant degenerative changes were assessed by X-ray study and corrected according to the method of Orwoll. (18) Anteroposterior and lateral X-rays of the thoracic and lumbar spine were taken for all women to assess the presence of fractures. The anterior, central, and posterior height of each of the 13 vertebral bodies from Th4 to L4 were measured. Vertebral fracture was defined as a reduction of as least 20% in the anterior, central, or posterior vertebral height according to the following criteria: (a) anterior wedge deformity ratio of anterior to posterior height 80%; (b)concavity deformity ratio of central to posterior height 80%; (c) crush deformity ratio of posterior height to posterior height of the adjacent vertebra 80%. Biochemical measurements Morning fasting samples of venous blood were taken. Serum 25(OH)D 3 (25-hydroxyvitamin D 125 I radioimmunoassay [RIA]; reference value (RV), ng/ml; Incstar Corp., Stillwater, MN, USA) and intact PTH (ipth; Immulite Intact PTH; RV, pg/ml; Diagnostic Products Corp., Los Angeles, CA, USA) were assayed. Serum total alkaline phosphatase (talp; Hitachi 704 autoanalyzer; RV, IU/liter;Boehringer Mannheim, Mannheim, Germany), bone ALP (balp; Tandem-T, Ostase Immuno- RadioMetric Assay; RV, g/ml; Hybritech Europe, Liege, Belgium), osteocalcin (OC; Osteocalcin 125 I RIA; RV, ng/ml; Incstar Corp.), tartrate-resistant acid phosphatase (TRAP; Hitachi 704 autoanalyzer; RV: 7 IU/liter; Boehringer Mannheim), fasting urine crosslinked carboxy-terminal telopeptide of type I collagen corrected by urinary creatinine (CTX; -CrossLaps RIA; RV postmenopausal women, g/mmol; Osteometer Biotech, Herlev, Denmark), and fasting urine calcium/ creatinine ratio were determined as bone turnover markers. The samples were analyzed in multiple analysis; the interassay CVs were % for 25(OH)D, 7% for ipth, % for balp, 2.2% for talp, 3.5% for OC, 13.7% for CTX, and 2.2% for TRAP. Definition of vitamin D insufficiency We selected 15 ng/ml (37 nm) as the lower 25(OH)D cut-off in our analysis, based on published data showing that serum ipth is increased in patients who have 25(OH)D concentrations equal to or below 15 ng/ml. (8,19,20) Moreover, a specific cut point was calculated as the 25(OH)D concentration at which maximum signification is reached comparing bone turnover markers and ipth (28 ng/ml). Statistical analysis Group means were compared using the two-tailed nonpaired Student s t-test. Simple linear regression analysis was used to study the relationship among 25(OH)D, ipth, and BMD measurements. Multiple linear regression was

3 1410 MEZQUITA-RAYA ET AL. TABLE 1. CLINICAL CHARACTERISTICS OF 161 POSTMENOPAUSAL WOMEN Total (n 161) 25(OH)D 15 (ng/ml; n 98) 25(OH)D 15 (ng/ml; n 63) notp (n 83) OTP (n 78) Age (years) * YSM * BMI (kg/m 2 ) * LS BMD (g/cm 2 ) * LS T score FN BMD (g/cm 2 ) * FN T score * 25(OH)D (ng/ml) * ipth (pg/ml) * Ca intake (mg/day) Data are mean SD. For ipth, RV pg/ml. OTP, osteoporotic patients; notp: nonosteoporotic patients. * p 0.05 versus nonosteoporotic patients; p 0.05 versus noninsufficiency 25(OH)D patients. used to estimate adjusted -coefficients for changes in BMD; also, partial correlations were completed to measure percentage variance explained by each covariate. Logistic regression was used to estimate crude and adjusted odds ratio (OR) for the dichotomous outcomes of osteoporosis. The Hosmer and Lemeshow goodness-of-fit test used in the models resulted in nonsignificant (p 0.3). The years since menopause (YSM) variable was entered in the model in the following categories: 0 10 YSM, YSM, YSM, and 30 YSM, the first being used as the reference category. The ipth levels variable was entered in the model in two categories using a cut-off at 72 pg/ml, the upper limit of the normal range measured in our laboratory. The reference category was the ipth 72 pg/ml group. The body mass index (BMI; kg/m 2 ) variable was entered in the model in two categories, with (BMI 30 kg/m 2 ) or without (BMI 30 kg/m 2 ) obesity, (21,22) with the obese group as the reference category. The dietary calcium intake variable was entered in the model in three categories: below to 500 mg/day, between 500 and 1000 mg/day, and greater than 1000 mg/day, with the upper category as the reference. We tested for differences in the relationship of vitamin D levels to change in these measurements by including interaction terms for vitamin D status in the models. None of these interaction terms were significant. Analyses were performed with adjustment for YSM, BMI, ipth, and dietary calcium intake. Statistical significance was defined as a value of p All analyses were performed in SPSS, version (SPSS Ltd., Chicago, IL, USA) using the multiple regression program and logistic regression program when calculating 95% CIs and p values. RESULTS Clinical characteristics The characteristics of the patients are shown in Table 1. The mean ( SD) serum 25(OH)D concentration for all 161 patients was ng/ml. The prevalence of vitamin D insufficiency [circulating 25(OH)D equal or less than 15 ng/ml] was 39.1%. According to the WHO criteria, (18) 83 patients (51.6%) were considered nonosteoporotic (normal bone mass or osteopenic; T score 2.5) and 78 patients (48.4%) were osteoporotic (T score 2.5). Forty-five women were diagnosed as having vertebral fracture, 19 (30.2%) in the vitamin D insufficiency group and 26 (26.6%) in the normal vitamin D group. Thirty-four subjects (43.6%) of the osteoporotic group had prevalent vertebral fractures. The dietary calcium intake was below the recommended dietary allowance (1500 mg/day for postmenopausal women) (23) in the entire sample. There were significant linear correlations between 25(OH)D, age, and YSM (age vs. 25(OH)D: r 0.247, p 0.002; YSM vs. 25(OH)D: r 0.317, p 0.001) and between ipth, age, and YSM (age vs. ipth: r 0.213, p 0.007; YSM vs. ipth: r 0.256, p 0.001). 25(OH)D, ipth, and BMD The average serum 25(OH)D was lower in the osteoporotic group (Table 1). Serum ipth levels were higher both in the osteoporotic and in the vitamin D insufficiency groups (Table 1) and even higher in subjects with vitamin D insufficiency independently of bone status (Fig. 1). More interestingly, the subjects with vitamin D insufficiency had a significantly lower BMD, with an average that fell 0.81 SD below the expected for their age at LS. A strong negative linear correlation was found between ipth and 25(OH)D (Fig. 2). There was a significant linear correlation between 25(OH)D and BMD at LS and FN (Fig. 3). Also, there was a significant linear correlation between ipth and BMD at LS (ipth vs. BMD [g/cm 2 ]: r 0.305, p 0.001) and FN (ipth vs. BMD [g/cm 2 ]: r 0.351, p 0.001). Bone turnover markers The mean values of all biochemical markers of bone turnover exhibited no differences between 25(OH)D 15 ng/ml and 25(OH)D 15 ng/ml groups or osteoporotic and

4 VITAMIN D INSUFFICIENCY IN POSTMENOPAUSAL WOMEN 1411 FIG. 1. ipth levels according to 25(OH)D and BMD groups. OTP, T score at LS or FN 2.5; notp, T score at LS or FN 2.5. levels, BMI, and YSM (Table 3). This final model explained 25.3% of the observed variance in lumbar spine BMD. For FN BMD, significant independent predictors of BMD were YSM, BMI, ipth, and serum 25(OH)D levels. The final model explained 36.8% of the observed variance in FN BMD (Table 3). Overall, the serum 25(OH)D accounted for a 10.04% of the variance in BMD at LS after adjusting for BMI and YSM and a 2.52% at FN after adjusting for YSM, ipth, and BMI. Taking into account the total effect of YSM, BMI, dietary calcium intake, ipth levels, and 25(OH)D levels, the YSM variable was associated the most strongly with OP followed by 25(OH)D levels and BMI (Table 4). The effects of ipth and dietary calcium intake were not statistically significant, but they should not be ignored because they increase the global significance of the model. DISCUSSION FIG. 2. Correlation between 25(OD)D and ipth. nonosteoporotic groups except CTX, which was higher in the vitamin D insufficiency group (CTX: g/ mmol vs g/mmol; p 0.012) and correlated with 25(OH)D (r 0.240; p 0.002). Also, there were internal significant correlations among bone turnover markers and between ipth and bone turnover markers (Table 2). However, CTX, talp, balp, and ipth were higher in patients with 25(OH)D 28 ng/ml (CTX: g/mmol vs g/mmol, p 0.012; talp: IU/liter vs IU/liter, p 0.045; balp: g/ml vs g/ml, p 0.006; ipth: pg/ml vs pg/ml, p 0.001). Bivariate and multivariate analysis After controlling for all other variables, LS BMD was found to be significantly associated with serum 25(OH)D Our study shows that vitamin D insufficiency is a common risk factor for osteoporosis, associated with increased bone remodeling and postmenopausal osteoporosis, in healthy (except for osteoporosis), community-dwelling, ambulatory postmenopausal women. In previous studies of elderly housebound people, medical inpatients, and nursing home residents, one-quarter to one-half had low vitamin D levels. (8 10,24) However, in our study, with ambulatory subjects without secondary causes or medications that might affect bone density, the prevalence of vitamin D insufficiency was 39.1%. The high frequency of vitamin D insufficiency in postmenopausal women in this sunny region should be of concern. The main factors contributing to vitamin D insufficiency are poor vitamin D intake, low sunlight exposure (staying indoors), and disorders or drugs known to affect vitamin D metabolism. (25) In our population, secondary causes affecting vitamin D metabolism were excluded. Serum 25(OH)D was measured from November to April, a winter period where there is normally no cyclical seasonal variation. In other countries in which dairy products are fortified with vitamin D, it is well known that calcium-deficient diets tend to be vitamin D-deficient too, because a single food, milk, is the principal dietary source of both of these nutrients. (26) In our country, this finding may be justified by the lack of a governmental mandate that food be supplemented with vitamin D. Hence, cutaneous synthesis would be the major source of the vitamin in ambulatory women of this age group. This could be an explanation for the low serum levels of 25(OH)D found in our sample. In our study, the pathogenic role of vitamin D insufficiency in the decreased bone mass is suggested by the significant correlation between 25(OH)D and BMD in LS and FN. Moreover, the average serum 25(OH)D was lower in the osteoporotic group and women with vitamin D insufficiency had a significantly lower BMD. Secondary hyperparathyroidism is a well-known consequence of vitamin D insufficiency. (3,24,27 29) Our data show a strong negative correlation between ipth and 25(OH)D and a significant correlation among ipth and bone turnover markers. This

5 1412 MEZQUITA-RAYA ET AL. FIG. 3. Correlation between 25(OD)D and BMD. (A) LS; (B) FN. biochemical picture suggests that increased concentrations of PTH might play an important role in the development of increased bone remodeling and bone loss in postmenopausal women with vitamin D insufficiency. Villarreal et al. (5) could not find in their population a correlation between 25(OH)D and ipth at physiological concentrations. In contrast, in our study and others reported previously (8,30) 25(OH)D is involved directly in the feedback control of PTH, even at physiological concentrations. We found that aging may lead to an increase in PTH levels and a decrease in vitamin D concentrations in postmenopausal women, as previous reports show. (31) Despite this fact, these findings are not likely to account entirely for the low bone mass found in the majority of our vitamin D insufficiency subjects. We observed that 25(OH)D and ipth still predict independently BMD at LS and FN, respectively, after adjusting for YSM, dietary calcium intake, and BMI. Vitamin D status appeared to be less related to proximal femur than to LS BMD. This may be caused by the fact that other mechanical factors (i.e., physical activity and weight) could influence proximal femur BMD to a higher extent. Moreover, the sex hormone deficiency makes LS bone more susceptible for vitamin D insufficiency. As it has been suggested previously, estrogens deficiency potentiates the effect of PTH excess because of vitamin D insufficiency. (32) Furthermore, hyperparathyroidism predisposes to cortical rather than cancellous bone loss, which would be more obvious at FN compared with LS and also may explain that ipth was a significant independent predictor of BMD at FN, influencing to a lower extent the vertebral bone mass. This dual effect of PTH on bone has been described classically in patients with primary hyperparathyroidism. (33,34) There were no differences in biochemical markers of bone turnover between 25(OH)D 15 ng/ml and 25(OH)D 15 ng/ml groups or osteoporotic and nonosteoporotic groups, except CTX. However, CTX, talp, balp, and ipth levels were higher in patients with 25(OH)D 28 ng/ml and there was a significant positive correlation between ipth and bone turnover markers. This result supports previous data suggesting that the 25(OH)D threshold level needed to prevent secondary hyperparathyroidism and bone loss should be higher. (26,27,35 38) Serum 25(OH)D is the most clinically available measurement of vitamin D status reflecting lifestyle and dietary habits. (25) Assuming a cut-off level of 15 ng/ml in our sample, the probability of meeting osteoporosis densitometric criteria was higher in the vitamin D insufficiency group, after adjusting for YSM, BMI, serum ipth levels and dietary calcium intake. These results could suggest another effect of vitamin D on bone metabolism independently of PTH excess as described in animal models and in vitro studies. (39,40) Limitations of our study include those associated with cross-sectional studies. All the subjects studied attended our unit for screening of osteoporosis; so, our sample is not representative of the general population. Otherwise, we probably have underestimated the prevalence of hypovitaminosis D by not identifying subjects with low serum 1,25(OH)D concentrations despite adequate serum 25(OH)D concentrations. Our most interesting finding shows that vitamin D contributes for 10% of the BMD variance at LS and 2.5% of BMD at FN and that the probability of meeting osteoporosis criteria is significantly higher in the vitamin D insufficiency group. Vitamin D contribution to the BMD is not negligible and represents an attractive candidate agent for its use in preventive interventions like systematic supplementation of dairy products. In conclusion, we found that vitamin D insufficiency in an otherwise healthy postmenopausal population is a common risk factor for osteoporosis associated

6 VITAMIN D INSUFFICIENCY IN POSTMENOPAUSAL WOMEN 1413 TABLE 2. CORRELATIONS AMONG ipth AND BIOCHEMICAL MARKERS OF BONE TURNOVER Variable ipth (pg/ml) balp ( g/ml) talp (IU/liter) OC (ng/ml) uca/cr ratio CTX ( g/mmol) balp talp * OC uca/cr ratio CTX 0.319* 0.366* TRAP (IU/liter) * 0.390* uca/cr ratio, fasting urine calcium/creatinine ratio. * p 0.001; p 0.005; p TABLE 3. MULTIPLE LINEAR REGRESSION ANALYSIS OF BMD Variable LS Partial correlation p FN Partial correlation p Constant (OH)D (ng/ml) YSM BMI (kg/m 2 ) BMI YSM ipth (pg/ml) (OH)D Model R ; p R ; p TABLE 4. BIVARIATE AND MULTIVARIATE ANALYSIS Variable Bivariate Multivariate OR CI 95% OR CI 95% YSM 1.09 a a 1.08 a a 10 years years years years Serum 25(OH)D levels (ng/ml) 0.9 a a 0.89 a a 15 ng/ml ng/ml BMI (kg/m 2 ) 0.92 a a 0.87 a a 30 kg/m kg/m Serum ipth levels (pg/ml) 1.02 a a 0.99 a a 72 pg/ml pg/ml Dietary calcium intake 0.69 a a 0.6 a a mg/day mg/day mg/day a As continuous variable. with increased bone remodeling and low bone mass. Because replacement therapy is inexpensive, simple, and safe, a widespread screening for vitamin D insufficiency and the normalization of vitamin D status should alter our routine medical practice and have important public health implications even in southern latitude countries. ACKNOWLEDGMENT We express our gratitude to Andrew F. Stewart for his exciting critical review of this article. This work was supported by a grant from Servicio Andaluz de

7 1414 MEZQUITA-RAYA ET AL. Salud (Exp 97/44 304) and the Hospital Clínico Foundation. REFERENCES 1. Consensus Development Conference 1994 Diagnosis, prophylaxis and treatment of osteoporosis. Am J Med 94: Kanis JA, Melton LJ III, Christiansen C, Johnston CC, Khaltaev N 1994 The diagnosis of osteoporosis. J Bone Miner Res 9: Parfitt AM, Gallagher JC, Heaney RP, Johnston CC, Neer R, Whedon GD 1982 Vitamin D, and bone health in the elderly. Am J Clin Nutr 35: Lukert B, Higgins J, Stoskopf M 1992 Menopausal bone loss is partially regulated by dietary intake of vitamin D. Calcif Tissue Int 51: Villareal DT, Civitelli R, Chines A, Avioli LV 1991 Subclinical vitamin D deficiency in postmenopausal women with low vertebral bone mass. J Clin Endocrinol Metab 72: Khaw KT, Sneyd MJ, Compston J 1992 BMD, parathyroid hormone and 25-hydroxyvitamin D concentrations in middle aged women. BMJ 305: Chapuy MC, Arlot ME, Duboeuf F, Crouzet B, Delmas PD, Meunier PJ 1992 Vitamin D, and calcium to prevent hip fractures in elderly women. N Engl J Med 327: Gloth FM, Gundberg CM, Hollis BW, Haddad JG, Tobin JD 1995 Vitamin D deficiency in homebound elderly persons. JAMA 274: McKenna MJ 1992 Differences in vitamin D status between countries in young adults and the elderly. Am J Med 93: Goldray D, Mizrahi-Sasson E, Merdler C, Edelstein Singer M, Algoetti A, Eisenberg Z, Jaccard N, Weisman Y 1989 Vitamin D deficiency in elderly patients in a general hospital. J Am Geriatr Soc 37: Silverberg SJ, Shane E, De la Cruz L, Segre GV, Clemens TL, Bilezikian JP 1989 Abnormalities in parathyroid hormone secretion and 1,25-dihydroxyvitamin D3 formation in women with osteoporosis. N Engl J Med 320: Tsai K, Ebeling PR, Riggs BL 1989 Bone responsiveness to parathyroid hormone in normal and osteoporotic postmenopausal women. J Clin Endocrinol Metab 69: Eastell R, Yergey AL, Vieira NE, Cedel SL, Kumar R, Riggs BL 1991 Interrelationship among vitamin D metabolism, true calcium absorption, parathyroid function, and age in women: Evidence of an age-related intestinal resistance to 1,25- dihydroxyvitamin D action. J Bone Miner Res 6: Prince RL, Dick I, Devine A, Price RI, Gutteridge DH, Kerr D, Criddle A, Garcia Webb P, St John A 1995 The effect of menopause and age on calciotropic hormones: A crosssectional study of 655 healthy women aged 35 to 90. J Bone Miner Res 10: Fernandez-Lloret S, Valenzuela-Ruiz A, Burgaleta-Mezo E, Ortiz-Vergara M 1997 Tablas de composición de alimentos. In: Fernandez-Lloret S (ed.) Tablas de Composición: Alimentos, Dietas Artificiales y Productos Infantiles, 3rd ed. Universidad de Granada, Granada, Spain, pp Diaz Curiel M, Carrasco de la Peña JL, Honorato Perez J, Perez Cano R, Rapado A, Ruiz Martinez I 1997 Study of BMD in lumbar spine and femoral neck in a Spanish population. Multicentre Research Project on Osteoporosis. Osteoporos Int 7: Orwoll ES, Oviatt SK, Mann T 1990 The impact of osteophytic and vascular calcifications on vertebral mineral density measurements in men. J Clin Endocrinol Metab 70: Report of a World Health Organization (WHO) Study group 1994 Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. World Health Organ Tech Rep Ser 843: Webb AR, Pilbeam C, Hanafin N, Holick MF 1990 An evaluation of the relative contributions of exposure to sunlight and of diet to the circulating concentrations of 25-hydroxyvitamin D in an elderly nursing home population in Boston. Am J Clin Nutr 51: Lips P, Wiersinga A, van Ginkel FC, Jongen MJ, Netelenbos JC, Hackeng WH, Delmas PD, van der Vijgh WJ 1988 The effect of vitamin D supplementation on vitamin D status and parathyroid function in elderly subjects. J Clin Endocrinol Metab 67: Sociedad Española para el Estudio de la Obesidad (SEEDO) 1996 Spanish consensus for the evaluation of obesity and the performance of epidemiologic studies. Med Clin (Barc) 107: Report of a World Health Organization (WHO) Consultation on Obesity 1998 Obesity: Preventing and managing the global epidemic. In: Program of Nutrition, Family and Reproductive Health. WHO, Geneva, Switzerland, pp National Institutes of Health Consensus Conference 1994 Optimal calcium intake. JAMA 272: Thomas MK, Lloyd Jones DM, Thadhani RI, Shaw AC, Deraska DJ, Kitch BT, Vamvakas EC, Dick IM, Prince RL, Finkelstein JS 1998 Hypovitaminosis D in medical inpatients. N Engl J Med 338: Silverberg SJ, Fitzpatrick LA, Bilezikian JP 1996 The role of parathyroid hormone and vitamin D in the pathogenesis of osteoporosis. In: Marcus R, Feldman D, Kelsey J (eds.) Osteoporosis. Academic Press, San Diego, CA, USA, pp Dawson-Hughes B, Harris SS, Krall EA, Dallal GE 1997 Effect of calcium and vitamin D supplementation on BMD in men and women 65 years of age older. N Engl J Med 337: Chapuy MC, Preziosi P, Maamer M, Arnaud S, Galan P, Hercberg S, Meunier PJ 1997 Prevalence of vitamin D insufficiency in an adult normal population. Osteoporos Int 7: Frame B, Parffit AM 1978 Osteomalacia: Current concepts. Ann Intern Med 89: Stanbury SW 1981 Vitamin D and hyperparathyroidism. J R Coll Physicians Lond 15: Haden ST, Fuleihan GEH, Angell JE, Cotran NM, LeBoff MS 1999 Calcidiol and PTH levels in women attending an osteoporosis program. Calcif Tissue Int 64: Marcus R, Madvig P, Young G 1984 Age related changes in parathyroid hormone and parathyroid hormone action in normal humans. J Clin Endocrinol Metab 58: Ooms ME, Lips P, Roos JC, van der Vijgh WJ, Popp Snijders C, Bezemer PD, Bouter LM 1995 Vitamin D status and sex hormone binding globulin: Determinants of bone turnover and BMD in elderly women. J Bone Miner Res 10: Silverberg SJ, Shane E, de la Cruz L, Dempster DW, Feldman F, Seldin D, Jacobs TP, Siris ES, Cafferty M, Parisien MV 1989 Skeletal disease in primary hyperparathyroidism. J Bone Miner Res 4: Wishart J, Horowitz M, Need A, Nordin BEC 1990 Relationship between forearm and vertebral mineral density in postmenopausal women with primary hyperparathyroidism. Arch Intern Med 150: Dawson-Hughes B, Harris SS, Krall EA, Dallal GE, Falconer G 1995 Rates of bone loss in postmenopausal women randomly assigned to one of two dosages of vitamin D. Am J Clin Nutr 61: Malabanan A, Veronikis IE, Holick MF 1998 Redefining vitamin D insufficiency. Lancet 351:

8 VITAMIN D INSUFFICIENCY IN POSTMENOPAUSAL WOMEN McKenna MJ, Freaney R 1998 Secondary hyperparathyroidism in the elderly: Means to defining hypovitaminosis D. Osteoporosis Int 8(Suppl 2):S3 S Thomas MK, Demay MB 2000 Vitamin D deficiency and disorders of vitamin D metabolism. Endocrinol Metab Clin North Am 29: Haussler MR, Whitfield GK, Haussler CA, Hsieh JC, Thompson PD, Selznick SH, Dominguez CE, Jurutka PW 1998 The nuclear vitamin D receptor: Biological and molecular regulatory properties revealed. J Bone Miner Res 13: Finkelman RD, Linkhart TA, Mohan S, Lau KH, Baylink DJ, Bell NH 1991 Vitamin D deficiency causes a selective reduction in deposition of transforming growth factor in rat bone: Possible mechanism for impaired osteoinduction. Proc Natl Acad Sci USA 88: Address reprint requests to: Manuel Muñoz-Torres, M.D, Plaza Isabel La Católica, 2, 3 Granada 18009, Spain Received in original form August 8, 2000; in revised form February 13, 2001; accepted March 1, 2001.