THE USE OF VITAMINS AND MINERALS IN SKELETAL HEALTH: AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND THE AMERICAN COLLEGE OF ENDOCRINOLOGY POSITION STATEMENT.
Endocr Pract. 2018 Oct 2;24(10):915-924. doi: 10.4158/PS-2018-0050. Epub 2018 Jul 23.
Hurley DL, Binkley N, Camacho PM, Diab DL, Kennel KA, Malabanan A, Tangpricha V.
Summary by VitaminDWiki with comments
- >1,000 lU/day for adults age >50
- Goal of >30 ng level in the blood
- If at risk of low vitamin D, take a test or supplement and take a test 3-4 months later
- test should be >4months later if a loading dose is not used
- Loading dose is OK provided it is followed by maintenance dosing of at least 1,000 - 2,000 IU daily
- Loading dose of vitamin D then monthly maintenance is the most popular – Nov 2018 - monthly, not daily
- Vitamin D sufficiency 10 to 30 ng, optimal 40 to 80 ng (no consensus)– May 2018
- Consensus Vitamin D category listing has
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Vitamin D is present only in small amounts in food, and is primarily produced in the skin upon exposure to ultraviolet B radiation (47) and hypovitaminosis D is common when dietary intake is low or poorly absorbed and sun exposure is limited. Vitamin D plays a major role in active GI transport of calcium and may improve muscle function and balance, thereby reducing fall risk (48), and important for patients with osteoporosis as falls cause >90% of hip fractures. Furthermore, vitamin D might also improve the BMD response to bisphosphonates (49, 50). As a result of all these skeletal effects, multiple medical organizations recommend optimizing vitamin D status as a core component in the treatment of osteoporosis. Defining "vitamin D inadequacy" is extremely controversial. RCTs evaluating nutrients are often confounded when "low" nutrient status is not established since nutrients reach a threshold effect in which greater amounts do not provide enhanced physiologic effects (51). As such, providing vitamin D to volunteers who are vitamin D replete should not be expected to demonstrate beneficial effects. Another major confounder is variability of the 25-hydroxyvitamin D [25(OH)D] assay. Despite being the best determinate of bodily vitamin D status (52), substantial variability between 25(OH)D assays and laboratories persists (53). The Office of Dietary Supplements Vitamin D Standardization Program (VDSP) facilitates standardization of the intra-assay variability and bias of 25(OH)D measurements, recommending a 10% coefficient variability (C.V.) for clinical laboratories (54). It is important to appreciate this assay variability. For example, a 25(OH)D laboratory result of 30 ng/mL meeting the 10% C.V. VDSP recommendation means that the "true" value is between 24 and 36 ng/mL (55). Such variability in 25(OH)D results represents a major challenge to meta-analysis of RCTs (56).
Based on this background of uncertainty, systematic reviews find vitamin D supplementation with daily doses of >800 International Units (IU) to reduce hip and non-vertebral fractures (57, 58). A reasonable clinical approach is a vitamin D intake of >1,000 lU/day for adults age >50, as vitamin D inadequacy is common in those with a low BMD or prior fragility fracture. AACE/ACE clinical practice guidelines recommend vitamin D sufficiency be defined as serum 25(OH)D >30 ng/mL, based on an increased prevalence of secondary HPT below this level (22). The IOM reviewed virtually the same evidence base and recommended 25(OH)D >20 ng/mL to define vitamin D sufficiency (52). The level that constitutes "high" vitamin D status is similarly controversial. A conservative upper level, based upon 25(OH)D values achieved by highly sun-exposed young adults is 50-60 ng/mL (59). Reasonable approaches to vitamin D assessment and treatment include an initial measurement of 25(OH)D in patients at risk of deficiency, or alternatively, vitamin D supplementation and subsequent 25(OH)D measurement 3-4 months later to assess dose adequacy. The amount of vitamin D required to correct deficiency and reach target levels varies among individuals due to not yet well-understood factors, to include obesity and ethnicity (60). Use of huge single doses of vitamin D is not recommended as limited data find this approach to paradoxically increase falls and fracture risk (61). It is essential that vitamin D replacement of deficient states be followed by maintenance dosing (e.g., 1,000-2,000 IU/day), recognizing that higher doses may be needed in patients with obesity or malabsorption.
It also discusses Calcium, Magnesium, Boron, Vitamin A, Vitamin K, Vitamin C, Vitamin E, Protein, Flavonoids, etc.Endocrinology position statement on Vitamin D, etc. does not say much – Oct 2018
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