Once foods in the United States were fortified with vitamin D, rickets appeared to have been conquered, and many considered major health problems from vitamin D deficiency resolved. But vitamin D deficiency is common. This review considers the role of vitamin D in skeletal and nonskeletal health and suggests strategies for the prevention and treatment of vitamin D deficiency.

Vitamin D Deficiency

Objective: The objective was to provide guidelines to clinicians for the evaluation, treatment, and prevention of vitamin D deficiency with an emphasis on the care of patients who are at risk for deficiency. Participants: The Task Force was composed of a Chair, six additional experts, and a methodologist. The Task Force received no corporate funding or remuneration. Consensus Process: Consensus was guided by systematic reviews of evidence and discussions during several conference calls and e-mail communications. The draft prepared by the Task Force was reviewed successively by The Endocrine Society's Clinical Guidelines Subcommittee, Clinical Affairs Core Committee, and cosponsoring associations, and it was posted on The Endocrine Society web site for member review. At each stage of review, the Task Force received written comments and incorporated needed changes. Conclusions: Considering that vitamin D deficiency is very common in all age groups and that few foods contain vitamin D, the Task Force recomme...

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Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline

OBJECTIVE\nThe objective was to provide guidelines to clinicians for the evaluation, treatment, and prevention of vitamin D deficiency with an emphasis on the care of patients who are at risk for deficiency.\n\n\nPARTICIPANTS\nThe Task Force was composed of a Chair, six additional experts, and a methodologist. The Task Force received no corporate funding or remuneration.\n\n\nCONSENSUS PROCESS\nConsensus was guided by systematic reviews of evidence and discussions during several conference calls and e-mail communications. The draft prepared by the Task Force was reviewed successively by The Endocrine Society's Clinical Guidelines Subcommittee, Clinical Affairs Core Committee, and cosponsoring associations, and it was posted on The Endocrine Society web site for member review. At each stage of review, the Task Force received written comments and incorporated needed changes.\n\n\nCONCLUSIONS\nConsidering that vitamin D deficiency is very common in all age groups and that few foods contain vitamin D, the Task Force recommended supplementation at suggested daily intake and tolerable upper limit levels, depending on age and clinical circumstances. The Task Force also suggested the measurement of serum 25-hydroxyvitamin D level by a reliable assay as the initial diagnostic test in patients at risk for deficiency. Treatment with either vitamin D(2) or vitamin D(3) was recommended for deficient patients. At the present time, there is not sufficient evidence to recommend screening individuals who are not at risk for deficiency or to prescribe vitamin D to attain the noncalcemic benefit for cardiovascular protection.

Evaluation, treatment, and prevention of vitamin D deficiency: An endocrine society clinical practice guideline (Journal of Clinical Endocrinology and Metabolism (2011) 96, (1911-1930))

As people get older, they may fall more often for a variety of reasons including problems with balance, poor vision, and dementia. Up to 30% may fall in a year. Although one in five falls may require medical attention, less than one in 10 results in a fracture.
This review looked at the healthcare literature to establish which fall prevention interventions are effective for older people living in the community, and included 159 randomised controlled trials with 79,193 participants.  
Group and home-based exercise programmes, usually containing some balance and strength training exercises, effectively reduced falls, as did Tai Chi. Overall, exercise programmes aimed at reducing falls appear to reduce fractures.
Multifactorial interventions assess an individual's risk of falling, and then carry out treatment or arrange referrals to reduce the identified risks. Overall, current evidence shows that this type of intervention reduces the number of falls in older people living in the community but not the number of people falling during follow-up. These are complex interventions, and their effectiveness may be dependent on factors yet to be determined.  
Interventions to improve home safety appear to be effective, especially in people at higher risk of falling and when carried out by occupational therapists. An anti-slip shoe device worn in icy conditions can also reduce falls.
Taking vitamin D supplements does not appear to reduce falls in most community-dwelling older people, but may do so in those who have lower vitamin D levels in the blood before treatment.  
Some medications increase the risk of falling. Three trials in this review failed to reduce the number of falls by reviewing and adjusting medications. A fourth trial involving family physicians and their patients in medication review was effective in reducing falls. Gradual withdrawal of a particular type of drug for improving sleep, reducing anxiety, and treating depression (psychotropic medication) has been shown to reduce falls.
Cataract surgery reduces falls in women having the operation on the first affected eye. Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition which causes sudden changes in heart rate and blood pressure.
In people with disabling foot pain, the addition of footwear assessment, customised insoles, and foot and ankle exercises to regular podiatry reduced the number of falls but not the number of people falling.
The evidence relating to the provision of educational materials alone for preventing falls is inconclusive.

Interventions for preventing falls in older people living in the community

ContextRaloxifene hydrochloride, a selective estrogen receptor modulator, prevents
bone loss in postmenopausal women, but whether it reduces fracture risk in
these women is not known.ObjectiveTo determine the effect of raloxifene therapy on risk of vertebral and
nonvertebral fractures.DesignThe Multiple Outcomes of Raloxifene Evaluation (MORE) study, a multicenter,
randomized, blinded, placebo-controlled trial.Setting and ParticipantsA total of 7705 women aged 31 to 80 years in 25 countries who had been
postmenopausal for at least 2 years and who met World Health Organization
criteria for having osteoporosis. The study began in 1994 and had up to 36
months of follow-up for primary efficacy measurements and nonserious adverse
events and up to 40 months of follow-up for serious adverse events.InterventionsParticipants were randomized to 60 mg/d or 120 mg/d of raloxifene or
to identically appearing placebo pills; in addition, all women received supplemental
calcium and cholecalciferol.Main Outcome MeasuresIncident vertebral fracture was determined radiographically at baseline
and at scheduled 24- and 36-month visits. Nonvertebral fracture was ascertained
by interview at 6-month-interim visits. Bone mineral density was determined
annually by dual-energy x-ray absorptiometry.ResultsAt 36 months of the evaluable radiographs in 6828 women, 503 (7.4%)
had at least 1 new vertebral fracture, including 10.1% of women receiving
placebo, 6.6% of those receiving 60 mg/d of raloxifene, and 5.4% of those
receiving 120 mg/d of raloxifene. Risk of vertebral fracture was reduced in
both study groups receiving raloxifene (for 60-mg/d group: relative risk [RR],
0.7; 95% confidence interval [CI], 0.5-0.8; for 120-mg/d group: RR, 0.5; 95%
CI, 0.4-0.7). Frequency of vertebral fracture was reduced both in women who
did and did not have prevalent fracture. Risk of nonvertebral fracture for
raloxifene vs placebo did not differ significantly (RR, 0.9; 95% CI, 0.8-1.1
for both raloxifene groups combined). Compared with placebo, raloxifene increased
bone mineral density in the femoral neck by 2.1% (60 mg) and 2.4% (120 mg)
and in the spine by 2.6% (60 mg) and 2.7% (120 mg) P<0.001
for all comparisons). Women receiving raloxifene had increased risk of venous
thromboembolus vs placebo (RR, 3.1; 95% CI, 1.5-6.2). Raloxifene did not cause
vaginal bleeding or breast pain and was associated with a lower incidence
of breast cancer.ConclusionsIn postmenopausal women with osteoporosis, raloxifene increases bone
mineral density in the spine and femoral neck and reduces risk of vertebral
fracture.

https://jamanetwork.com/journals/jama/articlepdf/191242/JOC90496.pdf

Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial

Skeletal fluorosis: histomorphometric analysis of bone changes and bone fluoride content in 29 patients.

The mechanisms underlying glucocorticoid-induced osteoporosis in humans are a defect in bone formation associated with increased bone resorption. The latter may be due to elevated parathyroid hormone (PTH) levels induced by the impairment of intestinal calcium absorption caused by corticosteroids. In this study we analysed the effects of corticosteroids in old ewes, a potential model for the study of human bone turnover. Two groups of seven 9-year-old female sheep were selected. The first group was injected intramuscularly with a daily dose of 30 mg methylprednisone (MP) during the first 2 months and 15 mg during the last month. After 2 and 3 months of treatment, blood samples were taken. At the end of the experiment the animals were slaughtered and the iliac crest kept for bone histomorphometry. Serum osteocalcin (sOC) rapidly and markedly decreased in the MP-treated group compared with controls (−77%;p<0.01). In contrast, at the end of the experiment serum calcium and PTH levels were similar in both groups. Histomorphometric analysis showed a significant reduction in the wall width of trabecular packets. Dynamic parameters reflecting bone formation at the tissue and cell levels were significantly lower in the MP-treated group than in controls, with a highly significant decrease in the mineralization rate (MAR: −63%,p<0.05) and double-labeled perimeter (dLPm/B.Pm: −92%p<0.05). The bone formation rate (BFR/B.Pm) also decreased by 84% and the adjusted apposition rate (Aj.AR) by 80%. The increase in the total formation period was mainly due to an increase in the inactive period. Significant correlations were found between sOC and MAR, dLPm/B.Pm and BFR/B.Pm (withr′ respectively 0.67, 0.76 and 0.51). In conclusion, the effects of corticosteroid on ewe bone remodeling are essentially characterized by a major bone formation defect without evidence of secondary hyperparathyroidism, although this cannot be totally excluded by our results. Ewes treated with glucocorticoids could represent a good model for evaluating the effects of drugs candidates for all bone conditions characterized by reduced bone formation resulting from osteoblastic depression.

Glucocorticoid-induced inhibition of osteoblastic bone formation in ewes: A biochemical and histomorphometric study

Dichloromethylene diphosphonate (C12MDP) is a diphosphonate which markedly inhibits bone resorption. We have tested CUMDP in Paget's disease, a disorder characterized by increased bone remodeling. Sixty-three patients with progressive Paget's disease were treated for 6 months with Cl2MDP at daily oral doses of 400, 800, 1600, or 2400 mg. Thirty-nine patients received calcium and vitamin D supplements during treatment. Patients in all treatment groups had significant reduction in serum alkaline phosphatase, urinary hydroxyproline, skeletal uptake of 99mtechnetium-diphosphonate scintiscans, and resorption parameters on iliac crest biopsy samples as assessed by quantitative histomorphometry. Treatment was well tolerated and did not induce a skeletal mineralization defect. The reduction in alkaline phosphatase and urinary hydroxyproline persisted 1 yr after withdrawal of treatment. The biochemical remission was sustained in half of the patients 2 yr after the end of treatment and was accompanied by a marked r...

Long Term Effects of Dichloromethylene Diphosphonate in Paget's Disease of Bone

Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DEXA) in 133 normal females on five regions of the femoral site: neck, trochanteric, intertrochanteric, Ward’s triangle, and total area of the proximal femur. One hundred and twenty-five women (56 older than 65, range 65–97, and 69 with an age range of 21–65) were also examined for spinal bone mineral density. The mean in vivo precision (CV%) of the measurements with respositioning assessed on five young and eight elderly patients was ranged from 0.7% to 1.7% but lowerfor Ward’s triangle (CV=2.95% and 3.87%). Between 30 and 90 years, a linear age-related bone mineral decrease was found at all sites with a similar magnitude of bone loss for the femoral neck, total or intertrochanteric regions (−33% to −39%). A greater decrease was found for the Ward’s triangle region (−61 %). In the subgroup of elderly women (65–97 years old), the lumbar BMD measured with an anteroposterior incidence did not decrease significantly with age, contrasting with an average 27% decrease of the BMD of the hip between 65 and 90 years of age.

Marie-Claire Chapuy

Papers

Skeletal fluorosis: histomorphometric analysis of bone changes and bone fluoride content in 29 patients.

Glucocorticoid-induced inhibition of osteoblastic bone formation in ewes: A biochemical and histomorphometric study

Long Term Effects of Dichloromethylene Diphosphonate in Paget's Disease of Bone

Bone mineral density of the hip measured with dual-energy X-ray absorptiometry in normal elderly women and in patients with hip fracture.

Bone histomorphometry in corticosteroid-induced osteoporosis and Cushing's syndrome.