|Year : 2016 | Volume
| Issue : 3 | Page : 150-155
Vitamin D status in hospitalized male patients in Ain Shams University Hospitals and relation to body composition
Menna El Araby1, Heba Y Kamel1, Tomader T Abdel Rahman1, Wessam S Sayed2, Ahmed K Mortagy1
1 Department of Geriatrics Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
|Date of Submission||09-Jan-2015|
|Date of Acceptance||10-Jun-2015|
|Date of Web Publication||7-Sep-2016|
Menna El Araby
Department of Geriatrics Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt, PO 11566
Source of Support: None, Conflict of Interest: None
Background Vitamin D deficiency is highly prevalent worldwide; its effect on bone is well known and understood, but the effect of this deficiency is still not clear.
Objective This study examines vitamin D status in Egyptian hospitalized elderly male patients and its relation to body composition, muscle strength, and performance.
Design This was a cross-sectional study.
Participants and methods Data collected from a previous cross-sectional study, in which a systematic random sampling technique was used where every third patient (skip interval) was included in the study and vitamin D was measured only to a selected number of patient who meets inclusion criteria, were selected for inclusion in the study on the basis of the exclusion criteria, which may have affected the parameters measured. Complete assessment of history and physical examination were performed.
Measurements Body composition was measured using bioelectrical impedance analysis (Geratherm), hand grip was measured using a Jamar handheld dynamometer, performance was measured using the timed get up and go test, and 25-hydroxyvitamin D was measured by enzyme-linked immunosorbent assay.
Results Our study included 88 elderly men 60 years of age or older; the mean age of the participants studied was 64.74 ± 4.6 years, and 86.3% were married, 22.7% were physically active, and 15.9% were nonsmokers. The mean BMI was 26.4 ± 7.2 kg/m2 and the mean vitamin D level was 12.15 ng/ml. The prevalence of vitamin D insufficiency was 19.3% and that of vitamin D deficiency was 79.5%. Vitamin D deficiency was not associated with age, occupation, marital status, smoking (type, duration, and quantity), hand grip, timed get up and go test, and parameters of body composition.
Conclusion Vitamin D deficiency and insufficiency is highly prevalent among elderly Egyptian men, and its impact on body composition, muscle function, and strength is not significantly noticeable.
Keywords: body composition, muscle function, muscle performance, status, vitamin D
|How to cite this article:|
El Araby M, Kamel HY, Abdel Rahman TT, Sayed WS, Mortagy AK. Vitamin D status in hospitalized male patients in Ain Shams University Hospitals and relation to body composition. Egypt Rheumatol Rehabil 2016;43:150-5
|How to cite this URL:|
El Araby M, Kamel HY, Abdel Rahman TT, Sayed WS, Mortagy AK. Vitamin D status in hospitalized male patients in Ain Shams University Hospitals and relation to body composition. Egypt Rheumatol Rehabil [serial online] 2016 [cited 2020 Jul 6];43:150-5. Available from: http://www.err.eg.net/text.asp?2016/43/3/150/189644
| Introduction|| |
Vitamin D deficiency is a pandemic, even though it is still undertreated and underdiagnosed worldwide . Vitamin D deficiency is prevalent irrespective of age, sex, race, and geography. On exposure to UVB rays, vitamin D photosensitizes subcutaneously; sufficient vitamin D levels can be maintained just by exposure to sunlight .
One study was carried out on elderly men; serum concentrations of 25-hydroxyvitamin D [25(OH)D] were measured and a deficiency was considered if the level of 25(OH)D less than 20 ng/ml. Deficiency was present in 26% and insufficiency (<30 ng/ml) was present in 72% of the population studied. Deficiency was particularly common among men during the winter and spring seasons (especially in the northern communities) and in the oldest and more obese men. For instance, in White men, in the winter or the spring season, who were more than 80 years old and did not engage in lawn/garden work, had a BMI greater than 25 kg/m2, and vitamin D intake below 400 IU/day, the prevalence of vitamin D deficiency was 86% .
The most well-known function of 1,25-dihydroxyvitamin D [1,25(OH)2D] is regulation of calcium and phosphorus level, which is involved in bone mineralization and remodeling. The absence of active vitamin D at sufficient levels in blood will lead to decreased calcium absorption from the intestine and secondary stimulation of the parathyroid gland and production of parathyroid hormone, which will increase reabsorption of calcium from the tubules of the kidney and resorption of bone to produce enough calcium and this will lead to weak and brittle bones, with increased susceptibility to fracture. Prolonged vitamin D deficiency in adults results in osteomalacia, osteoporosis, muscle weakness, and fracture .
Vitamin D deficiency leads to muscle weakness and pain, decreased strength, impaired balance, muscle function , increased bone turnover , and increased risk of falls and hip fractures  in older adults. Elderly individuals have decreased ability to synthesize vitamin D; this may be attributed to the following:
- Decreased exposure to sunlight and decreased ability of the skin to synthesize vitamin D,
- Reduced intake of the inactive forms of D2 (ergocalciferol) and D3 (cholecalciferol),
- Altered ability of absorption, and
- Decreased hydroxylation by the liver and kidneys .
Vitamin D synthesis decreases in the winter months; thus, vitamin D levels in spring may be reduced in western countries  among housebound elderly  and in inpatients . Vitamin D deficiency in patients with fragility fractures is highly prevalent (varying from 55 to 91.6%) .
The vitamin D receptor was found on the surface of skeletal muscle, indicating that it might play a regulatory role in the skeletal muscle ,. Two mechanisms are suggested for how vitamin D affects skeletal muscle. One suggested mechanism is that 1,25(OH)2D acts on vitamin d receptor (VDRs) within the muscle cells ,. After transportation to the nucleus, this ligand–receptor interaction is altered by various transcription factors and biochemical processes, yielding an active complex .
second explanation is that vitamin D work through its role on calcium, where it increase number and efficacy of binding site responsible for muscle contraction .
Vitamin D supplementation leads to a rapid response, and reversal of pathology cannot be explained by the slow genetic pathway; this is supported by evidence suggesting that vitamin D acts through the vitamin D membrane receptor ,. It binds to a cell membrane receptor with several secondary messengers that are activated from the cell membrane, leading to increased calcium uptake, a response that occurs within minutes through voltage-dependent calcium channels ,.
Other study disputes the fact of the presence of the vitamin D receptor ,.
Finally, muscle strength is affected by the genotype of the VDR. Several VDR polymorphisms have been determined that will consecutively affect muscle strength according to the type .
Prolonged vitamin D deficiency is associated with severe muscle weakness , and this was found in the elderly ,; deficiency resulted in marked disability ,. This disability and weakness was associated with marked improvement after replacement ,, and particularly in elderly men .
Vitamin D supplementation was associated with improvement in muscle function in those with vitamin D deficiency and because of an increase in the size and amount of type II (fast twitch) muscle fibers ,. It is noteworthy that type II fibers are responsible for power and anaerobic activities .
Given this background, the aim of the study was to identify vitamin D status among elderly hospitalized male patients and its relation to parameters of body composition, muscle strength, and performance.
| Participants and methods|| |
This was a cross-sectional study.
Data collected from a previous cross-sectional study, where systematic random sampling technique where every third patient (skip interval) and patient who measured vitamin D, were selected for inclusion in the study on the basis of the exclusion criteria, which might have affected the parameters measured.
- Patients on dialysis, patients with a history of liver cell failure, and severe malnutrition.
- Pace maker, diuretics use, and dehydration.
- Manifested degenerative joint disease, lumbar spinal canal stenosis, neurogenic, or vascular claudication pain.
- Cerebrovascular disease.
- Any amputations.
- Hand osteoarthritis.
- Patients taking the following drugs were excluded: antacids, calcium channel blockers, cholestyramine, phenobarbital, phenytoin, anticonvulsant, glucocorticoids.
- Kidney diseases (renal insufficiency, elevated creatinine, reduced glomerular filtration rate (GFR)).
All participants were subjected to a complete assessment of medical history including history of physical activity ,, assessment of BMI , and assessment of body composition by bioelectrical impedance analysis  and measurement of vitamin D levels.
The survey was conducted between June 2012 and June 2013. This study was approved by the Ain Shams Medical Ethics Committee.
Assessment of muscle mass
Assessment of body composition was performed using the bioelectrical impedance analysis  (Geratherm body analyzer scale, Germany), where the patient stood on the scale after entering details of age, sex, height, and physical activity. Feet had to be dry and each foot had to touch the two electrodes for at least 5 s until the end of the analysis. Results are obtained as weight, BMI, fat mass, fat-free mass, bone mass, and body water.
Assessment of muscle strength
Assessment of hand grip strength was performed using a Jamar handheld dynamometer (Jamar hydraulic hand dynamometer, JI, USA), where three trials were performed by both hands with a 1 min interval between each trial, and the average of the dominant hand was calculated .
Assessment of physical performance
This was done using the timed get up and go test, where the patient first received an explanation for the test and then he/she sat on a stool about 45 cm from the ground and was asked to stand without support. He/she could use an assistive device and was asked to walk at his/her own average speed for 3 m and to turn back and sit down again on the chair; the time is calculated from the moment the physician ask him to start till he/she sits down .
Physical activity refers to any bodily movement produced by skeletal muscles that increases energy expenditure above a basal level. It includes exercise or nonexercise physical activity. Exercise physical activity involves structured and repetitive bodily movements such as walking. Nonexercise physical activity involves standing or gardening. Thirty minutes or more of moderate physical activity 5 days a week is required to consider a participant physically active .
Five milliliters of venous blood was collected under completely aseptic conditions from each participant. After clotting, samples were centrifuged at 1000g for 15 min, and sera were separated and stored at −20°C for assay of serum 25(OH)D. Hemolyzed samples were discarded and only one freeze and one thaw cycle was performed. Measurement of total 25(OH)D (vitamin D2 and vitamin D3) in serum was carried out by an enzyme immunoassay using reagents provided by DRG 25(OH)D (total) enzyme-linked immunosorbent assay (ELISA, EIA-5396; DRG International Inc., Springfield Township, New Jersey, USA). The DRG 25(OH)D total ELISA kit is a solid-phase ELISA based on the principle of competitive binding. In the first step, samples have to be pretreated in separate vials, with denaturation buffer to extract the analyte, as most circulating 25(OH)D is bound to vitamin D-binding protein in vivo. After neutralization, biotinylated 25(OH)D (enzyme conjugate) and peroxidase-labeled streptavidin–enzyme complex are added. After careful mixing, the solution is transferred to the wells of a microtiter plate. Endogenous 25(OH)D of a sample competes with a 25(OH)D3–biotin conjugate for binding to the (vitamin D-binding globulin) vitamin D binding globulin (VDBG) that is immobilized on the plate. Binding of 25(OH)D–biotin is detected by peroxidase-labeled streptavidin. Incubation is followed by a washing step to remove unbound components. The color reaction is started by the addition of an enzyme substrate and stopped after a defined time (15 min). The color intensity is inversely proportional to the concentration of 25(OH)D in the sample . To deduce the concentration of 25(OH)D in serum samples and control material, a standard curve was constructed by plotting the absorbance obtained from each standard against its concentration with the absorbance value on the vertical (y) axis and concentration on the horizontal (x) axis using a linear graph paper. 25(OH)D status less than 10 ng/ml indicates deficiency and 10–29 ng/ml in case of insufficiency, whereas 30–100 ng/ml is considered sufficient .
Cause of admission
Patients were admitted because of various conditions such as uncontrolled diabetes, hypertension, heart failure, chronic obstructive lung disease, decompensated liver disease, and transient ischemic attack, but they were included after their condition was treated.
Comorbidities included diabetes, hypertension, ischemic heart disease, compensated heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and liver disease.
Data were collected and analytical statistics were obtained using the 15th version of the statistical package for the social sciences (SPSS; SPSS Inc., Chicago, Illinois, USA).
Numerical data were described as mean, SD, median, and minimum and maximum values (range). Non-numerical data were described as frequency and percentage.
Correlation analysis (using Pearson’s method)
To assess the strength of association between two quantitative variables, correlation analysis was carried out. The correlation coefficient, denoted symbolically as ‘r’, defines the strength and direction of the linear relationship between two variables. The P-value was always set at 0.05.
| Results|| |
Our study included 88 elderly men aged 60 years of age and older. The mean age of the participants studied was 64.74 ± 4.6 years. In total, 86.3% were married, 22.7% were physically active, and 15.9% were nonsmokers. The mean BMI was 26.4 ± 7.2 kg/m2. The mean vitamin D level was 12.1 ± 5.5 ng/ml [Table 1].
The prevalence of vitamin D deficiency was 19.3%, whereas insufficiency was 79.5% [Table 2]. Vitamin D was not significantly correlated with age, smoking, physical activity, BMI, fat-free mass, fat mass, hand grip, and timed get up and go test [Table 3].
|Table 2 Prevalence of vitamin D deficiency and insufficiency in the studied participants|
Click here to view
|Table 3 Correlation between vitamin D and descriptive data and parameters of body composition|
Click here to view
| Discussion|| |
The current study was carried out to assess the prevalence of vitamin D deficiency and insufficiency status in hospitalized patients and its relation to parameters of body composition, muscle strength, and performance.
In the current study the prevalence of vitamin D deficiency was 19.3% and that of vitamin D insufficiency was 79.5%; deficiency was considered when vitamin D was less than 10 ng/dl and insufficiency was defined as levels between 11 and 30 ng/dl ; this is comparable with a study carried out in southern Australia, where the prevalence of vitamin D deficiency was found in 22.7% of the population, with deficiency diagnosed at a serum 25(OH)D level below 50 nmol/l (<20 ng/ml) . However, in Shanghai, China, in a study on 5470 Chinese patients with various diseases, who were hospitalized between May 2012 and August 2013 (deficiency was defined as serum concentrations <15 ng/ml), only 53.31% would have been nondeficient because the 25(OH)D concentrations of most patients were between 10 and 15 ng/ml . In a study in San Paolo, Brazil, it was found that the prevalence of vitamin D insufficiency was 85.7% in a group with a mean age of 71 years .
It has been estimated that one billion individuals worldwide have vitamin D deficiency or insufficiency ,,,. According to several studies, 40–100% of the US and European elderly men and women still living in the community (not in nursing homes) have vitamin D deficiency ,,,.
The abundant sunlight in our country make us believe that vitamin D deficiency due to sufficient sunlight is restricted to countries of higher altitude. However, Lips et al.  and Van der Wielen et al.  reported a higher prevalence of hypovitaminosis D in southern Europe than in northern Europe.
It was found that the prevalence of vitamin D deficiency is high in Egypt even though it is considered a sunny country; this may be attributed to the life style of the population and the amount of exposure to sun light and we studied elderly individuals, who have decreased ability to synthesize vitamin D and decreased ability of absorption.
We believe that the cut-off value used by the US Endocrine Society guideline for White patients may not be clinically appropriate for other ethnic groups.
In the present study, it was found that age was not associated with vitamin D levels; this is not in agreement with a study carried out in Brazil, where the percentage of deficiency was 40.3% between the ages of 17 and 35 years, whereas between the ages of 91 and 100 years, it was 100% .
It is known that vitamin D synthesis decreases with age because of a decrease in subcutaneous fat and decreased gastrointestinal absorption, but this can be attributed to the fact that most of the studies compared adulthood with elderly not between different decades of the elderly population.
Smoking exerts a significant effect on calcium and vitamin D metabolism, which is not likely to be explained by other confounding lifestyle factors ,. However, in the current study, smoking was not associated with vitamin D levels, which could be explained by the high prevalence rate of deficiency and insufficiency, which might have led to masking of this relation.
Vitamin D supplementation increased muscle strength without the need for regular physical activity . Others found that calcium and vitamin D decreased the risk of falls documented by quadriceps, body sway and time needed to perform timed up and go test (TUG) test . Also, hand grip strength was better with higher levels of vitamin D assessed by a handheld dynamometer , and also with supplementation ,, which was not clear in our study because of the high percentage of deficiency and insufficiency among the study participants.
| Conclusion|| |
Vitamin D deficiency and insufficiency is highly prevalent among elderly Egyptian men and it not related to parameters of body composition, muscle function, or performance.
Larger studies are needed to identify vitamin D status in elderly Egyptian men, especially among community-dwelling elderly; also, larger studies are needed to assess its relation to muscle function and strength. To assess changes that would occur in muscle mass, strength and performance after supplementation of vitamin D.
Conflicts of interest
| References|| |
Van Schoor NM, Lips PWorldwide vitamin D statusBest Pract Res Clin Endocrinol Metab201125671680
Ritu G, Gupta AVitamin D deficiency in India: prevalence, causalities and interventionsNutrients20146729775
Orwoll E, Nielson CM, Marshall LM et al.
Vitamin D deficiency in older menJ Clin Endocrinol Metab20099412141222
Hazell TJ, DeGuire JR, Weiler HAVitamin D: an overview of its role in skeletal muscle physiology in children and adolescentsNutr Rev201270520533
Horlick MFVitamin D deficiencyN Engl J Med2007357266281
Mezquita-Raya P, Muñoz-Torres M, Luna JD, Luna V, Lopez-Rodriguez F, Torres-Vela E, Escobar-Jiménez FRelation between vitamin D insufficiency, bone density, and bone metabolism in healthy postmenopausal womenJ Bone Miner Res20011614081415
Cauley JA, Lacroix AZ, Wu L, Horwitz M, Danielson ME, Bauer DC et al.
Serum 25-hydroxyvitamin D concentrations and risk for hip fracturesAnn Intern Med2008149242250
Nurmi I, Kaukonen JP, Lüthje P, Naboulsi H, Tanninen S, Kataja M et al.
Half of the patients with an acute hip fracture suffer from hypovitaminosis D: a prospective study in southeastern FinlandOsteoporos Int20051620182024
Campbell PMF, Allain TJMuscle strength and vitamin D in older peopleGerontology200652335338
Ceglia L, Harris SSVitamin D and its role in skeletal muscleCalcif Tissue Int201392151162
Dusso AS, Brown AJMechanism of vitamin D action and its regulationAm J Kidney Dis199832S13S24
Nemere I, Dormanen MC, Hammond MW, Okamura WH, Norman AWIdentification of a specific binding protein for 1 alpha,25-dihydroxyvitamin D3 in basal-lateral membranes of chick intestinal epithelium and relationship to transcaltachiaJ Biol Chem19942692375023756
Nemere I, Schwartz Z, Pedrozo H, Sylvia VL, Dean DD, Boyan BDIdentification of a membrane receptor for 1,25-dihydroxyvitamin D3 which mediates rapid activation of protein kinase CJ Bone Miner Res19981313531359
Massheimer V, Fernandez LM, Boland R, de Boland ARRegulation of Ca2+uptake in skeletal muscle by 1,25-dihydroxyvitamin D3: role of phosphorylation and calmodulinMol Cell Endocrinol1992841522
De Boland AR, Boland RLNon-genomic signal transduction pathway of vitamin D in muscleCell Signal19946717724
Wacker M, Holick MF, Wacker M, Holick MF, Wacker M, Holick MFSunlight and Vitamin D: a global perspective for healthDermatoendocrinol2013551108
Wang Y, DeLuca HFIs the vitamin d receptor found in muscle?Endocrinology2011152354363
Geusens P, Vandevyver C, Vanhoof J, Cassiman JJ, Boonen S, Raus JQuadriceps and grip strength are related to vitamin D receptor genotype in elderly nonobese womenJ Bone Miner Res19971220822088
Mingrone G, Greco AV, Castagneto M, Gasbarrini G Awoman who left her wheelchairLancet1999353806
Ziambaras K, Dagogo-Jack SReversible muscle weakness in patients with vitamin D deficiencyWest J Med1997167435439
Prabhala A, Garg R, Dandona PSevere myopathy associated with vitamin D deficiency in western New YorkArch Intern Med200016011991203
Rimaniol JM, Authier FJ, Chariot PMuscle weakness in intensive care patients: initial manifestation of vitamin D deficiencyIntensive Care Med199420591592
Kenny AM, Biskup B, Robbins B, Marcella G, Burleson JAEffects of vitamin D supplementation on strength, physical function, and health perception in older, community-dwelling menJ Am Geriatr Soc20035117621767
Cannell JJ, Hollis BW, Sorenson MB et al.
Athletic performance and vitamin DMed Sci Sport Exerc20094111021110
World Health Organization. Regional office for the western pacific region pacific physical activity guidelines for adults: framework for accelerating the communication of physical activity guidelines2009ManilaWorld Health Organization Regional Office for the Western Pacific Region
American College of Cardiology/American Heart Association. Methodology manual for ACC/AHA guideline writing committees2006American College of Cardiology Foundation and the American Heart Association Inc
World Health Organization. World Health Organization physical status: the use and interpretation of anthropometry: report of a WHO Expert Committee Technical Report Series(1995) 8541995GenevaWHO
Chien M, Huang T, Wu YPrevalence of sarcopenia estimated using a bioelectrical impedance analysis prediction equation in community-dwelling elderly people in TaiwanJ Am Geriatric Soc20085617101715
Roberts HC, Denison HJ, Martin HJ et al.
A review of the measurement of grip strength in clinical and epidemiological studies: towards a standardized approachAge Ageing201140423429
Mathias S, Nayak U, Isaacs BBalance in elderly patients: the ’Get-up and Go’testArch Phys Med Rehabil198667387389
Pilz SVitamin D: clinical implications beyond musculoskeletal diseasesJ Lab Med201135211216
Holick MVitamin D: the underappreciated D-lightful hormone that is important for skeletal and cellular healthCurr Opin Endocrinol Diabetes200298798
Mao X, Zheng H, Liu ZAnalysis of 25(OH)D serum concentrations of hospitalized elderly patients in the shanghai areaPLoS One20149e90729
Maeda SS, Saraiva GL, Kunii ISFactors affecting vitamin D status in different populations in the city of São Paulo, Brazil: the São PAulo vitamin D Evaluation Study (SPADES)BMC Endocr Disord20131314
Holick MFHigh prevalence of vitamin D inadequacy and implications for healthMayo Clin Proc200681353373
Holick MF, Siris ES, Binkley N et al.
Prevalence of vitamin D inadequacy among postmenopausal North American women receiving osteoporosis therapyJ Clin Endocrinol Metab20059032153224
Glerup H, Mikkelsen K, Poulsen L et al.
Commonly recommended daily intake of vitamin D is not sufficient if sunlight exposure is limitedJ Intern Med2000247260268
Lips P, Hosking D, Lippuner K et al.
The prevalence of vitamin D inadequacy amongst women with osteoporosis: an international epidemiological investigationJ Intern Med2006260245254
Lips P, Duong T, Oleksik A, Black D, Cummings S, Cox D, Nickelsen TA global study of vitamin D status and parathyroid function in postmenopausal women with osteoporosis: baseline data from the multiple outcomes of raloxifene evaluation clinical trialJ Clin Endocrinol Metab20018612121221
Van der Wielen RPJ, Lowik MRH, van der Berg H, de Groot LC, Haller J, Moreiras O, van Staveren WASerum vitamin D concentration among elderly people in EuropeLancet1995346207210
Brot C, Jùrgensen NR, Sùrensen OHThe influence of smoking on vitamin D status and calcium metabolismEur J Clin Nutr199953920926
Yoshimura N, Muraki S, Oka H, Morita M, Yamada H, Tanaka S et al.
Profiles of vitamin D insufficiency and deficiency in Japanese men and women: association with biological, environmental, and nutritional factors and coexisting disorders: the ROAD studyOsteoporos Int20131127752787
Moreira-Pfrimer LD, Pedrosa MA, Teixeira L et al.
Treatment of vitamin D deficiency increases lower limb muscle strength in institutionalized older people independently of regular physical activity: a randomized double-blind controlled trialAnn Nutr Metab200954291300
Grady D, Halloran B, Cummings S, Leveille S, Wells L, Black D et al.
1,25-Dihydroxyvitamin D3 and muscle strength in the elderly: a randomized controlled trialJ Clin Endocrinol Metab1991;7311111117
Janssen HC, Samson MM, Verhaar HJMuscle strength and mobility in vitamin D-insufficient female geriatric patients: a randomized controlled trial on vitamin D and calcium supplementation Aging Clin Exp Res2010227884
Smedshaug GB, Pedersen JI, Meyer HECan vitamin D supplementation improve grip strength in elderly nursing home residents?A double-blinded controlled trialScand J Food Nutr2007517478
[Table 1], [Table 2], [Table 3]