Jurnal 1

Vitamin D Deficiency Among
Postmenopausal Women
with Osteoporosis
Orthopaedics Section
DOI: 10.7860/JCDR/2013/5022.2761
Original Article
Ramesh Narula, Mujtaba Tauseef, Iraqi Aftab Ahmad, Agarwal Kiran, Agarwal Ashok, Arya Anjana
ABSTRACT
Background: Hypovitaminosis D is widely prevalent in India
and is a formidable issue especially in postmenopausal women. The study intends to estimate the prevalence of vitamin D
deficiency among postmenopausal women with osteoporosis.
Methods: The study was performed at a referral teaching institute in north India between 2007 and 2009. One hundred and
ninety postmenopausal osteoporotic women were enrolled and
the clinical information was collected along with the assessment of biochemical parameters.
Results & Conclusion: Serum vitamin D was found to be deficient in two third of patients. A significant correlation was observed between body mass index and bone mineral density at
lumbar spine. Prevention and early detection of hypovitaminosis D is the key to reduce the incidence of osteoporosis among
postmenopausal women.
Key Words: Hypovitaminosis D, Fragility fracture, Postmenopausal
Introduction
With increasing life expectancy there is exponential increase in
osteoporotic fractures. It is projected that the number of hip fractures worldwide will exceed six million by 2050 [1]. A person with
osteoporotic vertebral fracture has 4 to 5 times higher risk of another vertebral fracture and 2 to 3 times higher risk of hip fracture
[2, 3]. The study intends to estimate the prevalence of vitamin D
deficiency among postmenopausal women with osteoporosis.
MATERIALS AND METHODS

The present study was conducted at the Department of Orthopedics and the Division of Endocrinology, Department of Medicine,
J. N. Medical College Hospital, AMU, Aligarh, India between 2007
and 2009. The study was approved by the board of studies and
the protocol was approved by the local institutional review committee. Informed consent was obtained from all subjects involved
in the study.
Results
Exclusion Criteria: Deranged renal function, abnormal thyroid

function, significant liver disease, history of cancer, regular therapy
with a phosphate binding antacid, estrogen replacement therapy
within the previous 9 -12 months, therapy with any other drug that
affect skeleton like steroids, anti convulsants and anticoagulants.
One hundred ninety women (146 with osteoporosis attending the

endocrine OPD and 44 patients attending orthopedics OPD with
fragility fracture) aged 42 to 80 years were studied. Out of one
hundred and forty-six post-menopausal females registered from
endocrine OPD, one hundred and fourteen had achieved natural
menopause and thirty-two had their uterus and ovaries removed
surgically due to some pathology before attaining menopause
and were included due to decreased bone density on DEXA scan.
Among the forty-four Orthopedic patients, all except one had attained natural menopause. This patient underwent hysterosalpingectomy due to fibroid uterus before attaining menopause.
All patients were given elemental calcium 1000 mg/day and vitamin
D 1000 IU/day. In this study a detailed history and physical examination was carried out for every subject who entered the study
as per predesigned performa covering all known risk factors for
primary osteoporosis and all known conditions leading to secondary osteoporosis. Blood samples were collected for hematological
parameters and ESR, estimation of serum calcium, serum phos-
The baseline clinical and biological characteristics of all the one

hundred and ninety patients included in the study are given in [Table/Fig-1]. History of back pain was present in eighty three patients
and fourteen patients had history of fragility fractures. Sixteen patients had history of cigarette smoking and 2 were chronic alcoholics but no significant liver disease. One hundred and twenty-three
patients were living a sedentary life style with no or little weight
Inclusion criteria: Women who were post-menopausal for at

least one year and had osteopenia or osteoporosis as evidenced
by bone mineral density <2.5 SD or fragility fractures.
336
phorus, serum 25-hydroxy vitamin D, serum TSH, serum alkaline

phosphatase, serum PTH, lipid profile, creatinine and fasting sugar.
Bone Mineral Density was estimated by GE Lunar Densitometer.at
three sites, lumbar spine (L1- L2 level), right hip and left hip. Serum
25-hydroxy vitamin D was estimated using chemiluminescent immunoassay and other biochemical parameters using spectrophotometric analysis. Statistical analysis was performed using SPSS
version 11.5 statistical package for windows (SPSS, Chicago, IL).
Continuous variables were expressed as mean +/- S.D or range,
and qualitative data was expressed in percentages. The association between continuous variables was tested by linear correlation
using Pearsons coefficient. All tests were two tailed, and a P-value
of </= 0.05 was considered significant.
Journal of Clinical and Diagnostic Research. 2013 February, Vol-7(2): 336-338
www.jcdr.net
Ramesh Narula et al., Hypovitaminosis D
Variable
Age (yrs)
N=(190)
Mean
S. D.
56
8.9
BMI (kg/m2)
26.4
4.7
Lumbar spine BMD (gm/cm2
0.849
0.134
-2.7
1.2
Lumbar spine t-score

Hip BMD (gm/cm2)
0.851
0.198
Hip t-score
-1.4
S.Calcium(ionised) (mmol/L)
1.07
0.07
S.25-OH vitamin D (ng/ml)
19.7
8.2
S. TSH (mIU/L)
2.45
3.25
Creatinine (mg%)
0.97
0.25
Total cholesterol (mg %)
178
41
Triglycerides (mg%
130
60
HDL (mg %)
47
13
LDL (mg %)
117
45
VLDL (mg %)
32
21
Milk Intake (ml/day)
164
128
Sun exposure (mts./day)
33
26
[Table/Fig-1]: Baseline Characteristics of patients (n= 190)
bearing and muscle building exercise. Serum phosphorus was in

normal range in all patients. Serum PTH was done randomly in forty-one subjects and was found to be within normal range. Serum
alkaline phosphatase done in all patients and levels were raised in
56 patients. Total serum protein level was low in twelve patients.
Serum creatinine was slightly raised in six patients who were either
due to dehydration or old age and improved on proper hydration
and repeat testing. In our study we also found a significant correlation between BMI and BMD at lumbar spine (p= 0.004).
We saw that majority of our subjects had only occasional or no
intake of milk and daily sun exposure of less than 30 minutes. But
on doing serum 25-hydroxy vitamin D levels in all patients, revealed
vitamin D deficiency (serum 25-OH vit. D = 5 - 20 ng/ml) in 118 out
of 190 subjects (62%) and severe vitamin D deficiency (serum 25OH vit. D = < 5 ng/ml) in four subjects (2.1%). Moreover what was
more important was that this vitamin D insufficiency was strongly
related to the baseline lumbar spine BMD (p< 0.05). In all the patients with osteoporotic fractures treated operatively or non operatively fracture united at six months of treatment and majority of the
patients were walking full weight bearing by that time except for
five patients with osteoporotic collapse of multiple vertebrae who
were able to manage to sit with brace application and had marked
improvement in pain but were not able to walk.
Discussion
Our observations reveal very high incidence of hypovitaminosis
D among postmenopausal women with osteoporosis. A strong
correlation was also observed between BMI & BMD. However, a
caution is advised to generalize our observation to the population
at large. Our results are restricted to a specific set of patients
presenting to a tertiary care referral centre which may not be representative of general community. An adequately powered community based study analyzing bone turn over markers in addition
is expected to provide better answer to the research question.
Despite the inverse correlation between markers of bone turnover and bone mass, their measurement has wide variations and
cannot substitute for measurement of BMD in the diagnosis of
osteoporosis. Because elevated values of both resorption and

formation markers do indicate increased risk for bone loss and
fractures, their measurement may become useful in determining
the need for therapy, particularly if they can be made more accurate and less expensive.
Genetic factors exert a strong and perhaps predominant influence on peak bone mass, but physiological, environmental, and
modifiable lifestyle factors can also play a significant role. Among
these are adequate nutrition and body weight, exposure to sex
hormones at puberty, and physical activity [4]. Vitamin D is required for optimal calcium absorption and thus is also important
for bone health. Indeed, in patients who are vitamin D deficient,
no more than 15 % of dietary calcium is absorbed, whereas in
persons who are not vitamin D deficient 30 80% of dietary
calcium is absorbed [5]. Decreased calcium leads to increased
parathyroid secretion which causes increased bone resorption
[6]. There is strong evidence that physical activity early in life
contributes to higher peak bone mass [7]. Some evidence indicates that resistance and high impact exercise are likely the most
beneficial. In our study we found that vitamin D deficiency (< 20
ng/ml) is quite common in India (64.3%) as has been reported
by various other studies Arya et al (2004) reported an incidence
of 66.3% using 15 ng/ml as the cut-off point [3]. Using 20 ng/ml
they reported an incidence of more than 78 %. We also found
a significant correlation between low 25-hydroxy vitamin D levels
in serum and baseline BMD at lumbar spine. Many studies have
earlier reported similar results [8,9,10,11].
All the fractures treated by various methods including devices with
improved anchorage techniques like locked plating and locking
screws united indicating that osteoporotic fractures usually unite
if immobilized properly by proper anchorage implants although it
may take a little longer for them to unite. In the present study, we
were not able to assess the effect on reduction in fracture risk due
to short period of study (15 months). One of our patients suffered
a refracture after undergoing surgery for fracture of femoral neck.
But this refracture occurred within 3 weeks of starting treatment
and role of treatment cannot be assessed. Fourteen of our patients had history of fragility fractures in the past and these patients were not taking any treatment for osteoporosis in the past.
Our study indicates very high incidence of hypovitaminosis D
among postmenopausal women with osteoporosis. Prevention of
vitamin D deficiency by appropriate diet, activity, sunlight exposure
appears to be the primary prerequisite in reducing the incidence
of osteoporotic fractures among postmenopausal women.
References
[1] Marie PJ, Hott M, Modrowski D et al. An uncoupling agent containing strontium prevents bone loss by depressing bone resorption and
maintaining bone formation in estrogen deficient rats. J bone Miner
Res.1993; 8:607-15.
[2] Meunier PJ, Strosman DO, Delmas PD et al, Strontium ranelate: a
dose dependent effects in established postmenopausal osteoporosis- a 2 year randomised placebo controlled trial. J Clin Endocrinol
Metab.2002; 87:2060-66.
[3] Arya V; Bhambri R, Godbole M, Mithal A:Vitamin D status and its relationship with bone mineral density in healthy Asian Indians; Osteoporosis International. Volume 15, Number 1, January 2004 , pp. 56-61(6).
[4] Factors involved in building and maintaining skeletal health throughout life.health-care.net: July 2005.
[5] Hollick MF, Vitamin D: the underappreciated D-lightful hormone that
is important for skeletal and cellular health. Curr Opin Endocr Diab.
2002; 9; 87-98.
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Ramesh Narula et al., Hypovitaminosis D
[6] Holick MF, Krane SM, Potts JT Jr. Calcium, phosphorus, and bone
metabolism: calcium regulating hormones. In: Fauci, AS, Braunwald
E, Isselbacher KJ, et al, eds. Harrisons principles of Internal Medicine. New York: McGraw-Hill. 1998:2214-27.
[7] Marcus R. The mechanism of exercise effects on bone. In: Bilezikian
JP, Raisz LG, Rodan GA, eds. Principles of Bone Biology. San Diego:
Academic press. 1996:1435-45.
[8] Batra Sameer, Yamin M, Sabharwal Sanjeev; Relationship between
vitamin D insufficiency in osteoporosis and blood bone biochemistry; Indian J orthop. 2006: 40:1: 41-45.
[9] Chittari V Harinarayan, Tirupati Ramalakshmi, Upadrasta V Prasad,
Desineni Sudhakar, Pemmaraju VLN Srinivasarao, Kadainti VS Sarma and Ethamakula G Tiruvenkata Kumar; High prevalence of low
AUTHOR(S):
1. Dr. Ramesh Narula
2. Dr. Mujtaba Tauseef
3. Dr. Iraqi Aftab Ahmad
4. Dr. Agarwal Kiran
5. Dr. Agarwal Ashok
6. Dr. Arya Anjana
PARTICULARS OF CONTRIBUTORS:
1. Associate Professor, Department of Orthopaedics,

Rohilkhand Medical College, Bareilly U.P.,
Pin-243006, India.
2. Consultant, Department of Orthopaedics,

Chhota Telpa, Chhapra, Bihar, Pin- 841301, India.
3. Professor, Department of Orthopaedics,

Rohilkhand Medical College, Bareilly, U.P.,

Pin-243006, India.
4. Associate Professor, Department of Gynaecology,


Pin-243006, India.
338
www.jcdr.net
dietary calcium, high phytate consumption, and vitamin D deficiency

in healthy south Indians; American Journal of Clinical Nutrition. Vol.
85, No. 4, 1062-1067, April 2007.
[10] Lips P, Duong T, Oleksik A, Black D, Cummings S, Cox D, Nickelson T.A Global study of vitamin D status and parathyroid function in
postmenopausal women with osteoporosis: baseline data from the
multiple outcomes of raloxifene evaluation clinical trial; Endocrinol.
Metab. 2001 Mar:86(3):1212-21.
[11] Ghannam NN, Hammami MM, Bakheet SM, Khan BA;Bone mineral
density of the spine and femur in healthy Saudi females: relation to
vitamin D status, pregnancy, and lactation: Calcif Tissue Int. 1999
Jul;65(1):23-8.
5.

6.

Associate Professor, Department of Paediatrics,

Pin-243006, India.
Assistant Professor, Department of Pathology,
Pin-243006, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING

AUTHOR:
Dr. Ramesh Narula,
Associate Professor, Department of Orthopaedics,
Pin-243006, India.
Phone: 09719740866
E-mail: rameshnarula55@gmail.com
Financial OR OTHER COMPETING INTERESTS:
None.
Date of Submission: Sep 03, 2012
Date of Peer Review: Nov 11, 2012
Date of Acceptance: Jan 01, 2013
Date of Online Ahead of Print: Jan 08, 2013
Date of Publishing: Feb 01, 2013

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Vitamin D Deficiency Among

Key Words: Hypovitaminosis D, Fragility fracture, Postmenopausal

MATERIALS AND METHODS

Exclusion Criteria: Deranged renal function, abnormal thyroid

One hundred ninety women (146 with osteoporosis attending the

The baseline clinical and biological characteristics of all the one

Inclusion criteria: Women who were post-menopausal for at

phorus, serum 25-hydroxy vitamin D, serum TSH, serum alkaline

Journal of Clinical and Diagnostic Research. 2013 February, Vol-7(2): 336-338

Ramesh Narula et al., Hypovitaminosis D

Lumbar spine BMD (gm/cm2

Lumbar spine t-score

S.25-OH vitamin D (ng/ml)

Total cholesterol (mg %)

Milk Intake (ml/day)

Sun exposure (mts./day)

[Table/Fig-1]: Baseline Characteristics of patients (n= 190)

bearing and muscle building exercise. Serum phosphorus was in

osteoporosis. Because elevated values of both resorption and

Ramesh Narula et al., Hypovitaminosis D

dietary calcium, high phytate consumption, and vitamin D deficiency

Associate Professor, Department of Paediatrics,

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING

Journal of Clinical and Diagnostic Research. 2013 February, Vol-7(2): 336-338

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