Vitamin D and bone health
- Conditions
- Apparently healthy subjects.
- Registration Number
- CTRI/2022/07/044030
- Lead Sponsor
- Department of Biotechnology
- Brief Summary
Vitamin D deficiency is common in areas with limited sunshine and also among indoor subjects in countries where there is plenty of sunshine (1-4). The focus of current studies is to investigate the functional significance of low and insufficient serum 25(OH)D in asymptomatic apparently healthy subjects. Investigations in this area is important in view of the fact that most of the meta-analysis studies indicate only a limited role of vitamin D in adults i.e. modest effect on prevention of vertebral fractures, fall and dental carries (5).
There are limited studies on functional significant of vitamin D deficiency and relevance of vitamin D supplementation beyond the growing age, among asymptomatic apparently healthy adults in India. Two large placebo controlled randomized controlled trials carried out by us on functional significance of vitamin D on muscle strength among young Indians females and males have not revealed any significant effect of vitamin D/Calcium supplementation on hand grip strength, six minutes walk distance, physical quality of life after six months and immune function like Th1/Th2 ratio and antibacterial peptide cathelicidin (6-8). Recently, Aloia *et al.,* (2018) et al., no significant effect of vitamin D supplementation in prevention of bone loss among African elderly women with osteoporosis in RCT (9).
Notwithstanding above, currently low serum 25(OH)D in apparently healthy normal subjects is considered to be synonymous with vitamin D deficiency. However, to justify this statement, low serum 25(OH) D should be associated with some symptoms and/or objective alteration in body/bone composition; either in acute or chronic form. Bone mineral density (BMD) and bone markers are the standard and common bone related parameter for assessing the effect of vitamin D supplementation (9,10). However, it has not turned out be a reliable or sensitive marker for vitamin D deficiency in asymptomatic subjects (5,9). Several reasons for these might be presence of host of confounding factors such genetic variation in genes linked with BMD and nutrition factors other than the vitamin D which can affect bone constituents relevant for osteoporosis. Nutrients like vitamin C and K as well as protein are also important for collagen and non collagenous proteins of the bone matrix (11,12). Malmir *et al.,* recently reported meta-analysis of observations on dietary vitamin C intake and low risk of hip fractures in osteoporosis as well as higher BMD at femoral neck and lumbar spine (11).
Bone fractures typical of osteoporosis i.e. vertebral and hip can occur in subjects with normal bone density (13). This is also exemplified in patients affected by chronic inflammatory disease especially if there is steroid hormone excess in the body, endogenous or exogenous (14). This has been explained by the fact that bone microarchitecture may be compromised in subjects despite normal BMD (14). Vinolas, *et al*., recently (2018) investigated 53 patients with endogenous Cushing’s syndrome and observed that only 24% of them had abnormal BMD, in contrast to 43% showing degraded microarchitecture (14). Similar situation might be prevalent in apparently normal subjects and could explain presence of stress and osteoporotic fractures in asymptomatic healthy subjects with normal BMD (13).
Bone microarchitecture can be assessed by bone histomorphometry. However, it is practically difficult to document the altered microstructure in large number of subjects because of the invasive nature of bone biopsy. Trabecular bone score (TBS) is a recently introduced tool for the assessment of bone microarchitecture (15-20). It is a gray-level textural metric that can be extracted from the two-dimensional lumbar spine DXA image. Bone texture in TBS correlates with bone microarchitecture such as trabecular number, trabecular separation, connectivity density, and bone volume fraction. Most of the available litretaure on TBS has been in symptomatic patients sepcific population like those with hyperparathyroidism (23). However, there is a paucity of information on TBS in asymptomatic subjects with chronic hypovitaminosis D, with no study reported from India, till date. The presnt study has been planned to assess the functional signoificance of low serum 25(OH)D on bone microarchitceture in a large cohort of apparently healthy Indian subjects with age range of 20 to 60 years including females.
Serum 25(OH)D measured in an individual for vitamin D status is usally a one time paramneter and may not adequately represent their term vitamin D status in the past. To take this fact into account, present study also plans to assess the role of vitamin D in the revrsibility of poor bone microachitectre in healthy subjects. A placebo controlled RCT of vitamin D and calcium supplementaion given for six months would be carried out in a two by two factorial mode out among subjects who have both subnormal 25(OH)D and subnormaormal TBS score as per the international norm (score <1.35).
**A) Rational of the study supported by cited literature**
Vitamin D is vital for human health. Its deficiency may lead to hypocalcemic seizures, rickets in infant and impaired bone health in adults. The optimal cut-off of serum 25(OH)D for vitamin D deficiency are not known. The Endocrine Society of USA suggest 25(OH)D > 30 ng/mL as vitamin D sufficient and Institute of Medicine, defines a cut-off of 20 ng/mL (1, 24). Subnormal serum 25(OH) D are frequent in healthy infants, children, adolescents and pregnant women in urban India (2-4,25-29). Recently, we observed that with better sunshine exposure even Indians as outdoor manual workers (26) show normal serum 25(OH)D with values > 40 ng/ml in several (26). The cut-off for serum 25(OH)D for normal vitamin D is an active area of debate and research. In our previous three studies, serum 1,25(OH)D was normal in subjects with low serum 25(OH)D (2,6,8). Similar observations were observed by others (30). Therefore, a firm stand on vitamin D supplementation and/or food fortification require additional data on functional significance of low serum 25(OH)D in healthy subjects. Besides, there is no safety study after long term cholecalciferol in tropical environment.
Our center is assessing the functional aspects of low serum 25(OH)D in apparently healthy Indian subjects since 2000. Though, there was inverse correlation between serum 25(OH)D and PTH in most studies, clinical indices such as skeletal muscle strength (6,8) and other biomolecules did not show correlation with vitamin D status (7). Our centre first assessed serum 25(OH)D and thyroid autoimmunity (29) in 642 healthy subjects aged 16–60 years, with mean serum 25(OH)D of 17·5 ± 10·2 nmol/l. Though TPOAb positivity was observed in 21% of subjects, the TPOAB positivity and thyroid dysfunctions were comparable between subjects with 25(OH)D ≤ 25 or > 25 nmol/l.
RCT on vitamin D/Ca supplementation have not shown promising effect on muscle strength in the elderly (5). In 2012, we conducted a RCT on vitamin D and/or calcium and muscle strength in 173 young females (age, 21.7 ± 4.4 yr, 25(OH)D, 9.3 ± 3.37 ng/ml). The groups were 1) double placebo, 2) calcium, 3) cholecalciferol, and 4) cholecalciferol/calcium. Cholecalciferol was given at 60,000 IU/wk for 8wk, then 60,000 IU/fortnight and elemental Ca 500 mg twice daily for 6 months. Post supplementation, serum 25(OH)D increased to 29.9 ± 8.35 ng/ml and 27.0 ± 9.54 ng/ml in two cholecalciferol groups. The hand grip strength and quality of life were comparable in groups indicating that cholecalciferol/Ca did not lead to improvement in the skeletal muscle strength.We also carried out a similar RCT on Vitamin D and calcium supplementation, skeletal muscle strength and serum testosterone in 228 young healthy adult males (8). The four study groups and cholecalciferol/Ca dose was exactly the same as described in our previous RCT in females (6). The baseline 25(OH)D was 21.5 ± 9.5 nmol/L. The parameters assessed were dominant arm handgrip and pinch-grip strength, 6 min walk test, dyspnoea-score, quality of life, serum 25(OH)D, 1,25(OH)2D, iPTH, total testosterone and free androgen index (FAI). After intervention, mean serum 25(OH)D was >75.0 nmol/L in cholecalciferol groups. However, the handgrip strength was comparable in the four groups. Subgroups analysis among subjects with baseline serum 25OH)D < 25.0 and <12.0 nmol/L showed similar results. The delta change in serum testosterone and FAI was also comparable in four groups.
Vitamin D has been considered to have beneficial effect on maintenance of immune system and prevention of autoimmunity and infections. In 2014, we assessed the effect of cholecalciferol and calcium supplementation on mRNA expression of cathelicidin Th1 (IFN-γ) and Th2 cytokines (IL-4 and its antagonist-IL-4δ2) and their transcription factors (T-bet, STAT4, GATA-3, STAT6) in the peripheral blood in healthy females with vitamin D deficiency (VDD) (7). 131 females with biochemical VDD were from our previous RCT among females described above on vitamin D supplementation and muscle strength. Cholecalciferol-supplemented groups showed significant rise of mean serum 25(OH)D (30.6 ± 7.51 and 28.6 ± 8.41 ng/ml. However, the mean mRNA transcripts of all the biochemical assessed were comparable in the supplemented and placebo groups.
There are limited number of RCT on the effect of vitamin D on morbidity and mortality in low birth weight infants in low income countries. Recently, Trilokpuri *et al.,*(25) assessed 2079 low birth-weight infants (>37 weeks’ gestation) in New Delhi with primary outcome of hospital admission for morbidity and mortality in the first six months of life. Vitamin D supplements (35 µg/week) for 6 months led to better vitamin D status and increased SD scores for weight, length, and arm circumference, but no decrease in the morbidity or mortality.
The relationship between vitamin D, BMD, prevention of fall and muscle strength especially in elderly has never been conclusively proven (5). In a recent RCT Aloia *et al.,*assessed effect of vitamin D supplementation in 260 elderly black African women, aged 60 years orolder in preventing bone loss (9). Though, serum PTH declined in the vitamin D supplemented active arm, the rate of bone loss in subjects with serum 25(OH)D >75 nmol/L was comparable to that of subjects with serum 25(OH)D at 50 nmol/L.
In view of widespread vitamin D deficiency in urban indoors, there is need to assess its functional parameters especially for bone health. TBS is a novel and non invasive tool to measure bone micro-architecture and has shown promising association with vitamin D status. This association might emerge more convincingly in urban Indian with chronic vitamin D deficiency. We plan to assess and correlete bone microarchitceture using TBS with serum 25(OH)D in a large cohort of asymptomatic healthy subjects. This study would help fill lacunae in the interpretation of biochemically low serum 25(OH)D. The RCT in the proposed work on vitamin D supplementation would be a step forward in understanding the role of vitamin D in reversing degraded trabecular bone score.
**B) Hypothesis:**
TBS is emerging a clinically relevant marker of bone microarchitecture and might correlate with serum 25(OH)D in Indians. Reversal of impaired TBS by vitamin D supplementation would provide the functional relevance of low serum 25(OH)D levels
**C) Key Questions**
1) Whether serum 25(OH)D levels correlate with TBS at lumbar spine in healthy subjects in age groups 20- 60 years. Lower age of 20 years has been selected because currently TBS software is standardized only for age 20 years and above. Large number of subjects assessed in this study would also help provide normal TBS data.
(2) Whether, those with low TBS and low serum 25(OH)D show improvement in the TBS after six months of vitamin D and calcium supplementation.
**Current status of research and development in subject (both International and National Status)**
Trabecular bone score is a recent tool for the assessing bone microarchitecture. It is a gray-level textural metric that can be extracted from the 2D lumbar spine DXA images. TBS correlate with bone microarchitecture such as trabecular number, trabecular separation, connectivity density, and bone volume fraction (15-22, 31)
**Principle of TBS:**A dense trabecular microstructure projected onto a plane generates an image of large pixel value with variations of smaller amplitude. A variogram of those projected images, calculated as the sum of the squared gray level differences between pixels at a specific distance can estimate a 3D structure. TBS is derived from the experimental variograms of 2D projection images. TBS is calculated as the slope of the log-log transform of the variogram, where the slope characterizes the rate of gray level amplitude variations. A steep variogram slope with a high TBS value is associated with better bone structure. TBS principles can be compared to an aerial view of a forest where individual elements i.e, trees cannot be separated out. The DXA image in TBS cannot discern the individual trabeculae. Although both aerial view of the forest and DXA have low resolution to sufficiently identify individual components like tree and trabeculae respectively, the missing areas i.e. ‘clearings in the forest’ and bone in the trabecular compartment or are clearly noticeable. A significant correlation in an imaging is usually preserved till a sampling size of 1000 µm. A DXA is a low resolution image with sampling size between 300 and 900 μm and image provides information on overall microarchitecture instead of individual trabeculae.
**TBS iNsight:**TBS iNsight is a software tool which can be installed on existing DXA scanners. TBS can be readily applied to common DXA desnitometers like Hologic (Delphi, QDR 4500, and Discovery; Waltham, MA, USA) densitometers. and GE Lunar (Prodigy and iDXA; Madison, WI, USA). The TBS is determined using the same region of interest as the BMD measurement, so that vertebrae excluded from the BMD calculation, e.g., vertebrae with fractures or osteoarthritis, are also excluded from the TBS analysis. The suggested cut-off values for TBS in postmenopausal women, as reported by TBS software is as follows:
**TBS value (unitless)**
< 1.200 (Degraded microarcitecture)
1.200 to 1.310 (partially degraded microarcitecture)
> 1.310 Normal
The precision of precision of TBS varies from 1.1- 2.1 % which comapare with spine BMD precison (0.7-1.7%) on DXA scan (31).
There are limited number of studies assessing the association between 25(OH) D status and TBS and most of the studies have been carried out in patients specific populations such as patients with hyperparathyroidism (23). Here we review briefly the relevant recent studies for our work.
Di Gregorio et al. (2015) studied 390 patients (M 72; F: 318; > 40 years (15). The groups were Naive of treatment (Naive, n = 67), calcium and vitamin D (n = 87), testosterone (n = 36), alendronate (n = 88), risedronate (n = 39), denosumab (n = 43) and teriparatide (n = 30). After 24 months, the TBS in the naive group decreased by 3.1% (p < 0.05). In contrats there was a significant improvement (p < 0.05) in the Ca and vitamin D group suggesting , TBS preservation with oral calcium and vitamin D supplementation.
Hansen *et al.* (2015), conducted a placebo controlled RCT in 230 postmenopausal women aged 75 years or less with baseline 25(OH) D levels of 14-27 ng/mL and no features of osteoporosis on BMD (16). Subjects were categorized in three arms i.e. placebo (n= 76), low dose vitamin D (800 IU/week, n= 75) and high dose vitamin D (50,000 IU/week, n= 79), supplementation. Participants in the high-dose cholecalciferol received a loading dose (50 000 IU/d for 15 days) to quickly raise their 25(OH) D levels to 30.0 ng/mL. After one year of supplementation there was no significant between-arm change in TBS.
Aloia *et al.,* in 2015 (17) assessed a cohort of 518 healthy postmenopausal African American women with a mean age of 66 years and a BMI of 30.1 Kg/m2. The women were healthy based on history, physical, and laboratory screens. Mean TBS and BMD of the spine were 1.300 ± 0.10 and 1.011 ± 0.165 g/cm2, respectively and revealed a significant correlation of r= 0.41, p < 0.0001. TBS values showed a trend near significance with serum 25(OH)D (P = 0.05). .
There is limited information on TBS and serum 25(OH)D in young children. Shawwa *et al.,* (18) studied the predictors of TBS in 170 boys and 168 prepubertal girls (13.2 ± 2.1 years), in a RCT where population was randomized to weekly placebo or one of the two vitamin D3 groups (1400 IU/week and 14,000 IU/week). TBS and serum 25(OH) D were measured at baseline and after 12 months. They could not find any significant effect of vitamin D supplementation on TBS values in both genders and different pubertal stages.
Hyde *et al.,* (2017) explored the relationship between maternal vitamin D (25(OH) D and offspring TBS (19). Maternal 25(OH)D was assessed at 16 weeks’ gestation and at 28–32 weeks’ gestation. 11 years later (2013–2016), mother–child pairs (n = 181) were recalled. Offspring of mothers with sufficient 25(OH) D levels (≥50 nmol/L) at recruitment had a higher TBS (1.363 vs. 1.340, P = 0.04). In linear regression, a 10 nmol/L increase in maternal 25(OH)D was associated with a 0.005 (P = 0.04) increase in TBS. TBS did not correlate with maternal 25(OH) at 28– 32 weeks.
EL Hage *et al* (2014) investigated the relation between serum 25-hydroxyvitamin D (25OHD) and TBS in 101 Lebanese postmenopausal women in the ages range of 45-89 years (60.9 ± 13.6 years) (20). Mean serum (25OHD)l was 27.2 ± 12.2 ng/ml and mean BMI was 26.9 ± 5.2 kg/m2. Age, weight, height, BMI and serum (25OHD) were not correlated to TBS, indicating serum (25OHD) not being the determinant of TBS in their group.
Mário Rui Mascarenhas *et al*., (21) evaluated influence of Vitamin D on TBS and BMD at the lumbar spine in a group of normal men ≥ 40 years. These men were divided in the normal, low BMD and osteoporosis groups, and as normal, vitamin D insufficiency and deficient. Vitamin D deficient group had lower TBS and showed significant correlation with 25(OH)D which was not there in BMD.
Alwan *et al.,* recently 2018 (22) assessed the relationship between serum 25(OH)D and TBS in a healthy adults involving. TBS was significantly higher in 25(OH)D-sufficient participants (≥30 ng/mL) in both males and females, thereby providing further evidence of positive relationship between vitamin D and optimal TBS values.
**The relevance of the proposed study**
The present study is especially relevant from the public health point of view with the back ground information of recently recognized vitamin D deficiency in urban Indians. There is need to document functional significance of low serum 25(OH)D in order to justify food fortification and supplementation with vitamin D. Among all the body tissue, bone is expected to benefit maximally with vitamin D supplementation. In the present study, we plan to assess the functional significance of low serum 25(OH)D on bone bone microarchitceture using TBS in a large cohort of asymptomatic subjects. The planned RCT on vitamin D supplementation would be a step forward in further understanding the role of vitamin D in reversing degraded trabecular bone score. This study would fill lacunae in the existing knowledge by assessing the effect of hypovitaminosis D on bone microarchitecture in asymptomatic healthy subjects. This would help in interpretation of biochemically low serum 25(OH)D and the intervention if any required for correcting the abnormality. If we observe significant association of TBS with vitamin D or benefit of vitamin D supplementation in reversing degraded TBS, it might emerge as the useful marker for vitamin D deficiency in apparently healthy subjects.
**The expected outcome of proposed study:**
Besides, publications and training of manpower, the presents study is especially relevant from the public health point of view in the back ground of vitamin D deficiency in urban indoor Indians (2). There is need to document functional significance of low serum 25(OH)D in order to justify food fortification and supplementation with vitamin D. Among all the body tissue, bone is expected to benefit maximally with vitamin D supplementation. In case of vitamin D insufficiency, it is possible that bone microarchitecture might be impaired despite intact BMD. However, bone strength, compactness and microarchitecture is difficult to document in large numbers because of the invasive nature and complicated analysis required for its assessment by bone biopsy and histomorphometry. In the present study, we plan to assess the functional significance of low serum 25(OH)D on bone bone microarchitceture using TBS in a large cohort of asymptomatic subjects. This study would fill lacunae in the existing knowledge by assessing the effect of hypovitaminosis D on bone microarchitecture in asymptomatic healthy subjects. This would help in interpret biochemically low serum 25(OH)D and the intervention if any required for correcting the abnormality. The planned RCT on vitamin D supplementation would be a step forward in further understanding the role of vitamin D in reversing degraded trabecular bone score.
**The preliminary work done so far**
Our team has been investigating and has completed several projects related to vitamin D deficiency in Dehi, since 1998 (2,3,4,6-8,26-29). Our first study on vitamin D status in urban subjects of Delhi, published in Am J Clinical Nutrition in the year 2000, showed a high prevalence of low serum 25(OH)D in urban indoor Indians (2). Subsequently, we have been assessing the extent of problem of vitamin D deficiency among urban and rural subjects of Delhi engaged in various activities such as farming, labourers engaged in construction work and street vendors in unorganised sector. These studies are showing a relatively better and normal status of vitamin D in these outdoor workers unlike urban indoors (26 ). Besides, we have been investigating the functional significance of vitamin D in asymptomatic healthy subjects who have vitamin D deficiency as per the biochemical criteria. The important studies among these relationship of serum 25(OH)D with BMD (10), thyroid autoimmunity (29) and role of vitamin D supplementation on improvement in muscle strength among asymptomatic healthy young Indian females and males (6,8). We already have the bone densitometry facility at out centre which has been functioning well for the past 16 years. Recently, software for assessing the trabecular bone score has been procured and is being used to study altered bone microarchitecture in several endocrine disorders. Thus, our centre is well equipped to conduct both the component of the proposed study in this project.
**Scope of applications indicating anticipated project and processes**
This study would fill lacunae in the existing knowledge by assessing the effect of hypovitaminosis D on bone microarchitecture in asymptomatic healthy subjects. This would help in interpretation of biochemically low serum 25(OH)D and the intervention if any required for correcting the abnormality. The planned RCT on vitamin D supplementation would be a step forward in the understanding the role of vitamin D in reversing degraded trabecular bone score. If a significant association of TBS with vitamin D or benefit of vitamin D supplementation in reversing degraded TBS is observed, it might serve the purpose of a useful marker for vitamin D deficiency in apparently healthy subjects.
The study objective is,
1: To assess the effect of vitamin D supplementation on TBS in apparently healthy subjects with low serum 25(OH)D and subnormal trabecular score (TBS) and high iPTH(>65 pg/ml).
**MATERIALS AND METHODS**
• The study will be conducted in the Department of Endocrinology and Metabolism.
• The ethical clearance will be obtained from institution ethics body.
• Study design:
Single arm study for analysis of effect pre and post intervention.
• Study duration: July 2022 – June2023.
BMD and TBS data of 900 subjects from age range 20 – 60 years is already available in the data bank of DXA machine in our department.
• We would be recruiting those subjects who would be found to deficient in vitamin D with serum 25(OH)D < 20 ng/ml, TBS < 1.310 and normal iPTH(<65pg/ml). These subjects would be drawn from the pool 900 subjects from age range 20 – 60 years, BMD and TBS data of these subjects are already available in the data bank of DXA machine in our department
**Inclusion and exclusion criteria.**
**Inclusion criteria:**
· Subgroup 1. Subjects with low serum 25(OH)D <20 ng/ml and subnormal TBS(<1.310) with elevated serum iPTH level (>65 pg/ml).
**Exclusion criteria:**
· Subjects who doesn’t give consent.
· Subjects who cannot be contacted
· Subjects who cannot be regularly followed up
· Subjects who started on vitamin D by himself in the interim between initial recruitment and RCT
· Pregnancy and lactation
· Subjects who have developed new systemic illness that are mentioned as exclusion criteria for objective
**Methodology**
· **Work Plan:**
**Sample size estimation:** Subjects from the above cohort with
Low serum 25(OH)D < 20.0ng/ml
Subnormal TBS(<1.310)
Elevated serum iPTH (>65.0 pg/ml).
All the subjects fulfilling above criteria in the cohort of 900 healthy subjects would be eligible and will be given cholecaliciferol and calcium supplementation. Supplementation would be given to them for Pre and post intervention. We have 120 subjects in this group. The mean (SD) of TBS is 1.230 ± 0.094 in these 120 subjects.
Sample size for assessment of effect of cholecaliciferol and calcium supplementation on TBS would be calculated as follows.
Assuming 5.0 % of improvement in TBS pre and post intervention, with an effect size of 0.659, with alpha error at 5.00 % and power of study of 90 %, the sample size will be 26. Assuming a drop rate of 20 % during follow up, we will finally require 32 subjects.
**Dosages of drug** –
Subjects will be given elemental calcium 500 mg tablet once a day and cholecalciferol sachet (60000 IU), one sachet per week for eight weeks followed by one sachet per month for next ten months. To assess the effect of calcium and cholecalciferol, on TBS measurement will be performed, at six months and one year of supplementation.
**Duration of supplementation.** – one year and assessment of response on TBS will be carried out at six months and one year.
**Study procedure(Data collection)**
All the subjects recruited in the study after screening and satisfying all inclusion and exclusion criteria will be subjected to following investigations.
· Serum total calcium, inorganic phosphorus and alkaline phosphatase, liver function tests
· Serum 25(OH) D and parathyroid hormone.
· BMD using dual energy Xâ€ray absorptiometry (central DXA) for the femoral neck, total hip and lumbar spine
Serum total calcium, inorganic phosphorus, alkaline phosphatase and albumin will be measured by cobas-c111 analyzer (Roche, Mannheim, Germany).Serum 25(OH)D and iPTH will be measured by chemiluminescence assay (CLIA) using DiaSorin LIAISON®(DiaSorin, Inc., Stillwater, MN,USA). Bone specific alkaline phosphates would be measured by ELISA.
The TBS will be measured at our DXA facility on the same visit. The BMD and TBS will be measured by dual energy X-ray absorptiometry (DXA), (Discovery A84023,HologicInc., MA,USA) available at the Department of Endocrinology, AIIMS. BMD would be assessed at lumbar spine (L1–L4, antero-posterior), left hip and non-dominant forearm as per the guidelines of the International Society for Clinical Densitometry(ISCD).The precision would be measured by testing BMD three times in 15 study subjects using ISCD precision assessment tool. The standard deviation for each patient would be calculated, and then the root mean square standard deviation for the group is calculated, which gives the precision error. Fractured vertebrae will be excluded from the BMD analysis. BMD of the patients will be recorded in terms of absolute mineral contenting/cm2 at various sites. For the assessment of trabecular bone score, data will be extracted from DXA images using TBS iNsight software (version3.0.2.0,medimaps, Merignac, France).This software is calibrated with our DXA machine. The methodology and criteria adopted for diagnosing osteopenia, osteoporosis and Bone mineral content would be as per the 2014 guidelines from National Osteoporosis Foundation (31).
**Statistical analysis.**
Quantitative data will be reported as mean, standard deviation (SD) and frequencies. Correlation coefficient will be used to assess the relationship between the TBS and 25(OH)D.
Student paired T test will be used to analyse the effect of Vitamin D supplementation from RCT data
**Ethical issues.**
Informed written consent will be obtained from the subjects prior to inclusion in the study. The identity of the subjects in the study will be kept confidential to respect their privacy. The decision to participate in the study will solely depend on participant‘s choice. The subjects have the right to withdraw their consent from participation at any time after inclusion in the study. No incentive will be given to participant or no charges will be levied upon the participation. Ethical clearance will be obtained from ethics committee of the institute.
BMD and TBS data of 900 subjects from age range 20 – 60 years is already available in the data bank of DXA machine in our department.
We would be recruiting those subjects who would be found to deficient in vitamin D with serum 25(OH)D < 20 ng/ml, TBS < 1.310 and high iPTH(>65pg/ml). These subjects would be drawn from the pool 900 subjects from age range 20 – 60 years, BMD and TBS data of these subjects are already available in the data bank of DXA machine in our department.
All the subjects fulfilling above criteria in the cohort of 900 healthy subjects would be eligible and will be given cholecalciferol and calcium supplementation. Supplementation would be given to them for Pre and post intervention. We have 120 subjects in this group. The mean (SD) of TBS is 1.230 ± 0.094 in these 120 subjects.
Sample size for assessment of effect of cholecalciferol and calcium supplementation on TBS would be calculated as follows.
Assuming 5.0 % of improvement in TBS pre and post intervention, with an effect size of 0.659, with alpha error at 5.00 % and power of study of 90 %, the sample size will be 26. Assuming a drop rate of 20 % during follow up, we will finally require 32 subjects.
**Dosages of drug** –
Subjects fulfilling the inclusion criteria will be given elemental calcium 500 mg tablet once a day and cholecalciferol sachet (60000 IU), one sachet per week for eight weeks followed by one sachet per month for next ten months. To assess the effect of calcium and cholecalciferol, on TBS measurement will be performed, at six months and one year of supplementation.
**Duration of supplementation.** – one year and assessment of response on TBS will be carried out at six months and one year.
**Study procedure (Data collection)**
All the subjects recruited in the study after screening and satisfying all inclusion and exclusion criteria will be subjected to following investigations.
· Serum total calcium, inorganic phosphorus and alkaline phosphatase, liver function tests
· Serum 25(OH) D and parathyroid hormone.
· BMD using dual energy Xâ€ray absorptiometry (central DXA) for the femoral neck, total hip and lumbar spine
Serum total calcium, inorganic phosphorus, alkaline phosphatase and albumin will be measured by cobas-c111analyzer (Roche, Mannheim, Germany).Serum 25(OH)D and iPTH will be measured by chemiluminescence assay (CLIA)using DiaSorin LIAISON®(DiaSorin, Inc., Stillwater, MN, USA). Bone specific alkaline phosphates would be measured by ELISA.
The TBS will be measured at our DXA facility on the same visit. The BMD and TBS will be measured by dual energy X-ray absorptiometry(DXA),(DiscoveryA84023,HologicInc., MA,USA)available at the Department of Endocrinology, AIIMS. BMD would be assessed at lumbar spine(L1–L4,antero-posterior),left hip and non-dominant forearm as per the guidelines of the International Society for Clinical Densitometry(ISCD).The precision would be measured by testing BMD three times in 15 study subjects using ISCD precision assessment tool. The standard deviation for each patient would be calculated, and then the root mean square standard deviation for the group is calculated, which gives the precision error. Fractured vertebrae will be excluded from the BMD analysis. BMD of the patients will be recorded in terms of absolute mineral contenting/cm2 at various sites. For the assessment of trabecular bone score, data will be extracted from DXA images using TBS iNsight soft ware (version3.0.2.0,medimaps, Merignac, France).This software is calibrated with our DXA machine. The methodology and criteria adopted for diagnosing osteopenia, osteoporosis and Bone mineral content would be as per the 2014 guidelines from National Osteoporosis Foundation (31).
**References:**
1. Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al; Endocrine Society. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96:1911-30.
2. Goswami R, Gupta N, Goswami D, Marwaha RK, Tandon N, Kochupillai N. Prevalence and significance of low 25-hydroxyvitamin D concentrations in healthy subjects in Delhi. Am J Clin Nutr. 2000; 72:472-5.
3. Goswami R, Kochupillai N, Gupta N, Goswami D, Singh N, Dudha A. Presence of 25(OH) D deficiency in a rural North Indian village despite abundant sunshine. J Assoc Physicians India. 2008; 56:755-7.
4. Goswami R, Mishra SK, Kochupillai N. Prevalence & potential significance of vitamin D deficiency in Asian Indians. Indian J Med Res. 2008; 127:229-38.
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- Detailed Description
Not available
Recruitment & Eligibility
- Status
- Open to Recruitment
- Sex
- All
- Target Recruitment
- 70
Apparently healthy subjects with serum 25(OH)D less than 20 ng/ml, TBS less than 1.310.
- More than 60 years, less than 20 years of age, serum 25(OH) more than 20 ng/ml.
- Subjects with co morbid condition like history of use of antitubercular, antiepileptic drugs or indigenous medicine for more than three months during past six months.
Study & Design
- Study Type
- Interventional
- Study Design
- Not specified
- Primary Outcome Measures
Name Time Method Improvement in trabecular bone score with cholecalciferol and Calcium supplementation Trabecular bone score will be measured at baseline, | at 6 months and 12 months after cholecalciferol and Calcium supplementation
- Secondary Outcome Measures
Name Time Method Trend in BMD At six months and one year.
Trial Locations
- Locations (1)
ALL INDIA INSTITUTE OF MEDICAL SCIENCES NEW DELHI
🇮🇳West, DELHI, India
ALL INDIA INSTITUTE OF MEDICAL SCIENCES NEW DELHI🇮🇳West, DELHI, IndiaRAVINDER GOSWAMIPrincipal investigator9818130879gosravinder@hotmail.com