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Fatigue fractures in military conscripts : A study on risk factors, diagnostics and long-term consequences Ruohola, Juha-Petri University of Helsinki, Faculty of Medicine, Institute of Clinical Medicine, Orthopaedics and Traumatology, Helsinki University Central Hospital Centre of Military Medicine, Helsinki 2007-03-09 Doctoral dissertation (article-based) It seems likely that low vitamin D levels are related to fatigue fractures, and that an increasing trend exists between TRACP-5b bone resorption marker elevation and fatigue fracture incidence. Though seldom detected by plain radiography, fatigue fractures often underlie unclear lower leg stress-related pain occurring in the distal parts of the tibia. Femoral neck fatigue fractures, when displaced, lead to long-term morbidity in a high percentage of patients, whereas, when non-displaced, they do not predispose patients to subsequent adverse complications. Importantly, an educational intervention can diminish the incidence of fracture displacement by enhancing awareness and providing instructions for earlier diagnosis of fatigue fractures

Stress fractures in the Israeli defense forces from 1995 to 1996. Givon U, Friedman E, Reiner A, Vered I, Finestone A, Shemer J. Clin Orthop Relat Res. 2000 Apr;(373):227-32. PMID: 10810481 Serum levels of bone specific alkaline phosphatase and osteocalcin were elevated in patients with high grade stress fractures compared with control subjects with no symptoms: 37.6 versus 26.2 units/L, and 10.8 versus 8.8 ng/mL, respectively. Levels of 25-hydroxy vitamin D were lower in patients with high grade stress fractures (25.3 ng/mL) than in control subjects (29.8 ng/mL). This study revealed that several parameters can distinguish soldiers with high grade stress fractures, but their predictive value and precise pathogenetic role remain unclear.

For many years, vitamin D was boring--even to doctors. Because it was considered good for bones and not much else, multitaskers like vitamin A, B vitamins and vitamin E hogged all the press. But recent studies have thrust this long-neglected nutrient into the spotlight. Scientists now think vitamin D may affect everything from diabetes to cancer. They're also finding that many people don't have enough of it.

David Feldman, MD, professor of medicine at Stanford, explores the biological action of Vitamin D beyond its widely understood role in the information and maintenance of bone. Emerging therapeutic uses of the vitamin include the prevention and treatment of breast, prostate and colon cancer, chronic kidney disease and arthritis, among other conditions.

Vitamin D toxicity, policy, and science. Vieth R. J Bone Miner Res. 2007 Dec;22 Suppl 2:V64-8. Review. PMID: 18290725 doi: 10.1359/jbmr.07s221

Vitamin D and skin physiology: a D-lightful story.\nHolick MF, Chen TC, Lu Z, Sauter E.\nJ Bone Miner Res. 2007 Dec;22 Suppl 2:V28-33.\nPMID: 18290718 \ndoi: 10.1359/jbmr.07s211\n

P.T. Liu, S. Stenger, H. Li, L. Wenzel, B.H. Tan, S.R. Krutzik, M.T. Ochoa, J. Schauber, K. Wu, C. Meinken, et al.\nVitamin D3-Triggered Antimicrobial Response--Another Pleiotropic Effect beyond Mineral and Bone Metabolism: Toll-Like Receptor Triggering of a Vitamin D-Mediated Human Antimicrobial Response. Science 311: 1770-1773, 2006\nJ. Am. Soc. Nephrol., November 1, 2006; 17(11): 2949 - 2953.

Matsumoto T, Miki T, Hagino H, Sugimoto T, Okamoto S, Hirota T, Tanigawara Y, Hayashi Y, Fukunaga M, Shiraki M, Nakamura T. A new active vitamin D, ED-71, increases bone mass in osteoporotic patients under vitamin D supplementation: a randomized, double-

Vitamin K2 is produced by animal tissues, including the mammary glands, from vitamin K1, which occurs in rapidly growing green plants. A growing body of published research confirms Dr. Price's discoveries, namely that vitamin K2 is important for the utilization of minerals, protects against tooth decay, supports growth and development, is involved in normal reproduction, protects against calcification of the arteries leading to heart disease, and is a major component of the brain. Vitamin K2 works synergistically with the two other "fat-soluble activators" that Price studied, vitamins A and D. Vitamins A and D signal to the cells to produce certain proteins and vitamin K then activates these proteins. Vitamin K2 plays a crucial role in the development of the facial bones, and its presence in the diets of nonindustrialized peoples explains the wide facial structure and freedom from dental deformities that Weston Price observe

Vitamin D status and its relationship to body fat, final height, and peak bone mass in young women.\nKremer R, Campbell PP, Reinhardt T, Gilsanz V.\nJ Clin Endocrinol Metab. 2009 Jan;94(1):67-73. Epub 2008 Nov 4.\nPMID: 18984659

This critical nutrient builds bones, helps fight infection and may protect against some cancers. Do we get enough?

A New Zealand study has found that South Asian women with insulin resistance improved markedly after taking vitamin D supplements Nutrition researcher Pamela von Hurst of the Institute of Food, Nutrition and Human Health at Albany, said while diet and exercise played a major part in the onset of type-2 diabetes, her findings reinforced the importance of vitamin D from the sun and supplements to prevent type-2 diabetes. Initial screening of 235 Auckland women from India, Pakistan and Sri Lanka aged 20 and older, revealed 47 per cent were insulin deficient and 84 per cent were vitamin D deficient. The 81 recruited for the study were split into two groups for a randomised controlled trial and given a vitamin D supplement or placebo. As well as an improvement in insulin resistance among those who took vitamin D for six months, Ms Von Hurst said post-menopausal women in the study also showed a reduced rate of bone breakdown.

Severe vitamin D deficiency in Swiss hip fracture patients. Bischoff-Ferrari HA, Can U, Staehelin HB, Platz A, Henschkowski J, Michel BA, Dawson-Hughes B, Theiler R. Bone. 2008 Mar;42(3):597-602. Epub 2007 Nov 28. PMID: 18180211 BACKGROUND: Most clinical guidelines for the prevention of hip fractures recommend 800 IU vitamin D per day. This dose shifted serum 25-hydroxyvitamin D levels (25(OH)D) in previous studies to between 60 and 100 nmol/l. AIM: To measure 25(OH)D levels and prevalence of vitamin D supplementation in individuals age 65+ with acute hip fracture. METHODS: 222 consecutive hip fracture patients were investigated over a 12 month period. Mean age of patients was 86 years and 77% were women. RESULTS: Mean serum 25(OH)D levels were low among hip fracture patients admitted from home (34.6 nmol/l), from assisted living (27.7 nmol/l), and from nursing homes (24 nmol/l). Severe vitamin D deficiency below 30 nmol/l was present in 60%, 80% were below 50 nmol/l, and less than 4% reached desirable levels of at least 75 nmol/l. Consistently, only 10% of hip fracture patients had any vitamin D supplementation on admission to acute care with significantly higher 25(OH)D levels among individuals supplemented with 800-880 IU/day (63.5 nmol/l). Controlling for age and gender, vitamin D supplementation, type of dwelling, and season were independently and significantly associated with 25(OH)D levels. CONCLUSION: These data provide evidence that current guidelines for the prevention of hip fractures need further effort to be translated into clinical practice.

Plasma calcidiol, season, and serum parathyroid hormone concentrations in healthy elderly men and women. Dawson-Hughes B, Harris SS, Dallal GE. Am J Clin Nutr. 1997 Jan;65(1):67-71. PMID: 8988915 Plasma calcidiol and serum PTH concentrations were inversely related, with PTH rising slowly as calcidiol concentrations declined below 110 nmol/L (95 CI: 60, 168 nmol/L). More than 90% of the men and women had calcidiol concentrations below this value in the wintertime. The high prevalence of lower wintertime calcidiol values may increase risk of bone loss in elderly men and women.

"Researchers at Johns Hopkins are reporting what is believed to be the first conclusive evidence in men that the long-term ill effects of vitamin D deficiency are amplified by lower levels of the key sex hormone estrogen, but not testosterone. In a national study in 1010 men, to be presented Nov. 15 at the American Heart Association's (AHA) annual Scientific Sessions in Orlando, researchers say the new findings build on previous studies showing that deficiencies in vitamin D and low levels of estrogen, found naturally in differing amounts in men and women, were independent risk factors for hardened and narrowed arteries and weakened bones. Vitamin D is an essential part to keeping the body healthy, and can be obtained from fortified foods, such as milk and cereals, and by exposure to sunlight.

Is a lower dose of vitamin D supplementation enough to increase 25(OH)D status in a sunny country? Pignotti GA, Genaro PS, Pinheiro MM, Szejnfeld VL, Martini LA. Eur J Nutr. 2009 Nov 28. [Epub ahead of print] PMID: 19946776 CONCLUSION: The dose given (400 IU/day) was not enough to achieve 25(OH)D concentration, considered optimal for bone health.

"For more than 80 years, scientists have known that vitamin D is important for building bones. And for most of those 80 years, people thought this was the only thing it was good for. In the past decade, however, we've learned two important things about vitamin D: it appears to have many other important health effects, and many Americans don't get enough of it. In 2008, new research pointed to a vitamin D deficiency as a possible contributing factor in heart disease. And the suspected link between vitamin D deficiency and cancer grew even stronger. This surely will spur much new research in 2009. Why is vitamin D deficiency so common? The vitamin is made in our skin when sunlight strikes it. Many Americans-especially those who live in the northern part of the country, are elderly or have dark skin-don't soak up enough sun. And the vitamin isn't found in many foods. The main sources are fatty fish (such as salmon, mackerel, herring and sardines) and milk, cereal and juices that have been fortified with it. Vitamin D deficiency often is unsuspected because it causes no direct symptoms; like high blood pressure, it does its damage silently."

Vitamin D and diabetes: improvement of glycemic control with vitamin D3 repletion. Schwalfenberg G. Can Fam Physician. 2008 Jun;54(6):864-6. PMID: 18556494 Conclusion These cases support information that is already known about VTD and its effect on the islet cell. As discussed above, this might be true only for vitamin D3 and not vitamin D2, although vitamin D2 has been shown to improve bone health. Vitamin D insufficiency or deficiency is common, and repletion might improve glycemic control early in type 2 diabetes. Diabetes is one of the fastest growing chronic diseases worldwide. Vitamin D3 is inexpensive and readily available. Well-designed clinical studies are required to ascertain if improving 25(OH)D levels from an insufficiency or deficiency to sufficiency improves glycemic control in diabetes. These studies need to be properly designed: a randomized controlled trial with VTD deficiency or insufficiency identified in diabetic patients of various ethnic

Factors that influence the cutaneous synthesis and dietary sources of vitamin D. Chen TC, Chimeh F, Lu Z, Mathieu J, Person KS, Zhang A, Kohn N, Martinello S, Berkowitz R, Holick MF. Arch Biochem Biophys. 2007 Apr 15;460(2):213-7. Epub 2007 Jan 8. PMID: 17254541 doi: 10.1016/j.abb.2006.12.017 Vitamin D is rare in food. Among the vitamin D-rich food, oily fish are considered to be one of the best sources. Therefore, we analyzed the vitamin D content in several commonly consumed oily and non-oily fish. The data showed that farmed salmon had a mean content of vitamin D that was ~25% of the mean content found in wild caught salmon from Alaska, and that vitamin D2 was found in farmed salmon, but not in wild caught salmon. The results provide useful global guidelines for obtaining sufficient vitamin D3 by cutaneous synthesis and from dietary intake to prevent vitamin D deficiency and its health consequences.ensuing illness, especially, bone fractures in the elderly.

Hypovitaminosis D in British adults at age 45 y: nationwide cohort study of dietary and lifestyle predictors. Hyppönen E, Power C. Am J Clin Nutr. 2007 Mar;85(3):860-8. PMID: 17344510 Conclusion: Prevalence of hypovitaminosis D in the general population was alarmingly high during the winter and spring, which warrants action at a population level rather than at a risk group level. Data from the 1958 birth cohort suggest that, at different cutoffs for hypovitaminosis D, a substantial public health problem exists in British whites. Obese participants and those living in Scotland were at the highest risk of hypovitaminosis D. However, the prevalence in the general population was very high during the winter and spring, which suggests that, to improve the situation, action is required at a population level rather than at a risk-group level. In the United States, calls have gone out for an increase in vitamin D fortification of foods (11), and the data from the current study suggest that such action is also warranted in the United Kingdom. Vitamin D is currently available without prescription as a dietary supplement only as part of cod liver oil or multivitamin products; hence, a need clearly exists to consider increased availability of over-the-counter supplements. Hypovitaminosis D has been implicated in the development of serious conditions, including diabetes, various types of cancer, and cardiovascular diseases, in addition to its essential role in maintaining bone health (1, 2). The high rates of hypovitaminosis D reported in this study suggest that immediate action is needed to improve the vitamin D status of the British population.