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Preserved physical function may explain how 25 OH D supplementation reduces falls and fractures. A total of community dwelling men and women mean age Associations were examined using generalized linear models. No significant associations were seen in men. In women, but not men, lower 25 OH D levels were associated with impaired performance on two lower extremity function tests in both cross-sectional and prospective analyses. These results provide additional evidence that 25 OH D is associated with physical function, which may explain how vitamin D supplementation reduces falls and fractures.

Vitamin D maintains serum calcium levels by increasing intestinal calcium and phosphorous absorption. Vitamin D stimulates stem cells in the bone to become mature osteoclasts, which mobilize calcium from the bone into the circulation for bone mineralization. Serum 25 OH D concentrations vary with latitude, season, race, age, and dietary intake.

Several studies have examined the effects of vitamin D on fractures and falls. In a meta-analysis, Bischoff Ferrari et al 15 found that the usual recommended dose of vitamin D —IU daily was ineffective for reducing fractures, but fracture prevention was demonstrated in persons taking more than IU daily; suggesting that higher doses of vitamin D intake are necessary for fracture prevention. Although most of the protective effects of vitamin D on fractures have been attributed to its effect on BMD, vitamin D may also mediate fracture risk by decreasing falls.

A similar meta-analysis by Jackson and colleagues also showed that the pooled relative risk for preventing falls was 0. In addition to the benefits on bone health and falls, vitamin D has a less well-known effect on muscle metabolism. Knockout mice without vitamin D receptors VDR demonstrated altered muscle development 19 and prolonged vitamin D deficiency in adults has been associated with severe muscle weakness, that improved after vitamin D supplementation.

Some trials observed no effect of vitamin D supplements on muscle strength 23 , 29 , 30 or disability in activities of daily living; 31 while a beneficial effect on muscle function was observed by others.

None of these studies, evaluated the association of 25 OH D levels with muscle strength in a population with high 25 OH D levels or a low prevalence of vitamin D deficiency. The present study of community dwelling men and women is the largest prospective study to examine sex specific differences between serum hydroxyvitamin D insufficiency and declining performance on physical function tests. Eighty two percent of the adults who were at least 30 years of age were enrolled in the RBS from to A high proportion of the surviving participants have been followed for various exposures and common diseases, using annual mailers and clinical evaluations repeated approximately every 4 years.

For the current analysis, we studied community-dwelling ambulatory Caucasian men and women who had serum hydroxyvitamin D assays and physical function tests measured in — Participants gave written informed consent. At both visits, participants completed a self-administered questionnaire that included personal and family medical history including fractures , medication and supplement use, and lifestyle factors physical activity, smoking and alcohol intake.

Height and weight were measured in the clinic with participants wearing light clothing and no shoes. Body mass index BMI was calculated as body weight kilograms divided by height meters 2. Comorbidities such as history of hypertension, diabetes cardiovascular disease, congestive heart failure, and stroke were obtained by self-report. At the baseline visit, blood for 25 OH D was obtained between 8 and 12 AM from fasting participants in tubes that were protected from sunlight.

Michael Holick Boston University , as described by Chen et al. The limit of detection was Serum creatinine levels were measured by Smith Kline Beecham clinical laboratories.

At both visits, lower extremity function was assessed using the timed up and go test TUG and timed chair stands TCS ; upper extremity strength was assessed using grip strength GS test.

TUG measures the amount of time it takes to rise from a chair, walk 3 meters, and return to a sitting position. Two trials of the TUG were performed by each participant and recorded to the tenth of a second. Increasing time to perform these activities reflect worse performance and a decline in function at the follow-up visit. For the TCS, participants were seated with their arms folded across their chests in a straight-backed chair and asked to stand up and sit down as quickly as possible five times without stopping or using their arms to push off.

The time to complete the TCS from initial seating to final standing position was recorded in seconds. Increasing time to complete the TCS reflect poorer performance and a decline in function at the follow-up visit. Grip strength was measured in each hand using a Jamar dynamometer. A trained examiner adjusted the handle so that that the dynamometer was held comfortably in the hand with the elbow flexed at 90 degrees and the forearm parallel to the floor.

The dynamometer was squeezed maximally while simultaneously lowering the arm on a 3 second count. GS was recorded to the nearest 0. Higher values reflect better performance.

For continuous variables with normal distributions, Student t tests were used. Differences in categorical variables were examined using Chi-square test. Serum 25 OH D concentrations were analyzed by sex-specific quartiles.

The presence of a nonlinear quadratic effect of 25 OH D concentration was examined but was not apparent, so only the linear associations were modeled. The average of the two TUG results are presented. The average grip strength was analyzed to reduce confounding due to hand dominance.

Percent change in physical function was calculated as the difference between baseline and follow-up values divided by baseline physical performance. Generalized linear models were used to examine the independent association between 25 OH D levels and each measure of physical function.

Potential confounders included in the multivariate models were age, sex, BMI, baseline physical activity level, alcohol and estrogen use only in women. Therefore, all analyses were stratified by sex. All analyses were performed using SAS version 8. Sex-specific baseline characteristics of the participants are shown in Table 1.

In this cohort, Even though three times more women were taking vitamin D supplements, the mean serum 25 OH D concentrations were higher in men Vitamin D supplement users had higher levels of 25 OH D than non-users. Mean 25 OH D levels did not vary by each 5-year age group in either men or women. The mean PTH level in the vitamin D deficient subjects was In bivariate analyses, lower 25 OH D levels were associated with female sex and increasing age, higher BMI and greater alcohol intake.

Levels of 25 OH D were lower in those who did not exercise and in smokers. Lower extremity function was 7. All of the associations were independent of age, BMI, baseline physical activity level, alcohol, estrogen use in women , and comorbidities including diabetes, hypertension, stroke, coronary artery disease, and congestive heart failure.

Figure 1 depicts the percent change in physical function by quartiles of hydroxyvitamin D over a 2. Physical function were measured by two physical performance tests: Timed Chair Stands is the time seconds it takes to complete 5 chair stands without stopping or using arms to push off.

Increase time to perform these tests reflected poorer physical performance. Women in the lowest quartile of hydroxyvitamin D had the largest relative increase on the physical function measures. However, grip strength was not associated with 25 OH D levels in either sex longitudinally. Analyses comparing vitamin D insufficiency vs. Physical function measures were not significantly different in men with vitamin D insufficiency or deficiency.

To examine the effect of non-participation at the follow-up visit on these results, we compared the baseline characteristics of those who did or did not return to the second visit. Therefore the magnitude of the associations observed here was likely attenuated by the selective attrition of those with lower 25 OH D levels and poorer physical function at baseline, a conservative bias.

Relatively few participants had missing data for GS 5. Baseline characteristics were not different between participants with missing data versus no missing data. Finally we determined whether impaired renal function explained our findings. Results excluding these participants were unchanged. We found a significant cross-sectional association between lower 25 OH D concentrations and poorer lower extremity function in community dwelling elderly women.

No associations were observed in men, who were less likely than women to have vitamin D insufficiency. The observed associations are likely underestimated, in that they were attenuated by the selective loss of older participants with lower 25 OH D levels and poorer function at baseline. Our findings are consistent with other cross-sectional studies.

Significant correlations between vitamin D metabolites and leg extension power have been found, 26 as well as with arm muscle strength, ability to climb stairs, physical activity and the absence of falls. Two similar prospective studies of serum 25 OH D and change in physical function has been published. The differences between these two cohorts may be explained by the fact that the participants in the WHAS were moderately to severely disable, unlike the RBS participants who were generally healthy with little to no disabilities.

This led the authors to speculate that the WHAS women were already below a threshold of strength where vitamin D could have an impact. The association between 25 OH D and physical function in the Rancho Bernardo cohort was observed only in women. This sex difference is unlikely explained by the slightly higher 25 OH D levels in men. Selective attrition of men is also unlikely since there were no differences in rates of follow-up or mortality by sex.

Rancho Bernardo men likely had more preserved muscle strength compared to women due to their higher reported physical activity. Other potential mechanisms such as differences in vitamin D receptor gene polymorphisms might also explain the sex specific differences.

There is increasing evidence suggesting that vitamin D intakes higher than those currently recommended are associated with better outcomes. The vitamin D threshold demonstrated in this study is consistent with previously suggested optimal levels, however, determining the exact level is confounded by assay differences.

Limitations to the present study should be noted. Nevertheless, it was of sufficient duration to show a clinically meaningful loss of function in women. Any bias should have caused a conservative estimate on the magnitude of the association, as a larger effect would be expected in a population with more vitamin D deficiency.

Participation bias likely attenuated the results, since those who did not return to the follow-up evaluation had lower 25 OH D levels and poorer physical function at baseline. Other residual confounders and causes of reduced physical function may have contributed to this association. As noted above, differences in 25 OH D assay methods make it difficult to define optimal levels when comparing results from different studies.

In conclusion, our findings support the hypothesis that 25 OH D levels are associated with muscle function, and supports recent data that higher 25 OH D levels are beneficial for various outcomes.

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