Nutrition 31 (2015) 931–934
Contents lists available at ScienceDirect
Nutrition journal homepage: www.nutritionjrnl.com
Applied nutritional investigation
Vitamin D serum levels are associated with handgrip strength but not with muscle mass or length of hospital stay after hip fracture David Nicoletti Gumieiro M.D., Ph.D. a, Bruna Paola Murino Rafacho M.Sc. b, Bruna Letıcia Buzati Pereira R.D., C.D.N. b, Karelin Alvisi Cavallari R.D., C.D.N. b, Suzana Erico Tanni M.D., Ph.D. b, Paula Schmidt Azevedo M.D., Ph.D. b, Bertha Furlan Polegato M.D., Ph.D. b, Leonardo Antonio Mamede Zornoff M.D., Ph.D. b, sio Innocenti Dinhane M.D. a, Daniel Innocenti Dinhane M.D. a, Kandir Gene Cac¸a ~o Pereira M.D., Ph.D. a, Sergio Alberto Rupp de Paiva M.D., Ph.D. b, Gilberto Jose Marcos Ferreira Minicucci M.D., Ph.D. b, * a b
Surgery and Orthopedic Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu, Brazil Internal Medicine Department, Botucatu Medical School, UNESP – Univ Estadual Paulista, Botucatu, Brazil
a r t i c l e i n f o
a b s t r a c t
Article history: Received 29 September 2014 Accepted 20 December 2014
Objectives: The aim of this study was to evaluate the association between serum levels of 25(OH) vitamin D3 with midupper arm muscle circumference (MUAMC), handgrip strength and length of hospital stay (LOS) after hip fracture. Methods: In total, 102 consecutive patients with hip fracture over the age of 65 were admitted to the orthopedic unit and prospectively evaluated. All of the patients were treated according to specific protocols depending on the type of fracture. Anthropometric measurements and handgrip strength were performed, and blood samples were taken for serum biochemistry and 25(OH) vitamin D3 analysis within the first 72 h of admission. All of the patients were followed during their hospital stay, and the length of stay was recorded. Results: Of the patients, two were excluded because of pathologic fractures. In total, 100 patients with a mean age of 80 7 y were included in the analysis. Among these patients, 73% were female, and 37% had vitamin D deficiency. The median LOS was 7 (5–11) d. Patients with vitamin D deficiency had lower handgrip strength in univariate analysis. In the multiple linear regression analysis with robust standard error, serum vitamin D levels adjusted by age and sex were associated with handgrip strength but not with MUAMC and LOS after hip fracture. Conclusions: In conclusion, vitamin D serum levels were associated with handgrip strength but not with muscle mass or length of hospital stay after hip fracture. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Vitamin D Sarcopenia Dynapenia Hip fracture
Introduction More than 300,000 patients have a hip fracture each year in the United States. Although the incidence rate varies dramatically across continents, there are expectations that this number will continue to rise, mainly in developing countries [1–4]. The
DNG: study design, data collection, and writing of the manuscript; BPM, BLBP, KAC, DID, KGID, PSA, BFP: data collection. SET: statistical analysis; LAMZ, GJCP, SARP, MFM: study design, data interpretation, and correction of the manuscript. * Corresponding author. Tel.: 01438222969; fax: 01438222238. E-mail address: [email protected] (M. F. Minicucci). http://dx.doi.org/10.1016/j.nut.2014.12.022 0899-9007/Ó 2015 Elsevier Inc. All rights reserved.
worldwide annual rate of hip fractures has been projected to increase from 1.66 million in 1990 to 6.26 million in the year 2050 [5,6]. Hip fractures have a great effect on patient independence, resulting in nursing home stays, increased mortality and lower quality of life [7,8]. Although an increased elderly population is the most important risk factor for osteoporotic fractures, the identification of modifiable risk factors is extremely important. Among these modifiable risk factors, vitamin D deficiency has been widely studied, and recent researchers suggest that this deficiency is a marker of ill health [9]. Vitamin D is a prohormone that has a key role in calcium and phosphate balance and bone structure [9]. Classical actions of
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vitamin D include intestinal calcium absorption by aiding the active transport of this ion through the enterocytes, bone resorption, and calcium reabsorption at the distal renal tubules in the presence of parathormone [10,11]. However, currently, beyond these known effects, data from ecological and observational studies have demonstrated associations between vitamin D deficiency and cancer, cardiovascular diseases, neurodegenerative diseases, and all-cause mortality [9]. Vitamin D deficiency is estimated to affect more than 1 billion people worldwide. Vitamin D deficiency also increases osteoporosis risk and consequently hip fractures [9–11]. In addition to osteoporosis, vitamin D deficiency also affects muscle strength and is associated with increased falls in older patients [12]. Visser et al. [13] demonstrated decreased muscle strength and appendicular skeletal muscle mass in patients with serum levels of vitamin D lower than 25 nmol/L in a prospective, population-based study. Dhanwal et al. [14] also observed in hip fracture patients in India that serum vitamin D concentrations had a positive correlation with handgrip strength. However, the association between vitamin D, muscle mass and length of hospital stay (LOS) was not yet studied in patients with hip fracture. Thus, the aim of this study was to evaluate the association between serum levels of 25(OH) vitamin D3 with midupper arm muscle circumference (MUAMC), handgrip strength and length of hospital stay (LOS) after hip fracture. Materials and methods This study was approved by the Ethics Committee of Botucatu Medical School. Written informed consent was obtained from all of the patients. In total, 102 consecutive patients with hip fracture greater than the age of 65 who were admitted to the orthopedic unit from January to December 2010 were prospectively evaluated. The presence of a pathologic hip fracture (fractures related to cancer) was an exclusion criterion. All of the patients were treated according to specific protocols depending on the type of fracture. The Fisher and Belle formula was used to estimate the required sample size using the following variables: 60% risk for vitamin D inadequacy (40–80%) in patients with hip fracture, 95% confidence interval and 10% sample error [10,15]. The result was 92 patients. Upon admission, patient demographic information including age and sex were recorded. Anthropometric measurements and handgrip strength were performed, and blood samples were taken for serum biochemistry and 25(OH) vitamin D3 analysis within the first 72 h of admission. Considering that the timing of surgery could influence 25(OH) vitamin D3 levels and hand grip strength measures, all measurements were performed before the surgery. All of the patients were followed during the hospital stay, and length of stay was recorded. The definition of diabetes mellitus was based on clinical features and a fasting glucose level of at least 126 mg/dL on two separate occasions or ongoing disease treatment. Systemic hypertension was defined as a systolic blood pressure higher than 140 mmHg and/or a diastolic blood pressure higher than 90 mmHg. Risk for vitamin D inadequacy was defined as serum 25(OH) vitamin D3 concentration lower than 20 ng/mL [16]. Anthropometric measures and handgrip strength Handgrip strengths were measured using a standard adjustable handle (TEC60; Technical Products; Clifton, NJ, USA). All of the measurements were performed for the non-dominant hand, with the elbow supported on the bed, and a trained examiner administered all of the tests. Subjects performed three maximum attempts for each measurement, and the best performance of these tests was recorded. During testing, the participant was strongly encouraged to exhibit the best possible force. One-minute rests were given between each attempt to minimize fatigue affects [17,18]. Mid-upper arm circumference (MUAC) was measured using an inelastic tape according to the standardization of Callaway et al. Triceps skinfold (TS) was measured with a Lange Skinfold Caliper according to the standardization of Harrison et al. [19]. Measurements were taken along the side of the body with no femur fracture according to the International Standards for Anthropometric Assessment recommendations [20]. All of the measures were performed three
times by the same examiner, and the average value was adopted as the final result. MUAMC was calculated with the formula: MUAC – (0.314*TS) [20]. Laboratory data analysis Total serum levels of C-reactive protein (CRP), albumin, creatinine and urea were measured using the dry chemistry method (Ortho-Clinical Diagnostics VITROS 950, Johnson & Johnson). The hemogram was performed with a Coulter STKS hematological autoanalyzer. 25(OH) vitamin D3 analysis Serum concentrations of 25(OH) vitamin D3 were assessed by highperformance liquid chromatography (HPLC, Immundiagnostik AG, Bensheim, Germany). A silica column (4-mm particle size 125 mm 4 mm I.D.) was used. The flow rate was 0.75 mL/min, and the ultra-violet detector was set to 264 nm. The internal standard was purchased from Sigma-Aldrich (St. Louis, MO, USA) (C9774), and the 25(OH) vitamin D3 standard was purchased from Chromsystems Instruments & Chemicals GmbH (Gräfelfing, Germany). Assay sensitivity was 2.5 mg/L, and the coefficient of variation was
Contents lists available at ScienceDirect
Nutrition journal homepage: www.nutritionjrnl.com
Applied nutritional investigation
Vitamin D serum levels are associated with handgrip strength but not with muscle mass or length of hospital stay after hip fracture David Nicoletti Gumieiro M.D., Ph.D. a, Bruna Paola Murino Rafacho M.Sc. b, Bruna Letıcia Buzati Pereira R.D., C.D.N. b, Karelin Alvisi Cavallari R.D., C.D.N. b, Suzana Erico Tanni M.D., Ph.D. b, Paula Schmidt Azevedo M.D., Ph.D. b, Bertha Furlan Polegato M.D., Ph.D. b, Leonardo Antonio Mamede Zornoff M.D., Ph.D. b, sio Innocenti Dinhane M.D. a, Daniel Innocenti Dinhane M.D. a, Kandir Gene Cac¸a ~o Pereira M.D., Ph.D. a, Sergio Alberto Rupp de Paiva M.D., Ph.D. b, Gilberto Jose Marcos Ferreira Minicucci M.D., Ph.D. b, * a b
Surgery and Orthopedic Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu, Brazil Internal Medicine Department, Botucatu Medical School, UNESP – Univ Estadual Paulista, Botucatu, Brazil
a r t i c l e i n f o
a b s t r a c t
Article history: Received 29 September 2014 Accepted 20 December 2014
Objectives: The aim of this study was to evaluate the association between serum levels of 25(OH) vitamin D3 with midupper arm muscle circumference (MUAMC), handgrip strength and length of hospital stay (LOS) after hip fracture. Methods: In total, 102 consecutive patients with hip fracture over the age of 65 were admitted to the orthopedic unit and prospectively evaluated. All of the patients were treated according to specific protocols depending on the type of fracture. Anthropometric measurements and handgrip strength were performed, and blood samples were taken for serum biochemistry and 25(OH) vitamin D3 analysis within the first 72 h of admission. All of the patients were followed during their hospital stay, and the length of stay was recorded. Results: Of the patients, two were excluded because of pathologic fractures. In total, 100 patients with a mean age of 80 7 y were included in the analysis. Among these patients, 73% were female, and 37% had vitamin D deficiency. The median LOS was 7 (5–11) d. Patients with vitamin D deficiency had lower handgrip strength in univariate analysis. In the multiple linear regression analysis with robust standard error, serum vitamin D levels adjusted by age and sex were associated with handgrip strength but not with MUAMC and LOS after hip fracture. Conclusions: In conclusion, vitamin D serum levels were associated with handgrip strength but not with muscle mass or length of hospital stay after hip fracture. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Vitamin D Sarcopenia Dynapenia Hip fracture
Introduction More than 300,000 patients have a hip fracture each year in the United States. Although the incidence rate varies dramatically across continents, there are expectations that this number will continue to rise, mainly in developing countries [1–4]. The
DNG: study design, data collection, and writing of the manuscript; BPM, BLBP, KAC, DID, KGID, PSA, BFP: data collection. SET: statistical analysis; LAMZ, GJCP, SARP, MFM: study design, data interpretation, and correction of the manuscript. * Corresponding author. Tel.: 01438222969; fax: 01438222238. E-mail address: [email protected] (M. F. Minicucci). http://dx.doi.org/10.1016/j.nut.2014.12.022 0899-9007/Ó 2015 Elsevier Inc. All rights reserved.
worldwide annual rate of hip fractures has been projected to increase from 1.66 million in 1990 to 6.26 million in the year 2050 [5,6]. Hip fractures have a great effect on patient independence, resulting in nursing home stays, increased mortality and lower quality of life [7,8]. Although an increased elderly population is the most important risk factor for osteoporotic fractures, the identification of modifiable risk factors is extremely important. Among these modifiable risk factors, vitamin D deficiency has been widely studied, and recent researchers suggest that this deficiency is a marker of ill health [9]. Vitamin D is a prohormone that has a key role in calcium and phosphate balance and bone structure [9]. Classical actions of
932
D. N. Gumieiro et al. / Nutrition 31 (2015) 931–934
vitamin D include intestinal calcium absorption by aiding the active transport of this ion through the enterocytes, bone resorption, and calcium reabsorption at the distal renal tubules in the presence of parathormone [10,11]. However, currently, beyond these known effects, data from ecological and observational studies have demonstrated associations between vitamin D deficiency and cancer, cardiovascular diseases, neurodegenerative diseases, and all-cause mortality [9]. Vitamin D deficiency is estimated to affect more than 1 billion people worldwide. Vitamin D deficiency also increases osteoporosis risk and consequently hip fractures [9–11]. In addition to osteoporosis, vitamin D deficiency also affects muscle strength and is associated with increased falls in older patients [12]. Visser et al. [13] demonstrated decreased muscle strength and appendicular skeletal muscle mass in patients with serum levels of vitamin D lower than 25 nmol/L in a prospective, population-based study. Dhanwal et al. [14] also observed in hip fracture patients in India that serum vitamin D concentrations had a positive correlation with handgrip strength. However, the association between vitamin D, muscle mass and length of hospital stay (LOS) was not yet studied in patients with hip fracture. Thus, the aim of this study was to evaluate the association between serum levels of 25(OH) vitamin D3 with midupper arm muscle circumference (MUAMC), handgrip strength and length of hospital stay (LOS) after hip fracture. Materials and methods This study was approved by the Ethics Committee of Botucatu Medical School. Written informed consent was obtained from all of the patients. In total, 102 consecutive patients with hip fracture greater than the age of 65 who were admitted to the orthopedic unit from January to December 2010 were prospectively evaluated. The presence of a pathologic hip fracture (fractures related to cancer) was an exclusion criterion. All of the patients were treated according to specific protocols depending on the type of fracture. The Fisher and Belle formula was used to estimate the required sample size using the following variables: 60% risk for vitamin D inadequacy (40–80%) in patients with hip fracture, 95% confidence interval and 10% sample error [10,15]. The result was 92 patients. Upon admission, patient demographic information including age and sex were recorded. Anthropometric measurements and handgrip strength were performed, and blood samples were taken for serum biochemistry and 25(OH) vitamin D3 analysis within the first 72 h of admission. Considering that the timing of surgery could influence 25(OH) vitamin D3 levels and hand grip strength measures, all measurements were performed before the surgery. All of the patients were followed during the hospital stay, and length of stay was recorded. The definition of diabetes mellitus was based on clinical features and a fasting glucose level of at least 126 mg/dL on two separate occasions or ongoing disease treatment. Systemic hypertension was defined as a systolic blood pressure higher than 140 mmHg and/or a diastolic blood pressure higher than 90 mmHg. Risk for vitamin D inadequacy was defined as serum 25(OH) vitamin D3 concentration lower than 20 ng/mL [16]. Anthropometric measures and handgrip strength Handgrip strengths were measured using a standard adjustable handle (TEC60; Technical Products; Clifton, NJ, USA). All of the measurements were performed for the non-dominant hand, with the elbow supported on the bed, and a trained examiner administered all of the tests. Subjects performed three maximum attempts for each measurement, and the best performance of these tests was recorded. During testing, the participant was strongly encouraged to exhibit the best possible force. One-minute rests were given between each attempt to minimize fatigue affects [17,18]. Mid-upper arm circumference (MUAC) was measured using an inelastic tape according to the standardization of Callaway et al. Triceps skinfold (TS) was measured with a Lange Skinfold Caliper according to the standardization of Harrison et al. [19]. Measurements were taken along the side of the body with no femur fracture according to the International Standards for Anthropometric Assessment recommendations [20]. All of the measures were performed three
times by the same examiner, and the average value was adopted as the final result. MUAMC was calculated with the formula: MUAC – (0.314*TS) [20]. Laboratory data analysis Total serum levels of C-reactive protein (CRP), albumin, creatinine and urea were measured using the dry chemistry method (Ortho-Clinical Diagnostics VITROS 950, Johnson & Johnson). The hemogram was performed with a Coulter STKS hematological autoanalyzer. 25(OH) vitamin D3 analysis Serum concentrations of 25(OH) vitamin D3 were assessed by highperformance liquid chromatography (HPLC, Immundiagnostik AG, Bensheim, Germany). A silica column (4-mm particle size 125 mm 4 mm I.D.) was used. The flow rate was 0.75 mL/min, and the ultra-violet detector was set to 264 nm. The internal standard was purchased from Sigma-Aldrich (St. Louis, MO, USA) (C9774), and the 25(OH) vitamin D3 standard was purchased from Chromsystems Instruments & Chemicals GmbH (Gräfelfing, Germany). Assay sensitivity was 2.5 mg/L, and the coefficient of variation was
