The term, “Osteopenia” is a descriptive radiologic diagnosis suggesting reduced bone mass that may be noticeable on an x-ray of the chest or lumbar spine. However, before bone loss is evident, approximately 30-40% of the skeleton has demineralized. (1)

Osteopenia can be caused by metabolic or endocrine conditions such as calcium deficiency, Vitamin D-deficient states, malnutrition, renal tubuler acidosis, scurvy, thyrotoxicosis, Cushing’s syndrome, male and female hypogonadal states, prolactinoma, or hyperparathyroidism. Certain medications such as Corticosteroids, Chronic heparin therapy, excessive thyroid hormones, Phenobarbital, Diphenylhydantoin, or chemotherapy can be a secondary cause of Osteopenia. More commonly, lifestyle choices are seen as a contributor to Osteopenia: nutrition, alcohol, smoking, inactivity or immobilization, and excessive intake of coffee or soft drinks. (1) However, the most common cause is simply age-related idiopathic osteoporosis.

Vitamin D (calcitriol) stabilizes calcium stores in the bones, preventing osteoporosis. Vitamin D is not really a vitamin, but rather a hormone obtained from sun exposure or the diet. UV B converts dehydrocholesterol to Vitamin D3 (cholecalciferol). Cholecalciferol (D3) is also found in animal foods and supplements. Vitamin D2 (Ergocalciferol) is derived from plant sources and supplements. Dietary Vitamin D2 is absorbed through the intestine. Vitamin D2 and D3 are later bound to the Vitamin D3 binding protein, which goes through the liver where it is converted to 25-hydroxy Vitamin D (calcidiol). The kidneys then convert it to Calcitriol.

Risk factors for osteoporosis include positive family history, life-long history of poor dietary calcium intake, particularly during adolescent years; Vitamin D deficiency; physical inactivity or immobilization; smoking; malnutrition; hypogonadal state; and ingestion of substances of high phosphate intake, such as soft drinks or large portions of red meats. Coffee is a calciuretic substance. Because fat cells can act as an endocrine organ and convert adrenal androgens to estrogens, lean body mass is a risk factor for osteoporosis, especially in Asian or Caucasian females.(2)

Screening for Vitamin D deficiency should include all women at 50, dark skinned individuals, veiled, home bound and nursing home, chronic aches, multiple fractures, pregnancy, malabsorption, and those with CHD.(8)

Don’t think you may be safe if you take a daily vitamin, or drink an occasional glass of Vitamin D enriched milk. In a study of over 400 pregnant women in Pittsburg, although greater than 90% used prenatal vitamins, 42% of White women had insufficient Vitamin D levels and 5% deficient. Fifty-four percent of term African American mothers suffered insufficient Vitamin D levels, with 29% deficient. Even if the mothers had subnormal Vitamin D levels, would not their babies have normal levels? Surprisingly, 56% of the white babies also had Vitamin D insufficiency, with 9.7% deficient. Of the term African American neonates, 46% were deficient, and 47% had Vitamin D insufficiency. (6) Any person at risk for osteoporosis should have a minimal intake of 1000mg elemental calcium daily, along with a minimal intake of 400IU vitamin D. Adults over 70 and pregnant women require 600 IU vitamin D daily. Most supplements now include Vitamin D along with Calcium. (3) Outdoor activities such as walking 45 minutes daily are also important. Not only do they involve weight bearing exercises (which stimulate bone remodeling and inhibit osteolysis), but minimal erythremic sunlight exposure of 15 minutes daily provides 400-1,200 units of Vitamin D from synthesis in the skin. (3) (4) Without adequate sun exposure, children and adults require 800IU to 1000 IU of vitamin D daily. (5) Many children and adolescents are sedentary and spending extended periods indoors. Adolescent females may already have low vitamin D levels, which accelerate future risk of osteoporosis. In one report, 54% had insufficient Vitamin D levels, and 17% were already deficient. (9). Nutritional guidance for patients of all ages includes avoiding excess phosphates (e.g., beverages containing phosphoric acid) and to include food sources rich in Vitamin D (e.g., seafood, eggs, organ meats, fish liver oils, and vitamin D fortified dairy products). (4)

In 1999, the USDA recommended “Adequate Intake” for Vitamin D:

51-70 years: 400 IU/Day
71 - Up: 600 IU/Day
Pregnancy: 600 IU/Day
Infants (Breast): 200 IU/Day
Children (< 16 oz. mild): 200 IU/Day (7)

However, like most things, you can have too much of a good thing. Vitamin D is fat soluble and excess amounts could be toxic.

In addition to preventing osteoporosis, adequate Vitamin D levels are important for other reasons. Correcting Vitamin D deficiency helped to prevent heart failure and improve cardiac function in women with CHF. (11) In an American Journal of Hypertension (8) article, Vitamin D deficiency resulted in blood pressure elevations (3mm Hg mean systolic, and 1.6 mm Hg mean diastolic BP) compared to those with normal levels. Elevations were highest in non-Hispanic blacks compared to whites. The bottom line is to also check and treat vitamin d deficiency in the hypertensive African American Population. (8). Treating Vitamin D deficiency augments and improved the efficacy of statins (12). Meta-analysis of five studies found that patients in the highest quintile (>33 ng/mL) of 25 OH had a 50% reduction in colo-rectal cancer risk. (13). A systematic review of 63 observational studies, showed an inverse correlation between Vitamin D status and several cancers: 30 colon, 13 breast, 26 prostate, 7 ovarian cancer. (14). Vitamin D reduces All Cause Mortality. In a meta analysis of 18 studies of 57,000 + adults where the average supplement dose was > 500 IU/Day, the result was a decrease in All Cause Mortality (RR=0.93). (10).
In addition to following instructions for prevention, patients diagnosed with Osteoporosis should have their calcium intake increased to 1500 mg/day with 800 IU Vitamin D. (3) (4) Vitamin D supplementation alone is not recommended exclusively as a treatment of osteoporosis, but only for Vitamin D deficiency that often co-exists with the diagnosis of an osteopenic state. Patients should reduce weight and avoid strenuous aerobic exercises (due to excessive stress on bones). Medications such as Fosamax, Actonel, Boniva, or Evista may be prescribed. Synthetic Calcitonin (intranasal Miacalcin) may be prescribed if the above are insufficient alone, or the patient is intolerant. (4)