Asma Arabi

Hypovitaminosis D in developing countries—prevalence, risk factors and outcomes

Hypovitaminosis D is a prevalent disorder in developing countries. Clinical manifestations of hypovitaminosis D include musculoskeletal disorders, such as nonspecific muscle pain, poor muscle strength and low BMD, as well as nonmusculoskeletal disorders, such as an increased risk of respiratory infections, diabetes mellitus and possibly cardiovascular diseases. In developing countries, the prevalence of hypovitaminosis D varies widely by and within regions; prevalence ranges between 30–90%, according to the cut-off value used within specific regions, and is independent of latitude. A high prevalence of the disorder exists in China and Mongolia, especially in children, of whom up to 50% are reported to have serum 25-hydroxyvitamin D levels <12.5 nmol/l. Despite ample sunshine throughout the year, one-third to one-half of individuals living in Sub-Saharan Africa and the Middle East have serum 25-hydroxyvitamin D levels <25 nmol/l, according to studies published in the past decade. Hypovitaminosis D is also prevalent in children and the elderly living in Latin America. Risk factors for hypovitaminosis D in developing countries are similar to those reported in Western countries and include extremes of age, female sex, winter season, dark skin pigmentation, malnutrition, lack of sun exposure, a covered clothing style and obesity. Clinical trials to assess the effect of vitamin D supplementation on classical and nonclassical clinical outcomes in developing countries are needed.

Official Positions for FRAX ® Clinical Regarding International Differences. From Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX ®

Osteoporosis is a serious worldwide epidemic. Increased risk of fractures is the hallmark of the disease and is associated with increased morbidity, mortality and economic burden. FRAX® is a web-based tool developed by the Sheffield WHO Collaborating Center team, that integrates clinical risk factors, femoral neck BMD, country specific mortality and fracture data and calculates the 10 year fracture probability in order to help health care professionals identify patients who need treatment. However, only 31 countries have a FRAX® calculator at the time paper was accepted for publication. In the absence of a FRAX® model for a particular country, it has been suggested to use a surrogate country for which the epidemiology of osteoporosis most closely approximates the index country. More specific recommendations for clinicians in these countries are not available. In North America, concerns have also been raised regarding the assumptions used to construct the US ethnic specific FRAX® calculators with respect to the correction factors applied to derive fracture probabilities in Blacks, Asians and Hispanics in comparison to Whites. In addition, questions were raised about calculating fracture risk in other ethnic groups e.g., Native Americans and First Canadians. In order to provide additional guidance to clinicians, a FRAX® International Task Force was formed to address specific questions raised by physicians in countries without FRAX® calculators and seeking to integrate FRAX® into their clinical practice. The main questions that the task force tried to answer were the following: The Task Force members conducted appropriate literature reviews and developed preliminary statements that were discussed and graded by a panel of experts at the ISCD-IOF joint conference. The statements approved by the panel of experts are discussed in the current paper.

Vitamin D receptor gene polymorphisms modulate the skeletal response to vitamin D supplementation in healthy girls

OBJECTIVES Vitamin D receptor (VDR) gene plays an important role in bone mass regulation. We have previously shown a beneficial effect of vitamin D supplementation on bone mass in girls. This study investigated whether the musculo-skeletal response to Vitamin D was modulated by polymorphisms in VDR gene. DESIGN Randomized placebo-controlled trial. METHODS 179 girls (10-17 years), were randomly assigned to placebo or Vitamin D3 for one year. VDR genotypes were determined in 167 girls using BsmI, TaqI and ApaI restriction enzymes. Bone mass at the spine, hip, forearm and total body, and lean mass were measured by DXA at baseline and at one year. RESULTS After one year, VDR gene polymorphisms using Bsm1 and TaqI restriction enzymes were associated with percent changes in bone area, BMC and BMD at multiple skeletal sites in the Vitamin D3 group but not in the placebo group. The least increments were observed in the BB and tt genotypes. No similar effect was observed with ApaI enzyme. This relationship between VDR genotypes and changes in BMD and BMC remained significant after adjustment for puberty, changes in lean mass, height and bone area. CONCLUSION VDR gene polymorphisms influence the skeletal response to vitamin D supplementation in healthy adolescent girls.

Age but not gender modulates the relationship between PTH and vitamin D

CONTEXT It is unclear whether the relationship between 25-OHD and PTH is modulated by age or gender. OBJECTIVE To assess the 25-OHD-PTH relationship in 340 adolescents (10-17 years) and 443 elderly (65-85 years) of the same ethnic group, and living in the same sunny country. ASSESSMENTS Calcium intake was estimated. Serum calcium, phosphorus, 25-OHD and PTH were measured. Body fat was determined by DXA. RESULTS 25-OHD levels were lower in the elderly in the overall group (p<0.001) and within genders. 25-OHD levels were lower in females in the overall group and within age subgroups (p<0.05). PTH levels were higher in the elderly in the overall population and in both genders (p<0.001). There were no gender differences in PTH levels within age subgroups. For the same 25-OHD level, PTH levels were comparable across genders but were 1.5-2 folds higher in the elderly compared to adolescents (p<0.001). PTH correlated positively with age (p<0.001), body fat (p=0.02), and negatively with calcium intake (p<0.001), and 25-OHD (p<0.001). The magnitude of the correlation with 25-OHD decreased after adjustment for age but not for gender. In multivariate analyses, age, 25-OHD and fat mass were independent predictors for PTH. In the elderly, after adjustment for serum creatinine, only 25-OHD and creatinine were independent predictors of PTH. CONCLUSION The negative relationship between 25-OHD and PTH is modulated by age but not gender. Desirable 25-OHD levels derived from examining the 25-OHD-PTH relationship should therefore take into account the age of the population of interest.

Hypovitaminosis d in patients with type 2 diabetes mellitus: a relation to disease control and complications.

Aims. This study aims at assessing the relationship between 25 (OH) vitamin D (25-OHD) levels and microvascular complications in patients with type 2 diabetes mellitus (DM2). Methods. 136 patients (59 ± 11 years) with DM2 (disease duration 8.6 ± 7 years) participated in this cross-sectional study. Anthropometric data, HbA1c, 25-OHD levels, serum creatinine, and urine microalbumin/creatinine ratio were collected. Dilated retinal exam was performed, and diabetic neuropathy was assessed using the United Kingdom Screening Score. Results. Serum 25-OHD correlated negatively with HbA1c (r = −0.20,  P = 0.049). Mean 25-OHD levels were lower in subjects with diabetic retinopathy compared to those without retinopathy (12.3 ± 5.5 versus 21.8 ± 13.7, P < 0.001) and lower in subjects with diabetic neuropathy compared to those without neuropathy (16.4 ± 10.4 versus 23.5 ± 14.5, P = 0.004). After adjustment for BMI, diabetes duration, and smoking, 25-OHD was an independent predictor of HbA1c (β  −0.14; P = 0.03). After adjustment for HbA1c, age, smoking, BMI and disease duration, 25-OHD were independent predictors for diabetic retinopathy: OR 2.8 [95% CI 2.1–8.0] and neuropathy: OR 4.5 [95% CI 1.6–12] for vitamin D < 20 versus vitamin D ≥ 20 ng/mL. Conclusion. Low serum 25-OHD level was an independent predictor of HbA1c, diabetic neuropathy, and diabetic retinopathy in patients with DM2.

Prognostic Factors of Multiple Sclerosis in Lebanon

ABSTRACT Background: Multiple sclerosis (MS) has a variable disease course. Identifying early predictive prognostic factors is of paramount importance. Most of the data on these factors however comes from studies performed in western countries. Such data is lacking in the Arab World. The objective of this study is to identify early predictors of disability among MS patients in Lebanon. Methods: 75 relapsing-remitting MS patients with 5 year follow-up from disease onset were selected from Project MS Lebanon database. The following parameters were studied as potential causes of early disability as defined by an EDSS ≥3, after five years from disease onset: age at onset of MS, gender, interval between first and second attack, residual deficit after first attack, initial symptoms, treatment for at least 1 year in the first 5 years, and the number of relapses in the first 2 and 5 years. Results: Patients with incomplete recovery from the first relapse were 11.66 times more likely to have a higher EDSS after 5 years (CI = 2.02–67.31, p = .001). Furthermore, the number of relapses during the first 5 years was also an independent predictor of EDSS ≥ 3 at 5 years (p = .024). Other factors were not shown to predict a worse outcome. Conclusion: Overall, early predictors of disability in MS among the Lebanese population were not very different from similar predictors in western countries.

Effect of age, gender and calciotropic hormones on the relationship between vitamin D receptor gene polymorphisms and bone mineral density

Background/Objectives:Hypovitaminosis D is a major public health problem worldwide and unexpectedly more so in sunny countries. Vitamin D receptor (VDR) gene is associated with inter-individual variance in bone mineral density (BMD). Studies assessing the effect of VDR gene polymorphisms on BMD yielded conflicting results. The aim of this study was to assess the relationship between VDR polymorphisms and BMD in the Lebanese, across age groups and genders and to assess the effect of PTH and lean mass and vitamin D levels on such relationship.Subjects/Methods:In total, 203 subjects aged 65–85 years and 336 children aged 10–17 years. Polymorphisms in the VDR gene were assessed with the restriction enzymes BsmI, TaqI and ApaI. Bone mineral content, BMD and lean mass were measured using Dual-Energy X-ray Absorptiometry (DXA). The dominant hand strength was measured in children.Results:Heterozygote genotype was the most frequent in both age groups. There was no difference in the frequency distribution of genotypes between the young and the elderly. No relationship between VDR genotypes and lean mass was found in either age group. Heterozygote boys had the lowest parathormone (PTH) and heterozygote elderly women had the highest BMD at the spine and forearm.Conclusions:In the Lebanese, the relationship between VDR polymorphisms and BMD differs by age. Survival does not seem to differ by VDR genotype. However, further studies are needed to assess the effect of VDR gene polymorphisms on mortality per se and time to mortality, not evaluated in this study.

Impact of maternal veiling during pregnancy and socioeconomic status on offspring’s musculoskeletal health

SummaryThe impact of maternal veiling during pregnancy and of socioeconomic status on offspring’s bone mass was investigated in 326 healthy adolescents. Veiling during pregnancy was associated with decreased musculoskeletal parameters in the offspring boys, but not girls. SES was a significant predictor of bone mass in both genders.IntroductionThis study investigates the effects of maternal veiling during pregnancy, a surrogate for low vitamin D level, and socioeconomic status (SES), a surrogate of nutritional status, on their offspring’s bone mass at adolescence.MethodsThree hundred and twenty-six healthy adolescents aged 13.1(2.0) years and their mothers were studied. The impact of maternal veiling on offspring’s bone mass was evaluated through regression analyses. Outcome variables were bone mineral density (BMD) and content (BMC) at the spine, hip, and total body of the children. Predictors were maternal veiling during pregnancy and SES. Covariates were height, body composition, Tanner staging, calcium intake, vitamin D and exercise in children.ResultsIn boys, adjusted analyses revealed that both maternal veiling during pregnancy and SES were significant predictors of bone mass, at multiple skeletal sites. In girls, SES but not maternal veiling during pregnancy was a significant predictor of bone mass at multiple sites.ConclusionMaternal veiling during pregnancy was associated with decreased musculoskeletal parameters of boys, but not girls. SES was a significant predictor of bone mass in both genders. These findings may have profound implications on children’s bone health.

High prevalence of metabolic syndrome in patients with psoriasis in Lebanon: a prospective study

Psoriasis is a chronic inflammatory disease that affects not only the skin but also other organs as well. Genetic factors play an important role in individual predisposition. Lately, a positive association has been confirmed between psoriasis and metabolic syndrome (MBS), in western as well as in Middle Eastern countries.

First update of the Lebanese guidelines for osteoporosis assessment and treatment.

With the demographic explosion, the human, social, and economic costs of osteoporosis in developing countries, including the Middle East, will continue to rise. In 2002, the Lebanese Guidelines for Osteoporosis Assessment and Treatment were developed to optimize quality of osteoporosis care in Lebanon and the region. They were endorsed by 5 Lebanese medical scientific societies, and by the Eastern Mediterranean Regional Office branch of the World Health Organization (WHO). In April 2006, the Lebanese Society for Osteoporosis and Metabolic Bone Disorders (OSTEOS) led an initiative to update several recommendations detailed in the original document, based on relevant new local and international data. Data from a population-based sample of elderly Lebanese validated the following recommendations: fracture risk assessment, expressed as relative risk per standard deviation (RR/SD) decrease, was comparable in Lebanese subjects to similarly derived estimates from Western studies; the use of the NHANES database (hip), and the densitometer American database (spine) was as good, if not superior to the use of a Lebanese database for identifying subjects with prevalent vertebral fractures. The original recommendation regarding the use of a gender-specific western database, densitometer for spine and NHANES for T-score derivation for men, remains unchanged. For skeletal site selection, the update recommends measuring the spine and hip for women < or =65 yr, hip only for subjects >65 yr, and adding the forearm in conditions associated with cortical bone loss or in the case of inability to measure axial sites. The original recommendations for conservative management in premenopausal women were reiterated. This First Update of the Lebanese Osteoporosis Guidelines validates previous recommendations using evidence from a population-based sample of elderly Lebanese, and lays the ground for transitioning the Lebanese Osteoporosis Guidelines to the WHO global fracture risk assessment model.