Vitamin D supplementation associated with 12-weeks multimodal training in older women with low bone mineral density: A randomized double-blind placebo-controlled trial

https://doi.org/10.1016/j.exger.2020.111211Get rights and content

Highlights

  • Multimodal exercise effective for imuscle strength and postural balance

  • Vitamin D supplementation little effect on muscle strength gain

  • Vitamin D supplementation little effect on postural balance gain

Abstract

Objective

To evaluate the influence of vitamin D supplementation with a multimodal exercise program on postural balance and muscle strength in older women with low bone mineral density (BMD) and vitamin D insufficiency.

Methods

12-week, randomized, double-blind, placebo-controlled clinical trial. Total of 422 subjects were screened for participation, and 46 met the inclusion criteria. Those were randomized into an experimental group (EG; n = 23) and control group (CG; n = 23). At the time of enrollment, all subjects had low BMD, vitamin D insufficiency, and were not practicing resistance exercise. Muscle strength assessments were performed by the 30-s sit to stand test; 15-steps climbing test; handgrip dynamometer and knee muscle strength using an isokinetic dynamometer at 60°/sec. Postural balance was clinically evaluated by the MiniBESTest and by a force platform. Dynamic balance was assessed by standing up from a chair and walk over a step, using also a force platform.

Results

In the EG, vitamin D levels increased in the post-treatment period (P < 0.001) whereas in CG levels remained unchanged (P = 0.86). Both groups improved muscular strength in the dynamometry isokinetic test: flexors PT/BW – right (P < 0.02) and left side (P < 0.04). In the dynamic postural balance during the task to step up over: the Lift Up Left was better in the CG (P = 0.01); the Moment Time left was better in the CG (P = 0.01); the Impact index left was better in the EG (P = 0.01). The Mini-BESTest - both groups improved the postural balance test (P < 0.001).

Conclusion

Vitamin D supplementation associated with multimodal exercise program did not augment muscle strength adaptation or postural balance in older women with low bone mineral density and vitamin D insufficiency.

Introduction

Vitamin D is essential for calcium absorption in the intestine (Ba̧czyk et al., 2012; El Maghraoui et al., 2012), as well as for maintaining muscle strength and postural balance (Ba̧czyk et al., 2012; El Maghraoui et al., 2012; O'Donnell et al., 2008), and is associated with lower limb function (Bischoff-Ferrari et al., 2004). Insufficiency or deficiency of vitamin D can be associated with muscle hypotrophy and may increase the risk of falls (Glerup et al., 2000), affecting one billion people worldwide (Shinchuk and Holick, 2007). Osteoporosis and osteopenia are determined by lower bone mineral densities (BMD) (Ba̧czyk et al., 2012). Osteoporosis is considered a public health burden that is responsible for the expenditure of USD$ 73 million from 2008 to 2010 by the Brazilian Unified Health System (Moraes et al., 2014).

Falls are the main causes of unintentional injuries (Edgren et al., 2019), and a major risk factor for fractures in older women with bone loss (El Maghraoui et al., 2012). Predisposing factors for falls are muscle weakness and increased center of gravity oscillation due to loss of sensorimotor control (Nikander et al., 2010). Falls in the older adults are associated with higher morbidity and mortality, disability, hospitalization, institutionalization and excessive utilization of social and health services (Mishra et al., 2011).

Resistance exercise is considered one of the best non-pharmacological interventions to stimulate bone formation and muscle strength (Karinkanta et al., 2007; Young et al., 2007). However, it is not known if individuals with vitamin D insufficiency have the same capacity to benefit from resistance exercise as compared to subjects with normal vitamin D levels. Regarding postural balance, sensory motor training is the best exercise modality for reducing the risk of falls.

Uusi-Rasi et al. (2015b) raises important considerations in the study design of randomized clinical trials on the effect of vitamin D on falling. In a 2-year randomized, double-blind, placebo-controlled vitamin D and open exercise trial (Uusi-Rasi et al., 2015a), they found that the rate of injurious falls and injured fallers more than halved with strength and balance training in home-dwelling older women, while neither exercise nor vitamin D affected the rate of falls and describe the importance of future research to determine the role of vitamin D in the enhancement of strength, balance, and mobility. Multimodal training program associated with Vitamin D among older women has been used in many study's in a Finland group (Karinkanta et al., 2007; Uusi-Rasi et al., 2012, Uusi-Rasi et al., 2015a, Uusi-Rasi et al., 2017). Also in a recent study (Daly et al., 2020) with 12-month supervised multimodal training program for older adults they found that the multimodal training program can effectively improve multiple musculoskeletal and functional outcomes in older adults and that these benefits can be sustained over a 6-month. Multimodal exercise programs (i.e., including both resistance and sensory-motor exercise) has become important for this population. Since there is no consensus regarding vitamin D supplementation association for muscle strength preservation/gain and postural balance, there is need for research to better understand the role of vitamin D in muscle performance and postural balance that would help in prevention strategies.

This study aimed to evaluate the influence of vitamin D supplementation associated with a multimodal exercise program on postural balance and muscle strength in older women with both low bone mineral density and vitamin D insufficiency.

Section snippets

Experimental design, local and ethics

A 12-week double-blind, randomized, parallel-group, placebo-controlled trial was conducted between December 2017 and February 2019 in XXXX, according to the guidelines of the Consolidated Standards of Reporting Trials (CONSORT).

The study was performed at the Motion Study Laboratory of the Institute of Orthopedics and Traumatology, XXXX School of Medicine and was approved by the Local Ethics Committee of the University XXX (number 306/15) (registered at clinicaltrials.gov as NCT XXXX) and all of

Results

The flowchart of participants is shown in Fig. 1. A total of 422 subjects were screened for participation and 46 met the inclusion criteria.

No differences between the two groups were detected in any of the main characteristics of the participants at baseline (Table 1).

During the intervention, the vitamin D levels increased from 22.9 (±5.6; CV = 24.3) ng/mL from baseline to 63.9 (±19.1) (min 29.8; CV = 82.7) ng/mL post-treatment at in the EG (P < 0.001). In the CG, the baseline vitamin D level

Discussion

The main findings of the present study are that there was an improvement in postural balance and muscle strength with a multimodal exercise program, independent of vitamin D supplementation.

The hypothesis of this study was not confirmed. We were expecting that vitamin D supplementation combined with exercise would improve muscle strength and postural balance to a greater extent than the CG. Thus, it could be expected in EG, a gain in muscle strength and maintenance of muscle function, by the

Conclusion

Vitamin D supplementation combined with multimodal exercise program did not improve muscle strength and postural balance in older women with low bone mineral density and insufficiency vitamin D to a greater extent than multimodal exercise alone.

Declaration of competing interest

The authors have nothing to declare.

Acknowledgments

We would like to thank the Anima Institute, Brazil. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

References (41)

  • D. Bunout et al.

    Effects of vitamin D supplementation and exercise training on physical performance in Chilean vitamin D deficient elderly subjects

    Exp. Gerontol.

    (2006)
  • L.M. Cangussu et al.

    Effect of isolated vitamin D supplementation on the rate of falls and postural balance in postmenopausal women fallers: a randomized, double-blind, placebo-controlled trial

    Menopause

    (2016)
  • D. Capiati et al.

    1,25(OH)2-vitamin D3 induces translocation of the vitamin D receptor (VDR) to the plasma membrane in skeletal muscle cells

    J. Cell. Biochem.

    (2002)
  • W.J. Chodzko-Zajko et al.

    Exercise and physical activity for older adults

    Med. Sci. Sports Exerc.

    (2009)
  • O.B. Curry et al.

    Calcium uptake by sarcoplasmic reticulum of muscle from vitamin D-deficient rabbits

    Nature

    (1974)
  • R.M. Daly et al.

    Effects of a 12-month supervised, community-based, multimodal exercise program followed by a 6-month research-to-practice transition on bone mineral density, trabecular microarchitecture, and physical function in older adults: a randomized controlled trial

    J. Bone Miner. Res. Off. J. Am. Soc. Bone Miner. Res.

    (2020)
  • J. Edgren et al.

    Counselling for physical activity, life-space mobility and falls prevention in old age (COSMOS): protocol of a randomised controlled trial

    BMJ Open

    (2019)
  • A. El Maghraoui et al.

    Hypovitaminosis D and prevalent asymptomatic vertebral fractures in Moroccan postmenopausal women

    BMC Womens Health

    (2012)
  • H. Glerup et al.

    Hypovitaminosis D myopathy without biochemical signs of osteomalacic bone involvement

    Calcif. Tissue Int.

    (2000)
  • S. Karinkanta et al.

    A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: randomized, controlled trial

    Osteoporos. Int.

    (2007)
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