Department of Nutrition and Dietetics, School of Sports and Nutrition, Amsterdam University of Applied Sciences.
Bachelor Nutrition and Dietetics
Amsterdam University of Applied Sciences Amsterdam, June 2018
Relation between vitamin D and
sarcopenia: a cross-sectional
research
2 What is the relation between vitamin D intake and sarcopenia in older adults aged 55 years and older?
Authors Jordy Buhrer Tavanier Merel Koenderink Project number 2018206
Graduation Company Lectorate weight management, VITAMINE-study Amsterdam University of Applied Sciences Dr. Meurerlaan 8
1067 SM Amsterdam Practice supervisor J. van den Helder
Supervisor R. Memelink
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Table of Contents
Preface ... 4 Summary ... 5 1. Introduction ... 6 2. Method ... 8 2.1 Population ... 8 2.2 Study design ... 8 2.3 Study parameters ... 8 2.4 Data management ... 10 3. Results ... 12 3.1 Subject characteristics ... 13 3.2 Regression analysis ... 143.2.1 Skeletal muscle mass index ... 14
3.2.2 Handgrip strength... 14 3.2.3 Gait speed ... 15 4. Discussion ... 16 5. Conclusion ... 18 5.1 Recommendation ... 18 10. References ... 19 11. Assesment form ... 22 Appendix 1 ... 24
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Preface
This thesis is the result of our final study project, to complete our Nutrition and Dietetics degree at the Amsterdam University of Applied Sciences (AUAS).
We assessed the relation between the vitamin D intake and sarcopenia amongst older adults in Amsterdam. To assess this relation, we have used the baseline data form the VITAMINE-project. Together with other students we have contributed in collecting new data in the Amsterdam Nutritional Assessment Center at the Dr. Meurerlaan 8.
Hereby we would like to thank our supervisor Robert Memelink for his assistance during this process. He helped us a lot with his feedback on the chapters we wrote and gave us applicable advice about how to improve our products. Furthermore, we would like to thank Jantine van den Helder and Jorinde Scholten for guiding us through the working days at the VITAMINE-project, the time they invested to provide us with feedback on our products and for teaching us how to write the different chapters of a thesis.
Amsterdam, 10 June 2018 Jordy Buhrer Tavanier Merel Koenderink
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Summary
Introduction
According to the world health organization the number of older people is increasing. The number of older adults aged from 60 and beyond will be doubled in 2050 to 22% of the world’s population. Ageing is associated with involuntary loss of muscle mass, strength and physical function. This is referred to as sarcopenia. From the age of 40, the human body tends to lose muscle tissue, and therefore a loss of muscle mass and strength occurs. This decline of muscle tissue happens in a progressive fashion, which can lead up to 50% of tissue being lost at the age of 80. Sarcopenia can lead to severe consequences in older adults. Such as loss of function, disability, falls and mortality. Well-nourished older adults with a good nutritional state, are more likely to maintain muscle tissue during ageing. Vitamin D might play an important role in maintaining the muscle mass, strength and physical function. Therefore, the aim of the study is to assess the relation between the intake of vitamin D and the determinants of sarcopenia.
Method
The study population consists of the participants from the VITAMINE-project. This project included 224 older adults from Amsterdam area at baseline, of which 70% is female. The study is a
quantitative observational study in a cross-sectional design. The independent study parameter is vitamin D intake. The dependent study parameters are the appendicular skeletal muscle mass, handgrip strength (HGS) and gait speed. These study parameters measure the three determinants of sarcopenia, muscle mass, muscle strength and physical function. The vitamin D intake is measured using the dietary intake and intake from supplements. Using a regression analysis, the relation between vitamin D and the determinants of sarcopenia is determined. The relation will also be corrected for potential confounders such as sex, age, level of education and activity level. Results
Using a regression analysis the following results are found. With a difference of one microgram vitamin D intake, the SMI differs positively with 5.9% (p=0.328), the HGS differs positively with 52.2% (p=0.448) and the gait speed differs positively with 0.2% (p=0.921). However, non of those findings were significant. Based on the cut-off points for sarcopenia determined by the EWGSOP, 20 older adults in the study population can be diagnosed with sarcopenia, which equals 9.8% of the participants. The average intake of vitamin D of the sarcopenic older adults is 4.65 ± 4.98 mcg per day. The average intake of vitamin D of the non-sarcopenic older adults is 5.27 ± 6.42 mcg per day. This difference was not significant.
Conclusion
This study has shown a non-significant relation between the intake of vitamin D and the three determinants of sarcopenia in older adults in Amsterdam. This means that we cannot state that vitamin D has a positive significant relation to the prevalence of sarcopenia in older adults in Amsterdam.
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1. Introduction
According to the world health organization the number of older people is increasing, compared to the number of children. The number of older adults aged from 60 and beyond will be doubled in 2050 to 22% of the world’s population. The total amount of people aged 60 years and older is estimated to increase to two billion; up from the 900 million in 2015 (1). The same increase in the older population is also expected in the Netherlands. In 2017 there were 3.2 million people aged 65 years and older, the expected number of older adults in 2040 will be 4.8 million (2).
The pace of aging in the population is notably faster than in the past (1). In 2040 26% of the Dutch population will be older than 65 years (3). This is due to an increase in life expectancy (1).Men born in 2015 have a life expectancy up to 79.7 years old. The life expectancy of women is estimated at 83.1 years. Compared to 2005 the life expectancy for men being 77.2 years and for women 81.6 years (4).
Ageing is associated with involuntary loss of muscle mass, strength and physical function. This is referred to as sarcopenia (5). According to the European Working Group on Sarcopenia in Older People (EWGSOP) the cut-off points for the determinants are the following: the walking speed for men and women is cut-off at ≤0.8m/s, the handgrip strength for men is cut-off at <30 kg, for women it is <20kg. Lastly, the skeletal muscle mass index is cut-off at ≤10.75 kg/m² for men and ≤6.75 kg/m² for women (6). An individual is diagnosed with sarcopenia if they have a low gait speed combined with a low skeletal muscle mass or when the gait speed is normal, but the hand grip and the skeletal muscle mass are low (6). From the age of 40, the human body tends to lose muscle tissue, and therefore a loss of muscle mass and strength occurs (7). This decline of muscle tissue is progressive, which can lead up to 50% of tissue being lost at the age of 80 (5). Sarcopenia can lead to severe consequences in older adults. Such as loss of function, disability, falls and mortality (8).
Older adults tend to fall more often because of these losses of muscle tissue (8). Fall accidents among older adults aged above 65 years old are increasing (9). Of the independent living adults 30% fall at least once a year and 15% of them fall at least twice a year (9). Those falls can lead up to severe problems and even death (10). Hip fractures, injuries and traumas are such problems. Therefore, healthcare costs of those accidents are increasing as well. The healthcare cost of an average fall can lead up to 3.400 euro (9). The number of older adults in the Netherlands is increasing, therefore the total amount of falls per year will also increase, as well as the death rate because of fall accidents and the healthcare costs (3).
Various studies have already shown that the risk of falling in older adults will increase when a decrease in muscle strength happens (9, 11, 12). Turning this around would be the desirable situation. A decrease in fall incidence could be the effect of a maintenance or buildup of muscle tissue during ageing.
Well-nourished older adults with a good nutritional state, are more likely to maintain or build up muscle tissue during ageing (13.) Most older adults have a loss of appetite and a lack of hunger. Therefore, a declining food and energy intake occurs (14). Consuming a lower amount of food than recommended corresponds to a lower intake of macronutrients and micronutrients than needed, vitamin D is one of the most important micronutrients missing (15). Vitamin D plays an important role in maintaining bone density, immune system, healthy teeth and muscle function (16). Vitamin D is needed for the absorption of calcium and calcium is important for maintaining good muscle
function (16, 17). A lack of vitamin D intake could lead to osteoporosis and muscle weakness (12, 18). That is why the recommended intake of vitamin D for older adults is higher than for younger people.
7 For men and women aged 70 and beyond a supplement of 20 µg vitamin D is recommended (19). For women aged 50-69 a supplement of 10µg vitamin D is recommended (19).
Muscle performance and balance can be improved by vitamin D intake and consequently lower the risk of falling in older adults (18). Most observational studies show that there is a positive correlation between serum vitamin status and muscle strength and postural stability (20). This research
however, is focused on the vitamin intake derived from food and supplements combined. A recent systematic review showed that multiple Randomized Controlled Trials state that vitamin D
supplements have an effect on muscle strength and function in older adults, however more studies have been published that show a lack of effect on vitamin D on muscle strength and function (20). More research needs to be done to determine the relation between vitamin D and muscle strength and function. A very recent randomized controlled trial from 2018, has shown that a combination of high whey protein, vitamin D and E supplements can preserve muscle mass and strength. This article proves that the combination of these three supplements have a positive effect (21). However, the effect of the element vitamin D itself is unknown. Therefore, the aim of this study is to assess the relation between vitamin D intake and muscle mass, muscle strength and physical function in older adults.
Because with these determinants, the relation between vitamin D and sarcopenia can be determined.
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2. Method
2.1 Population
The study population consists of the participants from the VITAMINE-project. This project included 224 older adults at baseline, of which 70% is female. The age ranges from 55 up to 91 years. The majority of the participants is older than 70 years, 38% of the male, and 39% of the female participants are younger than 70 years old.
The inclusion criteria for this research are as follows: the participant must be 55 years of age or older, the participant must agree that the general practitioner will be notified on study participation, the participant must sign an informed consent and the participant must be willing to follow the rules of the protocol. Lastly, in opinion of the study physician the participant must be able to comply with the protocol.
The exclusion criteria are as following, if the participant is unable to understand the Dutch language the participant will be excluded. If the investigator suspects that the participant has a current alcohol or drug abuse problem the participant will be excluded. If the participant suffers from cognitive impairment (MMSE<15) the participant will be excluded. Lastly, if the participant has had a knee or hip surgery in the last six months, the participant will be excluded.
2.2 Study design
The study is a quantitative observational study in a cross-sectional design. For our research we will analyze the baseline data from the VITAMINE-project. This data is collected by the VITAMINE-project. The VITAMINE-project is setup as an intervention study (22).
The included population completed a three-day dietary record as well as a medication and
supplementation list to provide the information about the vitamin D intake that was needed. Both dietary intake and intake through supplements will be measured. During the baseline measurements the muscle mass, muscle strength and physical function were measured at the Amsterdam
Nutritional Assessment Center (ANAC).
2.3 Study parameters
The independent study parameter is vitamin D intake. The dependent study parameters are the appendicular skeletal muscle mass, handgrip strength (HGS) and gait speed.
Other study parameters are socio-demographic characteristics and physical activity level. These will be used as subject characteristic and potential confounders. Confounders that will be analyzed are sex, age, level of education and activity level. The confounder sex will be analyzed because the recommended intake of vitamin D is different for men and women. The confounder age will be analyzed because the recommended intake of vitamin D differs for age groups. The confounder level of education will be analyzed because we expect that high educated older adults will be more
focused on a healthy eating pattern. Finally, the confounder activity level will be analyzed because we predict that a higher level of activity will influence the maintenance of muscle mass, muscle strength and physical function.
To measure these study parameters the following methods are used: the Dual Energy X-ray
Absorptiometry (DXA), handgrip strength (HGS), 3-meter walk test and the three-day dietary record. The DXA will be used to measure the skeletal muscle mass index (appendicular skeletal muscle mass/height²) (23). The HGS will be measured in kilograms and will be used to define muscle strength. Usual gait speed is to measure the physical function of older adults. The time needed to
9 perform the 3-meter walk test will be used to determine usual gait speed. Each study method will be shortly explained in the following paragraphs, the used methods and measured outcomes are shown in table 1.
Table 1: Used tests and measured outcome
Methods
Outcome
DXA (kg/m²)
Skeletal muscle mass indexHGS (kg)
Handgrip strength3-meter walk test (sec.)
Usual gait speed DXA Discovery A HologicThe Dual Energy X-ray Absorptiometry is a non-invasive procedure to assess the body composition with a very low radiation dose (24, 25). It measures lean body mass, lean leg mass, appendicular skeletal muscle mass, regional fat mass and bone mineral density. The older adults are asked to lay down on a table and remain still during the whole-body scan.
Handgrip strength
Handgrip strength (HGS) consists of three consecutive measures at each hand using a Jamar hand dynamometer. The results will be recorded to the nearest 1 kg. The strongest attempt from the dominant hand will be used as a parameter of muscle strength (26).
3-meter walk test
This test is part of the short physical performance battery (SPPB) which is a tool to assess the lower extremity function (27). Only the gait speed is used as a parameter in this study. To assess the gait speed the older adults walk a distance of three meters at their usual gait speed.
Three-day dietary record
This questionnaire is used to estimate the daily intake of macronutrients and micronutrients, the older adults are asked to hand in a three-day dietary record of what they consume (28). Each dietary record is checked for missing data. When necessary the participant is asked to provide more
information. The three-day dietary record is analyzed with the NEVO-2013 and entered in an excel sheet (29). The data out of the dietary records and the information about the daily supplement intake will be used to determine the intake of vitamin D in the older adults.
Socio-demographic characteristics
The socio-demographic characteristics are collected through a questionnaire with questions about age, sex, marital status, level of education and ethnicity.
Three-day activity level record
This questionnaire is used to estimate the major daily physical activities of the participants for three days. The participants document their activities every half an hour during the day. Each activity has its own physical activity level (PAL) (30). An average PAL of the day will be calculated.
10 Table 2: Confounders and variables used
2.4 Data management
The data used for answering the research question will be provided by the practice supervisor. All the measurement outcomes are documented on a case report form. These outcomes will also be put into an online research database. The data that has been put into the online database will be checked for mistakes by using double data entry. Any mistakes that were made will be corrected. These checks will make sure that all the data is complete, correct and consistent.
When all the data is collected it will be exported to SPSS version 24 where it will be checked for outliers. The outliers that were physiologically impossible or when the outliers differed more than two times the standard deviation from the mean were excluded from further analysis.
Before data analysis, the variables were checked on normality. Because of lacking normality for vitamin D, it was necessary to perform a log transformation on vitamin D. After the log
transformation on vitamin D intake a regression analysis was performed. The regression analysis is a technique to analyze a possible relation between two variables. One independent variable (vitamin D) and one dependent variable (muscle mass, strength or physical function) are used for this regression analysis. The different variables used are shown in table 2. The independent variable will be compared to each of the three dependent variables.
Unit /
category
Range
Measurement
level
Confounders
Sex
Man/woman 0/1 NominalAge
Years 55-100 ScaleLevel of
education
Primary education Secondary education MBO HBO WO 1-5 NominalActivity
level
PAL 1.0-2.5 ScaleVariables
Skeletal
muscle
mass
index
appendicular skeletal muscle mass/height² 5-15 ScaleHGS
kg 8.5 – 69 ScaleGait
speed
m/s 0.60 – 3.74 ScaleVitamin D
intake
µ 0-30 Scale11 The relation will also be corrected for potential confounders such as sex, age, level of education and activity level. A variable is considered a confounder when its effect on the regression coefficient is bigger than 10 percent. The different potential confounders are shown in table 2.
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3. Results
In this study 224 older adults were analyzed at baseline. In total 20 older adults were excluded from data analysis, due to a lack of valid data or missing data on the intake of vitamin D. After checking and correcting for outliers, the number of subjects available for muscle mass was 198 subjects. For muscle strength 201 subjects were available and for physical function 198 subjects were available.
Figure 1. Flowchart inclusion of subjects for data analysis
Analyzed subjects at baseline
N= 224
Subjects included for data analysis
N= 204
Missing values muscle mass N= 6
Subjects analyzed for muscle mass
N= 198
Missing values muscle strength
N= 3
Subjects analyzed for muscle strenght
N= 201
Missing values physical function
N= 6
Subjects analyzed for physical function
N= 198 Lack of valid or missing
data of vitamin D N= 20
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3.1 Subject characteristics
Table 3 shows the characteristics of the study population. The mean age of the study population was 72.2 ± 6.3 years, the BMI was 25.9 ± 3.8 kg/m² and body fat percentage was 29.7 ± 8.2 %. As shown in table 3 the mean intake of vitamin D was 5.6 ± 6.3 mcg. The mean skeletal muscle mass index was 7.32 ± 0.94 kg/m², the mean handgrip strength was 31.68 ± 11.18 kg and the mean gait speed was 1.30 ± 0.33 m/s.
Based on the cut-off points for sarcopenia determined by the EWGSOP, 20 older adults in the study population were diagnosed with sarcopenia, which equals 9.8% of the participants (6). Three older adults scored low on all three cut-off points, two older adults scored low on the gait speed and the skeletal muscle mass index and 15 older adults scored low on the handgrip strength and the skeletal muscle mass index.
The average intake of vitamin D of the sarcopenic older adults is 4.6 ± 5.0 mcg per day. The average intake of vitamin D of the non-sarcopenic older adults is 5.3 ± 6.4 mcg per day. That is a difference of less than one mcg vitamin D per day.
Table 3: Characteristics of study population
Total
(n=204)
Men
(n=63)
Women
(n=141)
Mean (SD) Mean (SD) Mean (SD)
Age
72.2 (6.3) 72.4 (6.4) 72.1 (6.3)Age <70/>70
78/126 (38.2%/61.8%) 23/39 (37.1%/62.9%) 55/87 (38.7%/61.3%)Height (m)
1.68 (0.09) 1.78 (0.07) 1.64 (0.06)Weight (Kg)
73.52 (13.07) 81.17 (13.24) 70.18 (11.54)BMI (Kg/m²)*
25.9 (3.8) 25.7 (3.5) 26.0 (3.9)Body fat
percentage
(%)
29.7 (8.2) 20.4 (5.2) 31.8 (5.4)Vitamin D
intake (mcg)
5.6 (6.3) 5.3 (6.1) 5.7 (6.4)SMI (kg/m²)*
7.32 (0.94) 8.24 (0.83) 6.92 (0.66)HGS (kg)*
31.68 (11.18) 43.53 (10.45) 26.39 (6.45)Gait speed
(m/s)
1.30 (0.33) 1.38 (0.35) 1.27 (0.31)PAL*
1.50 (0.14) 1.51 (0.16) 1.50 (0.13)14
3.2 Regression analysis
The intake of vitamin D was not normally distributed. Using a log transformation, it was possible to perform a linear regression analysis. The skeletal muscle mass index, handgrip strength and the gait speed were normally distributed. See Appendix 1 for corresponding figures.
3.2.1 Skeletal muscle mass index
In table 4 the linear regression analysis between the log transformed vitamin D intake and the skeletal muscle mass index is shown.
Table 4: linear regression analysis between log transformed vitamin D intake and the skeletal muscle mass index
Regression analysis – ln Vitamin D and SMI
SMI
B (SD) 95% Confidence intervalLower Bound Upper Bound
P-Value
Crude
0.064 (0.065) -0.064 0.192 0.328Adjusted*
0.057 (0.068) -0.078 0.192 0.404*adjusted for confounder physical activity
The regression coefficient from this ln vitamin D is converted to the regression coefficient for skeletal muscle mass index. This regression coefficient was B= 1.066 (p=0.328) for the crude model, and after adjustment for confounder physical activity the regression coefficient was B= 1.059 (p=0.404). This regression coefficient is the ratio between the SMI and the vitamin D intake. With a difference of one microgram vitamin D intake, the SMI differs positively with 5.9 %, though this relation is not
statistically significant.
3.2.2 Handgrip strength
In table 5 the linear regression analysis between the log transformed vitamin D intake and the handgrip strength is shown.
Table 5: linear regression analysis between log transformed vitamin D intake and the handgrip strength
Regression analysis – ln Vitamin D and HGS
HGS
B (SD) 95% Confidence intervalLower Bound Upper Bound
P-Value
Crude
0.581 (0.764) -0.926 2.088 0.448Adjusted*
0.420 (0.533) -0.632 1.472 0.432*adjusted for confounder gender, age and physical activity
The regression coefficient from this ln vitamin D is converted to the regression coefficient for handgrip strength. This regression coefficient was B= 1.788 (p=0.448) for the crude model, and after adjustment for confounders gender, age and physical activity the regression coefficient was B=1.522 (p=0.432). This regression coefficient is the ratio between the SMI and the vitamin D intake. With a difference of one microgram vitamin D intake, the HGS differs positively with 52.2%, though this relation is not statistically significant.
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3.2.3 Gait speed
In table 6 the linear regression analysis between the log transformed vitamin D intake and the gait speed is shown.
Table 6: linear regression analysis between log transformed vitamin D intake and the gait speed
Regression analysis – ln Vitamin D and gait speed
Gait Speed
B (SD) 95% Confidence interval Lower Bound Upper BoundP-Value
Crude
0.008 (0.022) -0.036 0.052 0.716Adjusted*
0.002 (0.022) -0.040 0.045 0.921*adjusted for confounders gender, age, physical activity and level of education
The regression coefficient from this ln vitamin D is converted to the regression coefficient for gait speed. This regression coefficient was B= 1.008 (p=0.716) for the crude model, and after adjustment for confounders gender, age, physical activity and level of education the regression coefficient was B=1.002 (p=0.921). This regression coefficient is the ratio between the gait speed and the vitamin D intake. With a difference of one microgram vitamin D intake, the gait speed differs positively with 0.2%, though this relation is not statistically significant.
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4. Discussion
The aim of the study was to determine the relation of vitamin D intake and the determinants of sarcopenia. Based on findings in the literature, the hypothesis was that a positive relation between vitamin D and muscle mass, muscle strength and physical function would be found.
Contradictive to these hypotheses, this study showed no significant relation between the intake of vitamin D and muscle mass, muscle strength or physical function in older adults. There was no significant evidence found indicating that a higher intake of vitamin D would result in a higher skeletal muscle mass index or a higher handgrip strength or a faster gait speed.
A positive relation between vitamin D intake and the SMI was found, however this result was not significant. According to a recent systematic review and meta-analysis of randomized controlled trials, performed by Beaudart, Buckinx and Rabenda, no significant effect was found between the intake of vitamin D and muscle mass (31). This result matches our outcome. Based on the mean age of 61.1 years, their study population matches ours.
A positive relation between vitamin D intake and the HGS was found, however this result was not significant. The main difference compared to what was found in the literature, is that Muir and Montero-Odasso found a significant result. Their conclusion is that a daily intake of 800 till 1000 IU would have a significant beneficial effect on muscle strength and balance in older adults older than 60 years (32). The difference in study design, is a possible reason for a different outcome. We performed a cross-sectional research, while they performed a longitudinal study. A longitudinal design has more strengths compared to a cross-sectional study, because of data collection in more than one time point (33).
A positive relation between vitamin D intake and the gait speed was found, however this result was not significant. The main difference compared to what was found in the literature, is that Dhaliwal et al, found a significant result. Their research showed a significant positive correlation between vitamin D serum values and gait speed and handgrip strength (34). The difference between our research and what was found in the literature, is the study design and the used methods. We performed a cross-sectional research and only used the vitamin intake derived from food and supplements, while they performed a longitudinal study and used serum vitamin D. Measuring the effect of vitamin D though a longitudinal study results in a more reliable outcome, than measuring the relation between vitamin D and muscle strength in a cross-sectional study (33).
While vitamin D intake did not show a significant relation with the separate determinants of
sarcopenia, we analyzed whether vitamin D intake differed between sarcopenic and non-sarcopenic older adults. We compared the mean intake of vitamin D between the sarcopenic and
non-sarcopenic older adults. The mean intake for non-non-sarcopenic older adults is 5.72 (±6.42) mcg vitamin D. The mean intake for the sarcopenic older adults is 4.65 (± 4.98) mcg vitamin D. The outcome of an independent samples t-test showed that there was no significant difference between the mean intake of vitamin D of both groups (p= 0.126).
One of the strengths of our study is that the EWGSOP was used to define sarcopenic cut-off points, this ensures that a valid judgment about the amount of sarcopenic older adults in the study
population can be given (6). Secondly in our study, 20 participants can be diagnosed with sarcopenia. This equals 9.8% of the study population. This matches with the Dutch population, which has 10-25% sarcopenic older adults (35). For measuring the skeletal muscle mass, the DXA is used. This is a proven valid tool to assess the skeletal muscle mass index (36). Finally, for measuring the handgrip
17 strength, the Jamar hand dynamometer is used. Which is the most widely used tool to assess muscle strength (37, 38).
This study has its limitations. First, the intake of vitamin D among the older adults is not normally distributed. The biggest part of the population had a low intake of vitamin D, and there was a small range of values. This makes it difficult to find a significant outcome for the effect of vitamin D on muscle mass, muscle strength and physical function. Secondly, for the results of handgrip strength a ratio of 1.522 was found. This means that with a difference of one microgram vitamin D intake, the handgrip strength would positively differ with 52.2%. The 95% confidence interval was 0.531 till 4.358, which means that the difference in handgrip strength could also be negative or four times as high. Therefore, the ratio of 1.522 is not reliable. Further, the study population consisted for 70% out of women, while in the Netherlands the ratio for women and men is 1.05 at age 72, which is the mean age of the study population (39, 40). Lastly, the vitamin D intake was collected using dietary records, while using blood serum values would be more reliable. Because there could be a difference between the intake and the amount vitamin D absorbed (41). Sunlight also has an effect on blood serum values of vitamin D (16).
This study showed a non-significant positive relation between the intake of vitamin D and muscle mass, muscle strength and physical function. Therefore, more research about the impact of vitamin D on the determinants of sarcopenia needs to be done.
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5. Conclusion
This study has shown a positive but non-significant relation between the intake of vitamin D and the three determinants of sarcopenia in older adults in Amsterdam.
The results of this cross-sectional study do not show a significant positive relation between vitamin D intake and muscle mass. The same can be said about the relation of vitamin D with muscle strength and physical function.
This means that we cannot state that vitamin D has a positive significant relation with the prevalence of sarcopenia in older adults in Amsterdam.
5.1 Recommendation
Based on these findings there is no reason to write new recommendations for the intake of vitamin D for older adults. Therefore, we recommend following the current existing supplementation advice on vitamin D, until more research is done.
Based on the mean intake of vitamin D in the non-sarcopenic and the sarcopenic older adults we can claim that most of the older adults do not reach the recommendation. Therefore, we advise health professionals to put more emphasis on the recommendation of vitamin D intake in older adults. Not only for the effect of vitamin D on sarcopenia but also for other health benefits.
We recommend studying the effect of vitamin D on sarcopenia in a longitudinal intervention study. We advise to split the study population into three groups. The participants in the control group take no supplements. The first group with an intervention takes 20 mcg vitamin D from supplements and the second one takes 40 mcg from supplements. After the intervention, the muscle mass, muscle strength and physical function will be measured and compared to the measurement at baseline, to measure the effect of the intervention over time. Some possible confounders should be taken into consideration, such as gender, age, physical activity, level of education and protein intake. To assure that the reception of vitamin D out of sunlight is also included we recommend using the blood serum values instead of only the intake of vitamin D derived from food or supplements.
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10. References
1. Ageing and health. World Health Organization, 2015 September. http://www.who.int/mediacentre/factsheets/fs404/en/
2. Stoeldraijer L, Duin van C, Huisman C. Bevolkingsprognose 2017-2060: 18,4 miljoen inwoners in 2060. 2017:5.
3. Prognose bevolking; geslacht en leeftijd, 2017-2060. Centraal Bureau voor de Statistiek. 2016 December 16.
http://statline.cbs.nl/Statweb/publication/?DM=SLNL&PA=83597NED
4. Levensverwachting; geslacht, leeftijd (per jaar en periode van vijf jaren). Centraal Bureau voor de Statistiek. 2017 Juni 6.
http://statline.cbs.nl/StatWeb/publication/?VW=T&DM=SLNL&PA=37360ned&D1=a&D2
=a&D3=0-1,11,21,31,41,51,66&D4=0,10,20,30,40,50,56-l&HD=120427-1726&HDR=G1,T&STB=G2,G3.
5. Walston JD. Sarcopenia in older adults. 2012;24(6):10
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4066461/#R18
6. Cruz-Jentoft AJ, Baeyens JP, Baurer JM, Boirie Y, Cederholm T, Landi F, Marin FC, Michel JP, Rolland Y, Schneider SM, Topinkova E, Vandewoude M, Zamboni M. Sarcopenia: European consensus on definition and diagnosis. Report of the European Working Group on Sarcopenia in Older People. 2010;39(4):412-423)
7. Metter EJ, Conwit R, Tobin J, Fozard JL. Age-associated loss of power and strength in the upper extremities in women and men. The Journals of gerontology. Series A, Biological sciences and medical sciences. 1997;52(5).
8. Dufour AB, Hannan MT, Murabito JM, Kiel DP, McLean RR. Sarcopenia definitions considering body size and fat mass are associated with mobility limitations: the
Framingham Study. The Journals of gerontology. Series A, Biological sciences and medical sciences. 2013;68(2)
9. Nederlandse Vereniging voor Klinische Geriatrie. Preventie van valincidenten bij ouderen. Alphen aan den Rijn. Van Zuiden. 2004.
https://www.nvkg.nl/sites/nvkg.nl/files/valincidenten-bij-ouderen-preventie-van.pdf 10. Overledenen; belangrijke doodsoorzaken (korte lijst), leeftijd, geslacht. Centraal Bureau
voor de Statistiek. 2017 December 28.
http://statline.cbs.nl/Statweb/publication/?DM=SLNL&PA=7052_95&D1=80-87&D2=a&D3=0&D4=62-66&HDR=G1,G2,G3&STB=T&VW=T
11. Stalenhoef PA, Diederiks JPM, Knottnerus JA, Kester ADM, Crebolder HFJM. A risk model for the prediction of recurrent falls in community-dwelling elderly: a prospective cohort study. J Clin Epidemiol 2002;55:1088-94
12. Davis JW, Ross PD, Nevitt MC, Wasnich RD. Risk factors for falls and for serious injuries on falling among older Japanese women in Hawaii. J Am Geriatr Soc 1999;47:792-8 13. Mithal A, Bonjour JP, Boonen S, Bruckhardt P, Degens H, El Hajj Fuleihan G, Josse R, Lips
P, Morales Torres J, Rizzoli R, Yoshiura N, Wahl DA, Cooper C and Dawson-Hughes B. Impact of nutrition on muscle mass, strenght, and performance in older adults. Osteoporosis International. 2013;24
14. Malafarina V, Uriz-Otano, Gil-Guerrero L, Iniesta R. The anorexia of ageing:
Physiopathology, prevalence, associated comorbidity and mortality. A systematic review. 2013; 74(4).
15. Robinson SM, Reginster JY, Rizzoli R, Shaw SC, Kanis JA. Does nutrition play a role in the prevention and management of sarcopenia? 2017.
20 http://www.voedingscentrum.nl/encyclopedie/vitamine-d.aspx
17. Calcium. Voedingscentrum. http://www.voedingscentrum.nl/encyclopedie/calcium.aspx 18. Dawson-Hughes B. Vitamin D and muscle function. The Journal of Steroid Biochemistry
and Molecular Biology. 2017;173:313-316)
19. Heeft een 50-plusser extra vitamines nodig? Voedingscentrum
http://www.voedingscentrum.nl/nl/service/vraag-en-antwoord/gezonde-voeding-en-voedingsstoffen/heeft-een-vitale-50-plusser-extra-vitamines-nodig.aspx .
20. Rejnmark L. Effects of Vitamin D on Muscle Function and Performance: A Review of Evidence from Randomized Controlled Trials. 2011;2(1).
21. Bo Y, Liu C, Ji Z, Yang R, An Q, Zhang X, You J, Duan D, Sun Y, Zhu Y, Cui H, Lu Q. A high whey protein, vitamin D supplement preserves muscle mass, stength, and quality of life in sarcopenic older adults: A double-blind randomized controlled trial.
22. Helder van den J. VITAMINE- VITale Amsterdamse ouderen IN dE Stad. Research protocol VITAMINE. 4e druk. Amsterdam: Hogeschool van Amsterdam; 2017.
23. Bassey EJ, Harries UJ. Normal values for handgrip strength in 920 men and women aged over 65 years, and longitudinal changes over 4 years in 620 survivors. Clin Sci (Lond). 1993;84(3):331-337.
24. Burkhart TA, Arthurs KL, Andrews DM. Manual segmentation of DXA scan images results in reliable upper and lower extremity soft and rigid tissue mass estimates. J Biomech. 2009;42(8):1138-1142.
25. Njeh CF, Fuerst T, Hans D, Blake GM, Genant HK. Radiation exposure in bone mineral density assessment. Appl Radiat Isot. 1999;50(1):215-236. doi: S0969804398000268 [pii]. 26. Brown M, Sinacore DR, Binder EF, Kohrt WM. Physical and performance measures for the identification of mild to moderate frailty. J Gerontol A Biol Sci Med Sci. 2000;55(6):M350- 5
27. Mangione KK, Craik RL, Palombaro KM, Tomlinson SS, Hofmann MT. Home-based legstrengthening exercise improves function 1 year after hip fracture: A randomized controlled study. J Am Geriatr Soc. 2010;58(10):1911-1917.
28. Zoeken, bekijken en vergelijken. Rijksinstituut voor Volksgezondheid en Milieu.
https://www.rivm.nl/Onderwerpen/N/Nederlands_Voedingsstoffenbestand/Toegang_N EVO_gegevens/NEVO_online/Zoeken_bekijken_en_vergelijken.
29. Luhrmann PM, Herbert BM, Gaster C, Neuhauser-Berthold M. Validation of a selfadministered 3-day estimated dietary record for use in the elderly. Eur J Nutr. 1999;38(5):235-240.
30. Bewegen. Voedingscentrum.
http://www.voedingscentrum.nl/encyclopedie/bewegen.aspx
31. Beaudart C, Buckinx F, Rabenda V. The effects of vitamin D on skeletal muscle strength, muscle mass, and muscle pouwer: a systematic review and meta-analysis of randomized controlled trials. 2014;99:4336-45.
32. Muir S, Montero-Odasso M. Effect of Vitamin D Supplementation on Muscle Strength, Gait and Balance in Older Adults: A Systematic Review and Meta-Analysis. 2011.
33. Fischer T and Julsing M. Onderzoek doen! Kwantitatief en kwalitatief onderzoek. Tweede druk. Groningen: Noordhoff uitgevers;2014.
34. Dhaliwal R, Mikhail M, Usera G, Stolberg A, Islam S, Ragolia L, Aloia J. The realtionship of physical performance and osteoporosis prevention with vitamin D in older African Americans (PODA). 2017.
35. Nieuwenhuijzen Kruseman AC, van der Klauw MM, Pijpers E. Hormonale en metabole oorzaken van spierzwakte en fractuurrisico bij ouderen. Nederlandse Tijdschrift voor geneeskunde.2005;149:1033-7.
21 36. Chen Z, Wang Z, Lohman T, Heymsflied SB, Outwater E, Nicholas JS, Bassford T, LaCroix A, Sherill D, Punyanitya M, Wu G and Going S. Dual-engergy X-ray absorptionmetry is a valid tool for assessing skeletal muscle mass in older women. 2007;137:2775-80.
37. Rijk JM, Roos PR, Deckx L, et al. Prognostic value of handgrip strength in people aged 60 years and older: A systematic review and meta-analysis. Geriatr Gerontol Int.
2016;16(1):5-20.
38. Roberts HC, Denison HJ, Martin HJ, et al. A review of the measurement of grip strength in clinical and epidemiological studies: towards a standardised approach. Age Ageing. 2011;40(4):423-9.
39. Statline Bevolking; geslacht, leeftijd en burgerlijke staat, 1 januari. Centraal Bureau voor de Statistiek. 2018 februari 9.
https://opendata.cbs.nl/statline/#/CBS/nl/dataset/7461bev/table?dl=5052 40. Bevolkingspiramide. Centraal Bureau voor de Statistiek. 2018 april 5.
https://www.cbs.nl/nl-nl/visualisaties/bevolkingspiramide 41. Vitamines. Voedingscentrum.
22
11. Assessment form
6 1
24
Appendix 1
Figure 1. Distribution of skeletal muscle mass index
25 Figure 3. Distribution of gait speed
26 Figure 5. P-P Plot of ln vitamin D intake per day
