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Vitamin D Status and Its Association with Parathyroid Hormone Concentrations in Women of Child-Bearing Age Living in Jakarta and Kuala Lumpur

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Vitamin D Status and Its Association with Parathyroid Hormone Concentrations in Women of Child-Bearing Age Living in Jakarta and Kuala Lumpur European Journal of Clinical Nutrition (2008) 62, 373–378 & 2008 Nature Publishing Group All rights reserved 0954-3007/08 $30.00 www.nature.com/ejcn ORIGINAL ARTICLE Vitamin D status and its association with parathyroid hormone concentrations in women of child-bearing age living in Jakarta and Kuala Lumpur TJ Green1, CM Skeaff1, JEP Rockell1, BJ Venn1, A Lambert2, J Todd2, GL Khor3, SP Loh3, S Muslimatun4, R Agustina4 and SJ Whiting5 1Department of Human Nutrition, University of Otago, Dunedin, New Zealand; 2Fonterra Brands Ltd, Auckland, New Zealand; 3Department of Nutrition & Health Sciences, Faculty of Medicine & Health Sciences, Universiti Putra, Malaysia; 4SEAMEO TROPMED Regional Center for Community Nutrition, University of Indonesia, Jakarta and 5College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada Objective: To describe the vitamin D status of women living in two Asian cities, – Jakarta (61S) and Kuala-Lumpur (21N), to examine the association between plasma 25-hydroxyvitamin D and parathyroid hormone (PTH) concentrations, and to determine a threshold for plasma 25-hydroxyvitamin D above which there is no further suppression of PTH. Also, to determine whether dietary calcium intake influences the relationship between PTH and 25-hydroxyvitamin D. Design: Cross-sectional. Setting: Jakarta, Indonesia and Kuala Lumpur, Malaysia. Participants: A convenience sample of 504 non-pregnant women 18–40 years. Main measures: Plasma 25-hydroxyvitamin D and PTH. Results: The mean 25-hydroxyvitamin D concentration was 48 nmol/l. Less than 1% of women had a 25-hydroxyvitamin D concentration indicative of vitamin D deficiency (o17.5 nmol/l); whereas, over 60% of women had a 25-hydroxyvitamin D concentration indicative of insufficiency (o50 nmol/l). We estimate that 52 nmol/l was the threshold concentration for plasma 25-hydroxyvitamin D above which no further suppression of PTH occurred. Below and above this concentration the slopes of the regression lines were À0.18 (different from 0; P ¼ 0.003) and À0.01 (P ¼ 0.775), respectively. The relation between vitamin D status and parathyroid hormone concentration did not differ between women with low, medium or high calcium intakes (P ¼ 0.611); however, even in the highest tertile of calcium intake, mean calcium intake was only 657 mg/d. Conclusion: On the basis of maximal suppression of PTH we estimate an optimal 25-hydroxyvitamin D concentration of B 50 nmol/l. Many women had a 25-hydroxyvitamin D below this concentration and may benefit from improved vitamin D status. European Journal of Clinical Nutrition (2008) 62, 373–378; doi:10.1038/sj.ejcn.1602696; published online 7 March 2007 Keywords: vitamin D; parathyroid hormone; women; survey; Jakarta; Kuala Lumpur Introduction et al. , 1997; Chapuy et al., 2002; Holick, 2004). Vitamin D inadequacy has also been associated with a number of Vitamin D is essential for bone health, and maintaining negative non-skeletal health outcomes such as increased adequate vitamin D status throughout the lifespan may help falls, poor dental health and increased risk of Type 1 diabetes reduce the risk of osteoporotic fracture (Dawson-Hughes as well as certain types of cancer (Holick, 2004; Bischoff- Ferrari et al., 2006; Wactawski-Wende et al., 2006). Exposure to sunlight is the major determinant of vitamin D status Correspondence: Dr CM Skeaff, Department of Human Nutrition, University of because there are few foods naturally rich in vitamin D. Otago, P.O. Box 56, Dunedin, New Zealand. Consequently, anything that influences the amount of UV E-mail: [email protected] light reaching the skin surface – for example season, time of Guarantor: T Green. Received 26 October 2006; revised 18 December 2006; accepted 2 January day, latitude, clothing and skin color – will affect vitamin D 2007; published online 7 March 2007 status (Holick, 1994). Vitamin D & PTH in Southeast Asian Women TJ Green et al 374 Suboptimal vitamin D status, – based on low circulating ethnicities were recruited in Kuala Lumpur, between January 25-hydroxyvitamin D concentrations, has been described in and March 2005. In Jakarta, 126 women 18–40 years, were many populations (Looker et al., 2002; Zittermann, 2003; recruited in late 2004. Demographic details of the women Ruston et al., 2004; Rockell et al., 2005, 2006). Recently, were collected using questionnaires. Approval to conduct the vitamin D insufficiency has been described not only in studies was obtained from the Ethics Committee of the populations living at higher latitudes but also in sun-rich Faculty of Medicine and Health Sciences, Universiti Putra, environments such as the Southern United States (Looker Malaysia and the Ethical Committee Faculty of Medicine, et al., 2002), Saudi Arabia (Fonseca et al., 1984) and Australia University of Indonesia, Jakarta. (McGrath et al., 2001). Vitamin D deficiency is common in northern parts of Asia such as China (Du et al., 2001) and Mongolia (Fraser, 2004), but has also been described in Dietary people living in the Indian subcontinent such as Bangladesh Dietary data were collected from each participant using a (Islam et al., 2006), India (Harinarayan, 2005) and Pakistan single 24-h recall. Calcium intake was calculated based on (Atiq et al., 1998). However, less is known about the vitamin local (Gizi, 1990; Tee et al., 1997) and United States food D status of southeast Asian people living near the equator. composition data (US Department of Agriculture, 2006). Women in some of these countries may be at risk of inadequacy because the custom of dress leaves very little skin exposed; as well, heat avoidance and shift work may Blood collection and laboratory analysis keep many indoors much of the day (Kung and Lee, 2006). Blood samples were taken by venipuncture into tubes There is a lack of consensus on the concentration of containing ethylenediaminetetraacetic acid following an circulating 25-hydroxyvitamin D required for optimal health overnight fast. Plasma was obtained by centrifuging the (Dawson-Hughes et al., 2005; Bischoff-Ferrari et al., 2006). whole blood at 1650 g for 15 min. Blood samples were stored Poor calcium absorption owing to vitamin D insufficiency at À801C until analyzed. Plasma 25-hydroxyvitamin D and results in a compensatory rise in parathyroid hormone intact PTH were determined using radioimmunoassay kits leading to accelerated bone loss (Aloia et al., 2006; (DiaSorin Stillwater, MN, USA). Two levels of controls Bischoff-Ferrari et al., 2006). Cutoffs that define vitamin D provided by the manufacturer were run in each assay. Inter- insufficiency are based primarily on the concentration of and intra-assay coefficient of variations based on repeated 25-hydroxyvitamin D above which there is no further suppres- analysis of a pooled control for vitamin D were 13 and 9%, sion of parathyroid hormone (PTH), somewhere between 25 respectively. We defined vitamin D deficiency as a 25- and 122 nmol/l (Aloia et al., 2006). However, these cutoffs hydroxyvitamin D less than 17.5 nmol/l and vitamin D have been based largely on studies in older Europeans and insufficiency as a 25-hydroxyvitamin D less than 50 nmol/l. only one was carried out in women of child-bearing age Inter- and intra-assay coefficient of variations based on a (Aloia et al., 2006). Furthermore, in these studies the PTH pooled control for PTH were 11 and 5%, respectively. suppressing effect of 25-hydroxyvitamin D has been found to differ with calcium intake (Aloia et al., 2006). Generally, at lower calcium intakes a higher concentration of 25-hydroxy- Analysis vitamin D was required to cause maximal suppression of Differences between Jakarta and Kuala-Lumpur were deter- PTH. The effect of calcium intake on the vitamin D has not mined using a Fisher’s Exact Test for categorical variables and been examined in South-East Asian populations. a Student’s t-test for continuous variables. Analysis of Here we describe the vitamin D status of young women variances, with a Bonferroni correction and a w2 test were living in two Asian cities, Jakarta (61S) and Kuala-Lumpur used to test for differences between the three Malay ethnic (21N), and explore the relation between plasma 25-hydro- (Malay, Chinese and Indian) groups. Results were considered xyvitamin D and parathyroid hormone concentrations. significant at Po0.05. To examine the relation between plasma 25-hydroxyvitamin D and PTH we used the MKSPLINE function of STATA (Stata Corp, TX, USA). Moving Methods the cutoff point for 25-hydroxyvitamin D concentration from 30 to 80 nmol/l, in single unit increments, we Subjects compared the slope of the regression line for data below Non-pregnant women, 18–40 years (n ¼ 504), were recruited the cutoff to that of the slope of the line for data above the using convenience sampling from the cities of Jakarta (61S) cutoff. We determined the 25-hydroxyvitamin D concentra- and Kuala-Lumpur (21N). Recruitment was through letters, tion at which the difference in slopes of the two lines was the posting of flyers, the internet and word of mouth. largest and the slope of the line for data above the cutoff was Women were excluded if they were breastfeeding, had not different from 0. breastfed within 12 months, or had a serious or chronic To examine the effect of calcium intake on the relation- illness. A total of 378 women, 18–40 years, comprising ship between PTH and 25-hydroxyvitamin D, participants roughly equal proportions of Malay, Chinese and Indian were divided into tertiles according to calcium intake (low, European Journal of Clinical Nutrition Vitamin D & PTH in Southeast Asian Women TJ Green et al 375 o207 mg/day; medium, 207–385 mg/day; and high, (P ¼ 0.014). Over two thirds of women in both countries were 4385 mg/d), and plasma 25-hydroxyvitamin D concentra- single and the majority of women had received secondary tion (low, o39 nmol/l; medium, 39–52 nmol/l; and high, education or higher.
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