Osteoporosis International

, Volume 23, Issue 2, pp 615–624 | Cite as

Does increased sunlight exposure work as a strategy to improve vitamin D status in the elderly: a cluster randomised controlled trial

  • P. N. Sambrook
  • I. D. Cameron
  • J. S. Chen
  • R. G. Cumming
  • S. Durvasula
  • M. Herrmann
  • C. Kok
  • S. R. Lord
  • M. Macara
  • L. M. March
  • R. S. Mason
  • M. J. Seibel
  • N. Wilson
  • J. M. Simpson
Original Article

Abstract

Summary

Sunlight exposure by improving vitamin D status could be a simple public health strategy in reducing falls among frail elder people. In a randomised controlled trial, adherence to sunlight exposure was low (median adherence, 26%) and no effect of increased UV exposure on falls risk was observed (incidence rate ratio (IRR) 1.06, P = 0.73).

Introduction

This study aimed to determine whether increased sunlight exposure was effective to improve vitamin D status and reduce falls in the elderly.

Methods

In a cluster randomised controlled trial (NCT00322166 at ClinicalTrials.gov), 602 residents aged 70 or more (mean age, 86.4 years; 71% female) were recruited from 51 aged care facilities in Northern Sydney, Australia. Participants were randomised by facility to receive either increased sunlight exposure (additional 30–40 min/day in the early morning) with (UV+) or without (UV) calcium supplementation (600 mg/day) or neither (control) for a year. The co-primary endpoints were change in serum 25 hydroxy vitamin D (25OHD) and falls incidence after 12 months.

Results

Adherence to sunlight exposure was low (median adherence, 26%; IQR, 7%–45%). Serum 25OHD levels were low at baseline (median, 32.9 nmol/L) and increased only slightly depending on the number of sunlight sessions attended over 12 months (P = 0.04). During the study, 327 falls occurred in 111 (54%) subjects in the control group, 326 falls in 111 (58%) subjects in the UV only group and 335 falls in 108 (52%) subjects in the UV+ group. By intention-to-treat analysis, there was no significant effect of increased UV exposure on falls risk (IRR, 1.06; 95% CI, 0.76–1.48; P = 0.73). However, in 66 participants who attended ≥130 sessions per year (adherence, ≥50% of 260 sessions–five per week), falls were significantly reduced (IRR, 0.52; 95% CI, 0.31–0.88; P = 0.01) compared with the control group.

Conclusions

Increased sunlight exposure did not reduce vitamin D deficiency or falls risk in frail older people. This public health strategy was not effective most likely due to poor adherence to the intervention.

Keywords

Aged care facility Elderly Falls Sunlight exposure Vitamin D deficiency 

Notes

Acknowledgement

The authors gratefully acknowledge the support we received from the staff members in the participating institutions.

Funding

This work was supported by a project grant from the Australian National Health and Medical Research Council.

Conflicts of interest

None.

References

  1. 1.
    Holick MF, Chen TC (2008) Vitamin D deficiency: a worldwide problem with health consequences. Am J Clin Nutr 87:1080S–1086SPubMedGoogle Scholar
  2. 2.
    Lips P (2001) Vitamin D deficiency and secondary hyperparathyroidism in the elderly: consequences for bone loss and fractures and therapeutic implications. Endocr Rev 22:477–501PubMedCrossRefGoogle Scholar
  3. 3.
    Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, Orav JE, Stuck AE, Theiler R, Wong JB, Egli A, Kiel DP, Henschkowski J (2009) Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ 339:b3692PubMedCrossRefGoogle Scholar
  4. 4.
    Norton R, Campbell AJ, Lee-Joe T, Robinson E, Butler M (1997) Circumstances of falls resulting in hip fractures among older people. J Am Geriatr Soc 45:1108–1112PubMedGoogle Scholar
  5. 5.
    Lord SR, Clark RD, Webster IW (1991) Physiological factors associated with falls in an elderly population. J Am Geriatr Soc 39:1194–1200PubMedGoogle Scholar
  6. 6.
    Thapa PB, Brockman KG, Gideon P, Fought RL, Ray WA (1996) Injurious falls in nonambulatory nursing home residents: a comparative study of circumstances, incidence, and risk factors. J Am Geriatr Soc 44:273–278PubMedGoogle Scholar
  7. 7.
    Tinetti ME (1987) Factors associated with serious injury during falls by ambulatory nursing home residents. J Am Geriatr Soc 35:644–648PubMedGoogle Scholar
  8. 8.
    Bischoff-Ferrari HA (2008) Optimal serum 25-hydroxyvitamin D levels for multiple health outcomes. Adv Exp Med Biol 624:55–71PubMedCrossRefGoogle Scholar
  9. 9.
    Bischoff-Ferrari HA, Willett WC, Wong JB, Stuck AE, Staehelin HB, Orav EJ, Thoma A, Kiel DP, Henschkowski J (2009) Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med 169:551–561PubMedCrossRefGoogle Scholar
  10. 10.
    Cameron ID, Murray GR, Gillespie LD, Robertson MC, Hill KD, Cumming RG, Kerse N (2010) Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev CD005465Google Scholar
  11. 11.
    Caro JJ, Ishak KJ, Huybrechts KF, Raggio G, Naujoks C (2004) The impact of compliance with osteoporosis therapy on fracture rates in actual practice. Osteoporos Int 15:1003–1008PubMedCrossRefGoogle Scholar
  12. 12.
    Siris ES, Selby PL, Saag KG, Borgstrom F, Herings RM, Silverman SL (2009) Impact of osteoporosis treatment adherence on fracture rates in North America and Europe. Am J Med 122:S3–S13PubMedCrossRefGoogle Scholar
  13. 13.
    Hughes CM (2004) Medication non-adherence in the elderly: how big is the problem? Drugs Aging 21:793–811PubMedCrossRefGoogle Scholar
  14. 14.
    Yasin S (1998) Detecting and improving compliance. Is concordance the solution? Aust Fam Physician 27:255–260PubMedGoogle Scholar
  15. 15.
    Grant AM, Avenell A, Campbell MK, McDonald AM, MacLennan GS, McPherson GC, Anderson FH, Cooper C, Francis RM, Donaldson C, Gillespie WJ, Robinson CM, Torgerson DJ, Wallace WA (2005) Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (randomised evaluation of calcium or vitamin D, RECORD): a randomised placebo-controlled trial. Lancet 365:1621–1628PubMedCrossRefGoogle Scholar
  16. 16.
    Jackson RD, LaCroix AZ, Gass M, Wallace RB, Robbins J, Lewis CE, Bassford T, Beresford SA, Black HR, Blanchette P, Bonds DE, Brunner RL, Brzyski RG, Caan B, Cauley JA, Chlebowski RT, Cummings SR, Granek I, Hays J, Heiss G, Hendrix SL, Howard BV, Hsia J, Hubbell FA, Johnson KC, Judd H, Kotchen JM, Kuller LH, Langer RD, Lasser NL, Limacher MC, Ludlam S, Manson JE, Margolis KL, McGowan J, Ockene JK, O’Sullivan MJ, Phillips L, Prentice RL, Sarto GE, Stefanick ML, Van Horn L, Wactawski-Wende J, Whitlock E, Anderson GL, Assaf AR, Barad D (2006) Calcium plus vitamin D supplementation and the risk of fractures. N Engl J Med 354:669–683PubMedCrossRefGoogle Scholar
  17. 17.
    Nowson CA, Diamond TH, Pasco JA, Mason RS, Sambrook PN, Eisman JA (2004) Vitamin D in Australia. Issues and recommendations. Aust Fam Physician 33:133–138PubMedGoogle Scholar
  18. 18.
    Chel VG, Ooms ME, Popp-Snijders C, Pavel S, Schothorst AA, Meulemans CC, Lips P (1998) Ultraviolet irradiation corrects vitamin D deficiency and suppresses secondary hyperparathyroidism in the elderly. J Bone Miner Res 13:1238–1242PubMedCrossRefGoogle Scholar
  19. 19.
    Corless D, Gupta SP, Switala S, Barragry JM, Boucher BJ, Cohen RD, Diffey BL (1978) Response of plasma-25-hydroxyvitamin D to ultraviolet irradiation in long-stay geriatric patients. Lancet 2:649–651PubMedCrossRefGoogle Scholar
  20. 20.
    Reid IR, Gallagher DJ, Bosworth J (1986) Prophylaxis against vitamin D deficiency in the elderly by regular sunlight exposure. Age Ageing 15:35–40PubMedCrossRefGoogle Scholar
  21. 21.
    Tang BM, Eslick GD, Nowson C, Smith C, Bensoussan A (2007) Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet 370:657–666PubMedCrossRefGoogle Scholar
  22. 22.
    DIPART (vitamin D individual patient analysis of randomized trials) Group (2010) Patient level pooled analysis of 68 500 patients from seven major vitamin D fracture trials in US and Europe. BMJ 340:B5463CrossRefGoogle Scholar
  23. 23.
    Bolland MJ, Avenell A, Baron JA, Grey A, MacLennan GS, Gamble GD, Reid IR (2010) Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ 341:c3691PubMedCrossRefGoogle Scholar
  24. 24.
    Zochling J, Chen JS, Seibel M, Schwarz J, Cameron ID, Cumming RG, March L, Sambrook PN (2005) Calcium metabolism in the frail elderly. Clin Rheumatol 24:576–582PubMedCrossRefGoogle Scholar
  25. 25.
    Clements MR, Johnson L, Fraser DR (1987) A new mechanism for induced vitamin D deficiency in calcium deprivation. Nature 325:62–65PubMedCrossRefGoogle Scholar
  26. 26.
    Heaney RP (2003) Vitamin D depletion and effective calcium absorption. J Bone Miner Res 18:1342PubMedCrossRefGoogle Scholar
  27. 27.
    Durvasula S, Kok C, Sambrook PN, Cumming RG, Lord SR, March LM, Mason RS, Seibel MJ, Simpson JM, Cameron ID (2010) Sunlight and health: attitudes of older people living in intermediate care facilities in southern Australia. Arch Gerontol Geriatr 51:e94–e99PubMedCrossRefGoogle Scholar
  28. 28.
    Campbell MK, Elbourne DR, Altman DG (2004) CONSORT statement: extension to cluster randomised trials. BMJ 328:702–708PubMedCrossRefGoogle Scholar
  29. 29.
    Holtzman J, Lurie N (1996) Causes of increasing mortality in a nursing home population. J Am Geriatr Soc 44:258–264PubMedGoogle Scholar
  30. 30.
    Sambrook PN, Cameron ID, Chen JS, Cumming RG, Lord SR, March LM, Schwarz J, Seibel MJ, Simpson JM (2007) Influence of fall related factors and bone strength on fracture risk in the frail elderly. Osteoporos Int 18:603–610PubMedCrossRefGoogle Scholar
  31. 31.
    Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, Leirer VO (1982) Development and validation of a Geriatric Depression Screening Scale: a preliminary report. J Psychiatr Res 17:37–49PubMedCrossRefGoogle Scholar
  32. 32.
    Hayes RJ, Moulton LH (2009) Cluster randomised trials: a practical approach. Chapman & Hall, LondonCrossRefGoogle Scholar
  33. 33.
    Lord SR, March LM, Cameron ID, Cumming RG, Schwarz J, Zochling J, Chen JS, Makaroff J, Sitoh YY, Lau TC, Brnabic A, Sambrook PN (2003) Differing risk factors for falls in nursing home and intermediate-care residents who can and cannot stand unaided. J Am Geriatr Soc 51:1645–1650PubMedCrossRefGoogle Scholar
  34. 34.
    Cutler DM, Everett W (2010) Thinking outside the pillbox—medication adherence as a priority for health care reform. N Engl J Med 362:1553–1555PubMedCrossRefGoogle Scholar
  35. 35.
    Chief Health Officer VA. Vitamin D and the Built Environment in Victoria—A guideline for planners, engineers, architects and policy makers in local and state government 2009. Available at: http://www.health.vic.gov.au/chiefhealthofficer/publications/vitamind.htm. Accessed 08/03/2010. 2010
  36. 36.
    MacLaughlin J, Holick MF (1985) Aging decreases the capacity of human skin to produce vitamin D3. J Clin Invest 76:1536–1538PubMedCrossRefGoogle Scholar
  37. 37.
    Holick MF, Matsuoka LY, Wortsman J (1989) Age, vitamin D, and solar ultraviolet. Lancet 2:1104–1105PubMedCrossRefGoogle Scholar
  38. 38.
    Davie M, Lawson DE (1980) Assessment of plasma 25-hydroxyvitamin D response to ultraviolet irradiation over a controlled area in young and elderly subjects. Clin Sci Lond 58:235–242PubMedGoogle Scholar
  39. 39.
    Heaney RP, Davies KM, Chen TC, Holick MF, Barger-Lux MJ (2003) Human serum 25-hydroxycholecalciferol response to extended oral dosing with cholecalciferol. Am J Clin Nutr 77:204–210PubMedGoogle Scholar
  40. 40.
    Sato Y, Iwamoto J, Kanoko T, Satoh K (2005) Amelioration of osteoporosis and hypovitaminosis D by sunlight exposure in hospitalized, elderly women with Alzheimer’s disease: a randomized controlled trial. J Bone Miner Res 20:1327–1333PubMedCrossRefGoogle Scholar
  41. 41.
    Webb AR, Engelsen O (2006) Calculated ultraviolet exposure levels for a healthy vitamin D status. Photochem Photobiol 82:1697–1703PubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2011

Authors and Affiliations

  • P. N. Sambrook
    • 1
    • 8
  • I. D. Cameron
    • 2
  • J. S. Chen
    • 1
  • R. G. Cumming
    • 3
  • S. Durvasula
    • 9
  • M. Herrmann
    • 4
  • C. Kok
    • 1
  • S. R. Lord
    • 5
  • M. Macara
    • 1
  • L. M. March
    • 1
  • R. S. Mason
    • 6
  • M. J. Seibel
    • 4
  • N. Wilson
    • 1
  • J. M. Simpson
    • 7
  1. 1.Institute of Bone and Joint ResearchUniversity of SydneySydneyAustralia
  2. 2.Rehabilitation Studies UnitUniversity of SydneySydneyAustralia
  3. 3.Centre for Education and Research on AgeingUniversity of SydneySydneyAustralia
  4. 4.Anzac Research InstituteUniversity of SydneySydneyAustralia
  5. 5.Prince of Wales Medical Research InstituteUniversity of NSWSydneyAustralia
  6. 6.Bosch InstituteUniversity of SydneySydneyAustralia
  7. 7.Sydney School of Public HealthUniversity of SydneySydneyAustralia
  8. 8.Institute of Bone and Joint ResearchSt LeonardsAustralia
  9. 9.Sydney Medical SchoolUniversity of SydneySydneyAustralia

Personalised recommendations