Cholecalciferol (vitamin D3), derived from animals protects against osteoporosis, high blood pressure, cancer, depression and a host of other diseases.

Cholecalciferol (vitamin D3), derived from animals protects against osteoporosis, high blood pressure, cancer, depression and a host of other diseases.

Reporter: Aviva Lev-Ari, PhD, RN


UPDATED on 1/15/2019

How to Manage Steroid-Induced Osteoporosis – Experts cover risk factors, recommendations, and treatments

by Jack Cush MD

Glucocorticoid-induced osteoporosis (GIOP) is a common problem, and the consequences can be catastrophic, especially in an aging population, and in patients with rheumatic disease.

Lenore Buckley, MD, MPH, and Mary Humphrey, MD, PhD, published a nice review of GIOP in the New England Journal of Medicine, highlighting the patients at risk, the consequences, treatments (including calcium, vitamin D, bisphosphonates, anabolic and biologic therapies), guidelines, and recommendations.

Key takeaways from the review include:

  • Risk factors for glucocorticoid-induced fractures include age (age >55), female sex, white race, and long-term use of prednisone at a dose of >7.5 mg per day.
  • Screening for fracture risk should be performed soon after the initiation of glucocorticoid treatment. The risk of fracture among patients who are ages ≥40 can be estimated with the use of bone mineral density (BMD) testing and the fracture risk assessment tool (FRAX).
  • Patients who receive glucocorticoids should be counseled about adequate intake of calcium and vitamin D, weight-bearing exercise, and avoidance of smoking and excessive alcohol intake.
  • Pharmacologic treatment is strongly recommended for anyone who has had a fracture, and for patients who are at least age 40 if, according to FRAX, the risk of major osteoporotic fracture is ≥20%, or the risk of hip fracture is at least 3%.
  • Pharmacologic treatment is also recommended for men who are ages ≥50, and for postmenopausal women, who are on glucocorticoids and have a BMD T score of −2.5 or less (indicating osteoporosis) at either the spine or the femoral neck.
  • Bisphosphonates are recommended as first-line treatment of osteoporosis because of their low cost and safety.
  • The risk of fracture decreases rapidly when glucocorticoids are discontinued. Exposure to glucocorticoids should be minimized as much as possible.


Glucocorticoid-Induced Osteoporosis

  • Lenore Buckley, M.D., M.P.H.,
  • and Mary B. Humphrey, M.D., Ph.D.



According to the Mayo Clinic, the major role of vitamin D is to maintain normal blood levels of calcium and phosphorus. Vitamin D helps the body absorb calcium, which forms and maintains strong bones. Vitamin D protects against osteoporosis, high blood pressure, cancer, depression and a host of other diseases.

According to the Vitamin D Council, the following people are more likely to be lacking in vitamin D:

  • People with darker skin. The darker your skin the more sun you need to get the same amount of vitamin D as a fair-skinned person. For this reason, if you’re Black, you’re much more likely to have vitamin D deficiency that someone who is White.
  • People who spend a lot of time indoors during the day. For example, if you’re housebound, work nights or are in hospital for a long time.
  • People who cover their skin all of the time. For example, if you wear sunscreen or if your skin is covered with clothes.
  • People that live in the North of the United States or Canada. This is because there are fewer hours of overhead sunlight the further away you are from the equator.
  • Older people have thinner skin than younger people and this may mean that they can’t produce as much vitamin D.
  • Infants that are breastfed and aren’t given a vitamin D supplement. If you’re feeding your baby on breast milk alone, and you don’t give your baby a vitamin D supplement or take a supplement yourself, your baby is more likely to be deficient in vitamin D.
  • Pregnant women.
  • People who are very overweight (obese).

Supplemental vitamin D comes in two forms:

Ergocalciferol (vitamin D2), derived from plants

Cholecalciferol (vitamin D3), derived from animals

D3 is the form naturally produced by our bodies in response to sun exposure.

After careful analysis of randomized controlled trials involving vitamin D supplementation, the Vitamin D Council recommends that doctors and health professionals use D3 supplements over D2. 


Vitamin D works if other nutrients are present in the diet. These include:

  • Magnesium
  • Vitamin K
  • Zinc
  • Boron
  • Vitamin A

That’s why it’s essential to eat a well-balanced, wholesome diet.

To find out if your vitamin D levels are low, ask your physician to order a vitamin D blood test.


Upper limits of recommended Vitamin D supplementation set by various organizations:

                 Vitamin D Council                         Endocrine Society              Food & Nutrition Board
Infants:    2000 IU/day                                            2000 IU/day                     1000-1500 IU/day
Children: 2000 IU/day / 25 lb body wt           4000 IU/day                      2500-3000 IU/day           Adults:    10,000 IU/day                                        10,000 IU/day                   4000 IU/day

Certain foods provide small amounts of vitamin D. Plant sources provide only the D2 form while the more beneficial D3 comes only from animal-based foods like:

  • Fish, such as salmon, mackerel, tuna and sardines
  • Egg yolk
  • Fortified milk*
  • Cod liver oil

*Pasteurized milk has been fortified milk with vitamin D since the early 1900s. Today, about 98 percent of the milk supply in the U.S. is fortified with about 400 International Units (IU) of vitamin D per quart. Traditionally, dairies fortified milk with vitamin D2, yet recently many have switched over to D3. Check the label to see which form of vitamin D is added to your brand. Other dairy products like cheese, yogurt and ice cream are typically not fortified with vitamin D. Plant-based fortified beverages like soy milk and almond milk use D2 because it’s a plant-derived form of vitamin D, which was produced in the early 1920s through ultraviolet exposure of foods like mushrooms and yeast.

According to the Vitamin D Council, if you have a parathyroid or granulomatous disorder or kidney disease, you should avoid vitamin D supplementation unless you have approval from your physician.

A new study published in the February 2015 Journal of the Academy of Nutrition and Dietetics concludes that vitamin D supplements are absorbed 32 percent more when taken with a meal containing a commonly consumed amount of fat compared to a meal without fat.

Seek the advice of your physician and registered dietitian before starting any supplement regimen.

For healthy recipes and a diet geared towards optimal health, pick up a copy of Layne’s book:Beyond The Mediterranean Diet: European Secrets Of The Super-Healthy.


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