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Extended report
For numbered affiliations see
end of the article
Correspondence to
Dr John McBeth, ARC
Epidemiology Unit, University
of Manchester, Oxford Road,
Manchester M13 9PT, UK;
john.mcbeth@manchester.
ac.uk
Accepted 11 December 2009
1448
Musculoskeletal pain is associated with very low
levels of vitamin D in men: results from the
European Male Ageing Study
John McBeth,1 Stephen R Pye,1 Terence W O’Neill,1 Gary J Macfarlane,2 Abdelouahid
Tajar,1 Gyorgy Bartfai,3 Steven Boonen,4 Roger Bouillon,5 Felipe Casanueva,6 Joseph
D Finn,1 Gianni Forti,7 Aleksander Giwercman,8 Thang S Han,9 Ilpo T Huhtaniemi,10
Krzysztof Kula,11 Michael E J Lean,9 Neil Pendleton,12 Margus Punab,13 Alan J Silman,1
Dirk Vanderschueren,14 Frederick C W Wu,15; EMAS Group
ABSTRACT
Introduction A study was undertaken to test the
hypothesis that musculoskeletal pain is associated with
low vitamin D levels but the relationship is explained
by physical inactivity and/or other putative confounding
factors.
Methods Men aged 40–79 years completed a postal
questionnaire including a pain assessment and attended
a clinical assessment (lifestyle questionnaire, physical
performance tests, 25-hydroxyvitamin D3 (25-(OH)
D) levels from fasting blood sample). Subjects were
classified according to 25-(OH)D levels as ‘normal’
(≥15 ng/ml) or ‘low’ (<15 ng/ml). The relationship
between pain status and 25-(OH)D levels was assessed
using logistic regression. Results are expressed as ORs
and 95% CIs.
Results 3075 men of mean (SD) age 60 (11) years
were included in the analysis. 1262 (41.0%) subjects
were pain-free, 1550 (50.4%) reported ‘other pain’ that
did not satisfy criteria for chronic widespread pain (CWP)
and 263 (8.6%) reported CWP. Compared with patients
who were pain-free, those with ‘other pain’ and CWP had
lower 25-(OH)D levels (n=239 (18.9%), n=361 (23.3)
and n=67 (24.1%), respectively, p<0.05). After adjusting
for age, having ‘other pain’ was associated with a 30%
increase in the odds of having low 25-(OH)D while CWP
was associated with a 50% increase. These relationships
persisted after adjusting for physical activity levels.
Adjusting for additional lifestyle factors (body mass index,
smoking and alcohol use) and depression attenuated
these relationships, although pain remained moderately
associated with increased odds of 20% of having low
vitamin D levels.
Conclusions These findings have implications at a
population level for the long-term health of individuals
with musculoskeletal pain.
INTRODUCTION
Musculoskeletal pain problems are one of the major
global causes of disability and one of the most
common reasons for primary care consultation.1
Musculoskeletal pain is common with, for example,
approximately 33%2 and 10%3 of the general pop-
ulation reporting low back pain and chronic wide-
spread pain (CWP), respectively. Despite extensive
investigations over the past 20 years, the aetiology
of these disabling pain disorders remains unclear.
Vitamin D may be associated with the presence of
musculoskeletal pain. The vitamin D receptor has
been identified in muscle tissue4 and could explain
the association with muscle weakness and regional
pain disorders5 such as low back pain. However,
most reports have focused on the relationship
between vitamin D and CWP and have shown that
CWP is associated with low levels of vitamin D.6–8
Osteomalacia, a condition linked with very low
levels of vitamin D of which widespread musculo-
skeletal pain is a feature, could explain that rela-
tionship. However, the available data are equivocal
with reports of no difference in vitamin D levels
when subjects with diffuse pain were compared
with subjects with osteoarthritis,9 and lower lev-
els in women but not in men with CWP.10 There
are a number of possible reasons why these differ-
ences have been observed. Varying cut-offs have
been used to define ‘low’ or ‘insufficient’ vitamin D
levels, although levels of ≤20 ng/ml that correspond
to physiological insufficiency are commonly used.
Also, variation in control subjects or a lack of a
control group makes it difficult to interpret results.
However, the most important problem to date has
been the lack of control for factors that may explain
the observed relationships. Low levels of physical
activity,11 depression in older subjects12 and smok-
ing13 are associated with low vitamin D levels.
These factors are also associated with the presence
of CWP, and it is possible that they may explain
some, if not all, of the observed associations.
While it is plausible that low vitamin D levels
could be causally related to CWP via osteomalacia,
the prevalence of osteomalacia could not explain
the high prevalence of CWP in the general popu-
lation. It is equally plausible that CWP leads to
low vitamin D levels, possibly via reduced levels
of physical activity and consequent reduced expo-
sure to sunlight. In the current study we tested the
hypothesis that the presence of CWP would predict
lower levels of vitamin D. The secondary hypoth-
esis was that any observed relationship would be
explained by low levels of physical activity and/or
other putative lifestyle and psychological confound-
ing factors.
METHODS
Subjects
The subjects included in this analysis were recruited
for participation in the European Male Ageing
Ann Rheum Dis 2010;69:1448–1452. doi:10.1136/ard.2009.116053
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Study (EMAS). Details regarding recruitment, response rates
and assessments have been described previously.14 Briefly, 3369
men were recruited from population-based sampling frames in
eight centres: Florence (Italy), Leuven (Belgium), Lodz (Poland),
Malmo (Sweden), Manchester (UK), Santiago del Compostella
(Spain), Szeged (Hungary) and Tartu (Estonia). Stratified random
sampling was used with the aim of recruiting equal numbers of
men in each of four 10-year age bands: 40–49, 50–59, 60–69 and
≥70 years. Subjects were invited by letter to complete a short
postal questionnaire and attend a local clinic for further screen-
ing. The study was funded by the European Union and ethical
approval for the study was obtained in accordance with local
institutional requirements in each centre.
Assessments
The short postal questionnaire included items concerning health
and lifestyle information. Subjects were asked about current
smoking (response: yes/no), alcohol consumption in the previ-
ous year (response: every day/5–6 days per week/3–4 days per
week/1–2 days per week/less than once a week/not at all) and
time spent exercising (walking or on a bicycle) out of doors each
day (response: none/<30 min/30 min to 1 h/>1 h). Those who
agreed to participate subsequently attended a hospital research
clinic to complete an interviewer-assisted questionnaire (IAQ).
The IAQ included the Physical Activity Scale for the Elderly
(PASE),15 which is a measure of participation in activities (sit-
ting, walking, light, moderate, or strenuous sport or recreational
activity, strength or endurance exercises, light or heavy house-
work/gardening) in the past 7 days with higher scores reflecting
higher levels of activity. The IAQ also included the 21-item Beck
Depression Inventory (BDI) to measure the presence and sever-
ity of depressive symptoms.16 In addition, physical performance
was assessed during the clinic visit by measuring the time in
seconds taken to go from a sitting to a standing position17 and
measuring the time in seconds taken to walk 50 feet.18 Height
and weight were measured in a standardised fashion.
Ascertainment of pain
Information on pain was collected in the postal questionnaire
by asking subjects: ‘In the past month have you had any pain
which has lasted for one day or more?’ If subjects answered
positively they were asked to indicate the site(s) of pain on
four-view body manikins. To assess chronicity, subjects were
asked whether they had been aware of the pain for 3 months or
more. Three groups of subjects were identified: those reporting
no pain, those reporting ‘other pain’ that did not satisfy criteria
for CWP and those with CWP. In classifying CWP, the criteria
included in the American College of Rheumatology (ACR) cri-
teria for fibromyalgia19 were used. These criteria require pain
lasting at least 3 months, both above and below the waist, on
the right and left sides of the body and in the axial skeleton.
These methods for collecting and classifying pain information
have been used frequently in population studies and construct
validity has been demonstrated.20 21 Further details have been
reported previously.22
25-Hydroxyvitamin D3 assay
A single fasting morning (before 10:00) venous blood sample
was obtained from all subjects. Serum was separated imme-
diately after phlebotomy, stored at −80°C and shipped on dry
ice to a single laboratory (University of Leuven) for measure-
ment of 25-hydroxyvitamin D3 (25-(OH)D). Serum 25-(OH)D
levels were determined using an equilibrium radioimmunoassay
Ann Rheum Dis 2010;69:1448–1452. doi:10.1136/ard.2009.116053
Extended report
(DiaSorin; Stillwater, Minnesota, USA). Intra- and inter-assay
coefficients of variation for 25-(OH)D were 11% and 9%,
respectively. The detection limit of the radioimmunoassay kit
was 1.5 ng/ml 25-(OH)D.
Analysis of data
The significance of any observed differences in age and
other continuous variables between those with ‘other pain’
or CWP compared with those who were pain-free were
determined using t tests, while χ2 tests were used for categori-
cal variables. Vitamin D deficiency has been defined variably
as a level <10–20 ng/ml.23 24 In our study the frequency of
CWP appeared if anything to increase at values <15 ng/ml (see
figure 1); based on this, we classified subjects as ‘low’ vitamin
D if the level was <15 ng/ml and ‘higher’ if the level was above
this. The physical performance tests and PASE scores were
treated as continuous variables. Body mass index (BMI) was
calculated as weight in kilograms divided by height in metres
squared. Scores of 0–9 on the BDI indicate that a person is
not depressed, 10–18 indicates mild to moderate depression,
19–29 indicates moderate to severe depression and 30–63 indi-
cates severe depression. For the purpose of the current analy-
sis, subjects were classified as ‘depressed’ (BDI score 10–63) or
‘not depressed’ (score 0–9).
Logistic regression was used to determine the association
between pain and 25-(OH)D status as the dependent variable.
The relationships were cumulatively adjusted for age and sea-
son during which the blood sample was collected, physical
activity and other putative confounding factors. Evidence of sta-
tistical interaction between pain status and all other variables
with 25-(OH)D status as the outcome variable was explored.
The comparison group for all analyses were those subjects
reporting no pain. The results are expressed as ORs and 95%
CIs. Statistical analysis was performed using STATA Version 9.2
(http://www.stata.com).
RESULTS
Of the 3369 participants, 3075 (91.3%) provided full data on
pain status and had their 25-(OH)D levels measured. In the total
sample the mean (SD) level of 25-(OH)D was 25.0 (12.7) ng/ml.
A total of 1262 (41.0%) reported no pain in the past month, 1550
(50.4%) reported ‘other pain’ and 263 (8.6%) reported pain that
satisfied the ACR criteria for CWP. Subjects with ‘other pain’ and
CWP had significantly lower mean 25-(OH)D levels than those
Figure 1 Prevalence of chronic widespread pain (CWP) by
25-hydroxyvitamin D3 (25-(OH)D) level.
1449
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Extended report

who were pain-free (24.8 (12.9) ng/ml and 23.9 (11.8) ng/ml performance measures, having ‘other pain’ and CWP remained
vs 25.6 (12.5) ng/ml, p<0.05). As shown in table 1, a significantly independently associated with low 25-(OH)D.
higher proportion of subjects with ‘other pain’ (23.2%) and CWP We then adjusted for other putative confounders. Smoking,
(25.5%) were classified as ‘low’ 25-(OH)D compared with those alcohol use and depression were all associated with the out-
reporting no pain (18.6%). There were no significant differences come. After adjusting for these variables, both ‘other pain’
in age or BMI between subjects with low and higher 25-(OH)D (OR 1.2, 95% CI 1.01 to 1.5) and CWP (OR 1.2, 95% CI 0.9
(table 1). However, self-reported physical activity in the past to 1.8) remained moderately associated with low 25-(OH)D,
week, PASE score and the two physical performance measures although the relationship with CWP was no longer statistically
were significantly associated with low 25-(OH)D. Similarly, significant.
subjects who currently smoked cigarettes and those who were
depressed were more likely to have low 25-(OH)D. The rela- DISCUSSION
tionship between alcohol use in the past week and 25-(OH)D The aim of this study was to determine whether, in a general
status was a U-shaped curve: subjects who reported alcohol use population sample of middle-aged men, reporting musculo-
for 3–4 days in the past week were least likely to be classified as skeletal pain would be associated with low levels of vitamin D
low 25-(OH)D while those reporting 0–2 days or 1–7 days were (measured by 25-(OH)D)). After adjusting for age, subjects clas-
more likely. sified as having ‘other pain’ and those with CWP had a mod-
After adjustment for age and season of blood sample collec- erately increased odds of low 25-(OH)D. These relationships
tion, subjects with ‘other pain’ were 30% (OR 1.3, 95% CI 1.1 to persisted after adjusting for measures of physical activity and
1.6) more likely to have low 25-(OH)D than those reporting no physical performance and other factors that may have con-
pain (table 2). This relationship was slightly more marked among founded the relationship including BMI, smoking, alcohol use
subjects with CWP who were 40% (OR 1.4, 95% CI 1.1 to 2.1) and depression. These data suggest that, although the relation-
more likely to have low 25-(OH)D. When the physical activity ship between CWP and vitamin D status is partially explained
measures were included in the analysis, self-reported activity of by the additional factors associated with pain, there remains a
≥30 min in the past week was protective against low 25-(OH)D moderate association with pain per se. The current study was
levels. Similarly, a higher PASE score, indicating increased levels cross-sectional and the true direction of causality is unclear. It is
of activity, was associated with a decreased likelihood of having equally plausible that low vitamin D predicts the onset of CWP.
low 25-(OH)D levels. Of the objective physical assessments, an The nature of the CWP and vitamin D relationship can only be
increased time to walk 50 feet was associated with an increased fully elucidated in a prospective study.
odds of having low 25-(OH)D. After adjusting for these physical Our study has a number of strengths: it was a large popula-
tion-based study that used standardised well-validated instru-
Table 1 Subject characteristics by vitamin D status ments to assess pain and putative confounders. A number of
subjects who were invited to participate in the study did not
25-(OH)D status
do so. Of those who did participate, a proportion (N=294) did
Higher (≥15 ng/ml), Low (<15 ng/ml),
N=2414 (78.5%) N=661 (21.5%) not provide pain data or a blood sample for assaying 25-(OH)
Pain status (N (%))
D levels. It is possible that the prevalence of pain and levels
No pain 1027 (81.4) 235 (18.6) of vitamin D may not reflect the true levels in the popula-
Other pain 1191 (76.8) 359 (23.2) tions from which the study sample was drawn. However, this
CWP 196 (74.5) 67 (25.5)† should not affect the results of the analysis which is based on
Physical activity measures an internal comparison of responders. One of the main limi-
Self-reported activity duration in past week (N (%)) tations in interpreting the data is the cross-sectional design
None 277 (72.5) 105 (27.5) and the difficulty in determining the temporal nature of the
<0.5 h 497 (74.3) 172 (25.7) relationships for which prospective studies are required. It is
0.5–1 h 860 (80.5) 209 (19.6)
possible, for example, that patients with CWP may alter their
>1 h 769 (81.8) 171 (18.2)*
lifestyle with resulting reduced exposure to sunlight which
PASE score (range 0–1100) 200.4 (91.0) 179.1 (91.8)†
Time taken to walk 50 feet (s) 13.4 (3.1) 14.1 (4.1)†
is the major source of vitamin D levels. Also, in the current
Time taken from sitting to standing (s) 12.6 (4.4) 13.0 (5.0)† analyses we have treated variables such as physical activity
Age and lifestyle measures and smoking as putative confounders. Of course it may be the
Age at interview (years) 60.0 (11.0) 59.4 (11.1) case that these variables are part of a pathway to developing
BMI (kg/m2) 27.6 (3.8) 27.9 (4.8) pain; it is plausible that low levels of physical activity lead
Current smoker (N (%)) to vitamin D deficiency which, in turn, leads to widespread
No 1968 (81.6) 443 (18.4) body pain. Including such factors in our multivariate models
Yes 429 (66.9) 212 (33.1)* may mean we have ‘overadjusted’ the observed relationships.
Alcohol use, number of days in past week (N (%))
Again, the nature of these relationships will be more trans-
None 364 (73.7) 130 (26.3)
parent in prospective studies. Finally, the data refer to a pre-
1–2 1160 (78.6) 315 (21.4)
3–4 316 (82.9) 65 (17.1)
dominantly Caucasoid European population and extrapolation
5–6 171 (79.2) 45 (20.8) beyond this should be undertaken with caution.
7 390 (79.3) 102 (20.7)* The results of previous clinic and population studies provide
Depressed (N (%)) somewhat conflicting data concerning the relationship between
No 1895 (80.3) 464 (19.7) vitamin D levels and CWP. In a population-based study that
Yes 475 (71.9) 186 (28.1)* included men and women,10 25-(OH)D status was found to be
All values are mean (SD) unless otherwise indicated. associated with CWP in women only. However, the relation-
*χ2 test, p<0.05. ship among women was unclear; after adjustment for confound-
†t test, p<0.05.
BMI, body mass index; CWP, chronic widespread pain; 25-(OH)D, 25-hydroxyvitamin ing factors there was no linear relationship between vitamin D
D3; PASE, Physical Activity Scale for the Elderly. status and reporting CWP. Only women with 25-(OH)D

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Table 2 Relationship between pain status and low (<15 ng/ml) 25-hydroxyvitamin D3 (25-(OH)D) levels
Adjustments
Age and season + Physical activity + Lifestyle factors
Pain status
No pain Referent Referent Referent
Other pain 1.3 (1.1 to 1.6) 1.3 (1.05 to 1.6) 1.2 (1.01 to 1.5)
CWP 1.5 (1.1 to 2.1) 1.4 (1.01 to 2.0) 1.2 (0.9 to 1.8)
Physical activity measures
Self-reported activity duration in past week
None Referent Referent
<0.5 h 0.9 (0.6 to 1.2) 0.9 (0.7 to 1.3)
0.5–1 h 0.6 (0.5 to 0.9) 0.7 (0.5 to 0.95)
>1 h 0.7 (0.5 to 0.9) 0.7 (0.5 to 0.9)
PASE score 0.997 (0.996 to 0.998) 0.997 (0.996 to 0.999)
Time taken to walk 50 feet 1.08 (1.05 to 1.1) 1.06 (1.03 to 1.1)
Time taken from sitting to standing 0.99 (0.97 to 1.02) 0.99 (0.97 to 1.02)
Lifestyle measures
BMI (kg/m2) – 1.02 (0.995 to 1.04)
Current smoker
No – Referent
Yes – 2.1 (1.7 to 2.7)
Alcohol use (number of days in past week)
None – 2.0 (1.3 to 2.9)
1–2 – 1.4 (0.997 to 1.9)
3–4 – Referent
5–6 – 1.5 (0.9 to 2.4)
7 – 1.5 (0.99 to 2.1)
Depressed
No – Referent
Yes – 1.3 (1.1 to 1.7)
All values are OR (95% CI).
Subjects with ‘higher’ (≥15 ng/ml) 25-(OH)D levels were the comparison group.
BMI, body mass index; CWP, chronic widespread pain; PASE, Physical Activity Scale for the Elderly.

levels between 10.4 and 20.4 ng/ml (compared with those with
30–40 ng/ml) were significantly more likely to report CWP while
those with 25-(OH)D levels of <10.4 ng/ml were not. No rela-
tionship was evident for men, even before adjustments were
made for putative confounders. There were some differences in
mean 25-(OH)D levels between that study and ours: subjects
without CWP in the current study had higher levels (25.6 ng/ ml
vs 21.4 ng/ml), although mean levels in subjects with CWP
were similar in both studies (23.9 ng/ml vs 21.3 ng/ml). In stud-
ies of clinic patients with fibromyalgia, up to half6 7 or all8 par-
ticipants have been reported to have ‘low’ (<50 and <20 ng/ml,
respectively) serum 25-(OH)D. 25-OHD levels were also lower
in patients with fibromyalgia than in patients with other rheu-
matic disorders including osteoporosis.25 In a population study
of UK women of South Asian origin, low (<10 ng/ml) 25-(OH)D
was more common among those with widespread pain than in
those reporting no pain. Osteomalacia, one consequence of low
vitamin D, could explain the presence of widespread pain. We
do not have information that would allow us to assess directly
whether the prevalence of osteomalacia was higher in those
with CWP than in the pain-free group. However, we did exam-
ine levels of serum calcium and found no significant differences
(mean (SD) mg/dl: no pain 2.4 (0.1) and CWP 2.4 (0.1), p=0.07).
Similarly, we found no difference in levels of serum parathor-
mone (mean (SD) ng/ml: no pain 28.6 (13.8) and CWP 29.4 (15.4),
p=0.38), high levels of which are associated with secondary bone
pain. In a study of clinic patients with fibromyalgia, vitamin D
deficiency (25-(OH)D <10 ng/ml) was associated with anxiety
and depression.26 Compared with subjects with osteoarthritis,
those with diffuse pain were found to have almost identical
25-OHD levels (29.2 and 28.8 ng/ml, respectively).9 In that study
the proportion of subjects with ‘insufficient’ levels (≤20 ng/ml)
within groups did not differ (osteoarthritis 20%, diffuse pain
29%; p=0.09). The data confirm an association with vitamin D
that is partially explained by other factors, particularly smoking,
alcohol and depression.
What are the clinical implications of these findings? It has
been suggested that all patients with CWP should be screened
for low levels of vitamin D,8 but that is likely to be expensive.27
A small trial that identified patients with fibromyalgia with lev-
els of 25-(OH)D between 9 and 20 ng/ml randomised 25 patients
to treatment with placebo and 25 patients to treatment with
vitamin D2 (ergocalciferol) 50 000 IU once per week.9 Three
months later mean 25-(OH)D levels had significantly improved
in those receiving the active treatment (31.2 ng/ml) compared
with those in the placebo group (19.3 ng/ml), although there was
no improvement in pain or pain-related functional ability. These
data contribute to the hypothesis that vitamin D insufficiency is
unlikely to be causally related to CWP and is likely to be a marker
for other factors that are associated with pain such as smoking,
alcohol use and depression. Nevertheless, irrespective of the ori-
gin of the low levels of vitamin D, the long-term implications for
low bone density and poor general health among patients with
CWP are clear. Musculoskeletal pain is one of the most common
reasons for consultation to primary care. In 2007, the consul-
tation rate for musculoskeletal and connective tissue disorders
(International Classification of Diseases (ICD) codes 710–739)
was 1691 per 10 000, which equates to 8 800 288 consultations
in England and Wales (http://www.rcgp.org.uk/pdf/BRU%20
Annual%20prevalence%20report%202007.pdf).
The current findings would suggest that those who present
with additional factors of smoking, alcohol use or depression
should be screened for low vitamin D levels and supplemented
appropriately.

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Extended report
The EMAS Study Group Florence (Gianni Forti, Luisa Petrone, Antonio Cilotti);
Leuven (Dirk Vanderschueren, Steven Boonen, Herman Borghs); Lodz (Krzysztof
Kula, Jolanta Slowikowska-Hilczer, Renata Walczak-Jedrzejowska); London (Ilpo
Huhtaniemi); Malmö (Aleksander Giwercman); Manchester (Frederick Wu, Alan
Silman, Terence O’Neill, Joseph Finn, Philip Steer, Abdelouahid Tajar, David Lee,
Stephen Pye); Santiago (Felipe Casanueva, Marta Ocampo, Mary Lage); Szeged
(Gyorgy Bartfai, Imre Földesi, Imre Fejes); Tartu (Margus Punab, Paul Korrovitz); Turku
(Min Jiang).
Acknowledgements The authors thank the men who participated in the eight
countries, the research/nursing staff in the eight centres: C Pott, Manchester,
E Wouters, Leuven, M Nilsson, Malmö, M del Mar Fernandez, Santiago de
Compostela, M Jedrzejowska, Lodz, H-M Tabo, Tartu, A Heredi, Szeged for their data
collection and C Moseley, Manchester for data entry and project coordination.
Funding Commission of the European Communities Fifth Framework Programme
‘Quality of Life and Management of Living Resources’ Grant QLK6-CT-2001-00258.
Other funders: Arthritis Research Campaign, Chesterfield.
Competing interests None.
Ethics approval This study was conducted with ethical approval of the eight
European centres in accordance with local requirements and written informed
consent was obtained from all participants.
Provenance and peer review Not commissioned; externally peer reviewed.
Author affiliations 1ARC Epidemiology Unit, University of Manchester, Manchester, UK
2Aberdeen Pain Research Collaboration (Epidemiology Group), University of Aberdeen, UK
3Department of Obstetrics, Gynaecology and Andrology, Albert Szent-Gyorgy Medical
University, Szeged, Hungary
4Leuven University Division of Geriatric Medicine, Katholieke Universiteit Leuven,
Leuven, Belgium
5Leuven University Center for Metabolic Bone Diseases, Katholieke Universiteit
Leuven, Leuven, Belgium
6Department of Medicine, Santiago de Compostela University, Complejo Hospitalario
Universitario de Santiago (CHUS), CIBER de Fisiopatología Obesidad y Nutricion
(CB06/03), Instituto Salud Carlos III; Santiago de Compostela, Spain
7Andrology Unit, Department of Clinical Physiopathology, University of Florence,
Florence, Italy
8Scanian Andrology Centre, Department of Urology, Malmö University Hospital,
University of Lund, Sweden
9Department of Human Nutrition, University of Glasgow, Glasgow, Scotland
10Department of Reproductive Biology, Imperial College London, Hammersmith
Campus, London UK
11Department of Andrology and Reproductive Endocrinology, Medical University of
Lodz, Lodz, Poland
12Clinical Gerontology, University of Manchester, Hope Hospital, Salford, UK
13Andrology Unit, United Laboratories of Tartu University Clinics, Tartu, Estonia
14Department of Andrology and Endocrinology, Katholieke Universiteit Leuven, Leuven,
Belgium
15Department of Endocrinology, Manchester Royal Infirmary, The University of
Manchester, Manchester, UK
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Ann Rheum Dis 2010;69:1448–1452. doi:10.1136/ard.2009.116053
 Downloaded from http://ard.bmj.com/ on June 24, 2015 - Published by group.bmj.com

Musculoskeletal pain is associated with very

low levels of vitamin D in men: results from
the European Male Ageing Study
John McBeth, Stephen R Pye, Terence W O'Neill, Gary J Macfarlane,
Abdelouahid Tajar, Gyorgy Bartfai, Steven Boonen, Roger Bouillon,
Felipe Casanueva, Joseph D Finn, Gianni Forti, Aleksander Giwercman,
Thang S Han, Ilpo T Huhtaniemi, Krzysztof Kula, Michael E J Lean, Neil
Pendleton, Margus Punab, Alan J Silman, Dirk Vanderschueren,
Frederick C W Wu and EMAS Group

Ann Rheum Dis 2010 69: 1448-1452 originally published online May 24,
2010
doi: 10.1136/ard.2009.116053

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http://ard.bmj.com/content/69/8/1448

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