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Vitamin D deficiency is associated with osteoporosis and is thought to increase the risk of cancer and CVD. Despite these numerous potential health effects, data on vitamin D status at the population level and within key subgroups are limited. The aims of the present study were to examine patterns of 25-hydroxyvitamin D (25(OH)D) levels worldwide and to assess differences by age, sex and region. In a systematic literature review using the Medline and EMBASE databases, we identified 195 studies conducted in forty-four countries involving more than 168 000 participants. Mean population-level 25(OH)D values varied considerably across the studies (range 4·9-136·2 nmol/l), with 37·3 % of the studies reporting mean values below 50 nmol/l. The highest 25(OH)D values were observed in North America. Although age-related differences were observed in the Asia/Pacific and Middle East/Africa regions, they were not observed elsewhere and sex-related differences were not observed in any region. Substantial heterogeneity between the studies precluded drawing conclusions on overall vitamin D status at the population level. Exploratory analyses, however, suggested that newborns and institutionalised elderly from several regions worldwide appeared to be at a generally higher risk of exhibiting lower 25(OH)D values. Substantial details on worldwide patterns of vitamin D status at the population level and within key subgroups are needed to inform public health policy development to reduce risk for potential health consequences of an inadequate vitamin D status. Key words: Vitamin D: Populations: Public healthVitamin D plays an important role in bone mineralisation and other metabolic processes in the human body such as Ca and phosphate homeostasis and skeletal growth (1,2) . Vitamin D deficiency, for example, causes rickets in children, leading to skeletal abnormalities, short stature, delayed development or failure to thrive (3) . In adults, low values of vitamin D are associated with osteomalacia, osteopenia, osteoporosis and subsequent risk of fractures (1) . In addition to beneficial effects on musculoskeletal health, observational studies have suggested that low 25-hydroxyvitamin D (25(OH)D) values are associated with an increased risk for several extraskeletal diseases including cancer, infections, autoimmune diseases and CVD (4) . In light of the global ageing population (5) ,an almost fourfold increase in osteoporotic hip fractures since 1990 (6) and the possible risk of other chronic diseases, patterns of low 25(OH)D levels are of substantial public health interest. Vitamin D status is traditionally measured through assays of 25(OH)D, the major circulating form of vitamin D (7) . Although 25(OH)D levels below 25 nmol/l have been associated with disorders of bone metabolism (8) and are used to indicate severe vitamin D deficiency, the threshold for defining adequate stores of vitamin D in humans has not been established clearly (9) . The Institute of Medicine has suggested, for example, that approximately 97·5 % of t...

This study provides an overview of 25(OH)D levels around the globe. It reveals large gaps in information in children and adolescents and smaller but important gaps in adults. In view of the importance of vitamin D to musculoskeletal growth, development, and preservation, and of its potential importance in other tissues, we strongly encourage new research to clearly define 25(OH)D status around the world.

The underlying causes of incident fractures--bone fragility and the tendency to fall--remain under-diagnosed and under-treated. This care gap in secondary prevention must be addressed to minimise both the debilitating consequences of subsequent fractures for patients and the associated economic burden to healthcare systems. Clinical systems aimed at ensuring appropriate management of patients following fracture have been developed around the world. A systematic review of the literature showed that 65% of systems reported include a dedicated coordinator who acts as the link between the orthopaedic team, the osteoporosis and falls services, the patient and the primary care physician. Coordinator-based systems facilitate bone mineral density testing, osteoporosis education and care in patients following a fragility fracture and have been shown to be cost-saving. Other success factors included a fracture registry and a database to monitor the care provided to the fracture patient. Implementation of such a system requires an audit of existing arrangements, creation of a network of healthcare professionals with clearly defined roles and the identification of a 'medical champion' to lead the project. A business case is needed to acquire the necessary funding. Incremental, achievable targets should be identified. Clinical pathways should be supported by evidence-based recommendations from national or regional guidelines. Endorsement of the proposed model within national healthcare policies and advocacy programmes can achieve alignment of the objectives of policy makers, professionals and patients. Successful transformation of care relies upon consensus amongst all participants in the multi-disciplinary team that cares for fragility fracture patients.

A multinational survey was conducted to evaluate the gaps between patients and physicians understanding of osteoporosis. The International Osteoporosis Foundation recommends the creation of community-wide patient support programmes to increase prevention and treatment awareness of osteoporosis. Introduction Osteoporosis is often undiagnosed and untreated, leaving millions of people at risk of debilitating fractures. A survey was designed to investigate any gaps that may exist between physician and patient knowledge of osteoporosis, understand barriers to patient adherence and identify ways to address unmet needs and improve communications. Methods Telephone interviews were conducted with patients (n=844) and physicians (n=837) in 13 countries in June/July 2009. Patients were women with postmenopausal osteoporosis currently taking (or in the past 2 years) prescribed medication. Physicians had experience in treating osteoporotic patients, which included only general practitioners who saw ≥10 (exception: in Hungary ≥5) and specialists who saw ≥20 patients with osteoporosis per month. Results Physicians consistently underestimated their patients' adherence to treatment and beliefs on the impact of osteoporosis on their quality-of-life. Physicians underestimated how many patients worry about breaking a bone (51% vs 79%), as well as patient concerns about declines in activity levels (40% vs 70%), becoming dependent on others (30% vs 60%) and not being able to work for longer (30% vs 57%). Patients believed the most credible osteoporosis information was from specialists (94%). Patients (75%) would like easy to understand materials and 49% would welcome inter-patient discussions of their

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