# Vitamin D concentration and focal brain atrophy in older adults: a voxel-based morphometric study

Pauline Ali, Matthieu Labriffe, Nastassia Navasiolava, Marc-antoine Custaud, Mickaël Dinomais, Cédric Annweiler, Sam Group

► To cite this version:

Pauline Ali, Matthieu Labriffe, Nastassia Navasiolava, Marc-antoine Custaud, Mickaël Dinomais, et al. Vitamin D concentration and focal brain atrophy in older adults: a voxel-based morphometric study. Annals of Clinical and Translational Neurology, 2020, 10.1002/acn3.50997. hal-02510288

HAL Id: hal-02510288

https://univ-angers.hal.science/hal-02510288

Submitted on 15 Feb 2023

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
BRIEF COMMUNICATION

# Vitamin D concentration and focal brain atrophy in older adults: a voxel-based morphometric study

Pauline Ali<fnref n="1" />,<fnref n="2" /> ID, Matthieu Labriffe<fnref n="1" />,<fnref n="3" />, Nastassia Navasiolava<fnref n="4" /> ID, Marc-Antoine Custaud<fnref n="4" />,<fnref n="5" /> ID,
Mickaël Dinomais<fnref n="1" />,<fnref n="2" /> ID & Cédric Annweiler<fnref n="6" />,<fnref n="7" />,<fnref n="8" />,<fnref n="9" />,<fnref n="10" /> ID on behalf of the SAM group

**Correspondence**

Pauline Ali, Les Capucins, Centre de Réadaptation Spécialisée et Soins Longue Durée, 11 Boulevard Jean Sauvage F-49100 Angers. Tel: +33 2 41 35 15 15; Fax: +33 2 41 35 18 05; E-mail: pauline.ali@hotmail.fr

**Funding Information**

The research was supported by the University Hospital of Angers, France (eudract number 2014-A01593-44). The funder had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.

Received: 4 December 2019; Revised: 20 January 2020; Accepted: 4 February 2020

Annals of Clinical and Translational Neurology 2020; 7(4): 554–558

doi: 10.1002/acn3.50997

**Abstract**

Vitamin D is involved in brain health and function. Our objective was to determine whether lower 25-hydroxyvitamin D (25OHD) concentration was associated with focal brain volume reduction in older adults. Serum 25OHD concentration was measured among 53 older adults (72 ± 5 years; 38% female; mean 25OHD = 67.3 ± 20.8 nmol/L). Gray matter volume (GMV) was automatically segmented using voxel-based morphometry with CAT12 software. Covariables were age, gender, education, total intracranial volume, and season. Serum 25OHD was positively associated with GMV in left calcarine sulcus (*P* < 0.05, TFCE, FWE-corrected). We found atrophy of the calcarine sulcus with lower 25OHD concentrations in older adults.

**Introduction**

Besides its classical function of bone metabolism regulation, vitamin D exhibits multiple biological targets mediated by its nuclear hormone receptor, the Vitamin D Receptor (VDR). VDRs are present in neurons and influence a number of physiological processes in the nervous system including the synthesis of neurotrophic agents, anti-inflammatory factors, and antioxidants.<sup>1,2</sup> Consistently, lower serum concentrations of 25-hydroxyvitamin D (25OHD) have been associated in older adults with brain

volumetric changes, including lower whole-brain volume and larger lateral ventricles,<sup>3</sup> with possible consequences on cognitive decline<sup>4</sup> and fall risk.<sup>5</sup> However, it remains unelucidated thus far which brain regions undergo atrophy in the case of hypovitaminosis D, and would explain the decrease in the overall volume of the brain in this population. Better understanding the neuroanatomical correlates of vitamin D status would yet offer a powerful mechanism to act on brain changes in older adults and maintain function later in life. We had the opportunity to examine the associations of serum 25OHD concentration with the

<footnote n="1">¹Laboratoire Angevin de Recherche en Ingénierie des Systèmes, EA7315, University of Angers – Université Angers, Angers, France</footnote>

<footnote n="2">²Department of Physical and Rehabilitation Medicine, Angers University Hospital, Angers, France</footnote>

<footnote n="3">³Department of Radiology, Angers University Hospital, Angers, France</footnote>

<footnote n="4">⁴Clinical Research Center, Angers University Hospital, Angers, France</footnote>

<footnote n="5">⁵MITOVASC Institute, UMR CNRS 6015, UMR INSERM 1083, University of Angers, Angers, France</footnote>

<footnote n="6">⁶Department of Geriatric Medicine, Angers University Hospital, Angers, France</footnote>

<footnote n="7">⁷Memory Clinic, Angers University Hospital, Angers, France</footnote>

<footnote n="8">⁸Research Center on Autonomy and Longevity, Angers University Hospital, Angers, France</footnote>

<footnote n="9">⁹UPRES EA 4638, University of Angers, Angers, France</footnote>

<footnote n="10">¹⁰Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada</footnote>
volume of gray matter (GM) in a cohort of community-
dwelling older adults, the IRMarche study.⁶ The objective
of this cross-sectional analysis was to determine whether
lower 25OHD concentrations were associated with focal
brain volume reductions.

**Methods**

Participants

We studied participants from the IRMarche study
enrolled between 2015 and 2017. Main inclusion criteria
were: age over 60 years, absence of clinical dementia
according to the consensual DSM IV criteria, and no neu-
rological, depression, or orthopaedic disorders. We
excluded participants with contraindication to MRI. All
participants included in the present analysis received a
full medical examination, a neuropsychological assess-
ment, a blood test with 25OHD assay, and a 3.0-Tesla
magnetic resonance imaging (MRI) scan of the brain.

Serum 25OHD concentration

Blood samples were collected from resting participants at the
same time as the brain imaging acquisition. Serum 25OHD
concentration, which reflects the vitamin D status, was mea-
sured using radioimmunoassay (DiaSorin Inc., Stillwater,
MN) in nmol/L at the University Hospital of Angers, France.
Vitamin D deficiency was defined for 25OHD concentrations
≤50 nmol/L according to the definition of the Institute of
Medicine (to convert to ng/mL, divide by 2.496).⁷

MRI procedure

MRI data acquisition

MRI data were acquired on the same 3.0-Tesla MRI scan-
ner (MAGNETOM Trio Tim system, Siemens, Erlangen,
Germany) at the University Hospital of Angers, France,
using a standard protocol. Acquisition parameters for
sequences including a high-resolution 3D T1-weighted
volume using a magnetization-prepared rapid acquisition
gradient-echo sequence, covering the whole brain (cere-
bellum included) were: 176 slices, repetition time
(TR) = 2300 msec, echo time (TE) = 4.18 msec, slice
thickness = 1 mm, field of view (FOV) = 256 × 256, flip
angle = 9, voxel size: 1 × 1 × 1 mm³.

Voxel-based morphometry

Voxel-based morphometry across the entire brain were
conducted with the Computational Anatomy Toolbox 12
(CAT12) (http://www.neuro.unijena.de/cat) implemented

in the Statistical Parametric Mapping 12 (SPM12) soft-
ware (https://www.fil.ion.ucl.ac.uk/spm/software/spm12/)
using a 2017a Matlab platform (The MathWorks, Natick,
MA, USA), following the standard procedure. First 3D T1
volumes were segmented in native-space to obtain three
tissues classes: GM, white matter, (WM) and cere-
brospinal fluid (CSF).<sup>8</sup> Then, nonlinear modulation GM
and WM volumes were aligned using the default DARTEL
(diffeomorphic anatomical registration using exponential
Lie algebra) template and were spatially normalized into
the Montreal Neurological Institute space (ICBM).<sup>9</sup>
Finally, images were smoothed by an isotropic Gaussian
kernel of 8mm full-width at half-maximum (FWHM). All
data were inspected and visually checked after the auto-
mated procedure by two authors (PA and MD).

Covariates

Age, gender, high education level, season, and total
intracranial volume (TIV) were included as potential con-
founders for the analysis. Education level was reported
with a structured questionnaire. Participants who passed
at least the Elementary School Recognition Certificate
were considered to have higher education level compared
with those who did not. The TIV was approximated for
each participant by calculating the sum of GM, WM, and
CSF maps obtained from the preprocessing steps.

Statistics

Statistical analyses were performed using Tanagra 2.0 soft-
ware (http://eric.univ-lyon2.fr/~ricco/tanagra/fr/tanagra.
html), Excel (Microsoft office Professional Plus 2013) and
CAT12. For neuroimaging, smoothed, modulated and
normalized data were used. With CAT12, morphometric
data from participants were associated with a linear
regression model with 25OHD concentration. We used
threshold-free cluster enhancement (TFCE) for a com-
bined nonparametric analysis about height and size of the
effects (http://www.neuro.uni-jena.de/tfce), and applied
FWE (family wise error) corrected threshold of *P* < 0.05
to control for multiple comparisons. Anatomy toolbox
2.1 was used for anatomical localizations.<sup>10</sup>

Ethics

The study was conducted in accordance with the ethical
standards set forth in the Helsinki Declaration (1983).
The entire study protocol was approved by the Angers
Ethical Review Committee (Comité de protection des per-
sonnes, CPP ouest II, Angers, France, n° A.C D 2014-
A01593-44, n° CPP: 2014/32). Written informed consent
was obtained at enrollment.
## Results

Fifty-three participants (mean ± SD, 72 ± 5 years; 38% female) met the selection criteria and were included in the present analysis. The mean serum 25OHD concentration was 67.3 ± 20.8 nmol/L [95% confidence interval (CI): 62–73] (range, 28–113 nmol/L) among studied participants, and the mean TIV was 1533 ± 154 cm³ [95% CI: 1492–1574] (range, 1212–1822 cm³). Twenty-nine participants (54%) had a high level of education. Twenty subjects (38%) were assessed (blood and MRI) in the autumn, 16 (30%) in the winter, 12 (23%) in the spring, and 5 (9%) in the summer.

Figure 1 illustrates the brain area that were positively associated with the serum 25OHD concentration after adjusting for potential confounders. The VBM analysis identified one cluster of 110 voxels located in the left calcarine sulcus (MNI coordinates (xyz) [−11 −44 8], TFCE = 1366, *P* < 0.05 FWE-corrected). No other regions were positively or negatively associated with serum 25OHD concentration.

## Discussion

Our results show that, among community-dwelling older adults, lower serum 25OHD concentration was associated with lower GMV in the left calcarine sulcus specifically. This finding provides insights into elucidating the role of vitamin D in older adults' brain, notably in the treatment of visual stimuli.

A growing body of preclinical evidence supports a role for vitamin D in brain health and morphology. In particular, vitamin D appears to have a trophic function in the differentiation and maturation of neurons by controlling the rate of mitosis and the levels of neurotrophins such as the Nerve Growth Factor (NGF) or the neurotrophin 3.¹ Vitamin D also promotes neuronal calcium homeostasis by downregulating the expression and density of calcium channels, and via the synthesis of calcium-related cytoplasmic proteins such as parvalbumine or calbinding protein.¹ As an illustration, in one study, vitamin D treatment protected neurons against amyloid-β peptide toxicity by downregulating calcium channels and inducing

<figure><img src="image_2.png" /><figcaption>**Figure 1.** Gray matter region showing a positive association with serum 25-hydroxyvitamin D concentration (red color). GMV: gray matter volume. The statistical map was co-registered and superimposed on 3D-T1 (A) sagittal slice (MNI coordinates: X = 82), (B) coronal slice (MNI coordinates: Y = 81), and (C) axial slice (MNI coordinates: Z = 80) (MNI T1 template available on MRICRON software; TFCE from 10 to 1397). Results are showed with a significance of *P* < 0.05 corrected for multiple comparisons (TFCE, FWE-corrected).</figcaption></figure>
NGF release.¹¹ Vitamin D also has antioxidant effects in cultures of rat mesencephalic cells.¹² Finally, vitamin D exhibits anti-inflammatory effects in the brain,¹³ consistent with reduced inflammatory brain injury following vitamin D repletion.¹⁴

The identification of focal brain atrophy related to vita-
min D has received little attention to date. Previous stud-
ies mostly focused on the changes of whole-brain
volume,¹⁵ ventricular volume,¹⁶ and hippocampal vol-
ume¹⁷,¹⁸ according to the vitamin D status.

The present analysis provides additional information
on the morphological brain changes related to vitamin D,
by providing that some specific subvolumes of GM are
affected with lower (i.e., worse) 25OHD concentration.
Another recent study evokes that vitamin D deficiency is
associated with thinner cingulate cortex.¹⁹

We found that lower 25OHD concentrations were asso-
ciated with GM atrophy in the left calcarine sulcus. Since
the calcarine sulcus is part of the primary visual cortex,
which is essential for the conscious treatment of visual
stimuli, our result is in agreement with previous epidemi-
ological findings that hypovitaminosis D is associated
with reduced visual performance among older adults.²⁰
This association was tentatively explained by the onset of
age-related macular degeneration (AMD),²¹ glaucoma,²²
or optic neuropathy²³ in the case of hypovitaminosis D.
However, no causal relationship has been established thus
far, and the result of the present study suggests a novel
mechanism possibly explaining how vitamin D influences
vision, by an effect on the primary visual cortex trophicity
rather than on the eye.

Some potential limitations of our study should be con-
sidered. Firstly, the study cohort was restricted to com-
munity-dwelling older adults recruited in one single
research center who might be unrepresentative of all older
adults. Secondly, although we were able to control for
important characteristics that could modify the associa-
tion, residual potential confounders such as the eye con-
dition or reduced sunlight exposure might still be
present. Thirdly, the cross-sectional design did not allow
any causal inferences making it difficult to determine
whether the focal brain atrophy precipitated hypovita-
minosis D or whether hypovitaminosis D played a role in
the onset of focal brain atrophy. Fourthly, VBM has been
criticized because of segmentation and normalization
defects. Segmentation of brain into GM and WM is a
major difficulty due to partial volume effects at the
boundary between GM and WM, and because of misla-
beling. We minimized these limitations by using SPM12
software that performs better than previous versions.

In conclusion, we found that lower serum 25OHD con-
centration was associated in older adults with GM atrophy
in the calcarine sulcus, part of the primary visual cortex.

This finding highlights for the first time that specific brain
areas are altered with hypovitaminosis D, and helps under-
standing the effects of vitamin D on brain health and func-
tion in older adults, notably the brain treatment of visual
stimuli. Further prospective observational cohorts and ran-
domized clinical trials, preferentially on a variety of adult
populations, are needed to clarify whether those with
hypovitaminosis D are more likely to experience loss of
GM in the visual cortex, and whether vitamin D supple-
mentation could prevent or limit this change.

Acknowledgments

The authors warmly thank the nurses of the Clinical
Research Center, the technicians of the Department of
Radiology at the University hospital of Angers for their
sustained help with the acquisition of the MRI data, and
the participants for their kind contribution in this chal-
lenging research. We thank Elena Tomilovskaya from the
Institute of Biomedical Problems, Russian Academy of
Sciences, Moscow, Russia for her help.

Author Contributions

Each author has made substantial contributions to the
conception or design of the work; or the acquisition,
analysis, or interpretation of data; or the creation of new
software used in the work; or have drafted the work or
substantively revised it; AND has approved the submitted
version; AND agrees to be personally accountable for the
author's own contributions and for ensuring that ques-
tions related to the accuracy or integrity of any part of
the work, even ones in which the author was not person-
ally involved, are appropriately investigated, resolved, and
documented in the literature. Mickaël Dinomais has full
access to all of the data in the study, takes responsibility
for the data, the analyses and interpretation, and the con-
duct of the research, and has the right to publish any and
all data, separate and apart from the attitudes of the
sponsor. Study concept and design: Mickaël Dinomais,
Cédric Annweiler, Marc-Antoine Custaud. Acquisition of
data: Matthieu Labriffe, Mickaël Dinomais, Nastassia
Navasiolava. Analysis and interpretation of data: Pauline
Ali, Mickaël Dinomais, Cédric Annweiler. Drafting of the
manuscript: Pauline Ali, Mickael Dinomais, Cédric
Annweiler. Critical revision of the manuscript for impor-
tant intellectual content: Matthieu Labriffe, Mickael Dino-
mais, Nastassia Navasiolava, Pauline Ali, Marc-Antoine
Custaud. Obtained funding: Mickaël Dinomais. Statistical
expertise: Pauline Ali, Mickaël Dinomais. Administrative,
technical, or material support: Nastassia Navasiolava,
Mickaël Dinomais, Marc-Antoine Custaud. Study supervi-
sion: Mickaël Dinomais.
## Conflict of Interest

C. Annweiler serves as an editor for Maturitas. All authors declare they do not have any other financial and personal conflicts of interest with this manuscript.

## References

1. Annweiler C, Schott A-M, Berrut G, et al. Vitamin D and ageing: neurological issues. Neuropsychobiology 2010;62:139–150.

2. Harms LR, Burne THJ, Eyles DW, McGrath JJ. Vitamin D and the brain. Best Pract Res Clin Endocrinol Metab 2011;25:657–669.

3. Annweiler C, Annweiler T, Montero-Odasso M, et al. Vitamin D and brain volumetric changes: systematic review and meta-analysis. Maturitas 2014;78:30–39.

4. Annweiler C, Dursun E, Féron F, et al. ‘Vitamin D and cognition in older adults’: updated international recommendations. J Intern Med 2015;277:45–57.

5. Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ 2009;339:b3692–b3692.

6. Labriffe M, Annweiler C, Amirova LE, et al. Brain activity during mental imagery of gait versus gait-like plantar stimulation: a novel combined functional MRI paradigm to better understand cerebral gait control. Front Hum Neurosci 2017;11:106.

7. Ross AC, Manson JE, Abrams SA, et al. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab 2011;96:53–58.

8. Ashburner J, Friston KJ. Voxel-based morphometry—the methods. NeuroImage 2000;11:805–821.

9. Ashburner J. A fast diffeomorphic image registration algorithm. NeuroImage 2007;38:95–113.

10. Eickhoff SB, Stephan KE, Mohlberg H, et al. A new SPM toolbox for combining probabilistic cytoarchitectonic maps and functional imaging data. NeuroImage 2005;25:1325–1335.

11. Dursun E, Gezen-Ak D, Yilmazer S. A novel perspective for Alzheimer’s disease: vitamin D receptor suppression by amyloid-β and preventing the amyloid-β induced alterations by vitamin D in cortical neurons. J Alzheimers Dis. 2011;23:207–219.

12. Ibi M, Sawada H, Nakanishi M, et al. Protective effects of 1 alpha,25-(OH)(2)D(3) against the neurotoxicity of glutamate and reactive oxygen species in mesencephalic culture. Neuropharmacology 2001;40:761–771.

13. Moore ME, Piazza A, McCartney Y, Lynch MA. Evidence that vitamin D3 reverses age-related inflammatory changes in the rat hippocampus. Biochem Soc Trans 2005;33(Pt 4):573–577.

14. Mowry EM, Waubant E, McCulloch CE, et al. Vitamin D status predicts new brain magnetic resonance imaging activity in multiple sclerosis. Ann Neurol 2012;72:234–240.

15. Buell JS, Dawson-Hughes B, Scott TM, et al. 25-Hydroxyvitamin D, dementia, and cerebrovascular pathology in elders receiving home services. Neurology 2010;74:18–26.

16. Annweiler C, Montero-Odasso M, Hachinski V, et al. Vitamin D concentration and lateral cerebral ventricle volume in older adults. Mol Nutr Food Res 2013;57:267–276.

17. Karakis I, Pase MP, Beiser A, et al. Association of serum vitamin D with the risk of incident dementia and subclinical indices of brain aging: the Framingham Heart Study. J Alzheimers Dis 2016;51:451–461.

18. Al-Amin M, Bradford D, Sullivan RKP, et al. Vitamin D deficiency is associated with reduced hippocampal volume and disrupted structural connectivity in patients with mild cognitive impairment. Hum Brain Mapp 2019;1:394–406.

19. Foucault G, Duval GT, Simon R, et al. Serum vitamin D and cingulate cortex thickness in older adults: quantitative MRI of the brain. Curr Alzheimer Res 2019;16:1063–1071.

20. Beauchet O, Milea D, Graffe A, et al. Association between serum 25-hydroxyvitamin D concentrations and vision: a cross-sectional population-based study of older adults. J Am Geriatr Soc 2011;59:568–570.

21. Annweiler C, Drouet M, Duval GT, et al. Circulating vitamin D concentration and age-related macular degeneration: Systematic review and meta-analysis. Maturitas 2016;88:101–112.

22. Goncalves A, Milea D, Gohier P, et al. Serum vitamin D status is associated with the presence but not the severity of primary open angle glaucoma. Maturitas 2015;81:470–474.

23. Annweiler C, Beauchet O, Bartha R, et al. Association between serum 25-hydroxyvitamin D concentration and optic chiasm volume. J Am Geriatr Soc 2013;61:1026–1028.