Archives of Osteoporosis (2025) 20:78

https://doi.org/10.1007/s11657-025-01563-y

POSITION PAPER

Joint position on vitamin D prescription in the adult Mexican

population by AMMOM, AMEC, AMG, CMIM, CMO, CMR, CONAMEGER,
FEMECOG, and FEMECOT
Jose Francisco Torres-Naranjo1 · Hugo Gutierrez-Hermosillo2 · Pedro Alberto Garcia-Hernandez3 ·
Roberto E. López Cervantes4 · Hilario E. Avila Armengol5 · Rafael Bedoya Torres6 · Alhelí Lucía Bremer Aztudillo7 ·
Juan Humberto Medina Chávez8 · Rocio Morales Delgado9 · Eva M. Perusquía Frías10 · Alan Rios Espinosa11 ·
Alejandro Vázquez Alanís12

Received: 11 December 2024 / Accepted: 27 May 2025

© The Author(s) 2025

www.t.me/MemodiAppArticulos
Abstract
Background Vitamin D deficiency remains a critical health concern linked to skeletal disorders such as osteoporosis, osteo-
malacia, and fractures. Recent evidence highlights the broader role of vitamin D in preventing chronic conditions, including
autoimmune diseases, diabetes, and cardiovascular events. However, inconsistencies in clinical practice across Mexico and
limited population-specific data necessitate standardized guidelines to address diagnostic and therapeutic challenges.
Objective To establish evidence-based recommendations for diagnosing and prescribing vitamin D supplements tailored to
the Mexican adult population, reducing practice variability while promoting optimal health outcomes.
Methods A multidisciplinary panel comprising specialists from nine leading Mexican medical organizations conducted
a consensus process using the Delphi methodology. The recommendations were developed using a combined approach,
integrating extensive literature reviews with expert consensus to address areas where empirical evidence is limited. The
process informed guidelines for vitamin D supplementation, measurement criteria, and therapeutic monitoring.
Results Key recommendations include: Measuring 25(OH)D levels in adults with risk factors or conditions associated
with hypovitaminosis D, avoiding routine screening in healthy individuals. Defining vitamin D deficiency as < 20 ng/mL,
insufficiency as 20–29 ng/mL, and sufficiency as 30–100 ng/mL. Preferring cholecalciferol for supplementation, with calcife-
diol reserved for specific cases requiring rapid correction or compromised hepatic hydroxylation. Regularly monitor serum
25(OH)D concentrations to achieve and maintain levels between 30 and 60 ng/mL, ensuring safety and therapeutic efficacy.
Conclusion This joint position provides a comprehensive framework for managing hypovitaminosis D in Mexican adults.
The recommendations aim to harmonize clinical practices, improve patient outcomes, and inform public health strategies for
equitable resource allocation. Ongoing evaluation and stakeholder feedback will ensure adaptability and relevance as new
evidence emerges.

Keywords Vitamin D · Supplementation · Hypovitaminosis · 25(OH)D

Introduction Our understanding of vitamin D has significantly evolved

in recent decades, broadening our perspective beyond its tra-
Vitamin D is a fat-soluble nutrient and a prohormone that ditional role. Recent research has sparked growing interest
plays a significant role in multiple physiological processes in its interaction with other body systems. Explorations into
within a complex hormonal system. This system is crucial for the effects of vitamin D supplementation have encompassed
numerous well-characterized physiological functions. Due to various areas of health, including its impact on the muscu-
its fundamental involvement in calcium homeostasis, hypovi- loskeletal and immune systems and its influence on chronic
taminosis D is associated with skeletal disorders such as diseases such as osteoporosis, sarcopenia, type 2 diabetes,
rickets, osteomalacia, and osteoporosis. myocardial infarction, and various types of cancer.
The widespread use of vitamin D supplementation, in the
Extended author information available on the last page of the article form of dietary sources and appropriate prescriptions, has

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substantially reduced the incidence of rickets, making it a rare driving the expert consensus process. The Delphi methodol-
disease among children in Mexico. However, many adults ogy, with four rounds of evaluation, was employed to reach
suffer from vitamin D deficiency. Consequently, they often a consensus opinion. In this process, a consensus criterion
receive pharmacological vitamin D compounds. Despite was established, requiring a minimum of 70% agreement
extensive research promoting diverse approaches to vitamin to validate the conclusions. This methodological approach
D supplementation that consider individual patient needs and ensures the rigor and representativeness of the consensus
the complexities of healthcare delivery, challenges persist opinions, grounding the recommendations in the critical
in Mexico. These challenges include unwarranted variation, review of scientific literature and the collective expertise of
disparities in care, and inefficiencies. Therefore, it is crucial experts. Essential lineaments that guided the recommenda-
to establish greater consensus on optimal dosages and supple- tions prioritize transparency, flexibility, inclusivity, clarity,
mentation protocols to optimize therapeutic outcomes while and feasibility to ensure that all stakeholders can understand
minimizing potential risks across various clinical scenarios. and implement them effectively.

Objective
Position statements and considerations
This joint statement aims to provide updated guidance
Below, we describe the consensus statements accompanied
diagnosing hypovitaminosis D and prescribing therapeutic
by relevant considerations. The direction of this work was
vitamin D supplements in the Mexican adult population while
based on evidence available up to 2023, and the expert panel
mitigating heterogeneity in clinical practice nationwide.
was urged to conduct exhaustive literature reviews on the
www.t.me/MemodiAppArticulos topics covered in this consensus document.
Methodology
Who should receive therapeutic vitamin D
The Mexican Association of Bone and Mineral Metabolism supplementation
(AMMOM), along with other national organizations, namely,
the Mexican Association for the Study of Climacteric Pharmacological vitamin D supplementation is recommen-
(AMEC), Mexican Academy of Geriatrics (AMG), the Col- ded for adults with documented hypovitaminosis D, defined
lege of Internal Medicine of Mexico (CMIM), the Mexican as serum 25-hydroxyvitamin D [25(OH)D] levels below 30
College of Orthopedics and Traumatology (CMO), the Mex- ng/mL (< 75 nmol/L).
ican College of Rheumatology (CMR), the National College Pharmacological vitamin D supplementation should be
of Geriatric Medicine (CONAMEGER), the Mexican Feder- established only in patients with suboptimal levels of
ation of Obstetrics and Gynecology Colleges (FEMECOG), 25(OH)D. While widespread prescription or consumption
and the Mexican Federation of Orthopedics and Traumatol- of pharmacological vitamin D supplements without specific
ogy Colleges (FEMECOT), jointly convened an expert panel. medical indication should not be promoted [15].
This panel consists of specialists from various disciplines in Pharmacological vitamin D supplementation in adults
the clinical aspects of vitamin D, including endocrinologists, with low baseline 25(OH)D levels has shown positive
gynecologists, geriatricians, internists, orthopedic surgeons, effects on individual health. Benefits have been observed
and rheumatologists. The primary focus was establishing a in relation to rickets [23], osteomalacia, osteoporosis, and
position statement in response to the widespread use and mineral metabolism. Regarding non-musculoskeletal health
potential overuse of vitamin D, by general practitioners and outcomes, there is evidence suggesting that pharmacological
specialists. vitamin D supplementation could have benefits in preventing
Panel members were selected based on their knowledge acute respiratory infections [54], cancer mortality [47], dia-
and experience in the field of vitamin D and their ability to betes mellitus prevention [40], and recently, reducing some
assess and analyze existing published information for clin- autoimmune diseases [19], as well as other conditions; how-
ical decision-making. Before inclusion in the expert panel, ever, this panel considers there is no conclusive evidence.
all members disclosed potential conflicts of interest. Expert It is important to note that while assessing 25(OH)D levels
panel members did not receive financial compensation during before initiating supplementation, in cases of fragility frac-
the analysis or preparation of the document. tures, especially hip fractures, where vitamin D deficiency
The panel was urged to conduct exhaustive literature may hinder recovery, supplementation may be necessary
reviews to address these aspects comprehensively and thor- even before obtaining laboratory results [49]. This is espe-
oughly explore the topics covered in this consensus document. cially relevant in institutions where 25(OH)D measurement
Identifying gaps in existing evidence was an essential step in is not available. In such cases, the benefit of supplementation

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Archives of Osteoporosis (2025) 20:78 Page 3 of 11 78

may outweigh the risk of not having accurate laboratory data deficiency and have been associated with increased risk of
immediately. fractures, cardiovascular disease, colorectal cancer, diabetes,
Consider that the main risk of excessive vitamin D sup- depressed mood, cognitive impairment, and mortality [22].
plementation is hypervitaminosis, extremely sporadic and Association with falls has been observed in studies of insti-
generally associated with excessive supplement consumption tutionalized elderly populations [36]. There is debate about
over long periods, or the lack of distinction between calcitriol, whether levels of 20–30 ng/mL (50–75 nmol/L) represent a
calcifediol, and cholecalciferol, which can lead to hypercal- deficiency, as levels > 24 ng/mL (> 60 nmol/L) have been
cemia with symptoms such as nausea, vomiting, abdominal associated with lower cardiovascular disease risk. Levels >
pain, hypercalciuria, and complications such as bone loss and 30 ng/mL (> 75 nmol/L) are associated with lower mortal-
renal insufficiency. ity and colorectal cancer risk [44]. Conflicting data exist on
whether levels > 30 ng/mL (> 75 nmol/L) are associated
When 25(OH)D levels measurement is recommended with lower fracture risk.
Given the diverse viewpoints on optimal concentrations of
Baseline 25(OH)D levels should be measured in adults before 25(OH)D in adults, this panel recommends defining vitamin
initiating pharmacological vitamin D supplementation. D deficiency as a 25(OH)D level below 20 ng/mL (< 50
Accurate determination of 25(OH)D blood levels is nmol/L), insufficiency as a 25(OH)D level of 20 to 29 ng/mL
essential before starting pharmacological vitamin D supple- (50–< 75 nmol/L), and sufficiency as a 25(OH)D level of
mentation in adults [10]. Measurement of 25(OH)D levels 30 to 100 ng/mL (75–250 nmol/L). Although the suggested
before pharmacological supplementation allows determining thresholds may be slightly higher at 30 ng/mL (75 nmol/L)
whether an individual has hypovitaminosis D and estab- for non-skeletal benefits, this aspect still requires study, so
lishing the appropriate therapeutic dosage. In this context, no specific recommendation is issued.
determining 25(OH)D in the blood is the most appropriate There is total consensus among the experts in this panel
way to diagnose hypovitaminosis D in adults, as it reflects that levels below 20 ng/mL (< 50 nmol/L) are associated with
both intake, endogenous production, and body reserves. bone health conditions, so any patient with values below this
Performing measurements before and during supplemen- figure should receive pharmacological supplementation.
tation provides more precise control and allows for rigorous Considering the absence of a safe upper limit in current
treatment monitoring and adjustments as necessary. In cases evidence, this panel recommends not exceeding 100 ng/mL
where the assessment of serum 25(OH)D concentration is serum levels and preferably maintaining levels between 30
not possible in high-risk groups, vitamin D supplementa- and 60 ng/mL, a range where most evidence converges.
tion should be carried out according to the recommendations
established for the general population, respecting the maxi-
Whom to measure 25(OH)D levels
mum doses for the corresponding age group [35].
Pharmacological vitamin D supplementation should not
Measurement of baseline 25(OH)D levels is recommended
be indicated in healthy adults with 25(OH)D values within
in adults with risk factors or clinical conditions associated
the optimal parameters.
with hypovitaminosis D.
25(OH)D level measurement in the adult population is
Optimal concentrations and intervention thresholds
not recommended as a general screening method. Instead,
it is suggested that 25(OH)D measurement be performed in
It is recommended that in adults, vitamin D deficiency be
adults with risk factors or clinical conditions associated with
defined as a 25(OH)D level of less than 20 ng/mL (< 50
hypovitaminosis D. This recommendation extends to patients
nmol/L), insufficiency as a 25(OH)D level of 20 to 29 ng/mL
receiving vitamin D formulations as part of routine treatment
(50–< 75 nmol/L), and sufficiency as a 25(OH)D level of 30
(e.g., osteoporosis), for whom determining 25(OH)D levels
to 100 ng/mL (75–250 nmol/L) Table 1 [12, 33].
is advised to appropriately adjust supplementation.
Levels < 20 ng/mL (≤ 50 nmol/L) are widely used
This panel suggests determining serum 25(OH)D levels
by researchers and available guidelines as indicative of
in the following conditions associated with hypovitaminosis
D [4–6, 13, 19, 20, 29, 34, 38, 39, 46, 48, 52, 53], (Table 2):
Table 1 Vitamin D status based on 25(OH)D levels in adults
Vitamin D status Serum 25(OH)D concentration
How to perform medical vitamin D supplementation
Sufficiency 30 a 100 ng/mL (75–250 nmol/L) in adults with hypovitaminosis D
Insufficiency 20 a 29 ng/mL (50–< 75 nmol/L)
Deficiency < 20 ng/mL (< 50 nmol/L) Vitamin D formulation and dosing should be established
based on serum 25(OH)D concentration, clinical conditions,

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Table 2 Indications for

measuring 25(OH)D in adults Musculoskeletal Disorders • Osteoporosis.
• Osteopenia.
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• Low-energy trauma bone fractures.
• Recurrent falls.
• Sarcopenia.
• Frailty Syndrome

Endocrine and Metabolic • Diabetes mellitus (type 1 and 2).

Diseases/Conditions • Metabolic syndrome.
• Obesity.
• Hyper- and hypoparathyroidism.
• Hyper- and hypothyroidism.
• Hypercalcemia and hypocalcemia.
• Hypercalciuria.
• Hyperphosphatemia.
• Hyper- and hypophosphatasia.
• Phosphaturia

Malabsorption Syndromes • Exocrine pancreatic insufficiency.

• Inflammatory bowel disease (Crohn’s disease, ulcer-
ative colitis).
• Cystic fibrosis.
• Celiac disease.
• Bariatric surgery.
• Radiation enteritis

Liver and Biliary Tract Diseases • Liver failure.

• Pancreatic insufficiency

Renal Diseases • Chronic kidney disease (especially stages 3–5)

Skin Diseases • Atopic dermatitis.

• Psoriasis

Reduced Vitamin D Production in the Skin • Advanced age (especially > 70 years).
• Use of sunscreen.
• Habitual full-body clothing

Long-term Medication Use • Antiepileptic drugs (e.g., valproate, phenytoin).

• Antiretroviral medications.
• Glucocorticoids.
• Systemic antifungal medications.
• Rifampicin.
• Bile acid sequestrants (cholestyramine).
• Lipase inhibitors (orlistat).
• Polypharmacy

Psychiatric and Central Nervous System • Major neurocognitive disorders.

Conditions • Parkinson’s disease.
• Anorexia nervosa

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Table 2 continued
Rheumatological, Granulomatous, and • Rheumatoid arthritis.
Neoplastic Diseases • Systemic lupus erythematosus.
• Multiple sclerosis.
• Sarcoidosis.
• Lymphomas
These are key indications for measuring 25(OH)D. Assessing 25(OH)D levels in patients with clinical con-
ditions associated with hypovitaminosis D is critical. While this list covers a wide range of conditions [4–6,
13, 19, 20, 29, 34, 38, 39, 46, 48, 52, 53], other clinical manifestations may also warrant 25(OH)D testing,
emphasizing the need for clinical judgment in individual cases.
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previous prophylactic schemes, available formulations, and The physician should select the appropriate medication
patient preferences [2]. presentation for each situation and ensure that the prescrip-
Age, gender, ethnicity, body mass index, weight, ges- tion clearly indicates both the presentation and the dosage per
tational status, body composition, baseline 25(OH)D, and intake and frequency of administration, in addition to clearly
genetic factors may influence the response to vitamin D explaining the administration regimen of the prescribed med-
intake and supplementation. It should be considered in all ication to the patient and/or caregivers and ensuring that it
adult patients undergoing medical vitamin D supplementa- has been understood correctly. The follow-up plan should
tion in any form [28]. Medical vitamin D supplementation also be agreed upon with the patient and caregiver [50].
should be implemented and monitored based on serum Different formulations of vitamin D available in Mexico
25(OH)D concentrations in order to achieve and maintain include cholecalciferol in presentations of 200 IU, 400 IU,
the optimal concentration [35, 43, 51, 55]. 800 IU, 1600 IU in tablets, 2000 IU in chewable tablets, 4000
IU in dispersible tablets, 5000 IU in gel caps and tablets, 5600
Formulation selection IU, 25,000 IU, 50,000 IU, and 100,000 IU in gel caps, as
well as calcifediol in a presentation of 0.266 mg in soft cap-
It is recommended that schemes for preventing and treating sules and calcitriol in capsules of 0.25 mcg. These should
vitamin D deficiency in adults in Mexico be based on using be prescribed according to specific medical guidelines for
cholecalciferol as the first-line option or calcifediol in spe- each patient, presentation, and clinical situation. Adjusting
cific medical conditions [32]. the presentation and dosage based on the patient’s prefer-
Supplementation with vitamin D2 (ergocalciferol) results ence for daily, weekly, or monthly therapy may positively
in a lower increase in plasma 25(OH)D compared to D3 influence adherence.
(cholecalciferol) per unit of administered vitamin D. There- The process of determining the appropriate dosage for
fore, vitamin D3 is advised for medical vitamin D supple- vitamin D replacement involves balancing the need to raise
mentation [3, 21, 31]. serum 25-hydroxyvitamin D levels with consideration of
Cholecalciferol is also recommended as the first option body weight and baseline 25(OH)D concentrations. Notably,
for both prophylactic and treatment options. There are dif- larger doses are often required for individuals with higher
ferences in the response to supplementation between chole- body weights, while those with lower baseline 25(OH)D
calciferol and calcifediol, due to higher absorption fraction levels exhibit more significant increases in response to sup-
and differences in tissue distribution of calcifediol compared plementation. Understanding these factors is essential for
to cholecalciferol, as well as hydroxylation of vitamin D3 to healthcare providers to tailor replacement regimens effec-
metabolites other than 25(OH)D [1, 7, 8]. tively.
Calcifediol should be used as a second option when chole- In contemporary clinical practice, standard protocols rec-
calciferol does not improve serum 25(OH)D concentration, ommend administering vitamin D supplements on a monthly,
an immediate increase in serum 25(OH)D concentration is weekly, or daily basis. However, individualized approaches
required, or hepatic hydroxylation capacity is decreased [9, may be necessary in cases of suspected malabsorption or poor
11, 14]. treatment adherence. Additionally, predictive equations like
those proposed by Singh and Bonham [45] or van Groningen
Presentation and dosage et al. [17] can be valuable tools for guiding dose selection.
For hypovitaminosis D, we suggest a daily intake of 6000
In agreement with the patient, the physician should select the IU or its equivalent, either weekly, monthly, or bimonthly
appropriate presentation and dosage of vitamin D for each sit- for three months. After this initial phase, measure 25-
uation and ensure that the patient and caregivers understand hydroxivitamin D levels. If they fall between 30 and 60
the administration and monitoring regimen [18]. ng/mL, continue with a dosage ranging from 600 to 4000

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IU, considering higher doses for individuals with conditions Whenever feasible, the risk of hypersensitivity to vitamin
such as obesity or those taking medications that interfere with D (hypercalciuria, hypercalcemia, nephrolithiasis, nephro-
vitamin D levels. calcinosis, or a history of other types of hypersensitivity to
Formulas to calculate the bolus dose for hypovitaminosis vitamin D in an individual or their relatives) should be eval-
D, such as the one proposed by Van Groningen et al. [17], uated before starting supplementation [16, 30].
can be employed if the physician opts for a more personal- In patients with skeletal symptoms, bone metabolic
ized approach to initiating oral vitamin D supplementation; disease, and bone mineral disorders (bone deformities,
therefore, according to this formula in a male patient with 15 bone pain, nonspecific musculoskeletal symptoms, fatigue
ng/ml serum 25(OH) vitamin D, would need 144,000 UI as syndrome, and a history of fragility fractures), calcium-
an initial dose if his weight is 60 kg (75–15) × 40 × 60), phosphate metabolism parameters (Ca, PO4, ALP, PTH,
but 240,000 UI if his weight is 100 kg (75–15) × 40 × 100). calcium/creatinine ratio in urine) must be evaluated and mon-
Caution should be exercised with any formula used. While itored. Likewise, bone mineral density can be determined
evidence suggests that boluses as large as 300,000 IU taken using bone DXA densitometry.
at once can be safe, it is advisable not to prescribe them, For some patients with chronic diseases (obesity, mal-
especially in older adults. absorption syndromes, liver diseases, chronic inflammatory
Clinicians must exercise caution and vigilance when pre- diseases) or taking medications that interfere with hep-
scribing vitamin D replacement therapy. They should explain atic cytochrome P450 (i.e., glucocorticoids, anticonvulsants,
the risks associated with vitamin D overdose and provide antiretroviral drugs, or anticancer drugs), or rapid restoration
instructions on symptoms suggestive of overdose. Subse- of vitamin D deficiency might be necessary, the use of cal-
quent medical visits should confirm that the product is being cifediol in therapeutic doses of 0.266 µg monthly or more
administered correctly. frequent is reasonable and justified.
While aiming to achieve serum 25(OH)D levels above Individuals who are overweight or obese require special
30 ng/mL, they must be mindful of potential assay variabil- attention, as these conditions generally require a higher dose
ity and individual patient factors. Maintaining serum levels of cholecalciferol compared to the recommended doses for
within an target 25(OH)D range is crucial for ensuring ther- individuals of the same age with normal body weight. In these
apeutic efficacy while minimizing the risk of toxicity. individuals, calcifediol may be considered as an alternative
Treatment should be continued for three months or until treatment regimen [24].
a stable, optimal serum 25(OH)D concentration is achieved. www.t.me/MemodiAppArticulos
If clinical conditions associated with hypovitaminosis D per-
sist, maintenance doses should be initiated.
How to evaluate therapeutic response

It is recommended that 25(OH)D levels in adults receiving

Evaluation of clinical conditions medical vitamin D supplementation be monitored.
Measurement of 25(OH)D levels is essential to evaluate
Clinical conditions that interfere with the metabolism and the response to the therapeutic intervention in adults receiv-
actions of vitamin D and its metabolites should be evaluated ing medical vitamin D supplementation. Three months after
in all adult patients with hypovitaminosis D [10]. initiating treatment, follow-up measurements of 25(OH)D
Since various clinical conditions can affect vitamin D levels are advised, and they should continue until target val-
metabolism, its action pathways, and tissue response, a ues are reached.
thorough medical history should be obtained before sup- Monitoring is crucial to determining whether the prescrip-
plementation [26]. The presence of these conditions should tion is adequate and ensuring therapeutic goals are achieved
be evaluated, and if necessary, relevant tests should be per- [37]. The time between starting vitamin D supplementa-
formed. Subsequently, the prescription should be adjusted tion and stabilizing the new plasma 25(OH)D concentration
according to the specific clinical condition of each patient. ranges from 6 to 16 weeks. Therefore, samples measuring
Patients with chronic kidney disease, especially those on 25(OH)D concentration must be taken after sufficient time
dialysis or in the end stage, are at risk of inadequate vitamin D to reach the new steady state to assess the dose-response rela-
activation, so complementary pharmacological supplemen- tionship [42]. Since calcitriol’s plasma half-life is very short,
tation with calcitriol should be considered [4, 46]. measuring plasma 25(OH)D concentration provides the most
Serum 25 (OH) D and calcium concentrations should useful information for assessing bioavailability and response
be carefully monitored in patients with chronic granuloma- to vitamin D administration [25, 27].
forming disorders such as sarcoidosis, tuberculosis, and The results of the 25 (OH) D test may vary depending on
chronic fungal infections and in patients with lymphoma. the assay method used, so follow-up measurements with the

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same assay are recommended whenever possible. We encour- excluding vitamin D hypersensitivity, prophylactic intake or
age the use of only validated assay methods. therapeutic intervention can be resumed.
After six weeks of therapy discontinuation, serum 25(OH)
Treatment adjustment D concentration should be reevaluated.

Vitamin D supplementation must be adjusted to achieve the

therapeutic goal or if 25(OH)D levels exceed established lim- Discussion
its.
Adjusting or replacing the vitamin D formulation is crucial This recommendation aligns closely with global standards,
to achieving the therapeutic goal or in case of an increase in as anticipated, given that it is based on current scientific
25(OH)D levels above established limits. evidence. However, two key factors distinguish this joint
In all cases, it is essential to verify whether the previous position and make it particularly impactful for improving
treatment regimen (dosage, compliance, type of preparation) healthcare practices in Mexico. Firstly, its emphasis on fea-
has been followed correctly and yielded appropriate results. sibility ensures that the recommendations can be applied
This is imperative because it is possible, albeit remote, that nationwide, regardless of varying healthcare settings and
the observed 25(OH)D levels have been achieved even with resource availability. Secondly, the collaborative consensus-
low patient compliance or that the patient has adjusted or building process involving leading medical societies lends
replaced the dosage on their initiative. considerable strength to the position. A unified voice from
Concentrations of 25(OH)D in Serum <30 ng/mL (<75 medical leaders holds significant sway in shaping health pol-
nmol/L) icy decisions related to vitamin D supplementation.
If the serum 25(OH)D concentration is suboptimal, the An essential aspect of these recommendations is prioritiz-
previous treatment regimen, intake, dosage, and compliance ing feasibility to ensure the primary goal is attainable. For
should be verified. If compliance is adequate, adjusting the example, when determining 25(OH)D levels in a patient, the
dose of cholecalciferol or switching to calcifediol when nec- emphasis is placed on achieving the result rather than spec-
essary is recommended. ifying the method used. Instead of mandating a particular
Concentrations of 25(OH)D in Serum 30–60 ng/mL (75– technology known for its accuracy, the focus is on allow-
150 nmol/L): ing patients to be evaluated using the available technology in
If serum 25(OH)D concentrations are stable at optimal their clinical environment. This approach acknowledges the
sufficiency values, the prescribed regimen should be contin- significant heterogeneity of resources within the nation.
ued after verifying that compliance is adequate. By prioritizing feasibility, these recommendations aim to
Concentrations of 25(OH)D in Serum 60 to 100 ng/mL ensure that all patients, regardless of their healthcare setting
(150 to 250 nmol/L) or available resources, have access to essential diagnostic
Verify if the previous treatment regimen was appropri- evaluations. This approach promotes equity in healthcare and
ate and correct accordingly (dosage, compliance, type of increases the likelihood of widespread implementation and
preparation). Adjust the dose to achieve serum 25(OH)D con- adherence to guidelines. Furthermore, by adopting a flex-
centrations between 30 and 60 ng/mL (75–150 nmol/L). ible approach to diagnostic methods, healthcare providers
Concentration of 25(OH)D in serum > 100 ng/mL (> 250 can adapt to varying clinical contexts and resource con-
nmol/L): straints, ultimately improving patient care outcomes. This
Levels above 100 ng/mL (> 250 nmol/L) of 25(OH)D pragmatic approach aligns with the overarching goal of deliv-
may be associated with a higher risk of toxicity, so it is rec- ering high-quality, evidence-based care while recognizing
ommended to adjust intake, dosage, compliance, and/or the and addressing the real-world challenges faced in healthcare
type of preparation used [30]. delivery.
In case of suspected vitamin D intoxication, therapy Through a systematic and evidence-based approach, we
should be discontinued immediately, and serum calcium, uri- have endeavored to standardize guidelines, enhance health-
nary calcium, and serum 25(OH)D concentration should be care delivery, and ultimately improve patient outcomes. Our
evaluated [41]. journey began with a thorough assessment of the hetero-
Vitamin D intoxication is defined as serum 25(OH)D con- geneity in vitamin D supplementation practices, analyzing
centrations > 100 ng/mL (> 250 nmol/L), accompanied by the complexities and challenges inherent in clinical decision-
hypercalcemia, hypophosphatemia, hypercalciuria, and sup- making. Drawing upon the expertise of diverse stakeholders
pression of PTH. and leveraging robust methodologies such as systematic
After achieving normocalcemia, normocalciuria, and tar- literature reviews and consensus-building techniques, we
get 25(OH)D concentrations ≤60 ng/mL (≤150 nmol/L), and meticulously crafted a joint position that reflects the latest

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scientific evidence, clinical best practices, and the collective evidence on the best option in various clinical scenarios led
wisdom of the medical community. to adaptation to the available formulations in the country.
Central to our approach was transparency, ensuring clarity Although pragmatic, this approach may not address possible
regarding available evidence, limitations, and areas neces- future options that could emerge in the market.
sitating further research. By acknowledging the provisional
nature of our recommendations and fostering an environment Conclusion
of continuous evaluation and refinement, we remain commit-
ted to advancing the science of vitamin D supplementation In conclusion, the development of Mexico’s national joint
while adapting to emerging knowledge and clinical insights. position on vitamin D supplementation is a significant land-
Moreover, our joint position underscores the importance mark in our ongoing efforts to address unwarranted variations
of inclusivity, recognizing the diverse perspectives and expe- in clinical practice. Through the collaboration of diverse
riences that shape clinical decision-making. By engaging stakeholders and robust methodologies, we have developed
with healthcare professionals, stakeholders, and the public, recommendations grounded in scientific evidence, clinical
we sought to ensure that our recommendations are prag- best practices, and the collaborative understanding of the
matic, feasible, and reflective of the varied contexts in which medical community. We aim to ensure these recommenda-
they will be implemented. Implementing our joint position tions are effectively implemented across healthcare settings,
promises to enhance vitamin D supplementation practices’ improving healthcare delivery and advancing public health
consistency, quality, and effectiveness across Mexico. By outcomes. As we move forward into the implementation and
providing clear guidance for healthcare providers, promoting evaluation phase, we remain committed to scientific rigor,
evidence-based decision-making, and fostering a culture of collaboration, and patient-centered care.
continuous improvement, we aim to elevate the standard of By acknowledging our consensus’s strengths and limita-
care and promote population health. tions, we position ourselves to continuously refine and adapt
This collective advocacy influences supplementation pro- our recommendations, better aligning them with the evolving
tocols and informs public health initiatives and funding needs of patients and healthcare providers. Through ongoing
allocation strategies. By leveraging their expertise and influ- evaluation and sustained collaboration, we endeavor to real-
ence, medical societies can effectively endorse policies ize the full potential of our collaborative efforts in fortifying
promoting optimal vitamin D intake and advancing popu- healthcare delivery and fostering the population’s well-being.
lation health outcomes.
Acknowledgements The authors thank the members of the expert
This consensus stands out for several strengths contribut- panel, Dr. Hilario Ávila Armengol, Dr. Rafael Bedoya Torres, Dra.
ing to its robustness and applicability in the medical field. Alhelí Lucía Bremer Aztudillo, Dr. J. Rafael Castro Alonso, Dr. Nicolás
A diverse panel was formed with representatives from var- Durán Martínez, Dra. María Teresa Flores Guzmán, Dr. Pedro A. Gar-
ious clinical and surgical specialties, composed of highly cía Hernández, Dr. Hugo Gutiérrez Hermosillo, Dr. Roberto E. López
Cervantes, Dra Patricia Loranca Moreno, Dr. Juan Humberto Medina
academic professionals. This diversity enriches the perspec- Chávez, Dr. Amador E. Macias Osuna, Dr. Víctor M. Mercado Cárde-
tive on the indications and contraindications of vitamin D, nas, Dr. Jesús Armando Montaño Uzcanga, Dra. Eva Perusquia Frías,
providing a comprehensive and applicable view in different Dr. Juan Luis Salgado Loza, Dr. Alan Ríos Espinosa, Dr. José Francisco
medical areas. The participation of various national medical Torres-Naranjo, Dr. Alejandro Vázquez Alanís and Dr. Gumersindo
Gaspar Vázquez Castillo.
organizations reinforces penetration into patient care sectors.
The methodology used in developing this document min- Author contribution FTN, HGH, and PAG conceived the idea of the
imizes the risk of bias, ensuring the quality and objectivity statement and drafted the original manuscript. All authors (FTN, HGH,
PAG, RLC, HAA, RBT, ABA, JMC, RMD, EPF, ARE, and AVA) crit-
of the recommendations. It is important to note that this doc-
ically revised the manuscript for intellectual content, language, and
ument represents the first consensus on vitamin D in Mexico presentation. All authors approved the final version of the article.
and is a joint position statement. The generated recommenda-
tions follow international standards and apply to both healthy Data Availability This position paper does not report original data. No
datasets were generated or analyzed during the current study.
adults and those facing various pathologies. Furthermore, the
importance of making therapeutic decisions with patients and
caregivers and respecting their preferences is acknowledged. Declarations
www.t.me/MemodiAppArticulos
However, this consensus also presents some limitations.
Evidence based on randomized clinical trials in the Mexican Conflicts of interest FTN has nothing to declare in the context of
population is scarce, which may influence the robustness of this paper but several ad hoc consultancies/speaking honoraria and/or
some recommendations. Although upper limits of 25(OH)D research funding from AMGEN, Asofarma, FAES Farma, and Menar-
ini. HGH has nothing to declare in the context of this paper but several
up to 100 ng/mL are established, current evidence suggests
ad hoc speaking honoraria from AMGEN, Asofarma, and MSD. PAG,
the possibility of lower limits, although there is inconsis- RLC, HAA, RBT, ABA, JMC, RMD, EPF, ARE, and AVA have no
tency in the data. Regarding dosing, the lack of compelling conflicts of interest.

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Archives of Osteoporosis (2025) 20:78 Page 9 of 11 78

Disclaimer Although most clinical recommendations are intended to 10. Bischoff-Ferrari HA, Giovannucci E, Willett WC et al (2006) Esti-
be applied nationwide, social disparities may prevent full implemen- mation of optimal serum concentrations of 25-hydroxyvitamin d
tation in certain regions. However, these recommendations can serve for multiple health outcomes. Am J Clin Nutr 84(1):18–28
as a valuable reference for public health agencies and policymakers, 11. Cipriani C, Romagnoli E, Pepe J et al (2013) Long-term bioavail-
guiding the improved allocation of health resources based on a solid ability after a single oral or intramuscular administration of 600,000
national medical position. Furthermore, feedback from clinicians and iu of ergocalciferol or cholecalciferol: implications for treatment
healthcare administrators may lead to future revisions and updates as and prophylaxis. J Clin Endocrinol Metab 98(7):2709–2715
necessary. 12. Cui A, Zhang T, Xiao P et al (2023) Global and regional preva-
lence of vitamin d deficiency in population-based studies from 2000
Endorsements The following societies endorse this consensus report: to 2022: a pooled analysis of 7.9 million participants. Front Nutr
College of Internal Medicine of Mexico (CMIM), Mexican Academy 10:1070808
of Geriatrics (AMG), Mexican Association for the Study of Climac- 13. Del Pinto R, Pietropaoli D, Chandar AK et al (2015) Associ-
teric (AMEC), Mexican Association of Bone and Mineral Metabolism ation between inflammatory bowel disease and vitamin d defi-
(AMMOM), Mexican College of Orthopedics and Traumatology ciency: a systematic review and meta-analysis. Inflamm Bowel Dis
(CMO), Mexican College of Rheumatology (CMR), National College 21(11):2708–2717
of Geriatric Medicine (CONAMEGER), Mexican Federation of Obstet- 14. Fisk CM, Theobald HE, Sanders TA (2012) Fortified malted milk
rics and Gynecology Colleges (FEMECOG), Mexican Federation of drinks containing low-dose ergocalciferol and cholecalciferol do
Orthopedics and Traumatology Colleges (FEMECOT). not differ in their capacity to raise serum 25-hydroxyvitamin d
concentrations in healthy men and women not exposed to uv-b. J
Open Access This article is licensed under a Creative Commons Nutr 142(7):1286–1290
Attribution 4.0 International License, which permits use, sharing, adap- 15. Fraile Navarro D, López García-Franco A, Nino de Guzman E
tation, distribution and reproduction in any medium or format, as et al (2021) Vitamin d recommendations in clinical guidelines:
long as you give appropriate credit to the original author(s) and the a systematic review, quality evaluation and analysis of potential
source, provide a link to the Creative Commons licence, and indi- predictors. Int J Clin Pract 75(11):e14805
cate if changes were made. The images or other third party material 16. Glade MJ (2012) A 21st century evaluation of the safety of oral
in this article are included in the article’s Creative Commons licence, vitamin D. Nutrition 28(4):344–356
unless indicated otherwise in a credit line to the material. If material 17. van Groningen L, Opdenoordt S, van Sorge A et al (2010) Chole-
is not included in the article’s Creative Commons licence and your calciferol loading dose guideline for vitamin d-deficient adults. Eur
intended use is not permitted by statutory regulation or exceeds the J Endocrinol 162(4):805–811
permitted use, you will need to obtain permission directly from the copy- 18. Grygorieva N, Tronko M, Kovalenko V et al (2023) Diagnosis, pre-
right holder. To view a copy of this licence, visit http://creativecomm vention and treatment of vitamin d deficiency in adults: Ukrainian
ons.org/licenses/by/4.0/. experts consensus statement. Pain Joints Spine 13(2):60–76
19. Guan SY, Cai HY, Wang P et al (2019) Association between
circulating 25-hydroxyvitamin d and systemic lupus erythemato-
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Authors and Affiliations

Jose Francisco Torres-Naranjo1 · Hugo Gutierrez-Hermosillo2 · Pedro Alberto Garcia-Hernandez3 ·

Roberto E. López Cervantes4 · Hilario E. Avila Armengol5 · Rafael Bedoya Torres6 · Alhelí Lucía Bremer Aztudillo7 ·
Juan Humberto Medina Chávez8 · Rocio Morales Delgado9 · Eva M. Perusquía Frías10 · Alan Rios Espinosa11 ·
Alejandro Vázquez Alanís12

B Jose Francisco Torres-Naranjo 1 Centro de Investigación Ósea y de la Composición Corporal

[email protected] (CIO), Guadalajara, México
Hugo Gutierrez-Hermosillo 2 Escuela Nacional de Estudios Superiores, Unidad Leon,
[email protected] Universidad Nacional Autonoma de México, Mexico City,
México
Pedro Alberto Garcia-Hernandez
[email protected] 3 Universidad Autónoma de Nuevo León, San Nicolás de los
Garza, México
Roberto E. López Cervantes
[email protected] 4 Federación Mexicana de Colegios de Ortopedia y
Traumatologia, Guadalajara, México
Hilario E. Avila Armengol
[email protected] 5 Colegio Mexicano de Reumatología, Mexico City, México
Rafael Bedoya Torres 6 Federación Mexicana de Colegios de Obstetricia Y
[email protected] Ginecología. A. C., Ciudad de México, CDMX, México
Alhelí Lucía Bremer Aztudillo 7 Facultad de Medicina y Psicología, Universidad Autónoma de
[email protected] Baja California, Tijuana, México
Juan Humberto Medina Chávez 8 Academia Mexicana de Geriatría, Mexico City, México
[email protected] 9 Geriatric Service, Hospital Universitario “Dr. José E.
Rocio Morales Delgado González”, Universidad Autónoma De Nuevo León,
[email protected] San Nicolás de los Garza, México
Eva M. Perusquía Frías 10 Colegio De Medicina Interna De México, Mexico City,
[email protected] México
Alan Rios Espinosa 11 Asociación Mexicana para el Estudio del Climaterio, Mexico
[email protected] City, México
Alejandro Vázquez Alanís 12 Asociación Mexicana de Metabolismo Óseo Y Mineral
[email protected] (AMMOM), Santiago de Querétaro, México

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