Abstract
Background
Benign paroxysmal positional vertigo (BPPV) is a common vestibular disorder characterized by brief episodes of vertigo triggered by changes in head position and is associated with displaced otoconia in the inner ear. Emerging evidence suggests that metabolic conditions, such as vitamin D deficiency, osteoporosis, and obesity, increase the risk of BPPV recurrence. This study investigated the associations between BPPV recurrence and these metabolic conditions using a large population-based dataset.
Methods
A nested case-control study was conducted using data from the Korean National Health Insurance Service cohort, including 507,744 individuals diagnosed with BPPV between 2005 and 2017. BPPV cases were identified by International Classification of Diseases, 10th revision, Clinical Modification codes, vestibular function tests, and canalith repositioning procedures. Univariate and multivariate analyses were performed to assess the impact of vitamin D deficiency, osteoporosis, body mass index (BMI), and supplementation on BPPV recurrence.
Results
The overall BPPV recurrence rate was 20.8%. Patients with vitamin D deficiency had a significantly higher recurrence rate (25.2%) compared with those with normal vitamin D levels (20.8%) (P < 0.001). Vitamin D supplementation significantly reduced the risk of recurrence (adjusted hazard ratio [aHR], 1.099; 95% confidence interval [CI], 1.003–1.203; P = 0.042), with a more pronounced effect in female patients (aHR, 1.110; 95% CI, 1.011–1.219; P = 0.029). Overweight individuals (BMI 25–30 kg/m2) with vitamin D deficiency had a significantly increased risk of recurrence compared with normal BMI (hazard ratio [HR], 1.207; 95% CI, 1.045–1.393; P = 0.010), whereas no significant difference in risk was observed in obese individuals (BMI ≥ 30 kg/m2) (HR, 1.096; 95% CI, 0.706–1.702; P = 0.682). Osteopenia and osteoporosis were not identified as an independent risk factor for BPPV recurrence. However, among postmenopausal women (age 50–69), osteopenia was a significantly associated with an increased risk of BPPV recurrence. Notably, combined calcium and vitamin D supplementation was associated with increased recurrence risk (HR, 1.122; 95% CI, 1.011–1.246; P = 0.030), especially in women aged 40–49 years (HR, 1.464; 95% CI, 1.030–2.082; P = 0.034).
Conclusion
Vitamin D deficiency, osteopenia among postmenopausal women and higher BMI are significant risk factors for BPPV recurrence. Vitamin D supplementation reduces recurrence risk, particularly in women and younger individuals. However, combined calcium and vitamin D supplementation may be associated with an increased risk of recurrence in specific subgroups. These findings underscore the importance of metabolic health in the pathophysiology and management of BPPV and suggest that targeted interventions reduce the burden of recurrent vertigo in affected populations.
Keywords: Benign Paroxysmal Positional Vertigo, Vitamin D, Osteoporosis, Obesity, Body Mass Index, Korea
Graphical Abstract
INTRODUCTION
Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo and characterized by brief episodes of dizziness triggered by changes in head position.1,2 BPPV is caused by displaced calcium carbonate crystals (otoconia) in the inner ear. During head motion, otoconia displaced from the utricular macula can disrupt endolymph flow in the semicircular canal or they may attach to the cupula, resulting in acute vestibular symptoms.3 While BPPV itself is generally considered idiopathic, emerging evidence suggests that certain metabolic conditions, including vitamin D deficiency and osteoporosis, increase the risk of BPPV or its recurrence.4,5,6,7
Calcium plays a central role in the pathophysiology of BPPV through its influence on the otoconia, which are composed of calcium carbonate. Abnormalities in calcium metabolism due to dietary deficiency, hormonal changes, or systemic conditions like osteoporosis can affect the stability of otoconia, predisposing individuals to BPPV.8,9 Ensuring proper calcium intake and addressing underlying metabolic conditions may be beneficial in preventing the recurrence of BPPV.9
Vitamin D plays a crucial role in calcium homeostasis and bone health, which affects otoconia stability. Vitamin D deficiency has been associated with an increased risk of BPPV recurrence.4,10,11 Jeong et al.12 found that patients with recurrent BPPV had significantly lower serum vitamin D levels compared with those without recurrence, suggesting that vitamin D deficiency contributes to the pathogenesis of BPPV. In addition, vitamin D supplementation in patients with recurrent BPPV has been reported to significantly reduce the recurrence rate, suggesting a causal relationship.10,13,14
Osteoporosis, a condition characterized by reduced bone density, is also implicated as a risk factor for BPPV.7,15,16 The link between osteoporosis and BPPV may arise from the shared pathophysiological mechanisms involving calcium metabolism.17 Individuals with osteoporosis may have fragile otoconia, increasing the likelihood of detachment of such calcium crystals to cause vertigo. Research indicates a higher prevalence of BPPV in individuals with osteoporosis, particularly postmenopausal women.9
Some reports have suggested that the relationship between BPPV and vitamin D deficiency or osteoporosis is supported by weak evidence.18,19 This is primarily attributed to the retrospective design and small sample sizes of most studies. To establish a robust causal relationship, larger-scale studies with more comprehensive methodologies are required.
In this context, we conducted a population-based big data study using data from the National Health Insurance Services (NHIS) of Korea. This study investigated the relationship between BPPV recurrence and vitamin D deficiency or osteoporosis, aiming to provide more conclusive evidence on these relationships using a larger and more diverse dataset.
METHODS
Database and data collection
This nested case-control study used data from the Korean NHIS national cohort, a comprehensive database established in 1989 to provide universal healthcare coverage for all Korean citizens. The NHIS database contains extensive and representative medical information, including patient demographics, personal details, diagnostic codes, prescribed medications, procedures, insurance eligibility, and claim histories. With its robust and wide-ranging data, the NHIS serves as a valuable resource for large-scale epidemiological research. Access to this database for research purposes requires proper authorization, ensuring the security and confidentiality of the data. This retrospective, longitudinal cohort study used the Korean NHIS dataset (research management number: NHIS-2025-02-1-056).
Study population
The operational definition of BPPV from NHIS data was a combination of three certain codes for diagnosis, examination, and treatment. The International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) diagnostic code of H811 (BPPV) was used for diagnosis. Electronic Data Interchange (EDI) codes for vestibular function tests (spontaneous and gaze nystagmus test by frenzel glass, F6321; positional nystagmus test by frenzel glass, F6322; spontaneous and gaze nystagmus test by electronystagmography, F6331; positional nystagmus test by electronystagmography, F6332; and video-nystagmography, FZ733) were used for examination. The EDI codes for the canalith repositioning maneuver (MX035) were used for treatment. A total of 782,979 participants who were diagnosed with BPPV (H811) between 2005 and 2017 was enrolled in the study. Patients who did not undergo vestibular function tests (EDI codes F6321, F6322, F6331, F6332, and FZ733) or did not undergo the canalith repositioning maneuver (EDI code MX035) within 2 weeks of being diagnosed with BPPV were excluded from the study (n = 173,552 and n = 86,296, respectively). To exclude recurrent cases of BPPV, patients with a prior diagnosis of BPPV (ICD-10-CM code H811) within the past 3 years were excluded from the study (n = 3,250). We defined recurrence of BPPV case as a new diagnosis by vestibular function tests and subsequently treated with a canalith repositioning maneuver, occurring at least one month after the last canalith repositioning maneuver. Additionally, participants who had missing data on sex, age, residential status, or socioeconomic status were excluded (n = 12,137). Finally, a total of 507,744 participants was included in the BPPV group. Among those participants, 3,647 had vitamin D deficiency. Data on the body mass index (BMI, kg/m2) for 398,678 patients with BPPV were obtained from previous health check-up records. The T-score of bone mineral density data for 52,869 females with BPPV, 30–39 years old, was obtained.
The population-selection scheme is shown in Fig. 1.
Fig. 1. Operational definitions used for population selection.
ICD = International Classification of Diseases, BPPV = benign paroxysmal positional vertigo, VFT = vestibular function test, EDI = Electronic Data Interchange, CRM = canalith repositioning maneuver.
Variables
We examined various clinical and demographic factors, including age, sex, and metabolic conditions (vitamin D deficiency, osteoporosis, and calcium deficiency). Additionally, we analyzed BMI categories and comorbidities such as hypertension, diabetes, dyslipidemia, kidney disease, head trauma, and other inner ear diseases. BMI was categorized as follows: normal < 25 kg/m2, overweight 25–30 kg/m2, and obese ≥ 30 kg/m2. Patients with vitamin D deficiency were identified using the ICD-10-CM code E559. Osteoporosis was classified using T-score (normal: ≥ −1, osteopenia: −2.5 < T-score < −1, osteoporosis: ≤ −2.5) and identified using ICD-10-CM codes M80, M81, and M82. Information on drugs including vitamin D and calcium was collected for those with such prescriptions for treating vitamin D deficiency or osteoporosis.
Statistical analysis
Baseline comparisons between groups were conducted using descriptive statistics. Univariate and multivariate Cox regression analyses were performed to determine hazard ratio (HR) and adjusted hazard ratio (aHR) for BPPV recurrence in relation to vitamin D deficiency, osteoporosis, BMI, and supplementation. Subgroup analyses were conducted by age, sex, and BMI to assess potential differential effects. All statistical analyses were performed using SAS Enterprise Guide version 7.1 (SAS Institute, Cary, NC, USA) and R-Studio version 4.0.3 (R Foundation for Statistical Computing, Vienna, Austria), with statistical significance set at P < 0.05.
Ethics statement
The study data were approved by the Ethics Committee of the National Health Insurance Service (NHIS-2024-1-075). The study protocol was approved by the Institutional Review Board (IRB) of the Catholic University of Korea, Seoul St. Mary’s Hospital (KC24ZIS0498). The NHIS provided the study data as publicly accessible, and the requirement for patient consent was waived by the IRB.
RESULTS
Baseline characteristics
The baseline characteristics of the study population are presented in Table 1. The study population comprised 507,744 individuals with BPPV, and the mean patient age was 52.36 ± 15.83 years. The proportion of female patients was 68%. Osteoporosis was present in 21.9% of the population, with smaller percentages of the population exhibiting calcium (1.4%) and vitamin D deficiencies (0.7%). The mean BMI was 23.64 ± 9.67, with a portion classified as overweight (BMI 25–30, 31.5%) or obese (BMI ≥ 30, 25.0%). Urban residency was predominant (70.4%), and the recurrence rate of BPPV was 20.8%.
Table 1. Baseline characteristics of the groups.
| Demographics | BPPV (N = 507,744) | |
|---|---|---|
| Age, yr | 52.36 ± 15.83 | |
| Sex | ||
| Male | 162,653 (32.0) | |
| Female | 345,091 (68.0) | |
| Osteoporosis | 111,358 (21.9) | |
| Calcium deficiency | 6,873 (1.4) | |
| Vitamin D deficiency | 3,637 (0.7) | |
| BMI, kg/m2 | 23.64 ± 9.67 | |
| < 25 | 271,927 (53.6) | |
| 25–30 | 53,896 (10.6) | |
| ≥ 30 | 81,183 (16.0) | |
| Recurrence rate | 105,726 (20.8) | |
| Residential status | ||
| Urban | 359,104 (70.4) | |
| Rural | 148,640 (29.3) | |
| Socioeconomic status | ||
| Q1 (bottom 20%) | 90,457 (17.8) | |
| Q2 | 67,635 (13.3) | |
| Q3 | 81,986 (16.2) | |
| Q4 | 110,069 (21.7) | |
| Q5 (top 20%) | 157,597 (31.0) | |
| Hypertension | 179,584 (35.4) | |
| Diabetes | 113,500 (22.4) | |
| Dyslipidemia | 183,419 (36.1) | |
| Chronic kidney disease | 25,900 (5.1) | |
| Head trauma | 40,673 (8.0) | |
| Other inner ear diseases (total) | 59,837 (11.8) | |
| ISSNHL | 1,053 (0.2) | |
| Meniere’s disease | 38,434 (7.6) | |
| Vestibular neuritis | 25,515 (5.0) | |
| Otologic surgery | 4,042 (0.8) | |
| Hypothyroidism | 45,209 (8.9) | |
| Hyperthyroidism | 33,715 (6.6) | |
| Gastric cancer | 4,771 (0.9) | |
| Colon cancer | 3,985 (0.8) | |
| Breast cancer | 4,763 (0.9) | |
| Cervical cancer | 1,684 (0.3) | |
Values are presented as number (%) or mean ± standard deviation.
BPPV = benign paroxysmal positional vertigo, BMI = body mass index, ISSNHL = idiopathic sudden sensorineural hearing loss.
Effect of vitamin D supplementation on BPPV recurrence
Patients with vitamin D deficiency (n = 3,637) were analyzed for BPPV recurrence in relation to vitamin D supplementation (Table 2). The overall recurrence rate of vitamin D deficiency was 25.3% (Fig. 2). Multivariate analysis revealed that supplementation significantly reduced the risk of recurrence (aHR, 1.099; 95% confidence interval [CI], 1.003–1.203; P = 0.042). In contrast, patients without supplementation had a higher risk of recurrence (aHR, 1.212; 95% CI, 1.105–1.330; P < 0.001). Notably, the protective effect of supplementation was more pronounced in female patients (aHR, 1.110; 95% CI, 1.011–1.219; P = 0.029). In addition, the risk of recurrence was notably higher among male patients who did not receive vitamin D supplementation (aHR, 1.597; 95% CI, 1.304–1.955; P < 0.001). The influence of vitamin D supplementation on BPPV recurrence varied across age groups. Patients 20–29 years old with supplementation demonstrated the lowest recurrence rates, while those 50–59 and 60–69 years old with supplementation showed moderate recurrence rates. In older patients (≥ 70 years), the effect of supplementation was less significant, highlighting potential age-related variability in treatment efficacy.
Table 2. Univariate and multivariate cox regression analyses of benign paroxysmal positional vertigo recurrence regarding VitD supplementation among patients with VitD deficiency (N = 3,637).
| Variables | No. at risk | Event No. (%) | Univariate analysis | Multivariate analysis | |||||
|---|---|---|---|---|---|---|---|---|---|
| HR | 95% CI | P value | aHR | 95% CI | P value | ||||
| VitD supplementation | |||||||||
| Yes | 1,867 | 470 (25.2) | 1.237 | 1.130–1.354 | < 0.001 | 1.099 | 1.003–1.203 | 0.042 | |
| No | 1,770 | 449 (25.4) | 1.245 | 1.135–1.366 | < 0.001 | 1.212 | 1.105–1.330 | < 0.001 | |
| Male | |||||||||
| Yes | 167 | 28 (16.9) | 0.943 | 0.657–1.367 | 0.758 | 0.885 | 0.611–1.283 | 0.519 | |
| No | 340 | 94 (27.7) | 1.617 | 1.312–1.980 | < 0.001 | 1.597 | 1.304–1.955 | < 0.001 | |
| Female | |||||||||
| Yes | 1,700 | 442 (26.0) | 1.196 | 1.089–1.313 | < 0.001 | 1.110 | 1.011–1.219 | 0.029 | |
| No | 1,430 | 355 (24.8) | 1.133 | 1.021–1.257 | 0.019 | 1.117 | 1.006–1.240 | 0.030 | |
| Age 20–29 yr | |||||||||
| Yes | 25 | 4 (16.0) | 1.004 | 0.377–2.676 | 0.994 | 0.998 | 0.371–2.634 | 0.981 | |
| No | 75 | 20 (26.7) | 1.816 | 1.171–2.818 | 0.008 | 1.803 | 1.162–2.797 | 0.009 | |
| Age 30–39 yr | |||||||||
| Yes | 92 | 24 (26.1) | 1.004 | 0.978–2.177 | 0.064 | 1.420 | 0.951–2.119 | 0.086 | |
| No | 251 | 60 (23.9) | 1.272 | 0.987–1.639 | 0.063 | 1.266 | 0.983–1.632 | 0.068 | |
| Age 40–49 yr | |||||||||
| Yes | 211 | 51 (24.2) | 1.204 | 0.914–1.584 | 0.186 | 1.141 | 0.867–1.503 | 0.347 | |
| No | 365 | 93 (25.5) | 1.268 | 1.035–1.555 | 0.022 | 1.251 | 1.021–1.534 | 0.031 | |
| Age 50–59 yr | |||||||||
| Yes | 528 | 139 (26.3) | 1.208 | 1.023–1.427 | 0.026 | 1.107 | 0.937–1.308 | 0.233 | |
| No | 550 | 145 (26.4) | 1.219 | 1.038–1.435 | 0.017 | 1.189 | 1.010–1.400 | 0.037 | |
| Age 60–69 yr | |||||||||
| Yes | 565 | 157 (27.8) | 1.245 | 1.064–1.457 | 0.006 | 1.143 | 0.976–1.338 | 0.097 | |
| No | 550 | 145 (26.4) | 1.079 | 0.966–1.343 | 0.500 | 1.041 | 0.836–1.297 | 0.720 | |
| Age 70–79 yr | |||||||||
| Yes | 349 | 83 (23.8) | 1.084 | 0.873–1.345 | 0.465 | 1.021 | 0.823–1.268 | 0.849 | |
| No | 137 | 34 (24.8) | 1.146 | 0.818–1.604 | 0.428 | 1.111 | 0.793–1.556 | 0.540 | |
| Age 80–89 yr | |||||||||
| Yes | 90 | 10 (11.1) | 0.587 | 0.315–1.091 | 0.092 | 0.554 | 0.297–1.031 | 0.062 | |
| No | 27 | 3 (11.1) | 0.584 | 0.188–1.812 | 0.352 | 0.586 | 0.189–1.820 | 0.356 | |
| VitD deficiency | 3,637 | 919 (25.3) | < 0.001 | ||||||
Yes and No refer to whether VitD supplementation was administered to patients.
VitD = vitamin D, HR = hazard ratio, CI = confidence interval, aHR = adjusted hazard ratio.
Fig. 2. Comparison of the recurrence rate of BPPV in individuals with and without vitamin D deficiency. Vitamin D-deficient patients showed a higher recurrence rate than patients with normal vitamin D levels.
***P < 0.001.
Effects of BMI and vitamin D deficiency on BPPV recurrence
The univariate Cox regression analysis (Tables 3 and 4) demonstrated that higher BMI categories (overweight and obese) were associated with an increased risk of BPPV recurrence compared with normal BMI (Fig. 3).
Table 3. Univariate Cox regression analyses of BPPV recurrence regarding body mass index and VitD deficiency.
| Variables | No. at risk | Event No. (%) | Univariate analysis | |||
|---|---|---|---|---|---|---|
| HR | 95% CI | P value | ||||
| BPPV | 398,678 | 85,735 (21.5) | ||||
| Normal < 25 | 271,927 | 58,941 (21.7) | Ref | |||
| 25 ≤ overweight < 30 | 53,896 | 18,697 (34.7) | 1.246 | 1.193–1.301 | < 0.001 | |
| Obese ≥ 30 | 81,183 | 30,529 (37.6) | 1.380 | 1.323–1.440 | < 0.001 | |
| No VitD deficiency | 395,439 | 2,889 (21.9) | ||||
| Normal < 25 | 269,529 | 58,312 (21.6) | Ref | |||
| 25 ≤ overweight < 30 | 112,483 | 23,697 (21.1) | 0.973 | 0.958–0.988 | < 0.001 | |
| Obese ≥ 30 | 13,427 | 2,889 (21.5) | 0.995 | 0.959–1.033 | 0.794 | |
| VitD deficiency | 3,239 | 837 (25.8) | ||||
| Normal < 25 | 2,398 | 629 (26.2) | Ref | |||
| 25 ≤ overweight < 30 | 754 | 188 (24.9) | 0.949 | 0.806–1.117 | 0.528 | |
| Obese ≥ 30 | 87 | 20 (23.0) | 0.882 | 0.565–1.377 | 0.582 | |
| Yes VitD supplementation | 1,707 | 445 (26.1) | ||||
| Normal < 25 | 1,261 | 333 (26.4) | Ref | |||
| 25 ≤ overweight < 30 | 403 | 101 (25.1) | 0.955 | 0.764–1.193 | 0.684 | |
| Obese ≥ 30 | 43 | 11 (25.6) | 1.003 | 0.550–1.829 | 0.993 | |
| No VitD supplementation | 1,532 | 392 (25.6) | ||||
| Normal < 25 | 1,137 | 296 (26.0) | Ref | |||
| 25 ≤ overweight < 30 | 351 | 87 (24.8) | 0.942 | 0.742–1.197 | 0.626 | |
| Obese ≥ 30 | 44 | 9 (20.5) | 0.773 | 0.398–1.499 | 0.446 | |
BPPV = benign paroxysmal positional vertigo, VitD = vitamin D, HR = hazard ratio, CI = confidence interval.
Table 4. Univariate Cox regression analyses of benign paroxysmal positional vertigo recurrence in relation to VitD deficiency and supplementation within the same body mass index categories.
| Variables | No. at risk | Event No. (%) | Univariate analysis | |||
|---|---|---|---|---|---|---|
| HR | 95% CI | P value | ||||
| Normal < 25 | ||||||
| Normal | 269,529 | 58,312 (21.6) | Ref | |||
| VitD deficiency | 2,398 | 629 (26.2) | 1.237 | 1.143–1.338 | < 0.001 | |
| VitD supplementation | 1,261 | 333 (26.4) | Ref | |||
| No VitD supplementation | 1,137 | 296 (26.0) | 0.985 | 0.843–1.152 | 0.853 | |
| 25 ≤ overweight < 30 | ||||||
| Normal | 112,483 | 23,697 (21.1) | Ref | |||
| VitD deficiency | 754 | 188 (24.9) | 1.207 | 1.045–1.393 | 0.010 | |
| VitD supplementation | 403 | 101 (25.1) | Ref | |||
| No VitD supplementation | 351 | 87 (24.8) | 0.973 | 0.731–1.297 | 0.853 | |
| Obese ≥ 30 | ||||||
| Normal | 13,427 | 2,889 (21.5) | Ref | |||
| VitD deficiency | 87 | 20 (23.0) | 1.096 | 0.706–1.702 | 0.682 | |
| VitD supplementation | 43 | 11 (25.6) | Ref | |||
| No VitD supplementation | 44 | 9 (20.5) | 0.766 | 0.317–1.848 | 0.552 | |
VitD = vitamin D, HR = hazard ratio, CI = confidence interval.
Fig. 3. Comparison of the recurrence rate of BPPV according to BMI category. Overweight (25–30 kg/m2) and obese (≥ 30 kg/m2) patients showed a higher recurrence rate than patients with a healthy weight.
BPPV = benign paroxysmal positional vertigo, BMI = body mass index.
***P < 0.001.
Overweight individuals with vitamin D deficiency had a significantly increased risk of BPPV recurrence, with an HR of 1.207 (95% CI, 1.045–1.393; P = 0.010) compared with individuals in the normal weight group. In contrast, obese individuals did not exhibit a statistically significant increase in recurrence risk (HR, 1.096; 95% CI, 0.706–1.702; P = 0.682). However, vitamin D supplementation did not show any significant difference among groups.
Effect of osteoporosis on BPPV recurrence
The relationship between osteoporosis and BPPV recurrence was analyzed using univariate Cox regression analysis (Tables 5 and 6). Osteopenia did not show a significant association with BPPV recurrence (HR, 1.028; 95% CI, 0.987–1.070; P = 0.189). Similarly, osteoporosis did not demonstrate a significant increase in recurrence risk (HR, 1.020; 95% CI, 0.974–1.069, P = 0.404) (Fig. 4). The recurrence rate was slightly higher in the osteopenia group (24.2%) compared with the normal group (23.6%), but this difference was not significant. The effect of osteoporosis on recurrence risk was more pronounced in older age groups, although was not significant (Table 6). Patients with osteopenia aged 50–59 years showed a 1.92-fold significantly higher risk of BPPV recurrence compared with the reference group (30–39 years) (P = 0.024). Patients aged 60–69 years with osteopenia showed an even higher recurrence risk (2.08-fold increase), which was also statistically significant (P = 0.012).
Table 5. Univariate Cox regression analyses of BPPV recurrence regarding osteoporosis in female.
| Variables | No. at risk | Event No. (%) | Univariate analysis | |||
|---|---|---|---|---|---|---|
| HR | 95% CI | P value | ||||
| BPPV | 52,869 | 12,668 (24.0) | ||||
| Normal | 17,174 | 4,054 (23.6) | Ref | |||
| Osteopenia | 22,746 | 5,503 (24.2) | 1.028 | 0.987–1.070 | 0.190 | |
| Osteoporosis | 12,949 | 3,111 (24.0) | 1.020 | 0.974–1.069 | 0.404 | |
| Age 30–39 yr | ||||||
| Normal | 92 | 14 (15.2) | Ref | |||
| Osteopenia | 89 | 12 (13.5) | 0.863 | 0.399–1.865 | 0.708 | |
| Osteoporosis | 37 | 4 (10.8) | 0.692 | 0.228–2.101 | 0.515 | |
| Age 40–49 yr | ||||||
| Normal | 7,307 | 1,652 (22.6) | Ref | |||
| Osteopenia | 6,537 | 1,463 (22.4) | 0.988 | 0.921–1.060 | 0.736 | |
| Osteoporosis | 2,276 | 531 (23.3) | 1.040 | 0.943–1.147 | 0.429 | |
| Age 50–59 yr | ||||||
| Normal | 6,563 | 1,593 (24.3) | Ref | |||
| Osteopenia | 9,466 | 2,303 (24.3) | 1.001 | 0.939–1.067 | 0.974 | |
| Osteoporosis | 5,583 | 1,288 (23.1) | 0.942 | 0.875–1.014 | 0.112 | |
| Age 60–69 yr | ||||||
| Normal | 3,212 | 795 (24.8) | Ref | |||
| Osteopenia | 6,654 | 1,725 (25.9) | 1.052 | 0.968–1.145 | 0.233 | |
| Osteoporosis | 5,053 | 1,288 (25.5) | 1.031 | 0.944–1.126 | 0.499 | |
Normal, T score ≥ −1; Osteopenia, −2.5 < T score < −1; Osteoporosis, T score ≤ −2.5.
BPPV = benign paroxysmal positional vertigo, HR = hazard ratio, CI = confidence interval.
Table 6. Univariate Cox regression analyses of benign paroxysmal positional vertigo recurrence regarding age (30–69 years) in females within the same T-score categories.
| Variables | No. at risk | Event No. (%) | Univariate analysis | |||
|---|---|---|---|---|---|---|
| HR | 95% CI | P value | ||||
| Normal, yr | ||||||
| 30–39 | 92 | 14 (15.2) | Ref | |||
| 40–49 | 7,307 | 1,652 (22.6) | 1.524 | 0.902–2.576 | 0.117 | |
| 50–59 | 6,563 | 1,593 (24.3) | 1.655 | 0.979–2.797 | 0.601 | |
| 60–69 | 3,212 | 795 (24.8) | 1.698 | 1.002–2.878 | 0.049 | |
| Osteopenia, yr | ||||||
| 30–39 | 89 | 12 (13.5) | Ref | |||
| 40–49 | 6,537 | 1,463 (22.4) | 1.748 | 0.991–3.086 | 0.054 | |
| 50–59 | 9,466 | 2,303 (24.3) | 1.924 | 1.091–3.393 | 0.024 | |
| 60–69 | 6,654 | 1,725 (25.9) | 2.078 | 1.178–3.665 | 0.012 | |
| Osteoporosis, yr | ||||||
| 30–39 | 37 | 4 (10.8) | Ref | |||
| 40–49 | 2,276 | 531 (23.3) | 2.299 | 0.860–6.146 | 0.097 | |
| 50–59 | 5,583 | 1,288 (23.1) | 2.263 | 0.848–6.037 | 0.103 | |
| 60–69 | 5,053 | 1,288 (25.5) | 2.543 | 0.953–6.784 | 0.062 | |
Normal, T score ≥ −1; Osteopenia, −2.5 < T score < −1; Osteoporosis, T score ≤ −2.5.
HR = hazard ratio, CI = confidence interval.
Fig. 4. BPPV recurrence rates according to age in patients with osteopenia.
Postmenopausal women (50–69 years) showed a significant higher recurrence rate than the reference group (30–39 years).
BPPV = benign paroxysmal positional vertigo.
*P < 0.05.
Effects of calcium and vitamin D supplementation on BPPV recurrence in osteoporosis patients
The effects of calcium and vitamin D supplementation on recurrence of BPPV in female patients with osteoporosis was evaluated using univariate Cox regression analysis (Table 7). Calcium supplementation alone did not significantly affect recurrence rates. Patients who received a combination of calcium and vitamin D supplementation had a higher recurrence rate of 25.6%, with a significantly increased risk of recurrence compared with those without supplementation (HR, 1.122; 95% CI, 1.011–1.246; P = 0.030). Among women 40–49 years old, those receiving combined calcium and vitamin D supplementation had a significantly higher recurrence rate of 29.2%, with a 46% increased risk compared with those without supplementation (HR, 1.464; 95% CI, 1.030–2.082; P = 0.034). In older age groups (50–69 years), the effect of combined supplementation was not significant, although a borderline trend toward increased recurrence was observed in women aged 60–69 years (P = 0.097).
Table 7. Univariate Cox regression analyses of BPPV recurrence regarding Ca supplementation in female osteoporosis patients.
| Variables | No. at risk | Event No. (%) | Univariate analysis | |||
|---|---|---|---|---|---|---|
| HR | 95% CI | P value | ||||
| BPPV | 12,949 | 3,111 (24.0) | ||||
| No Ca supplementation | 3,997 | 957 (23.2) | Ref | |||
| Ca supplementation | 6,727 | 1,614 (24.0) | 1.035 | 0.955–1.123 | 0.398 | |
| Ca + VitD supplementation | 2,225 | 570 (25.6) | 1.122 | 1.011–1.246 | 0.030 | |
| Age 30–39 yr | 37 | 4 (10.8) | ||||
| No Ca supplementation | 14 | 1 (7.1) | Ref | |||
| Ca supplementation | 22 | 3 (13.6) | 1.872 | 0.195–17.998 | 0.587 | |
| Ca + VitD supplementation | 1 | 0 | 0 | |||
| Age 40–49 yr | 2,276 | 531 (23.3) | ||||
| No Ca supplementation | 792 | 168 (21.2) | Ref | |||
| Ca supplementation | 1,354 | 325 (24.0) | 1.148 | 0.953–1.383 | 0.147 | |
| Ca + VitD supplementation | 130 | 38 (29.2) | 1.464 | 1.030–2.082 | 0.034 | |
| Age 50–59 yr | 5,583 | 1,288 (23.1) | ||||
| No Ca supplementation | 1,689 | 394 (23.3) | Ref | |||
| Ca supplementation | 3,043 | 695 (22.8) | 0.969 | 0.856–1.096 | 0.615 | |
| Ca + VitD supplementation | 851 | 199 (23.4) | 0.992 | 0.837–1.176 | 0.927 | |
| Age 60–69 yr | 5,053 | 1,288 (25.5) | ||||
| No Ca supplementation | 1,502 | 364 (24.2) | Ref | |||
| Ca supplementation | 2,308 | 591 (25.6) | 1.066 | 0.935–1.214 | 0.341 | |
| Ca + VitD supplementation | 1,243 | 333 (26.8) | 1.134 | 0.988–1.316 | 0.097 | |
BPPV = benign paroxysmal positional vertigo, HR = hazard ratio, CI = confidence interval, Ca = calcium, VitD = vitamin D.
DISCUSSION
This large-scale, population-based study provides compelling evidence linking vitamin D deficiency and osteoporosis to an increased risk of BPPV recurrence. Our findings demonstrate that vitamin D supplementation significantly reduces the risk of BPPV recurrence, particularly among females and younger individuals. Additionally, osteoporosis was identified as an independent risk factor for recurrent BPPV. However, contrary to expectations, combined calcium and vitamin D supplementation was associated with an increased risk of recurrence, particularly in certain subgroups.
Our study revealed that patients with vitamin D deficiency had a higher risk of BPPV recurrence, and vitamin D supplementation significantly reduced this risk. This supports the hypothesis that vitamin D plays a critical role in otoconia stability by regulating calcium metabolism.20 Disruption in calcium homeostasis due to vitamin D deficiency may lead to otoconial dislodgement, precipitating BPPV episodes. This finding aligns with previous studies reporting lower serum vitamin D levels in patients with recurrent BPPV compared with those without recurrence.4,11,12
Interestingly, the protective effect of vitamin D supplementation was more pronounced in women, which may be attributed to postmenopausal hormonal changes affecting bone and calcium metabolism. Estrogen deficiency after menopause is known to accelerate bone loss and reduce calcium absorption, potentially destabilizing otoconia and increasing susceptibility to BPPV.21 Moreover, age-related analysis indicated that vitamin D supplementation was most effective in reducing recurrence rates in middle-age groups (50–69 years), whereas its impact was less significant in individuals aged ≥ 70 years. This could be due to diminished vitamin D receptor sensitivity, reduced cutaneous synthesis of vitamin D, and impaired calcium absorption in older adults.22 In addition, otolith dysfunction particularly utricular dysfunction may contribute the BPPV recurrence.23 In elderly patients, underlying pathologies such as otolith dysfunction is more likely to be presents and also influence the risk of BPPV recurrence. In elderly individuals, BPPV frequently coexists with reduced physical activity and frailty.24 While the canalith repositioning maneuver remains the primary treatment, vestibular rehabilitation may offer additional benefits by enhancing balance, improving mobility, and reducing recurrence.25
Our study also revealed a significant interaction among BMI, vitamin D deficiency, and risk of BPPV recurrence. Individuals with higher BMI categories (overweight and obese) exhibited increased risk of BPPV recurrence compared with those with a normal BMI. There are very few reports on the relationship of obesity and dizziness. Demircan and Öner27 reported obesity as a risk factor of BPPV.26 Obesity may influence vestibular function through mechanisms related to metabolic dysregulation, inflammation, and altered calcium and vitamin D metabolism.28 When analyzing the effect of vitamin D supplementation across BMI categories, we observed that supplementation provided modest benefits in reducing recurrence risk, with the most pronounced effect seen in individuals with a normal BMI. In contrast, the protective effect of vitamin D supplementation was attenuated in overweight and obese individuals, which could be due to reduced vitamin D receptor sensitivity, impaired absorption, and altered metabolic clearance rates commonly observed in obesity. This observation is consistent with previous studies indicating that higher doses of vitamin D may be required to achieve optimal serum levels in individuals with obesity.29
Osteoporosis and osteopenia were not identified as a significant risk factor for BPPV recurrence. However, postmenopausal women with osteopenia showed a higher recurrence rate of BPPV. The association between osteoporosis and BPPV can be explained by shared pathophysiological mechanisms involving calcium metabolism. Osteoporotic individuals often have compromised bone turnover and reduced calcium stores, which may lead to fragile otoconia, increasing the likelihood of dislodgement.8 This association was particularly strong in postmenopausal women, reinforcing the role of bone health in vestibular function.21 Our study results did not replicate the above-mentioned findings, which may be due to the relatively limited study population.
Contrary to our initial hypothesis, while calcium supplementation alone did not significantly reduce BPPV recurrence, the combination of calcium and vitamin D supplementation was associated with increased recurrence risk, particularly in younger osteoporotic women (aged 40–49 years). Additionally, a borderline trend toward increased recurrence was observed in women aged 60–69 years. This unexpected finding suggests that excess calcium intake combined with vitamin D may lead to calcium dysregulation within the vestibular system, potentially affecting otoconia stability. Alternatively, this could reflect confounding factors, such as more severe osteoporosis in those receiving combined supplementation, or differences in adherence, dosing, or baseline vitamin D levels. Moreover, younger women who receive such supplementation may represent a subpopulation with more severe or early-onset osteoporosis, potentially linked to genetic predispositions, autoimmune disorders, or other systemic metabolic abnormalities. These underlying factors could themselves be associated with a higher recurrence risk, independent of supplementation. It is also important to note that the number of osteoporotic women aged 40–49 years who received combined calcium and vitamin D supplementation was relatively small (n = 130), which may have limited the statistical power and introduced variability in the observed association, potentially leading to a confounding result. Further studies are needed to elucidate these mechanisms.
The primary strength of our study lies in its large sample size and the use of a comprehensive national database, which enhances the generalizability of the findings. Additionally, the use of standardized diagnostic codes and treatment records minimizes the risk of misclassification bias. While our previous study focused on risk factor involved with the occurrence and recurrence of BPPV using same national database, the present study specifically emphasizes the role of vitamin D deficiency and osteoporosis in BPPV recurrence.30
However, several limitations should be acknowledged. First, the retrospective design limits our ability to establish causality. Second, we lacked data on serum vitamin D levels; bone mineral density; and lifestyle factors such as dietary intake, physical activity, and sun exposure, which could influence BPPV risk. Third, reliance on administrative data may introduce coding errors or misclassification. Last, while we observed significant associations, residual confounding cannot be ruled out.
Our findings suggest that routine assessment of vitamin D levels, bone health, and BMI in patients with recurrent BPPV may help identify individuals at higher risk. Vitamin D supplementation, particularly in those with documented deficiency or osteoporosis, may serve as an adjunctive strategy to reduce BPPV recurrence. In addition, overweight or obese patients have a higher risk of BPPV recurrence. Additionally, weight management and addressing metabolic comorbidities may play a role in BPPV prevention.
Future prospective studies with detailed clinical, biochemical, and radiological data are warranted to confirm these findings and explore the underlying mechanisms. Randomized controlled trials assessing the efficacy of vitamin D and calcium supplementation in preventing BPPV recurrence will provide more definitive evidence for clinical guidelines.
Our study identified vitamin D, osteopenia among postmenopausal women and higher BMI as significant risk factors for recurrence of BPPV. Vitamin D supplementation appears to reduce the risk of BPPV recurrence, particularly among women and younger individuals. However, combined supplementation with calcium and vitamin D may be associated with an increased recurrence risk in certain subgroups. These findings highlight the role of metabolic health in the pathophysiology and management of BPPV, suggesting that targeted interventions could help alleviate the burden of recurrent vertigo in affected populations.
Footnotes
Funding: This study was supported by grants from the ENT Fund of The Catholic University of Korea for the 2021 program year (Grant No. 5-2021-B0001-00046) and 2023 program year (Grant No. 52023B000100277).
Disclosure: The authors have no potential conflicts of interest to disclose.
- Conceptualization: Seo JH, Kwak SH, Lee DH.
- Data curation: Lee YH.
- Formal analysis: Han JS, Lim JH, Seo JH, Lee DH.
- Funding acquisition: Kwak SH, Lee DH.
- Methodology: Seo JH, Kwak SH, Lee DH, Lee YH.
- Visualization: Kwak SH, Lee YH, Lee DH.
- Writing - original draft: Kwak SH.
- Writing - review & editing: Kwak SH, Lee DH.
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