Vitamin D Deficiency

Aka: Vitamin D Deficiency, Hypovitaminosis D

advertisement

II. Epidemiology

  1. Vitamin D Deficiency is common in U.S. (esp. in northern climates)
  2. Incidence increasing due to Sunscreen use and less Time Outdoors
  3. Age over 65 are associated worldwide with Vitamin D Deficiency in >50% of people

III. Precautions

  1. Vitamin D Testing has increased substantially increased since 2010, often for vague, unrelated symptoms
    1. Low Vitamin D levels result in a cascade of additional tests and referrals
    2. However, levels are often inaccurate, variable and with no universal defined lower limit of normal
  2. Vitamin D Replacement (esp. high dose) for asymptomatic, low Vitamin D typically offers little benefit
    1. Contrast with truly indicated replacement in severe Vitamin D Deficiency (e.g. Rickets, Osteomalacia)
  3. References
    1. Lazris (2024) Am Fam Physician 110(3): 302-4 [PubMed]

IV. Risk Factors: Infants

  1. Anticonvulsants
  2. Chronic disease with fat malabsorption
  3. Exclusively Breast-fed infant without Vitamin D Supplementation
  4. Low maternal Vitamin D levels
  5. Lack of Sun Exposure
    1. Direct sunlight avoidance is recommended by AAP for those under 6 months
    2. Darker skin pigmentation (requires 3-6 fold more Sun Exposure)

V. Risk Factors: Adults

  1. Age over 65 years
    1. Related to housebound status and decreased Vitamin D absorption
  2. Comorbid illness
  3. Malnourished
  4. Total Parenteral Nutrition
  5. Lack of Sun Exposure (or thorough sun screen use)
    1. Those with darker skin require 3-6 fold more exposure
  6. Renal disease (Renal Failure, Nephrotic Syndrome)
    1. Renal losses of Vitamin D
  7. Hepatic disease (Cirrhosis)
  8. Gastrointestinal malabsorption
    1. Gastric surgery (resection or Gastric Bypass)
    2. Crohn's Disease
    3. Cystic Fibrosis
    4. Celiac Disease
  9. Small Bowel Resection
  10. Medications
    1. Anticonvulsant use (e.g. Phenobarbital, Phenytoin)
      1. Requires 2-5 fold more Vitamin D intake daily
    2. Corticosteroids (long-term use) or other Immunosuppressants
    3. Rifampin
    4. Antiviral Medications

VI. Pathophysiology

  1. Effects of Vitamin D Deficiency
    1. Altered secretion of Parathyroid Hormone
    2. Altered mineral ion metabolism
      1. Hypocalcemia
      2. Hypophosphatemia
    3. Mineralization defects in skeleton
      1. Osteomalacia in adults
      2. Rickets in children
  2. Step-by-step outcome of Vitamin D Deficiency
    1. Malabsorption of Calcium and Phosphorus
      1. Calcium absorption drops to 10% of normal
      2. Phosphorus absorption drops to 60% of normal
    2. Inadequate intestinal Calcium absorption
      1. Results in Hypocalcemia
      2. Severe Hypocalcemia occurs in later deficiency
    3. PTH secreted to compensate for Hypocalcemia
      1. Results in secondary Hyperparathyroidism
      2. Osteoclasts dissolve bone to mobilize Calcium from bone
        1. Exacerbates Osteomalacia and Osteoporosis
    4. Increased PTH results in phosphate wasting
      1. Severe hypophophatemia results

VII. Symptoms

  1. Early
    1. Diffuse Myalgias (may be associated marked serum Creatine Phosphokinase or CPK elevations)
    2. Proximal Muscle Weakness
      1. Associated with increased Fall Risk
  2. Later
    1. Bone pain
      1. Low Back Pain (especially older women)
      2. Extremity pain
    2. Secondary Hyperparathyroidism
      1. Osteoporosis
      2. Osteomalacia
    3. Symptomatic mineral disturbance
      1. See Hypocalcemia
      2. See Hypophosphatemia
  3. Other symptoms
    1. Abdominal Pain
    2. Seizures

VIII. Signs

  1. Bone pain reproduced with pressure applied to Sternum or tibia

IX. Differential Diagnosis

  1. See Hypocalcemia
  2. See Hypophosphatemia
  3. See Hyperparathyroidism
  4. Myalgias
    1. See Polymyositis Differential Diagnosis
    2. Consider in those diagnosed with Fibromyalgia, Myositis, Malingering

X. Associated Conditions: Conditions linked to Vitamin D Deficiency

  1. Musculoskeletal Conditions
    1. Osteomalacia
    2. Osteoporosis
    3. Rickets
  2. Other associated conditions (but insufficient evidence that supplementation prevents these conditions)
    1. Fall Risk
    2. Cardiovascular Disease
    3. Colon Cancer
    4. Major Depression

XI. Labs

  1. Serum 25-Hyroxyvitamin D Level
    1. Routine screening is not recommended
    2. Vitamin D testing or supplementation is not indicated in Major Depression, Fatigue, Osteoarthritis or Chronic Pain
    3. Preferred test (but expensive)
    4. Levels <20 ng/ml suggest deficiency (<30 ng/ml per endocrine society)
  2. Ionized Serum Calcium
  3. Serum Phosphorus
  4. Serum Creatine Phosphokinase
    1. May increase significantly in Vitamin D Deficiency with myalgias
  5. Consider testing for Vitamin D Deficiency mimics in Differential Diagnosis
    1. Thyroid Stimulating Factor
    2. Rheumatoid Factor
    3. Serum Vitamin B12

XII. Management

  1. Treat Hypocalcemia
    1. Symptomatic Hypocalcemia or Ionized Calcium <3.2 mg/dl
  2. Treat Hypophosphatemia
  3. Vitamin D Replacement
    1. See Vitamin D Replacement
  4. Vitamin D maintenance
    1. Guidelines do not recommend routine Vitamin D screening (outside Hypercalcemia, Renal Insufficiency)
    2. Maintain Vitamin D at least above 20 ng/ml (and >29 ng/ml per endocrine society)
    3. See Vitamin D for maintainance doses

XIII. Prevention

  1. Adequate dosing depends on latitude
    1. In northern climates 1000-2000 IU daily may be more appropriate
    2. Higher doses may be required in those with risk factors above

XIV. References

  1. Rendon et al. (2017) Crit Dec Emerg Med 31(6): 15-21
  2. Bordelon (2009) Am Fam Physician 80(8): 841-6 [PubMed]
  3. Holick (2007) N Engl J Med. 357(3):266-81 [PubMed]
  4. Holick (2008) Am J Clin Nutr 87:1080S-1086S [PubMed]
  5. LeFevre (2018) Am Fam Physician 97(4): 254-60 [PubMed]

Images: Related links to external sites (from Bing)

These images are a random sampling from a Bing search on the term "Vitamin D Deficiency." Click on the image (or right click) to open the source website in a new browser window. Search Bing for all related images

Related Studies

Ontology: Vitamin D Deficiency (C0042870)

Definition (CSP) condition due to a deficiency of vitamin D.
Definition (MSH) A nutritional condition produced by a deficiency of VITAMIN D in the diet, insufficient production of vitamin D in the skin, inadequate absorption of vitamin D from the diet, or abnormal conversion of vitamin D to its bioactive metabolites. It is manifested clinically as RICKETS in children and OSTEOMALACIA in adults. (From Cecil Textbook of Medicine, 19th ed, p1406)
Concepts Disease or Syndrome (T047)
MSH D014808
ICD9 268.9, 268
ICD10 E55 , E55.9
SnomedCT 190649007, 154728003, 190639009, 124886009, 34713006
English Deficiencies, Vitamin D, Deficiency, Vitamin D, Vitamin D Deficiencies, Unspecified vitamin D deficiency, VITAMIN D DEFICIENCY, Avitaminosis D NOS, Vitamin D deficiency, unspecified, DEFIC VITAMIN D, VITAMIN D DEFIC, vitamin D deficiency, vitamin D deficiency (diagnosis), avitaminosis D, avitaminosis D (diagnosis), Vitamin D deficiency NOS, Vitamin D Deficiency [Disease/Finding], d deficiencies vitamin, deficiency vitamin d, vitamin d deficiencies, d deficiencies vitamins, d deficiency vitamin, vitamin d deficiency, d deficiency vitamins, d vitamin deficiency, Avitaminosis D NOS (disorder), Deficiency of vitamin D (disorder), Hypovitaminosis D, Vitamin D Deficiency, Vitamin D deficiency, Avitaminosis D, Vitamin D deficiency (disorder), deficiency; vitamin, D, vitamin; deficiency, D, Avitaminosis D, NOS, Vitamin D deficiency, NOS
German VITAMIN-D-MANGEL, unspezifischer Vitamin D-Mangel, Vitamin-D-Mangel, nicht naeher bezeichnet, Vitamin D-Mangel, Vitamin-D-Mangel
Dutch niet-gespecificeerde vitamine-D-deficiëntie, deficiëntie; vitamine, D, vitamine; deficiëntie, D, Vitamine D-deficiëntie, niet gespecificeerd, vitamine-D-deficiëntie, Vitamine D-deficiëntie, Vitamine-D-gebrek, Deficiëntie, vitamine-D-, Vitamine-D-deficiëntie
French Carence en vitamines D non précisée, CARENCE EN VITAMINE D, Déficit en vitamine D, Carence en vitamine D, Carence en vit D
Italian Carenza non specificata di vitamina D, Carenza di vitamina D
Portuguese Carência de vitamina D NE, CARENCIA EM VITAMINA D, Carência de vitamina D, Deficiência de Vitamina D
Spanish Déficit no especificado de vitamina D, VITAMINA D, DEFICIT, déficit de vitamina D (trastorno), avitaminosis D, SAI, avitaminosis D, SAI (trastorno), avitaminosis D, deficiencia de vitamina D, hipovitaminosis D (trastorno), hipovitaminosis D, Déficit de vitamina D, Deficiencia de Vitamina D
Japanese ビタミンＤ欠乏、詳細不明, ビタミンＤ欠乏, ﾋﾞﾀﾐﾝDｹﾂﾎﾞｳｼｮｳｻｲﾌﾒｲ, ﾋﾞﾀﾐﾝDｹﾂﾎﾞｳ, ビタミンD欠乏症
Swedish Vitamin D-brist
Finnish D-vitamiinin puutos
Russian VITAMINA D NEDOSTATOCHNOST', ВИТАМИНА D НЕДОСТАТОЧНОСТЬ
Czech Blíže neurčený deficit vitaminu D, Deficit vitaminu D, vitamin D - nedostatek, nedostatek vitaminu D
Korean 상세불명의 비타민 D 결핍증, 비타민 D 결핍증
Croatian Not Translated[Vitamin D Deficiency]
Polish Hipowitaminoza D, Niedobór witaminy D
Hungarian Nem meghatározott D-vitamin hiány, D-vitamin hiány
Norwegian D-vitaminmangel, Vitamin D-mangel
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Vitamins

advertisement

2025 Family Practice Notebook, LLC. Terms | Privacy | About | Site Map | Newsletter | Blog

Footer Site Logo