eMedicine Specialties > Endocrinology > Metabolic Disorders

Vitamin D Deficiency and Related Disorders

Author: Vin Tangpricha, MD, PhD, Associate Professor of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine
Coauthor(s): Natasha B Khazai, MD, Instructor of Medicine, Division of Endocrinology, Emory University School of Medicine
Contributor Information and Disclosures

Updated: Oct 5, 2009

Introduction

Background

Vitamin D deficiency in children can manifest as rickets (it is the most common cause of nutritional rickets), which presents as bowing of the legs. Vitamin D deficiency in adults results in osteomalacia, which presents as a poorly mineralized skeletal matrix. These adults can experience chronic muscle aches and pains.1 (See images below and Images 1-3.)

Findings in patients with rickets.

Findings in patients with rickets.

[ CLOSE WINDOW ]
Findings in patients with rickets.

Findings in patients with rickets.


Radiograph in a 4-year-old girl with rickets depi...

Radiograph in a 4-year-old girl with rickets depicts bowing of the legs caused by loading.

[ CLOSE WINDOW ]
Radiograph in a 4-year-old girl with rickets depi...

Radiograph in a 4-year-old girl with rickets depicts bowing of the legs caused by loading.


Anteroposterior and lateral radiographs of the wr...

Anteroposterior and lateral radiographs of the wrist of an 8-year-old boy with rickets demonstrates cupping and fraying of the metaphyseal region.

[ CLOSE WINDOW ]
Anteroposterior and lateral radiographs of the wr...

Anteroposterior and lateral radiographs of the wrist of an 8-year-old boy with rickets demonstrates cupping and fraying of the metaphyseal region.


Vitamin D is important for calcium homeostasis and for optimal skeletal health. The term vitamin D refers to either vitamin D2 or vitamin D3. Vitamin D3, also known as cholecalciferol, is either made in the skin or obtained in the diet from fatty fish. Vitamin D2, also known as ergocalciferol, is obtained from irradiated fungi, such as yeast. Vitamin D2 and vitamin D3 are used to supplement food products or are contained in multivitamins. Past studies suggested that vitamin D3 may be more effective than vitamin D2 in establishing normal vitamin D stores.2,3 However, a study by Holick and colleagues demonstrated that vitamin D2 and vitamin D3 appear to be equipotent in raising 25(OH)D concentrations when given in daily doses of 1000 IU.4

Pathophysiology

Vitamin D deficiency can result from a variety of causes, including inadequate exposure to sunlight, malabsorption problems, lack of vitamin D in breast milk, and the effects of certain medications. (See Causes.)

The production of vitamin D3 in the skin involves a series of reactions initiating with 7-dehydrocholesterol. Upon exposure to ultraviolet B (UVB) radiation between the wavelengths of 290-315 nm, 7-dehydrocholesterol is converted to previtamin D3, which is then converted to vitamin D3 after a thermally induced isomerization reaction in the skin. From the skin, newly formed vitamin D3 enters the circulation by binding to vitamin D binding protein (DBP). In order to become active, vitamin D requires 2 sequential hydroxylations to form 1,25-dihydroxyvitamin D (1,25[OH]2 D).

Vitamin D is initially hydroxylated in the 25 position by the hepatic microsomal and/or mitochondrial enzyme vitamin D 25-hydroxylase. The second hydroxylation occurs in the kidney by the P450 enzyme 25-hydroxyvitamin D-1 alpha-hydroxylase. Upon entering the cell, the 1,25(OH)2 D hormone binds to the vitamin D receptor (VDR). The bound vitamin D receptor then forms a heterodimer with the retinoic acid X receptor (RXR). This heterodimer then goes to the nucleus to bind deoxyribonucleic acid (DNA) and increases transcription of vitamin D–related genes.

The major function of vitamin D is to increase the efficiency of calcium absorption from the small intestine. Heaney and colleagues demonstrated that maximum calcium absorption occurs at levels of 25-hydroxyvitamin D (25[OH]D) greater than 32 ng/mL.5 Vitamin D also enhances the absorption of phosphorus from the distal small bowel. Adequate calcium and phosphorus absorption from the intestine is important for proper mineralization of the bone. The second major function of vitamin D is for the maturation of osteoclasts to resorb calcium from the bones.

Inadequate circulating 25(OH)D is associated with elevated parathyroid hormone (PTH); this condition is called secondary hyperparathyroidism. The rise in PTH may result in increased mobilization of calcium from the bone, which results in decreased mineralization of the bone.

Of note, prolonged exposure to the sun does not cause vitamin D toxicity. This is because after prolonged UVB radiation exposure, the vitamin D made in the skin is further degraded to the inactive vitamin D metabolites tachysterol and lumisterol.  

Frequency

United States

Vitamin D insufficiency is highest among people who are elderly, institutionalized, or hospitalized. In the United States, 60% of nursing home residents6 and 57% of hospitalized patients7 were found to be vitamin D deficient.

However, vitamin D insufficiency is not restricted to the elderly and hospitalized population; several studies have found a high prevalence of vitamin D deficiency among healthy, young adults. A study from Boston determined that nearly two thirds of healthy, young adults in Boston were vitamin D insufficient at the end of winter.8

International

Similar rates of vitamin D deficiency have been reported in Europe9 and Canada. A greater prevalence of vitamin D deficiency exists in Middle Eastern countries. A study of 316 young adults aged 30-50 from the Middle East showed that 72.8% had 25(OH)D values of less than 15 ng/dL (that is, severely deficient). This was significantly more common in women than in men (83.9% vs 48.5%). The difference between sexes probably reflects the cultural and religious practices leading to less skin exposure in women than in men.10,11,12,13

Mortality/Morbidity

  • The treatment of vitamin D insufficiency can decrease the risk of hip and nonvertebral fractures.14,15 A meta-analysis by Boonen et al of postmenopausal women and of men aged 50 years or older reporting a risk of hip fracture found that oral vitamin D supplementation reduced the risk of hip fractures by 18% when vitamin D and calcium were taken together.16 Most of the trials that demonstrated the antifracture efficacy of vitamin D used approximately 800 IU of vitamin D3. The minimum 25(OH)D level at which antifracture efficacy was observed was 30 ng/ml (74 nmol/L), suggesting a threshold for optimal levels of 25(OH)D for fracture protection.
  • Bischoff-Ferrari et al, in another meta-analysis, evaluated the efficacy of oral vitamin D supplementation in the prevention of hip and other nonvertebral bone fractures.17 The analysis, of individuals aged 65 years or older, took into account 12 double-blind, randomized, controlled trials (RCTs) for nonvertebral fractures (n = 42,279) and 8 RCTs for hip fractures (n = 40,886), comparing the results obtained from the use of oral vitamin D (with or without calcium) with those derived from the administration of calcium alone and from placebo use.

    The results indicated that vitamin D offers dose-dependent protection against fractures. In this study, doses of more than 400 IU per day were found to reduce fractures by at least 20% in individuals aged 65 years or older. In contrast to the Boonen study, the investigators maintained that these effects were independent of calcium supplementation.
  • Vitamin D insufficiency contributes to osteoporosis by decreasing intestinal calcium absorption.5,18 Treatment of vitamin D deficiency has been shown to improve bone mineral density.19,20 An analysis of the Third National Health and Nutrition Examination Survey (NHANES III) demonstrated a positive correlation between circulating 25(OH)D levels and bone mineral density.21
  • Vitamin D supplementation has been associated with a reduction in falls involving the older population. A meta-analysis demonstrated that vitamin D supplementation resulted in a reduction in falls of about 22% in ambulatory and institutionalized elderly subjects, as compared with controls.22,23
  • Epidemiologic data suggest that vitamin D deficiency places adults at risk for developing cancer24,25,26,27,28 ; these apparently include breast, colon, and prostate cancer.29,30 Several studies using cultured cancer cells in mice models have also supported the notion that vitamin D prevents the growth of cancers.31 Larger, randomized clinical trials are underway in humans to establish the role of vitamin D in the prevention of cancers.
  • Vitamin D insufficiency may increase the risk for type I and type II diabetes mellitus.32,33 In NHANES III, lower vitamin D status was associated with higher fasting glucose and 2-hour glucose after an oral glucose tolerance test.34 Furthermore, vitamin D supplementation in adults has been associated with improved insulin sensitivity in several small, case-control studies.32
  • A meta-analysis evaluated the effect of vitamin D supplementation (using a mean supplementation dosage of about 500 IU daily) on all-cause mortality in 18 randomized controlled trials and found a 7% relative risk reduction for death.35

Race

Darker skin interferes with the cutaneous synthesis of vitamin D. A study from by Holick and coauthors demonstrated that non-Hispanic black subjects require 6 times the amount of UV radiation necessary to produce the similar serum vitamin D concentration seen in non-Hispanic white subjects.36 The explanation for the increased radiation necessary to increase vitamin D levels is that melanin absorbs ultraviolet radiation. 

A higher prevalence of vitamin D insufficiency exists among non-Hispanic black persons. Dawson-Hughes and colleagues demonstrated that in Boston, 73% of elderly black subjects were vitamin D insufficient, compared with 35% of elderly non-Hispanic whites.37 In a large survey of 1500 healthy black women younger than 50 years, 40% were vitamin D deficient (25[OH]D <16 ng/mL), as compared with 4% of 1400 white women in that study.38 The decreased efficacy of vitamin D production by darker-pigmented skin explains the higher prevalence of vitamin D insufficiency among darker-skinned adults. 

Age

Vitamin D production in the skin declines with advancing age, making elderly populations more dependent on dietary vitamin D. For the average older person, higher dietary intake of vitamin D may be required to achieve optimal serum levels of 25(OH)D.33

Clinical

History

Vitamin D deficiency is often a silent disease. As previously mentioned, vitamin D deficiency in children can present as bowing of the legs from rickets. In adults, vitamin D deficiency results in osteomalacia, which presents as a poorly mineralized skeletal matrix. Adults in these cases can experience chronic muscle aches and pains.1

Vitamin D deficiency is the most common cause of nutritional rickets. Rare genetic forms of rickets occur because of defects in vitamin D metabolism. Vitamin D – dependent rickets type I occurs because of a defect in the renal 25-hydroxyvitamin D-1 alpha-hydroxylase that results in decreased 1,25(OH) 2 D production. Vitamin D – dependent rickets type II occurs when a mutation exists in the VDR.

Physical

  • In children with a severe vitamin D deficiency, the examination may reveal bowing in the legs.
  • In adults with a severe vitamin D deficiency, the examination can reveal periosteal bone pain. This is best detected using firm pressure on the sternal bone or tibia.

Causes

  • Inadequate exposure to sunlight - This causes a deficiency in cutaneously synthesized vitamin D. Adults in nursing homes or health care institutions are at a particularly high risk.39
  • Vitamin D malabsorption problems - People who have undergone resection of the small intestine are at risk for this condition. Diseases associated with vitamin D malabsorption include celiac sprue, short bowel syndrome,40 and cystic fibrosis.41
  • Minimal amounts of vitamin D in human breast milk - The American Academy of Pediatrics recommends vitamin D supplementation starting at age 2 months for infants fed exclusively with breast milk.42
  • Medications - Some medications are associated with vitamin D deficiency. Drugs such as Dilantin, phenobarbital, and rifampin can induce hepatic p450 enzymes to accelerate the catabolism of vitamin D.

More on Vitamin D Deficiency and Related Disorders

Overview: Vitamin D Deficiency and Related Disorders
Differential Diagnoses & Workup: Vitamin D Deficiency and Related Disorders
Treatment & Medication: Vitamin D Deficiency and Related Disorders
Follow-up: Vitamin D Deficiency and Related Disorders
Multimedia: Vitamin D Deficiency and Related Disorders
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Holick MF. Vitamin D deficiency: what a pain it is. Mayo Clin Proc. Dec 2003;78(12):1457-9. [Medline].

  2. Armas LA, Hollis BW, Heaney RP. Vitamin D2 is much less effective than vitamin D3 in humans. J Clin Endocrinol Metab. Nov 2004;89(11):5387-91. [Medline]. [Full Text].

  3. Trang HM, Cole DE, Rubin LA, et al. Evidence that vitamin D3 increases serum 25-hydroxyvitamin D more efficiently than does vitamin D2. Am J Clin Nutr. Oct 1998;68(4):854-8. [Medline]. [Full Text].

  4. Holick MF, Biancuzzo RM, Chen TC, et al. Vitamin D2 is as effective as vitamin D3 in maintaining circulating concentrations of 25-hydroxyvitamin D. J Clin Endocrinol Metab. Mar 2008;93(3):677-81. [Medline].

  5. Heaney RP, Dowell MS, Hale CA, et al. Calcium absorption varies within the reference range for serum 25-hydroxyvitamin D. J Am Coll Nutr. Apr 2003;22(2):142-6. [Medline]. [Full Text].

  6. Elliott ME, Binkley NC, Carnes M, et al. Fracture risks for women in long-term care: high prevalence of calcaneal osteoporosis and hypovitaminosis D. Pharmacotherapy. Jun 2003;23(6):702-10. [Medline].

  7. Thomas MK, Lloyd-Jones DM, Thadhani RI, et al. Hypovitaminosis D in medical inpatients. N Engl J Med. Mar 19 1998;338(12):777-83. [Medline]. [Full Text].

  8. Tangpricha V, Pearce EN, Chen TC, et al. Vitamin D insufficiency among free-living healthy young adults. Am J Med. Jun 1 2002;112(8):659-62. [Medline].

  9. van der Wielen RP, Löwik MR, van den Berg H, et al. Serum vitamin D concentrations among elderly people in Europe. Lancet. Jul 22 1995;346(8969):207-10. [Medline].

  10. Gannagé-Yared MH, Chemali R, Yaacoub N, et al. Hypovitaminosis D in a sunny country: relation to lifestyle and bone markers. J Bone Miner Res. Sep 2000;15(9):1856-62. [Medline].

  11. Looker AC, Gunter EW. Hypovitaminosis D in medical inpatients. N Engl J Med. Jul 30 1998;339(5):344-5; author reply 345-6. [Medline].

  12. Fuleihan GE, Deeb M. Hypovitaminosis D in a sunny country. N Engl J Med. Jun 10 1999;340(23):1840-1. [Medline].

  13. Mishal AA. Effects of different dress styles on vitamin D levels in healthy young Jordanian women. Osteoporos Int. 2001;12(11):931-5. [Medline].

  14. Chapuy MC, Arlot ME, Duboeuf F, et al. Vitamin D3 and calcium to prevent hip fractures in the elderly women. N Engl J Med. Dec 3 1992;327(23):1637-42. [Medline].

  15. Trivedi DP, Doll R, Khaw KT. Effect of four monthly oral vitamin D3 (cholecalciferol) supplementation on fractures and mortality in men and women living in the community: randomised double blind controlled trial. BMJ. Mar 1 2003;326(7387):469. [Medline]. [Full Text].

  16. Boonen S, Lips P, Bouillon R, et al. Need for additional calcium to reduce the risk of hip fracture with vitamin d supplementation: evidence from a comparative metaanalysis of randomized controlled trials. J Clin Endocrinol Metab. Apr 2007;92(4):1415-23. [Medline]. [Full Text].

  17. [Best Evidence] Bischoff-Ferrari HA, Willett WC, Wong JB, et al. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med. Mar 23 2009;169(6):551-61. [Medline].

  18. Heaney RP. Vitamin D depletion and effective calcium absorption. J Bone Miner Res. Jul 2003;18(7):1342; author reply 1343. [Medline].

  19. Dawson-Hughes B, Harris SS, Krall EA, et al. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N Engl J Med. Sep 4 1997;337(10):670-6. [Medline]. [Full Text].

  20. Harwood RH, Sahota O, Gaynor K, et al. A randomised, controlled comparison of different calcium and vitamin D supplementation regimens in elderly women after hip fracture: The Nottingham Neck of Femur (NONOF) Study. Age Ageing. Jan 2004;33(1):45-51. [Medline]. [Full Text].

  21. Bischoff-Ferrari HA, Dietrich T, Orav EJ, et al. Positive association between 25-hydroxy vitamin D levels and bone mineral density: a population-based study of younger and older adults. Am J Med. May 1 2004;116(9):634-9. [Medline].

  22. Bischoff HA, Stahelin HB, Dick W, et al. Effects of vitamin D and calcium supplementation on falls: a randomized controlled trial. J Bone Miner Res. Feb 2003;18(2):343-51. [Medline].

  23. 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. Oct 1 2009;339:b3692. [Medline].

  24. [Best Evidence] Lappe JM, Travers-Gustafson D, Davies KM, et al. Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial. Am J Clin Nutr. Jun 2007;85(6):1586-91. [Medline]. [Full Text].

  25. Chen TC, Holick MF. Vitamin D and prostate cancer prevention and treatment. Trends Endocrinol Metab. Nov 2003;14(9):423-30. [Medline].

  26. Garland CF, Comstock GW, Garland FC, et al. Serum 25-hydroxyvitamin D and colon cancer: eight-year prospective study. Lancet. Nov 18 1989;2(8673):1176-8. [Medline].

  27. Garland CF, Garland FC, Gorham ED. Calcium and vitamin D. Their potential roles in colon and breast cancer prevention. Ann N Y Acad Sci. 1999;889:107-19. [Medline].

  28. Garland FC, Garland CF, Gorham ED, et al. Geographic variation in breast cancer mortality in the United States: a hypothesis involving exposure to solar radiation. Prev Med. Nov 1990;19(6):614-22. [Medline].

  29. Chen TC, Wang L, Whitlatch LW, et al. Prostatic 25-hydroxyvitamin D-1alpha-hydroxylase and its implication in prostate cancer. J Cell Biochem. Feb 1 2003;88(2):315-22. [Medline].

  30. Freedman DM, Rajaraman P, Fuhrman B, et al. Sunlight, hormone replacement status and colorectal cancer risk in post-menopausal women. Int J Cancer. Sep 30 2009;[Medline].

  31. Tangpricha V, Flanagan JN, Whitlatch LW, et al. 25-hydroxyvitamin D-1alpha-hydroxylase in normal and malignant colon tissue. Lancet. May 26 2001;357(9269):1673-4. [Medline].

  32. Mathieu C, Gysemans C, Giulietti A, et al. Vitamin D and diabetes. Diabetologia. Jul 2005;48(7):1247-57. [Medline].

  33. Holick MF. Vitamin D: importance in the prevention of cancers, type 1 diabetes, heart disease, and osteoporosis. Am J Clin Nutr. Mar 2004;79(3):362-71. [Medline]. [Full Text].

  34. Scragg R, Sowers M, Bell C. Serum 25-hydroxyvitamin D, ethnicity, and blood pressure in the Third National Health and Nutrition Examination Survey. Am J Hypertens. Jul 2007;20(7):713-9. [Medline].

  35. [Best Evidence] Autier P, Gandini S. Vitamin D supplementation and total mortality: a meta-analysis of randomized controlled trials. Arch Intern Med. Sep 10 2007;167(16):1730-7. [Medline].

  36. Clemens TL, Adams JS, Henderson SL, et al. Increased skin pigment reduces the capacity of skin to synthesise vitamin D3. Lancet. Jan 9 1982;1(8263):74-6. [Medline].

  37. Harris SS, Soteriades E, Coolidge JA, et al. Vitamin D insufficiency and hyperparathyroidism in a low income, multiracial, elderly population. J Clin Endocrinol Metab. Nov 2000;85(11):4125-30. [Medline]. [Full Text].

  38. Nesby-O'Dell S, Scanlon KS, Cogswell ME, et al. Hypovitaminosis D prevalence and determinants among African American and white women of reproductive age: third National Health and Nutrition Examination Survey, 1988-1994. Am J Clin Nutr. Jul 2002;76(1):187-92. [Medline]. [Full Text].

  39. Liu BA, Gordon M, Labranche JM, et al. Seasonal prevalence of vitamin D deficiency in institutionalized older adults. J Am Geriatr Soc. May 1997;45(5):598-603. [Medline].

  40. Tangpricha V, Luo M, Fernández-Estívariz C, et al. Growth hormone favorably affects bone turnover and bone mineral density in patients with short bowel syndrome undergoing intestinal rehabilitation. J Parenter Enteral Nutr. Nov-Dec 2006;30:480-6. [Medline].

  41. Koutkia P, Lu Z, Chen TC, Holick MF. Treatment of vitamin D deficiency due to Crohn's disease with tanning bed ultraviolet B radiation. Gastroenterology. Dec 2001;121(6):1485-8. [Medline].

  42. Gartner LM, Greer FR. Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Pediatrics. Apr 2003;111(4 Pt 1):908-10. [Medline]. [Full Text].

  43. Hollis BW, Wagner CL. Normal serum vitamin D levels. N Engl J Med. Feb 3 2005;352(5):515-6; author reply 515-6. [Medline].

  44. Chapuy MC, Preziosi P, Maamer M, et al. Prevalence of vitamin D insufficiency in an adult normal population. Osteoporos Int. 1997;7(5):439-43. [Medline].

  45. Holick MF. Vitamin D deficiency. N Engl J Med. Jul 19 2007;357(3):266-81. [Medline].

  46. Lu Z, Chen TC, Zhang A, et al. An evaluation of the vitamin D3 content in fish: is the vitamin D content adequate to satisfy the dietary requirement for vitamin D?. J Steroid Biochem Mol Biol. Mar 2007;103(3-5):642-4. [Medline].

  47. Holick MF, Shao Q, Liu WW, et al. The vitamin D content of fortified milk and infant formula. N Engl J Med. Apr 30 1992;326(18):1178-81. [Medline].

  48. Tangpricha V, Koutkia P, Rieke SM, et al. Fortification of orange juice with vitamin D: a novel approach for enhancing vitamin D nutritional health. Am J Clin Nutr. Jun 2003;77(6):1478-83. [Medline]. [Full Text].

  49. Bischoff H, Stahelin HB, Vogt P, et al. Immobility as a major cause of bone remodeling in residents of a long-stay geriatric ward. Calcif Tissue Int. Jun 1999;64(6):485-9. [Medline].

  50. Elidrissy AT, Sedrani SH, Lawson DE. Vitamin D deficiency in mothers of rachitic infants. Calcif Tissue Int. May 1984;36(3):266-8. [Medline].

  51. Heaney RP. Vitamin D, nutritional deficiency, and the medical paradigm. J Clin Endocrinol Metab. Nov 2003;88(11):5107-8. [Medline]. [Full Text].

  52. Holick MF. Vitamin D: a millenium perspective. J Cell Biochem. Feb 1 2003;88(2):296-307. [Medline].

  53. Malabanan A, Veronikis IE, Holick MF. Redefining vitamin D insufficiency. Lancet. Mar 14 1998;351(9105):805-6. [Medline].

  54. Suda T, Ueno Y, Fujii K, et al. Vitamin D and bone. J Cell Biochem. Feb 1 2003;88(2):259-66. [Medline].

  55. Tangpricha V, Luo M, Fernández-Estívariz C, et al. Growth hormone favorably affects bone turnover and bone mineral density in patients with short bowel syndrome undergoing intestinal rehabilitation. J Parenter Enteral Nutr. Nov-Dec 2006;30:480-6. [Medline].

[ CLOSE WINDOW ]

Keywords

vitamin D deficiency, D vitamin, vitamin D, vitamin D calcium, vitamin D3, low vitamin D, rickets, osteomalacia, vitamin D2, deficiency of vitamin D, cholecalciferol, ergocalciferol, nutritional rickets, fat soluble vitamins, elevated parathyroid hormone, PTH, secondary hyperparathyroidism, vitamin B2, calcium absorption, phosphorus absorption, bone mineralization, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, 1,25(OH)2D, circulating 25(OH)D, osteoporosis, bone mineral density, cutaneous synthesis of vitamin D, cutaneous vitamin D production, vitamin D synthesis, melanin, vitamin D malabsorption, calcium absorption from the small intestine, vitamin D insufficiency

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Vin Tangpricha, MD, PhD, Associate Professor of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine
Vin Tangpricha, MD, PhD is a member of the following medical societies: American College of Clinical Endocrinologists, American College of Endocrinology, Endocrine Society, and Massachusetts Medical Society
Disclosure: NIH Grant/research funds Other

Coauthor(s)

Natasha B Khazai, MD, Instructor of Medicine, Division of Endocrinology, Emory University School of Medicine
Natasha B Khazai, MD is a member of the following medical societies: American Association of Clinical Endocrinologists and Endocrine Society
Disclosure: Nothing to disclose.

Medical Editor

Udaya M Kabadi, MD, Professor, Department of Medicine, University of Iowa College of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Romesh Khardori, MD, Chief, Division of Endocrinology, Metabolism and Molecular Medicine, Professor, Department of Internal Medicine, Southern Illinois University School of Medicine
Romesh Khardori, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Medical Association, American Society of Andrology, Endocrine Society, and Illinois State Medical Society
Disclosure: Nothing to disclose.

CME Editor

Mark Cooper, MBBS, PhD, FRACP, Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University
Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD, Professor of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.