Vitamin D Deficiency and Related Disorders Treatment & Management

  • Author: Vin Tangpricha, MD, PhD; Chief Editor: George T Griffing, MD   more...
 
Updated: Apr 20, 2012
 

Approach Considerations

The Endocrine Society, along with the Canadian Society of Endocrinology and Metabolism and the National Osteoporosis Foundation, published a clinical practice guideline in 2011 titled "Evaluation, Treatment and Prevention of Vitamin D Deficiency." The committee recommended screening of only those individuals who are at high risk for vitamin D deficiency, including patients with osteoporosis or a malabsorption syndrome, as well as black and Hispanic individuals, obese persons (BMI >30 kg/m2), and those with several other medical conditions.

The daily maintenance dose of vitamin D varies by age, but most children and adults generally require 600-2000 IU of vitamin D daily. For vitamin D-deficient children and adults, higher doses of vitamin D given either daily or weekly are recommended, followed by an increase in the daily dose of vitamin D.[49]

Follow-up

After correction of their vitamin D status with oral vitamin D, patients should have a repeat test of their 25(OH)D level to confirm that they are in the normal range. If the 25(OH)D concentration remains persistently low despite several attempts at correction with oral vitamin D, a trial of UVB light therapy (ie, by tanning lamps) may be considered to improve vitamin D status.

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Sun Exposure

Sensible sun exposure, especially between the hours of 10:00 am and 3:00 pm produces vitamin D in the skin that may last twice as long in the blood compared with ingested vitamin D.[50] If sun exposure produces slight pinkness, the amount of vitamin D produced in response to exposure of the full body is equivalent to ingesting 10,000-25,000 IU.[51] A variety of factors reduce the skin’s vitamin D-3 production, including increased skin pigmentation, aging, and the topical application of a sunscreen.

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Diet

Individuals who do not have exposure to sunlight are at risk for vitamin D deficiency if they do not ingest adequate amounts of foods that contain vitamin D.

However, most dietary sources of vitamin D do not contain sufficient amounts of the vitamin to satisfy daily requirements. Foods thought to contain high amounts of vitamin D3 are oily fish, such as salmon, mackerel, and blue fish, as well as fortified milk and other dairy products.

A single serving (3.5 oz) of wild-caught salmon has 988 ± 524 IU of vitamin D3, an amount that remains unchanged after baking but that decreases by 50% if the salmon is fried in vegetable oil.[52] In comparison, farm-raised salmon has only 25% of the vitamin D3 content found in the flesh of wild salmon. Blue fish and mackerel have vitamin D3 levels of 280 ± 68 IU and 24 IU, respectively.[52]

Fortified milk may contain less than the stated amount of vitamin D3 on the product (in some cases less than 80% of the amount).[53] Vegetables are not a good source for vitamin D.

The following foods contain the indicated amounts of vitamin D, as reported by the US Department of Agriculture's (USDA's) Nutrient Data Laboratory:

  • Fortified milk (8 oz) - 100 IU
  • Fortified orange juice (8 oz)[54] - 100 IU
  • Fortified cereal (1 serving) - 40-80 IU
  • Pickled herring (100 g) - 680 IU
  • Canned salmon with bones (100 g) - 624 IU
  • Mackerel (100 g) - 360 IU
  • Canned sardines (100 g) - 272 IU
  • Codfish (100 g) - 44 IU
  • Swiss cheese (100 g) - 44 IU
  • Raw shiitake mushrooms (100 g) - 76 IU
  • Most multivitamins (1 tab) - 400 IU
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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 and Endocrine Society

Disclosure: NIH Grant/research funds Principal Investigator; Genzyme Grant/research funds Principal Investigator; Amgen Grant/research funds Sub Investigator

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.

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.

Additional Contributors

Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, and Endocrine Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska

Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References

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

  2. 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].

  3. 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].

  4. 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].

  5. 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].

  6. 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].

  7. 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].

  8. 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].

  9. 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].

  10. 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].

  11. 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].

  12. 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].

  13. Shoben AB, Kestenbaum B, Levin G, Hoofnagle AN, Psaty BM, Siscovick DS, et al. Seasonal variation in 25-hydroxyvitamin d concentrations in the cardiovascular health study. Am J Epidemiol. Dec 15 2011;174(12):1363-72. [Medline].

  14. 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].

  15. 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].

  16. 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].

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

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

  19. 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].

  20. 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].

  21. 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].

  22. 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].

  23. 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].

  24. 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].

  25. 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].

  26. [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].

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

  28. 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].

  29. 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].

  30. 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].

  31. 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].

  32. 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].

  33. Muir SW, Montero-Odasso M. Effect of vitamin d supplementation on muscle strength, gait and balance in older adults: a systematic review and meta-analysis. J Am Geriatr Soc. Dec 2011;59(12):2291-300. [Medline].

  34. [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].

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

  36. 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].

  37. 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].

  38. 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].

  39. 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].

  40. 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].

  41. 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].

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

  43. 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].

  44. Joergensen C, Hovind P, Schmedes A, Parving HH, Rossing P. Vitamin d levels, microvascular complications, and mortality in type 1 diabetes. Diabetes Care. May 2011;34(5):1081-5. [Medline].

  45. [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].

  46. Bjelakovic G, Gluud LL, Nikolova D, et al. Vitamin D supplementation for prevention of mortality in adults. Cochrane Database Syst Rev. Jul 6 2011;CD007470. [Medline].

  47. 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].

  48. 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].

  49. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. Jun 6 2011;[Medline].

  50. Haddad JG, Matsuoka LY, Hollis BW, Hu YZ, Wortsman J. Human plasma transport of vitamin D after its endogenous synthesis. J Clin Invest. Jun 1993;91(6):2552-5. [Medline]. [Full Text].

  51. Holick MF, Chen TC. Vitamin D deficiency: a worldwide problem with health consequences. Am J Clin Nutr. Apr 2008;87(4):1080S-6S. [Medline].

  52. 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].

  53. 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].

  54. 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].

  55. Hollis BW. Short-term and long-term consequences and concerns regarding valid assessment of vitamin D deficiency: comparison of recent food supplementation and clinical guidance reports. Curr Opin Clin Nutr Metab Care. Nov 2011;14(6):598-604. [Medline].

  56. 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].

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

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

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

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

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

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

 
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Findings in patients with rickets.
Radiograph in a 4-year-old girl with rickets depicts bowing of the legs caused by loading.
Anteroposterior and lateral radiographs of the wrist of an 8-year-old boy with rickets demonstrates cupping and fraying of the metaphyseal region.
 
 
 
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