Vitamin D Deficiency and Related Disorders Treatment & Management
- Author: Vin Tangpricha, MD, PhD; Chief Editor: Romesh Khardori, MD, PhD, FACP more...
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.
In a population-based study, the electronic medical records of more than 1,200,000 members of a health maintenance organization (HMO) were analyzed to determine the upper limit of vitamin D beyond which there is an increased risk of acute coronary syndrome (ACS) or mortality.[60, 61] The lowest risk of mortality and morbidity was reported in members with vitamin D levels in the 20-36 ng/mL range. The hazard ratio increased not only below but also above this range, with adjusted hazard ratios of 1.88 among subjects with vitamin D levels lower than 10 ng/mL, 1.25 among those with levels of 10-20 ng/mL, and 1.13 among those with levels higher than 36 ng/mL (P < 0.05).
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. 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. A variety of factors reduce the skin’s vitamin D-3 production, including increased skin pigmentation, aging, and the topical application of a sunscreen. A clinical study from Sweden comparing full body irradiation with UVB lamps 3 times a week for 6 weeks to a daily vitamin D3 supplement of 1,600 IU daily for 6 weeks found UVB therapy to be more efficacious in raising serum 25(OH)D concentrations. This suggests that UVB therapy may be a useful therapeutic approach in selected individuals.
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. 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.
Fortified milk may contain less than the stated amount of vitamin D3 on the product (in some cases less than 80% of the amount). 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)  - 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
It should be kept in mind that the potency of vitamin D supplements from different manufacturers can vary widely. In one study, pills from sealed bottles of over-the-counter cholecalciferol supplements (1000 IU, 5000 IU, and 10,000 IU) contained 52-135% of the dose listed on the labels. Analysis of bottles with the same lot number revealed that potency ranged from 57% to 138% of what was on the bottle. Compounded 50,000-IU pills contained 52-105% of the expected dose, and 1000-IU compounded pills contained 23-146%.
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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