Vitamin D deficiency
In medicine, vitamin D deficiency is "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."
Health science has reached no consensus on what constitutes optimal and suboptimal vitamin D status, evaluated by blood plasma concentration of 25-hydroxyvitamin D, currently the best status indicator.
Recommended serum levels are 20 ng/mL (50 nmol/L) according to the Institute of Medicine (IOM) and 30 ng/mL (75 nmol/L) according to the International Osteoporosis Foundation, Osteoporosis Canada, and Endocrine Society.
Institute of Medicine states (page 13):
- Levels over 20 ng/ml: "Practically all persons are sufficient"
- Levels 12-20 ng/ml: "Some, but not all, persons are potentially at risk for inadequacy."
- Levels below 12 ng/ml: "persons are at risk of deficiency."
A more recent cohort study agrees that levels about 20 ng/ml are desirable.
Vitamin D and bone density
Vitamin D levels and prevention of fractures
One review concluded that "mean serum 25(OH)D levels of about 75 to 110 nmol/l provide optimal benefits for all investigated endpoints without increasing health risks."
Epidemiology and prevalence
About a quarter of older adults have levels below 20 ng/mL.
Low levels of vitamin D are common in medical inpatients.
Levels below 47.5 nmol/L are associated with increased risk of hip fracture in women. Low levels are associated (below 20 nmol/L and maybe below 63 nmol/L) with increased fracture risk in men.
Vitamind D levels are related to 'total vitamin D intake from foods and supplements, waist circumference, recreational physical activity, race-ethnicity, regional solar irradiance, and age."
"The FokI, BsmI, ApaI, and TaqI VDR polymorphisms are not associated with BMD or with fractures, but the Cdx2 polymorphism may be associated with risk for vertebral fractures" according to an observational study. However, TaqI and FokI polymorphisms of the vitamin D receptor may be important to treatment of Mycobacterium tuberculosis.
Vitamin D was reported to be associated with widespread musculoskeletal pain like fibromyalgia. However, this was an uncontrolled study and more recent studies make the associated between Vitamin D and non-specific pain doubtful and suggest that earlier recommendations to screen patients with musculoskeletal pain for deficiency of vitamin D may not be justified.
Clinical practice guidelines direct treatment. Treatment of adults can be either 50,000 IU of D2 or D3 once a week for eight weeks or 6,000 IU daily. This is followed by 1,500 to 2,000 IU per day. Some populations may require higher doses.
A more recent randomized controlled trial showed that, among white women with vitamin D insufficiency and deficiency (levels 13 to 50 nmol/L;5 to 20 ng/mL ), a dose of 600 to 800 IU per day of vitamin D3 will raise the level above Institute of Medicine recommendations (20 ng/mL or 50 nmol/L) in 97% of women. D3 may be more effective than D2.
Obese patients need more vitamin D to raise their level.
Does higher than at least 800 IU daily may be best for prevention of fractures.
Daily intake of 1000 mg of elemental calcium as calcium carbonate with 400 IU of vitamin D3 may increase urolithiasis according to the Women's Health Initiative randomized controlled trial. This trial has been criticized because average age of the women at enrollment was 62 and they were only followed for 7 years; both problem may obscure benefit on fracture prevention.
| || Vitamin D plus calcium
|Absolute difference||Number needed|
|Hip fractures||175||199||24 less in supplementation group||1986 to treat*|
|Urolithiasis||449||381||68 more in supplementation group||284 to harm|
|* Among compliant patients. There was no significant benefit among all patients (absolute rate difference of 0.02 would indicate a number needed to treat of 5000 if the value were significant in a larger study).|
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