Vitamin D deficiency

Vitamin D deficiency can be difficult to notice because symptoms may not occur for several months or years. In some cases, individuals may not exhibit any symptoms at all.

Vitamin D deficiency is more common in adults. Symptoms in adults may include:

• Bone pain
• Muscle weakness
• Muscle cramps
• Fatigue
• Loss of appetite
• Increased susceptibility to illness
• Hair loss
• Pale skin
• Depression (feelings of sadness)
• Insomnia

Severe vitamin D deficiency in children can lead to:

• Muscle pain and weakness
• Bone pain
• Lethargy
• Frequent respiratory infections
• Rickets (a bone condition that causes growth abnormalities and joint deformities)
• Bone fractures
• Slow growth and developmental delays
• Seizures due to low calcium levels

• Inadequate vitamin D synthesis in the skin
• Insufficient dietary intake of vitamin D
• Poor absorption of vitamin D from food
• Vitamin D is not converted to its active form
• Certain medications that interfere with the body's ability to convert or absorb vitamin D

Various risk factors associated with these causes are discussed in the next section.

Risk Factors For Vitamin D Deficiency

Some of the most common risk factors associated with vitamin D deficiency are discussed as follows:

Inadequate vitamin D synthesis in the skin

• Decreased sun exposure: Reduced exposure to sunlight is a major risk factor for vitamin D deficiency. Research suggests that 20 minutes of sunshine daily with over 40% of the skin exposed is required to avoid vitamin D deficiency.
• Deeper skin tone: Individuals with deeper skin tones or darker skin produce less vitamin D with the same amount of sunlight exposure than individuals with lighter skin color.
• Staying and working indoors: Individuals who stay home almost all the time and hardly go out during the day are more prone to vitamin D deficiency.
• Working overnight shifts: Those working night shifts may have a higher risk of vitamin D deficiency due to less opportunity for sunlight exposure compared to daytime workers.
• Old age: Older individuals often spend the majority of their time indoors, receiving minimal exposure to natural sunlight. Additionally, as skin thins with age, vitamin D synthesis becomes less efficient.
• Physical blocking of sunlight: Full coverage clothing and the use of sunscreens can decrease the amount of vitamin D production in the skin in cases of severe sun protection.
• Geographic factors: Factors such as higher latitude (living far from the equator), lower altitude (less distance from sea level), winter season, air pollution, and cloud-shading may limit sun exposure and affect vitamin D production.

Inadequate dietary intake of vitamin D

• Unbalanced diet: Inadequate intake of vitamin D-rich foods, such as milk, dairy, and animal-based sources like fish, fish oils, egg yolks, fortified milk, and beef liver, is a major risk factor for vitamin D deficiency.
• Vegetarian diet: A vegetarian diet that includes only plant-based foods and no animal products is linked to vitamin D deficiency.
• Eating disorders: Eating disorders such as anorexia nervosa and bulimia nervosa are strongly associated with vitamin D deficiency and decreased bone density.
• Medically restricted diets: Individuals on medically restricted diets due to certain medical conditions are at a higher risk of various nutrient deficiencies, including vitamin D deficiency.
• Fad diets: Fad diets, which are popular dietary patterns known to be quick fixes for obesity, often eliminate food groups containing vitamin D, increasing the risk of deficiency.
• Lactose intolerance: Studies have shown that individuals who are genetically intolerant to lactose may suffer from vitamin D deficiency due to dietary restrictions of milk and dairy products.

Poor absorption of vitamin D from food

• Medical conditions: Various medical conditions interfere with the absorption of vitamin D from the diet, including intestinal malabsorption (Celiac disease, Crohn’s disease, ulcerative colitis), pancreatic insufficiency (Cystic fibrosis), and cholestasis syndrome (Biliary atresia).
• Gut resection or small bowel resection: This surgery, performed to remove a part of the small bowel when blocked or diseased, negatively impacts the absorption of vitamin D from food.
• Weight loss surgeries: Weight-loss surgeries, such as gastric bypass surgery, reduce the size of the stomach and can lead to poor absorption of vitamin D.

Genetic or endocrine disorders

• Chronic liver diseases
• Kidney diseases
• Hyperparathyroidism
• Growth hormone deficiency
• Diabetes mellitus
• Hereditary resistance to vitamin D

Note: Research indicates that genetic influence on vitamin D levels is estimated to be around 80%, significantly higher than the dietary and environmental influences of around 25%.

Certain medications

• Steroids (such as prednisolone, dexamethasone)
• Anti-seizure drugs (such as carbamazepine, topiramate, phenobarbital, and phenytoin)
• Tuberculosis drugs (such as rifampicin)
• Cholesterol-lowering drugs (such as cholestyramine and colestipol)
• Antifungal agents (such as ketoconazole)
• Antiretroviral drugs for treating HIV

Perinatal factors

• Breastfed infants: Infants who are exclusively breastfed but do not receive supplemental vitamin D or adequate sunlight exposure are at increased risk of developing vitamin D deficiency and rickets.
• Maternal vitamin D deficiency during pregnancy: Vitamin D deficiency is observed in both pregnant women and newborn infants. Maternal deficiency can lead to deficiency in the newborn and is linked with various complications during pregnancy and delivery.

Other factors

• Smoking: Vitamin D deficiency is higher among smokers. Research has shown that smoking may affect the gene that activates the production of vitamin D-3 in the body.

History and Physical Examination

During screenings for vitamin D deficiency, a medical practitioner analyzes potential risk factors and the personal health history. Various signs and symptoms of vitamin D deficiency are evaluated.

Blood Tests

• 25-hydroxy vitamin D (25-OH D), or calcidiol: The 25-(OH)D serum concentration is widely accepted as the best indicator of vitamin D status in individuals.
• 1,25-dihydroxy vitamin D (1,25(OH)2 D), or calcitriol: This test measures the bioactive form of vitamin D. The serum concentration of the active hormone 1α,25-(OH)2D does not provide sufficient information on vitamin D status.

The 25-(OH)D has an almost 1000-fold greater concentration than 1,25-(OH)2D and has a longer half-life of 20 days, making it more stable in circulation. Therefore, total-body vitamin D stores are best measured by assessing the circulating levels of 25-(OH)D.

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Imaging Tests

• Bone X-rays: This imaging test can be advised if the doctor suspects that the patient may have bone weakness and softness.
• Dual-energy x-ray absorptiometry (DEXA) scan: This test helps in measuring bone mineral density in patients with chronic vitamin D deficiency.

Vitamin D deficiency can be prevented by adhering to its Recommended Dietary Allowance (RDA). The RDA of vitamin D indicates the daily intake sufficient to maintain bone health and normal calcium metabolism in healthy individuals. It is listed in both micrograms (mcg) and international units (IU). One mcg of vitamin D is equal to 40 IU.

The RDA according to various age groups is as follows:

• 0-12 months: 400 IU (10 mcg)
• 1-70 years: 600 IU (15 mcg)
• Over 70 years: 800 IU (20 mcg)

Some tips for avoiding vitamin D deficiency include:

1. Do not shy away from the sun: Research shows that approximately 5–30 minutes of sun exposure, particularly between 10 a.m. and 4 p.m., either daily or at least twice a week to the face, arms, hands, and legs without sunscreen usually leads to sufficient vitamin D synthesis.
2. Consume vitamin D-containing foods: Include these foods regularly as part of a healthy balanced diet to top up your vitamin D levels:
   • Fatty fish – salmon, sardines, pilchards, tuna, mackerel
   • Seafood – oysters, shrimp
   • Red meat and liver
   • Mushrooms
   • Egg yolks
   • Cod liver oil
   • Soya products
3. Include fortified foods containing vitamin D:
   • Cow’s milk, almond, and oat milk
   • Breakfast cereals
   • Other dairy products, such as yogurt
   • Orange juice
4. Maintain a healthy body weight: Maintaining a healthy body weight and avoiding being overweight can help sustain vitamin D levels. Cycling and exercising regularly outside can assist in maintaining a healthy weight and sun exposure.
5. Treat underlying medical conditions: Individuals with underlying health conditions such as celiac disease and cystic fibrosis may experience impaired nutrient absorption. Therefore, treating these conditions may help boost the levels of certain nutrients, including vitamin D.

The treatment of vitamin D deficiency involves taking vitamin D supplements. The form of vitamin D that is taken is called ergocalciferol or calciferol. Vitamin D can be administered in various forms, including injectables or as a medicine (liquid or tablets). The doctor will discuss the dosage and the best treatment schedule, depending on the severity, age, and individual situation.

Supplements

Both D2 (ergocalciferol) and D3 (cholecalciferol) are available as dietary supplements and are well absorbed in the gut. Both D2 and D3 raise serum 25(OH)D levels; however, most studies indicate that vitamin D3 increases serum 25(OH)D levels to a greater extent and maintains these higher levels longer than vitamin D2.

• For initial supplementation, it is recommended to take Vitamin D3 for eight weeks at either 6,000 IU daily or 50,000 IU weekly. Note: Once the serum vitamin D exceeds 30 ng/mL, a daily maintenance dose of 1,000 to 2,000 IU is recommended.
• For high-risk adults who are vitamin D deficient due to an underlying condition, a higher initial supplementation dose of Vitamin D3 at 10,000 IU daily is necessary. Note: Once the serum vitamin D level exceeds 30 ng/mL, a maintenance dose of 3,000 to 6,000 IU/day is recommended.
• Children with vitamin D deficiency require 1,000 IU/day of vitamin D3 or 50,000 IU of vitamin D3 once weekly for 6 weeks. Note: Once the serum vitamin D level exceeds 30 ng/mL, a maintenance treatment of only 1,000 IU/day is recommended.

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Vitamin D, also known as the sunshine vitamin, is extremely beneficial for maintaining overall good health. Home care for Vitamin D deficiency includes adhering to the following points:

• Increase sun exposure, aiming for at least 15 minutes a day.
• Incorporate vitamin D-rich foods into your diet, such as fatty fish, fortified dairy products, and egg yolks.
• Consider vitamin D supplements after consulting with a healthcare provider.
• Regularly monitor vitamin D levels through blood tests as recommended by your doctor.
• Maintain a healthy lifestyle with regular exercise to support overall health.

Not getting enough vitamin D may raise the risk for other diseases and conditions, some of which can be life-threatening. Some of the complications of vitamin D deficiency include:

Bone Related Diseases

• Rickets: A childhood disease in which the child's bones become too soft, causing them to warp, bend, and break more easily.
• Osteomalacia: Refers to the softening of bones in adults.
• Osteoporosis: A bone disease that develops when bone mineral density and bone mass decrease.

Lifestyle-Related Diseases

• Type 2 Diabetes: Vitamin D deficiency is associated with decreased insulin release and insulin resistance, predisposing individuals to diabetes.
• Obesity: Vitamin D deficiency is strongly linked to being overweight and obese.
• Polycystic Ovary Syndrome (PCOS): Vitamin D deficiency is considered a risk factor for PCOS, with the degree of deficiency correlating with the severity of the condition.

Cardiovascular Diseases

• Heart Diseases: Many studies have shown that vitamin D deficiency increases the risk of developing hypertension, heart failure, and coronary artery disease.
• Stroke: A condition in which the blood supply to the brain is disrupted. Vitamin D deficiency can increase the risk of ischemic stroke in healthy individuals.

Autoimmune Diseases

• Multiple Sclerosis: Vitamin D deficiency may play a role in immune system functioning and the development of autoimmune disorders such as multiple sclerosis.
• Type 1 Diabetes: Low vitamin D is associated with insulin resistance, contributing to the development of type 1 diabetes.

Eye-Related Diseases

• Age-Related Macular Degeneration (AMD): An eye disease that can blur central vision. Lack of vitamin D appears to increase oxidative damage leading to degeneration of photoreceptors in the eyes.

Neurological Diseases

• Depression: People with depression have a higher likelihood of having vitamin D deficiency.
• Sleep Disturbances: Vitamin D deficiency can increase the risk of sleep disorders, including difficulty falling asleep, shorter sleep duration, and nocturnal awakenings in children and adults.
• Alzheimer's Disease: Vitamin D participates in the clearance of amyloid beta (Aβ) aggregates, a hallmark of Alzheimer's disease. Low serum vitamin D levels have been associated with a greater risk of dementia and Alzheimer's disease.
• Parkinson's Disease: Long-term low vitamin D levels may lead to the loss of nerve cells, predisposing individuals to Parkinson's disease, characterized by uncontrollable movements, stiffness, and difficulty in balance and coordination.

Respiratory Diseases

• Tuberculosis: Vitamin D deficiency is associated with an increased risk of developing active tuberculosis in individuals with latent tuberculosis infection (LTBI).
• Upper Respiratory Tract Infections: Upper respiratory tract infections of viral origin, such as influenza, are strongly linked to vitamin D deficiency.

Cancers

Vitamin D deficiency has been linked to an increased risk of prostate, ovarian, breast, lung, esophageal, colon, liver, and pancreatic cancer.

Some of the alternative therapies that can augment diet, supplements, and sun exposure include:

• Exercise: A sedentary lifestyle and physical inactivity are significant risk factors for vitamin D deficiency. Engaging in vigorous exercises such as running and jogging for three or more hours a week can help maintain optimum levels of vitamin D.
• Yoga: Practicing yoga asanas early in the morning during sunlight can help replenish vitamin D levels and alleviate symptoms such as muscle pain, fatigue, and exhaustion. Sunlight also boosts the immune system and elevates mood.