Vitamin D Deficiency
Deficiencies Vitamin D
Vitamin D deficiency can result from inadequate nutritional intake, inadequate exposure to sunlight or malabsorption. Vitamin D is important for calcium homeostasis and for optimal skeletal health. A deficiency results in impaired bone mineralization and leads to osteomalacia, or rickets when diagnosed in children. The amount of vitamin D recommended for all infants, children and adolescents is 600 IU per day. The flesh of fatty fish, beef liver, cheese and egg yolks are among the best sources.
Presentation
Vitamin D deficiency in infants causes development of rickets in them. Such children exhibit peculiar characteristics of delayed walking, and prefer prolonged periods of sitting. In older children, walking becomes painful and in severe cases, bow legs may develop. In adolescent girls, the pelvic bones flatten, which in turn causes narrowing of the birth canal. Vitamin D deficiency is the major and common cause of nutritional rickets.
In adults, vitamin D deficiency may precipitate as osteomalacia. Affected adults complain of muscle aches and pain. Such individuals are also prone to frequent fractures due to poorly mineralized skeletal matrix [7].
Entire Body System
Weight Loss
- We present a case of a 30-year-old woman presented with muscle weakness, weight loss, hypercalcaemia and a pathological fracture, eventually with rapidly progressive musculoskeletal disease.[ncbi.nlm.nih.gov]
- This weight-loss surgery removes part of the stomach and/or the intestines. Reducing the size of these organs lowers the amount of vitamin D-containing nutrients that can be absorbed. Obesity .[my.clevelandclinic.org]
- The benefits of vitamin D, backed up by tons of research , ring loud and clear: strong bones, improved mood, even more efficient weight loss . But signs that you're low on the nutrient are a bit quieter.[womenshealthmag.com]
Malnutrition
- Primary intestinal lymphangiectasia is a rare disease of children, which is characterized by chronic diarrhea and complicated with malnutrition, including fat-soluble vitamin deficiency.[ncbi.nlm.nih.gov]
- Abbreviations DHQ: diet history questionnaire IQR: interquartile range MAM: moderate acute malnutrition NIH: National Institutes of Health PEM: protein energy malnutrition PTH: parathyroid hormone SAM: severe acute malnutrition SD: standard deviation[doi.org]
- Senior Fall Prevention Lap Buddy How to Prevent Senior Malnutrition[aplaceformom.com]
- Foods fortified with vitamin D almost eradicated rickets, a weak bone condition that stems from malnutrition. However, “it’s nearly impossible for anyone to satisfy vitamin D needs through diet alone,” says Dr. Holick.[prevention.com]
Musculoskeletal
Osteoporosis
- Both PHPT and VDD contributed to severe osteoporosis, which could be exacerbated by not attaining his peak bone mass and by immobilization because of a fragile fracture with delayed healing.[ncbi.nlm.nih.gov]
- Mayo Clinic Proceedings. 2010;85(8):752-758 National Osteoporosis Sociaety (NOS) 2018.[gpnotebook.co.uk]
Muscle Weakness
- Apart from the well-known effects on bone metabolism, this condition is also associated with muscle weakness, predominantly of the proximal muscle groups.[ncbi.nlm.nih.gov]
Bone Pain
- This study aimed to determine the association of vitamin D deficiency with tibial bone pain and tenderness. METHODS: Patients with leg pain, defined as local pain and tenderness over tibial bones for 6 weeks were consecutively selected.[ncbi.nlm.nih.gov]
- Muscle and Bone Pain Muscle and bone pain that does not have another cause, such as illness or injury, may be caused by a deficiency in Vitamin D. In many cases, this pain is caused by an extreme deficiency in the vitamin.[vitamins.lovetoknow.com]
Proximal Muscle Weakness
- We report a four-year-old African boy referred for proximal muscle weakness, fatigability and episodic limb pain.[ncbi.nlm.nih.gov]
- Children with established vitamin D deficiency present with features of rickets (skeletal abnormalities, developmental delay, failure to thrive), whereas adults present with signs and symptoms of osteomalacia (bone pain and tenderness, proximal muscle[bestpractice.bmj.com]
- Common manifestations of vitamin D deficiency are symmetric low back pain, proximal muscle weakness, muscle aches, and throbbing bone pain elicited with pressure over the sternum or tibia.[aafp.org]
Rachitic Rosary
- Rachitic rosary — Beadlike bumps present at the junction of the ribs with their cartilages—often seen in children with rickets.[medical-dictionary.thefreedictionary.com]
- rosary and Harrison’s sulcus, extending from the costal cartilage transversely outward to the axilla.[news-medical.net]
- Costochondral thickening can look like beadlike prominences along the lateral chest wall (rachitic rosary).[merckmanuals.com]
- However, severe vitamin D deficiency may manifest as rickets with the below clinical features: Bony Signs - Swelling of wrists and ankles - Leg deformities (genu varum or valgum) - Rachitic rosary in the chest wall ( enlarged costochondral joints) - Delayed[starship.org.nz]
Urogenital
Dyspareunia
- Desquamative inflammatory vaginitis (DIV) is a chronic disorder associated with yellow vaginal discharge, vulvovaginal burning and pruritus, and dyspareunia.[ncbi.nlm.nih.gov]
Neurologic
Febrile Convulsions
- The patient presented with a history of febrile convulsions, for which he received phenobarbital treatment.[ncbi.nlm.nih.gov]
Workup
Serum levels of 25(OH) D less than 15 or 20 ng/mL are defined as vitamin D deficiency. Whereas, levels below 30mg/mL are considered to be insufficient levels of vitamin D. When the serum level of 25(OH) D is above 30ng/mL, then maximum intestinal absorption of calcium occurs. On the other hand, when the levels begin to fall below 30ng/mL, then the levels of parathyroid hormone get elevated. This is considered to be another important marker for vitamin D deficiency [8]. It indicates an inverse relationship between parathyroid hormone and 25(OH) D. Measuring the serum 25(OH) D levels is the best method to determine vitamin D deficiency.
Serum
Calcium Decreased
- Vitamin D supplementation combined with calcium decreased body sway and falls in a German study [ 5 ] and decreased hip as well as other non-vertebral fractures in French nursing home residents [ 9 ], whereas the results in more healthy elderly, living[doi.org]
Other Pathologies
Lymphocytic Infiltrate
- Primary Sjögren's syndrome (pSS) is a chronic autoimmune disease characterized by progressive lymphocyte infiltration of the exocrine glands.[ncbi.nlm.nih.gov]
Biopsy
Hepatocellular Carcinoma
- A 68-year-old man with type 2 diabetes mellitus and chronic hepatitis B infection was referred to the nephrology department before planned surgery for hepatocellular carcinoma. He had been receiving low-dose adefovir dipivoxil (ADV) for 11 years.[ncbi.nlm.nih.gov]
Treatment
Vitamin D deficiency is treated through administration of its supplements. The dosage schedule depends on the age of the individual, and extent of deficiency that has set in. A daily maintenance dose of vitamin D for children and adults is given to be about 600 – 2000 IU daily. For the deficient population, doses higher than the recommended limits are suggested to be taken on weekly basis with additional extra allowance to meet daily requirements.
It is necessary that the 25(OH) D levels are checked post supplementation program. This is required to know whether the levels have reached the normal levels or not. If the levels continue to remain low, then the method of UVB light therapy is used for improving the vitamin D status [9].
Prognosis
Timely initiation of treatment is necessary to prevent occurrence of hip and nonvertebral fractures. Individuals should be put on supplements of vitamin D, when the first signs of deficiency are noticed. Prolonged deficiency of vitamin D can cause onset of severe and debilitating conditions, such as fractures, rickets and osteoporosis. Several studies have also demonstrated a relation between low levels of circulating vitamin D, and increase risk of developing, diabetes mellitus, cardiovascular disease and cancer [6].
Etiology
Vitamin D deficiency can occur due to the following factors:
- Lack of exposure to sunlight: Vitamin D is synthesized in the skin when exposed to sunlight. Individuals who stay indoors, or children who do not indulge in outdoor games, may develop vitamin D deficiency [2].
- Malabsorption: Individuals with malabsorption syndromes, such as celiac disease, cystic fibrosis, and short bowel syndrome, or those who have undergone resection of small intestine also develop vitamin D deficiency.
- Insufficient amounts of vitamin D in breast milk: Human breast milk does not contain adequate amounts of vitamin D. Therefore, infants who are exclusively breast fed are at risk of developing deficiency of vitamin D.
- Medications and drugs: Certain types of medications such as rifampin, dilantin and phenobarbital, are known to interfere with absorption of vitamin D causing its deficiency.
Epidemiology
Vitamin D deficiency is a common phenomenon for the elderly population and those who are hospitalized. It has been estimated that in the US, about 60% of nursing residents and 57% of patients who were hospitalized developed vitamin D deficiency [3].
Seasonal variations also have an impact on the vitamin D status of individuals. A study carried out on healthy individuals of Boston revealed that, at the end of winter season, the individuals under study had insufficient levels of vitamin D [4].
Pathophysiology
Vitamin D primarily exists in 2 different forms, D2 known as ergocalciferol and D3 known as cholecalciferol. The D3 form is synthesized when the body is exposed to sunlight. Some dietary sources such as fish oils and salted fish also contain vitamin D3. Vitamin D is important for optimal functioning of various body organs. However, its most vital functioning is to promote the absorption of calcium and phosphate from the intestine, thereby maintaining optimal bone health. Therefore, deficiency of vitamin D causes poor bone health predisposing individuals to develop several bone disorders [5].
Prevention
In order to avoid vitamin D deficiency from setting in, it is required that individuals get adequate exposure to sun. Children should be encouraged to indulge more in outdoor games. Infants who are exclusively breastfed should be started on vitamin D supplements after 2 months; this is so because breast milk does not contain adequate amounts of vitamin D. In addition, pregnant women should also be given vitamin D supplements, to prevent onset of its deficiency in the woman and the fetus. Elderly population who do not get enough sun exposure should also take daily of 10 micrograms of vitamin D [10].
Summary
Vitamin D deficiency is characterized by insufficient levels of vitamin D in body that can cause several debilitating conditions. Lack of intake, exposure to sunlight and, or, malabsorption can cause deficiency of vitamin D to set in. Vitamin D is vital for calcium and phosphorus homeostasis, as well as is important for maintaining skeletal health. Most often signs of mild vitamin D deficiency do not show up easily. However, in cases of severe deficiency, affected individuals often end up contracting bone diseases such as rickets and osteomalacia [1].
Patient Information
Definition
Vitamin D deficiency occurs due to lack of intake, sun exposure, or certain malabsorption syndrome. Infants who are only breast fed are also susceptible to develop deficiency of vitamin D.
Cause
Individuals who stay indoors, such as hospitalized patients, or nursing residents, do not get sufficient sun exposure. Lack of sun exposure can cause vitamin D deficiency to set in. In addition, malabsorption syndromes, such as celiac disease, cystic fibrosis and short bowel syndrome, can also increase the risk of developing vitamin D deficiency.
Symptoms
Symptoms of vitamin D deficiency in infants include delayed crawling and walking. Affected children prefer to sit rather than walk, and in severe cases can develop rickets. In adults, vitamin D deficiency manifests as development of osteomalacia.
Diagnosis
Serum level of 25(OH) D is assessed to diagnose vitamin D deficiency. Levels low than 15 or 20ng/mL confirms vitamin D deficiency.
Treatment
Treatment involves giving vitamin D supplements to the affected individuals. In case, when supplements do not work, then UVB light therapy can be considered.
References
Article
- Holick MF. Vitamin D deficiency: what a pain it is. Mayo Clin Proc. Dec 2003;78(12):1457-9.
- Gloth FM 3rd, Gundberg CM, Hollis BW, et al. Vitamin D deficiency in homebound elderly persons. JAMA 1995; 274:1683.
- 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
- Tangpricha V, Pearce EN, Chen TC, Holick MF. Vitamin D insufficiency among free-living healthy young adults. Am J Med 2002; 112:659
- 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.
- 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.
- Weisberg P, Scanlon KS, Li R, Cogswell ME. Nutritional rickets among children in the United States: review of cases reported between 1986 and 2003. Am J Clin Nutr 2004; 80:1697S.
- 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.
- Lagunova Z, Porojnicu AC, Aksnes L, et al. Effect of vitamin D supplementation and ultraviolet B exposure on serum 25-hydroxyvitamin D concentrations in healthy volunteers: a randomized, crossover clinical trial. Br J Dermatol 2013; 169:434.
- 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