Vitamin D Deficiency

Contents
• Background
• Risk factors for vitamin D deficiency
• Clinical features
• The association between vitamin D and ill
health
• Who should we test
• Vitamin D supplementation
• Who should we treat?
• Summary
 Risk factors for Vitamin D
deficiency
• Lack of UVB sunlight exposure
– Northern latitude (90% UK too far north to have adequate
levels for 6 months of the year!)
– Occlusive garments
– Pigmented skin
– Sunscreen with SPF 15+ blocks 99% vitamin D synthesis
• Poor oral intake
• Elderly
• Liver disease
 Epidemiology
• Vitamin D deficiency is common in children and adults.
• It has been estimated that 1 billion people worldwide have
vitamin D deficiency.
• A recent survey in the UK showed that more than 50% of the
adult population have insufficient levels of vitamin D and that
16% have severe deficiency during winter and spring. The
highest rates were found in Scotland, Northern England and
Northern Ireland.
• One study found the prevalence of rickets in non-Caucasian
children to be 1.6%
 Clinical features
Symptom/Sign Children Adult
Seizures  
Tetany  
Hypocalcaemia  
Irritability 
Leg Bowing 
Knock knees 
Impaired linear growth 
Delayed Walking 
Limb girdle pain  
Proximal myopathy  
Muscle pain  
 What is the association between
low vitamin D and ill- health?
• Low concentrations of Vitamin D have been associated with
many non-skeletal diseases
– CVD, weight gain, diabetes, infectious disease, MS,
depression, dementia, declining physical status and muscle
strength and all cause mortality
• Conclusion: The discrepancy between observational and
intervention studies suggest that low Vitamin D status is a
marker of ill health i.e. it is consequence rather than cause.
• There is evidence to support routine supplementation of frail
older people to reduce all cause mortality
• Supplementation reduces falls and fracture risk
 Who should we test
• Patients with bone disease whose outcomes may be improved
with Vitamin D treatment
– osteomalcia and Paget’s
• Patients with musculoskeletal symptoms that could be
attributed to Vitamin D deficiency e.g. osteomalacia is
associated with bone, joint and muscle pain and hyperalgesia.
• We should consider testing patients with chronic widespread
pain.
• Routine testing is not necessary in patients with osteoporosis
or fragility fracture who will be treated with oral drugs and co-
prescribed Vitamin D supplementation
 What about testing in asymptomatic
patients?
• Routine testing of higher risk individuals is
NOT recommended
– They should take routine supplementation
• No evidence for screening or treatment in
asymptomatic patients found to be deficient
 Vitamin D Supplementation
• In 2012 the CMOs for the UK wrote to all GPs
• Lifestyle:
– How much sunshine should we be recommending
to our patients?
• Sunscreen should be used only after an initial short
period, while of course stressing the importance of
avoiding sunburn!
• Diet
 AKT Question:
You speak to a 56 year old lady following a # distal
radius to discuss dietary modifications. Her bloods
are: Calcium 2.44, Vitamin D 11
• Which one of the following food has the
highest vitamin D content?
• A : Cup of mushrooms
• B : Herring 100g
• C : Large boiled egg
• D : Mackerel 100g
• E : Vitamin D fortified cereal 30g
Group Recommended daily Example products
dose of
supplementation

All pregnant and breastfeeding 10mcg 400IU daily Healthy Start or Pregnacare
Women - Especially young vitamin tablets
women
Children - aged 6months-5years 7-8.5mcg 300IU daily Healthy Start vitamin drops
Breast-fed infants from 1month (contain 7.5mcg per 5 drops)
of age IF mother has not taken or
Abidec drops (contain 10mcg
supplements in pregnancy
per
Babies fed infant formula
0.6ml)
(which is fortified) do NOT need
supplementation until receiving
<500ml formula daily

Adults 10mcg 400IU daily Standard combinations of

calcium and vit D containing
Everyone aged over 65
10mcg 400IU daily
Other adults who may be at risk Vitamin D alone supplements
eg. Darker skin, poor sun available OTC eg. Boots, Holland
exposure etc. & Barrett etc (10mcg/400IU and
25mcg/1,000IU)
 Test results
• Serum 25OHD < 30 nmol/L is deficient.
• Serum 25OHD of 30–50 nmol/L may be inadequate
in some people.
• Serum 25OHD > 50 nmol/L is sufficient for almost the
whole population.
 Who do we treat?
• Deficient – treatment recommended
• Inadequate – treatment advised if:
– Symptomatic
– Bone disease
– Bone risk factors e.g steroids
– Increase risk of deficiency in future eg dark skin,
malabsorption
• Sufficient – No treatment required
 How do we treat?
• Oral vitamin D3 (cholecalciferol) is recommended
with high fixed loading dose, followed by
supplementation.
• Should be taken with food to maximise
absorption.
• A total loading dose of 300 000IU over 6-10
weeks
– eg cholecalciferol 20 000 – 2 weekly for 7 weeks
• Then for maintenance dose 800-2000 IU daily
 Monitoring
• Serum calcium should be checked 1 month after
completing the loading regimen (as treatment may
unmask undiagnosed primary hyperparathyroidism).
If hypercalcaemic, then stop the Vit D and get
specialist advice
• Further routine monitoring of serum 25OHD is
unnecessary, but it may be appropriate in some
cases (e.g. still symptomatic, malabsorption, poor
compliance etc). It takes 3 to 6 months of treatment
to reach new steady state levels, so there is no point
in re-testing levels sooner.
 Summary
• There is no rationale for testing asymptomatic patients
• Low levels of Vitamin D are associated with a wide range
of diseases, but this is likely to be consequence rather
than cause
• Test if you suspect osteomalacia, and in at risk patients
with musculoskeletal and widespread body pain
• The evidence supports routine supplementation in at risk
groups.
• There is evidence that routine supplementation of older
people prevents falls and fractures
 References
• Vitamin D and Bone Health: A Practical Clinical
Guideline for Patient Management, National
Osteoporosis Society, April 2013
• Vitamin D status and ill health: a systematic
review; Autier et Al. The Lancet Diabetes &
Endocrinology,January 2014
• DoH 2012 guidelines