Vitamin D deficiency

Symptoms of Vitamin D Deficiency 

Vitamin D deficiency can be difficult to be noticed because symptoms may not occur for several months or years. Sometimes, the individuals may not have 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

• Getting sick more easily

• Hair loss

• Pale skin

• Depression (feeling of sadness)

• Sleeplessness

Severe deficiency of vitamin D 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 development delays 

• Seizures due to low calcium levels 

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Causes Of Vitamin D Deficiency

Some of the common causes of vitamin D deficiency include:

• 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 of 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 

If an individual is staying home almost all the time and hardly going out during the day they are more prone to vitamin D deficiency. 

• Working overnight shifts 

Those working in night shifts can be at a higher risk factor for vitamin D deficiency, because of less opportunity for sunlight exposure compared with daytime workers.

• Old age 

Most old aged individuals spend the majority of their time indoors, getting 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 use of sunscreens can decrease the amount of vitamin D production in the skin in cases of severe sun protection.

• Geographic factors 

The following geographic factors may limit sun exposure and affect Vitamin D production

-Higher latitude (living far away from the equator)

-Lower altitude (less distance from sea level)

-Winter season

-Air pollution 

-Cloud-shading 

Inadequate dietary intake of vitamin D

• Unbalanced diet

Inadequate intake of vitamin D rich foods like milk, dairy and animal-based sources like fish and fish oils, egg yolks, fortified milk, and beef liver etc is a major risk factor for Vitamin D deficiency.

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•  Vegetarian diet

Vegetarian diet that includes only plant-based fare and no animal products is also linked to vitamin D deficiency.

• Lactose intolerance

Various studies have shown that individuals who are genetically intolerant to lactose (the sugar present in milk) may suffer from a vitamin D deficiency. This has to do with dietary restriction of milk and dairy products rich in Vitamin D.

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• Eating disorders

Eating disorders like anorexia nervosa, bulimia nervosa are strongly associated with Vitamin D deficiency and decreased bone density.

• Medically restricted diets 

Individuals who are on medically restricted diets due to certain medical conditions are at the highest chance of various nutrient deficiencies including vitamin D deficiency. 

• Fad diets

A fad diet is a popular dietary pattern known to be a quick fix for obesity but for long-term weight loss. These diets do not promote a healthy and sustainable diet and lifestyle habits. Certain fad diets eliminate food groups that contain vitamin D and hence, increase the risk of its deficiency. 

Poor absorption of vitamin D from food 

• Medical conditions

Various medical conditions interfere with the absorption of Vitamin D from the diet. Some egs. include:

-Intestinal malabsorption (Celiac disease, Crohn’s disease, ulcerative colitis) 

-Pancreatic insufficiency (Cystic fibrosis)

-Cholestasis syndrome (Biliary atresia)

• Gut resection or small bowel resection

This surgery is done to remove a part of the small bowel when it is blocked or diseased. This 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. This can lead to poor absorption of Vitamin D.

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Genetic or endocrine disorders

The following conditions have a strong link with Vitamin D deficiency: 

• Chronic liver diseases

• Kidney diseases

• Hyperparathyroidism

• Growth hormone deficiency

• Diabetes mellitus 

• Hereditary resistance of vitamin D

Research has shown that the genetic influence on vitamin D levels is estimated to be around 80%, which is much higher than the dietary and environmental influences of around 25%.

Certain medications 

Certain medications can lower vitamin D levels by activating the degradation of vitamin D. These include: 

• Steroids (such as prednisolone, dexamethasone)

• Anti-seizure drugs (such as carbamazepine, topiramate, phenobarbitone, and phenytoin)

• Tuberculosis drugs ( such as rifampicin)

• Cholesterol-lowering drugs (such as cholestyramine and colestipol).

• Antifungal agents (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 vitamin D deficiency can lead to deficiency in their newborn baby and has been linked with various complications during pregnancy and delivery.

Other factors

• Smoking 

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

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Diagnosis Of Vitamin D Deficiency 

History and physical examination

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

Blood tests 

Simple blood tests can be useful in determining the levels of vitamin D in the blood. 

• 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 enough information on the 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 and hence is more stable in the 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.

Prevention Of Vitamin D Deficiency 

Vitamin D deficiency can be prevented by adhering to its Recommended Dietary Allowance (RDA). 

RDA of vitamin D indicates daily intake that is sufficient to maintain bone health and normal calcium metabolism in healthy people. It is listed in both micrograms (mcg) and international units (IU). 1 mcg vitamin D is equal to 40 IU. RDA according to various age groups is as follows:

• 0-12 months: 400 IU (10 mcg)  

• 1-70 years: 600 IU (15 mcg)

• > 70 years: 800 IU (20mcg) 

Some tips for avoiding Vitamin D deficiency include:

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.

Consume vitamin D-containing foods 

Try to 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

• Sea foods oysters, shrimp

• Red meat and liver

• Mushrooms

• Egg yolks

• Cod liver oil

• Soya products

Also include fortified foods containing vitamin D. These include:

• Cow’s milk, almond, and oat milk.

• Breakfast cereals.

• Other dairy products, such as yogurt.

• Orange juice 

Maintain a healthy body weight

Maintaining a healthy body weight and avoiding being overweight can help maintain vitamin D levels. Cycling and exercising regularly outside the house can both help in maintaining a healthy weight and sun exposure. 

Treat underlying medical conditions 

People with underlying health conditions such as celiac disease and cystic fibrosis affect the absorption of nutrients. Therefore treating the underlying condition may help in boosting the level of certain nutrients, including vitamin D.

Did you know? 

Tanning booths are not therapies for vitamin D deficiency
Sunlight is composed of Ultraviolet A (UV A) and UV B but only UV B is required for vitamin D deficiency. The tanning booths use UV A as the major light source and hence do not help with Vitamin D deficiency. On the contrary, they can lead to the development of skin cancer.

Specialist To Visit

The symptoms of vitamin D deficiency can range from mild to severe. Doctors that can help you diagnose and treat vitamin D deficiency include 

• General physicians

• Orthopedics 

• Endocrinologists

• Pediatrician (in case of children)

Orthopedics focuses on injuries and diseases affecting the musculoskeletal system (bones, muscles, joints, and soft tissues). An endocrinologist is qualified to diagnose and treat hormone-related diseases and conditions. You can consult a pediatrician if you notice any signs and symptoms of Vitamin D deficiency in children.

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Treatment Of Vitamin D Deficiency 

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

Supplements

Both D2 (ergocalciferol) and D3 (cholecalciferol) are available as dietary supplements. They  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 the initial supplementation it is recommended to take Vitamin D3  for eight weeks either 6,000 IU daily or 50,000 IU weekly can be considered. 

(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 dose of initial supplementation of Vitamin D3 at 10,000 IU daily is needed.
  
  

(Note:  Once serum vitamin D level exceeds 30 ng/mL, 3000 to 6000 IU/day maintenance dose is recommended.)

• Children having vitamin D deficiency require 1000 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, only 1000 IU/day maintenance treatment is recommended). 

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Home Care For Vitamin D Deficiency 

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 points mentioned in the prevention section.

Complications Of Vitamin D Deficiency 

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

Bone related diseases

• Rickets: It is a childhood disease in which the child's bones become too soft, causing them to warp, bend and break more easily.

• Osteomalacia: It refers to softening of bones in adults.

• Osteoporosis: It is 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 to diabetes. 

• Obesity: Vitamin D deficiency is strongly linked to being overweight and obese.

• Polycystic Ovary Syndrome (PCOS):  Vitamin D deficiency is considered as a risk factor of PCOS. It has also been noted that the degree of vitamin D deficiency correlates with the severity of PCOS. 

Cardiovascular diseases 

• Heart diseases: Many research studies have shown that vitamin D deficiency increases the risk of developing hypertension, heart failure, and coronary artery disease.

• Stroke: Stroke is 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): It is an eye disease that can blur central vision. Lack of vitamin D appears to increase oxidative damage that leads to degeneration of photoreceptors in the eyes.

Neurological diseases

• Depression: People with depression have higher chances of having vitamin D deficiency.

• Sleep disturbances: Vitamin D deficiency can increase the risk of sleep disorders like difficulty in 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 which is a hallmark of Alzheimer's disease (AD). A low level of serum vitamin D has been associated with a greater risk of dementia and AD.

• Parkinson's disease: Low vitamin D levels for a long time, may lead to loss of nerve cells. This can predispose to the development of Parkinson's disease, which is characterized by uncontrollable movements, like shaking, stiffness, and difficulty in balance and coordination.

Respiratory diseases 

• Tuberculosis:   Vitamin D deficiency is associated with an increased risk of developing active TB in individuals with Latent tuberculosis infection (LTBI). 

• Upper respiratory tract infections: Upper respiratory tract infections of viral origin like influenza(flu) are strongly linked to Vitamin D deficiency.

Cancers

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

Alternative Therapies For Vitamin D Deficiency 

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

Exercise 

A sedentary lifestyle and physical inactivity are important risk factors for vitamin D deficiency. Vigorous exercises such as running, and jogging, three or more hours a week can help in maintaining optimum levels of vitamin D. 

Yoga 

Doing yoga asanas early in the morning during sunlight can help replenish vitamin D levels and counter symptoms, including muscle pain, fatigue, and exhaustion. Sunshine also boosts the immune system and elevates the mood.