VITAMIN D DEFICIENCY
DR SANJEEV AGGARWAL
MEDICAL OFFICER , DTE OF ISM & HOMOEOPATHY,
GOVT OF DELHI
Osteoporosis - An Overview
Osteoporosis Is Defined As
"A Disease Characterized By Low Bone Mass,
Microarchitectural Deterioration Of Bone
Tissue, Or Both, Leading To Skeletal Fragility."
Osteopenia Is A Precursor To Osteoporosis
Osteoporosis affects an estimated 30 % of
postmenopausal white and asian women in the u.s.
Rates are lower, though not inconsequential,
among other groups: approx. 10 % of african
american women and 13 to 16 % of latin american
women age 50 and older have osteoporosis.
Hip fractures occur in 15 % of elderly women.
Only one-third of hip-fracture patients will return
to pre-fracture independence.
As our population ages, the number of hip fractures is
expected to triple by 2040.
Long-term sequelae include fractures of hip, spine,
wrist, ribs, etc.; chronic fracture pain; and compression
of internal organs from repeated vertebral compression
fractures and kyphosis.
As with post-menopausal women, hypogonadism in
men may accelerate bone loss.
Corticosteroid therapy, severe hyperthyroidism, and
hyperparathyroidism can also cause rapid bone loss.
Family History Of Fracture In First-Degree
Relative (Particularly Prior To Age 80)
Personal History Of Fracture After Age 40
Current Cigarette Smoking
Peak bone mass is reached in the
late twenties for women, midthirties for men
daily allowances of calcium and
vitamin d is as:
RECOMMENDED DAILY INTAKE
INFANTS 0 TO 6 MONTHS
INFANTS 6 TO 12 MONTHS
CHILDREN 1-3 YEARS OLD
CHILDREN 4-8 YEARS OLD
CHILDREN & YOUNG ADULTS 9-18 YRS 1300 MG
ADULTS 19-50 YEARS
WOMEN AND MEN OVER 50 YEARS
AGE RECOMMENDED DAILY INTAKE
BIRTH TO 11 MONTHS
AGES 1 TO 70 YEARS
AGE 70 AND OVER
Symptoms & Diseases Associated With Vitamin
It is estimated that anywhere from 30 to 100% of
Americans, depending upon their age and community
living environments, are deficient in Vitamin D. More
than half of all American children are vitamin deficient.
Supposedly almost 3/4s of pregnant women are vitamin
D deficient, predisposing their unborn children to all
sorts of problems. Worldwide, it is estimated that the
epidemic of vitamin D deficiency affects one billion
people. It is clinically observed that over 80% of
patients whose vitamin D levels are deficient.
The flu: vitamin D deficiency predisposes children to
respiratory diseases; study conducted showed that
vitamin D reduces the incidence of respiratory
infections in children.
Muscle weakness: muscle weakness is usually
caused by vitamin D deficiency because for skeletal
muscles to function properly, their vitamin D
receptors must be sustained by vitamin D.
Psoriasis: synthetic vitamin D analogues were found
useful in the treatment of psoriasis.
Chronic kidney disease: patients with advanced
chronic kidney diseases (especially those requiring
dialysis) are unable to make the active form of
Diabetes: 10,366 children were given 2000 international
units (IU)/day of vitamin D3 per day during their first
year of life. The children were monitored for 31 years
and in all of them, the risk of type 1 diabetes was
reduced by 80 percent.
Asthma: Vitamin D may reduce the severity of asthma
Periodontal disease: Those suffering from this chronic
gum disease that causes swelling and bleeding gums
should consider raising their vitamin D levels to produce
defensins and cathelicidin, compounds that contain
microbial properties and lower the number of bacteria
in the mouth.
Cardiovascular disease: women with low vitamin D levels
(17 ng/m [42 nmol/L]) had a 67 percent increased risk of
Schizophrenia and Depression: it was discovered that
maintaining sufficient vitamin D among pregnant women
and during childhood was necessary to satisfy the vitamin
D receptor in the brain integral for brain development and
mental function maintenance in later life.
Cancer: increased doses of the sunshine vitamin were
linked to a 75 percent reduction in overall cancer growth
and 50 percent reduction in tumor cases among those
already having the disease, vitamin D supplementation to
help control the development and growth of breast cancer
specially estrogen-sensitive breast cancer.
How much vitamin D do I need ?
If your blood level is above 45ng/ml and for maintenance, I
recommend 2,000-4,000 IU daily depending on age, weight,
season, how much time is spent outdoors, where one lives, skin
color and obviously blood levels. In other words if you are older,
larger, living in the northern latitudes during the winter, are not
getting sun and have dark skin, I recommend the higher
If your blood level is 35-45 ng/ml, I recommend you correct it
with 5,000 of vitamin D3 a day for 3 months under a doctor’s
supervision and then recheck your blood levels.
If your blood level is less than 35 ng/ml, I recommend you
correct it with 10,000 of vitamin D3 a day under a doctor’s
supervision and then recheck your blood levels after 3 months. It
takes a good 6 months usually to optimize your vitamin D levels
if you’re deficient. Once this occurs, you can lower the dose to
the maintenance dose of 2,000 – 4,000 IU a day.
What are the symptoms of vit D deficiency?
There is no clear pattern of symptoms. In fact many people remain
asymptomatic despite low levels. But here are common symptoms
General muscle pain and weakness
High blood pressure
Constipation or diarrhea
Individuals at High Risk for Vitamin D
Individuals most likely to have vitamin D
deficiency are those who do not take
supplements, are elderly, are darkly pigmented,
are obese, have osteoporosis or osteopenia,
avoid any sun exposure without sunscreen, are
typically veiled, live in a highly polluted
environment, or have Crohn's disease or other
reasons for fat malabsorption.
Recommendations for Treatment of Vitamin D
Deficiency or Insufficiency
Serum 25(OH)D Level (ng/mL) 20-30 ;
Vitamin D3 Suppl Dose (IU)
12-20 ; < 12
Frequency of Vitamin D Supplementation Daily
< 12 (symptomatic)
Why do we need vitamin D?
A main action of vitamin D is to help calcium
and phosphorus in our diet to be absorbed
from the gut. Calcium and phosphorus are
needed to keep bones healthy and strong. So,
vitamin D is really important for strong and
healthy bones. In addition, vitamin D seems
to be important for muscles and general
health. There is also some evidence that
vitamin D may also help to prevent other
diseases such as cancer, diabetes and heart
Where body is unable to make enough vitamin D
This can occur for various reasons:
People who get very little sunlight on their skin are at risk of vitamin
D deficiency. This is more of a problem in the more northerly parts of
the world (including the UK) where there is less sun. In particular:
People who stay inside a lot. For example, those in hospital for a long time, or
People who cover up a lot of their body when outside. For example, wearing
veils such as the niqab or burqa.
Strict sunscreen use can potentially lead to vitamin D deficiency, particularly if
high sun protection factor (SPF) creams (factor 15 or above) are used.
Nevertheless, children especially should always be protected from the
harmful effect of the sun's rays and should never be allowed to burn or be
exposed to the strongest midday sun.
Elderly people have thinner skin than younger people and so are unable
to produce as much vitamin D. This leaves older people more at risk of
vitamin D deficiency.
People who have darker skin. For example people of African, AfricanCaribbean and South Asian origin, because their bodies are not able to
make as much vitamin D.
Some medical conditions can affect the way the body handles vitamin D.
People with Crohn's disease, coeliac disease, and some types of liver and
kidney disease, are all at risk of vitamin D deficiency.
Rarely, some people without any other risk factors or diseases become
deficient in vitamin D. It is not clear why this occurs. It may be due to a
subtle metabolic problem in the way vitamin D is made or absorbed. So,
even some otherwise healthy, fair-skinned people who get enough sun
exposure can become deficient in vitamin D.
Vitamin D deficiency can also occur in people taking certain medicines.
Examples include: carbamazepine, phenytoin, primidone, barbiturates
and some anti-HIV medicines.
How common is vitamin D deficiency?
It is very common. A recent survey in the UK
showed that more than half of adults in the
UK did not have enough vitamin D. In the
winter and spring about 1 in 6 people have a
severe deficiency. It is estimated that about 9
in 10 adults in the UK of South Asian origin
may be vitamin D-deficient. Most affected
people either don't have any symptoms, or
have tiredness or vague aches and pains, and
are unaware of the problem.
What are the symptoms of vitamin D
Many people have no symptoms, or only
vague ones such as tiredness or general
aches. Because symptoms of vitamin D
deficiency are often very nonspecific or
vague, the problem is often missed. The
diagnosis is more easily reached in severe
deficiencies with some of the classical
(typical) symptoms and bone deformities.
Cautions when taking vitamin D supplements
Care is needed with vitamin D supplements in certain situations:
If you are taking certain other medicines: digoxin (for an irregular
heartbeat - atrial fibrillation) or thiazide diuretics such as
bendroflumethiazide (commonly used to treat high blood pressure). In
this situation, avoid high doses of vitamin D, and digoxin will need
monitoring more closely.
If you have other medical conditions: kidney stones, some types of
kidney disease, liver disease or hormonal disease. Specialist advice may
Vitamin D should not be taken by people who have high calcium levels
or certain types of cancer.
You may need more than the usual dose if taking certain medicines
which interfere with vitamin D. These include: carbamazepine,
phenytoin, primidone, barbiturates and some medicines for the
treatment of HIV infection.
The outlook is usually excellent. Both the vitamin levels and the
symptoms generally respond well to treatment. However, it can take
time (months) for bones to recover and symptoms such as pain to get
better or improve.
The complications of severe deficiency have been mentioned. Rickets
can occur in children, and osteomalacia in adults. These diseases affect
the strength and appearance of bones, and can lead to permanent
bone deformities if untreated or if treatment is delayed.
Vitamin D has been linked to other diseases. In recent years there have
been associations with conditions such as cancer, heart disease,
infectious disorders, autoimmune disease and diabetes. This does not
mean that all people with vitamin D deficiency will get these problems.
Nor does it mean that if you have one of these illnesses, a vitamin D
deficiency is the cause. In these cases, vitamin D is thought to be just
How Does Vitamin D Protect Against Radiation-Induced Damage?
Scientists have identified a total of nearly 3,000 genes that are
upregulated by vitamin D, so it makes sense that it would have
"multifaceted protective actions," as researchers noted in the
International Journal of Low Radiation.
The report found that the most active molecular form of vitamin D -D3 (also known as calcitriol) -- may offer protection against a variety
of radiation-induced damages, including those caused by
background radiation or a low-level nuclear incident, through the
Cell cycle regulation and proliferation
Cellular differentiation and communication
Programmed Cell Death (PCD)
Anti-angiogenesis (a process that stops tumors from making new
blood vessels, which means they stop growing)
Three Points to Remember About Vitamin D
When using vitamin D therapeutically, it's important to remember the
Your best source for vitamin D is exposure to the sun, without sunblock on your skin, until your skin turns the lightest shade of pink.
While this isn't always possible due to the change of the seasons and
your geographic location (and your skin color), this is the ideal to aim
for. Vitamin D supplementation or use of a safe tanning bed can fill the
gaps during the winter months outside of the tropics, when healthy
sun exposure is not an option.
If you supplement with vitamin D, you'll only want to supplement
with natural vitamin D3 (cholecalciferol). Do NOT use the synthetic
and highly inferior vitamin D2.
Get your vitamin D blood levels checked! The only way to determine
the correct dose is to get your blood tested since there are so many
variables that influence your vitamin D status.
Factors influence skin synthesis of
Skin Synthesizes Vitamin D When Exposed To Sunlight (Uvb
Radiation), Which Is Usually Sufficient To Meet The Daily
Skin Production Of Vitamin D3 Decreases With Age
Beginning In The Third Decade
The 25-Oh Vitamin D3 Levels Were Three Times Lower In
Elderly People Age 62 To 80 Than In People Age 22 To 30
Given The Same Sunlight Exposure
Variation In Vitamin D Synthesis Occurs Because Sunlight
Exposure And Uvb Radiation Absorption Vary With Degree
Of Skin Pigmentation, Season, Latitude, Time Of Day,
Atmospheric Conditions, And Duration Of Exposure
Vitamin D Synthesis Is Significantly Decreased And
Sometimes Completely Stopped By The Application Of
Chronic Use Of Sunscreens Can Reduce Serum Vitamin D
Clothing, Glass, Plastic, And Plexiglas Also
Prevent Uvb Radiation Absorption
Dark Skin Pigmentation Makes Individuals
More Vulnerable To Vitamin D Deficiency As
Melanin Blocks Absorption Of Uvb Radiation
In Developed Countries, Fortification Of Dairy
Products With Vitamin D Has Reduced The
Incidence Of Osteomalacia
Vitamin D Is Crucial To Normal Bone Growth And
When Uv Light Shines On A Lipid Present In Skin Cells,
The Compound Is Transformed Into Vitamin D
People Native To Equatorial And Low Latitude Regions
Of The Earth Have Dark Skin Pigmentation As A
Protection Against Strong, Nearly Constant Exposure To
Increased Melanin Pigmentation, Present In People
Native To Lower Latitudes, Reduces The Production Of
The Dose Of Ultraviolet Light Required To Stimulate Skin
Synthesis Of Vitamin D Is About Six Times Higher In
African Americans Than In People Of European Descent
Susceptibility To Vitamin D Deficiency Is Increased In
These Populations By The Traditional Clothing Of Many
Cultural Groups Native To Low Latitudes
What is used to to synthesize Vitamin D in skin
Sun exposure and cholesterol. Sun exposure
converts 7-dehydrocholesterol to previtamin D3,
which is then converted to Vitamin D.
Does Skin Synthesize Vitamin D?
Yes. In presence of ultraviolet rays cholesterol
in blood is converted into vitamin D. Which
gets one hydrogen atom attached in liver and
another in kidney to from active form of
What Part of the skin synthesizes vitamin D?
The Stratum Spinosum and Basale from the
What activates the skin to start process of
producing Vitamin D?
When might skin not be able to produce enogh
when the skin has not absorbed sufficent
sunlight specifially u.v rays
Sun Protection Practices
AVOID SUN BURNING, INTENTIONAL TANNING, AND USING
APPLY SUNSCREEN GENEROUSLY.
WEAR SUN-PROTECTIVE CLOTHING, WIDE-BRIMMED HAT, AND
USE EXTRA CAUTION NEAR WATER, SNOW, AND SAND.
GET VITAMIN D THROUGH DIET AND VITAMIN D SUPPLEMENTS.
IOM Recommendation on Vitamin D
RECOMMENDED DIETARY ALLOWANCES
0- 12 MO:
1- 70 YRS:
600 IU/D **
* COVERING THE REQUIREMENTS OF ≥ 97.5%
** INCLUDES PREGNANT AND NURSING
Sunlight exposure is the primary source of vitamin D for most
people. Solar ultraviolet-B radiation (UVB; wavelengths of 290
to 315 nanometers) stimulates the production of vitamin D3 from
7-dehydrocholesterol (7-DHC) in the epidermis of the skin
vitamin D is actually more like a hormone than a vitamin, a
substance that is required from the diet.
Vitamin D3 enters the circulation and is transported to the liver,
where it is hydroxylated to form 25-hydroxyvitamin D3 (calcidiol;
the major circulating form of vitamin D).
In the kidneys, the 25-hydroxyvitamin D3-1-hydroxylase enzyme
catalyzes a second hydroxylation of 25-hydroxyvitamin D, resulting
in the formation of 1,25-dihydroxyvitamin D3 (calcitriol, 1alpha,25dihydroxyvitamin D]—the most potent form of vitamin D
Vitamin D Miracles
Sunlight and vitamin D are critical to all life forms. The principal
function of vitamin D is to promote calcium absorption in the gut
and calcium transfer across cell membranes, thus contributing to
strong bones and a calm, contented nervous system. It is also well
recognized that vitamin D aids in the absorption of magnesium, iron
and zinc, as well as calcium.
Actually, vitamin D does not in itself promote healthy bone. Vitamin
D controls the levels of calcium in the blood. If there is not enough
calcium in the diet, then it will be drawn from the bone. High levels
of vitamin D (from the diet or from sunlight) will actually
demineralize bone if sufficient calcium is not present.
Vitamin D will also enhance the uptake of toxic metals like lead,
cadmium, aluminum and strontium if calcium, magnesium and
phosphorus are not present in adequate amounts. Vitamin D
supplementation should never be suggested unless calcium intake is
sufficient or supplemented at the same time.
Receptors for vitamin D are found in most of the cells in the body and
research during the 1980s suggested that vitamin D contributed to a
healthy immune system, promoted muscle strength, regulated the
maturation process and contributed to hormone production.
During the last ten years, researchers have made a number of exciting
discoveries about vitamin D. They have ascertained, for example, that
vitamin D is an antioxidant that is a more effective antioxidant than vitamin
E in reducing lipid peroxidation and increasing enzymes that protect against
Vitamin D deficiency decreases biosynthesis and release of insulin. Glucose
intolerance has been inversely associated with the concentration of vitamin
D in the blood. Thus, vitamin D may protect against both Type I and Type II
The risk of senile cataract is reduced in persons with optimal levels of D and
PCOS (Polycystic Ovarian Syndrome) has been corrected by
supplementation of D and calcium.
Vitamin D plays a role in regulation of both the "infectious"
immune system and the "inflammatory" immune system.
Low vitamin D is associated with several autoimmune diseases
including multiple sclerosis, Sjogren's Syndrome, rheumatoid
arthritis, thyroiditis and Crohn's disease.
Osteoporosis is strongly associated with low vitamin D.
Postmenopausal women with osteoporosis respond favorably (and
rapidly) to higher levels of D plus calcium and magnesium.
D deficiency has been mistaken for fibromyalgia, chronic fatigue or
Infertility is associated with low vitamin D. Vitamin D supports
production of estrogen in men and women. PMS has been
completely reversed by addition of calcium, magnesium and
vitamin D. Menstrual migraine is associated with low levels of
vitamin D and calcium.
Breast, prostate, skin and colon cancer have a strong association with low levels
of D and lack of sunlight.
Activated vitamin D in the adrenal gland regulates tyrosine hydroxylase, the
rate limiting enzyme necessary for the production of dopamine, epinephrine
and norepinephrine. Low D may contribute to chronic fatigue and depression.
Seasonal Affective Disorder has been treated successfully with vitamin D. In a
recent study covering 30 days of treatment comparing vitamin D
supplementation with two-hour daily use of light boxes, depression completely
resolved in the D group but not in the light box group. 40
High stress may increase the need for vitamin D or UV-B sunlight and calcium.
People with Parkinsons and Alzheimers have been found to have lower levels of
Low levels of D, and perhaps calcium, in a pregnant mother and later in the
child may be the contributing cause of "crooked teeth" and myopia. When
these conditions are found in succeeding generations it means the genetics
require higher levels of one or both nutrients to optimize health.
Behavior and learning disorders respond well to D and/or calcium combined
with an adequate diet and trace minerals.
Vitamin D and Heart Disease
Research suggests that low levels of vitamin D may contribute to
or be a cause of syndrome X with associated hypertension,
obesity, diabetes and heart disease. Vitamin D regulates
vitamin-D-binding proteins and some calcium-binding proteins,
which are responsible for carrying calcium to the "right location"
and protecting cells from damage by free calcium. Thus, high
dietary levels of calcium, when D is insufficient, may contribute
to calcification of the arteries, joints, kidney and perhaps even
Many researchers have postulated that vitamin D deficiency
leads to the deposition of calcium in the arteries and hence
atherosclerosis, noting that northern countries have higher
levels of cardiovascular disease and that more heart attacks
occur in winter months.
Scottish researchers found that calcium levels in the hair
inversely correlated with arterial calcium—the more
calcium or plaque in the arteries, the less calcium in the
hair. Ninety percent of men experiencing myocardial
infarction had low hair calcium. When vitamin D was
administered, the amount of calcium in the beard went
up and this rise continued as long as vitamin D was
consumed. Almost immediately after stopping
supplementation, however, beard calcium fell to presupplement levels.
Administration of dietary vitamin D or UV-B treatment
has been shown to lower blood pressure, restore insulin
sensitivity and lower cholesterol.
The Battle of the Bulge
Did you ever wonder why some people can eat all
they want and not get fat, while others are
constantly battling extra pounds? The answer may
have to do with vitamin D and calcium status.
Sunlight, UV-B, and vitamin D normalize food intake
and normalize blood sugar. Weight normalization is
associated with higher levels of vitamin D and
adequate calcium. Obesity is associated with
vitamin-D deficiency. In fact, obese persons have
impaired production of UV-B-stimulated D and
impaired absorption of food source and
When the diet lacks calcium, whether from D or calcium
deficiency, there is an increase in fatty acid synthase, an
enzyme that converts calories into fat. Higher levels of
calcium with adequate vitamin D inhibit fatty acid
synthase while diets low in calcium increase fatty acid
synthase by as much as five-fold.
In one study, genetically obese rats lost 60 percent of
their body fat in six weeks on a diet that had moderate
calorie reduction but was high in calcium. All rats
supplemented with calcium showed increased body
temperature indicating a shift from calorie storage to
calorie burning (thermogenesis).
The Right Fats
The assimilation and utilization of vitamin D is
influenced by the kinds of fats we consume. Increasing
levels of both polyunsaturated and monounsaturated
fatty acids in the diet decrease the binding of vitamin
D to D-binding proteins. Saturated fats, the kind found
in butter, tallow and coconut oil, do not have this
effect. Nor do the omega-3 fats.66 D-binding proteins
are key to local and peripheral actions of vitamin D.
This is an important consideration as Americans have
dramatically increased their intake of polyunsaturated
oils (from commercial vegetable oils) and
monounsaturated oils (from olive oil and canola oil)
and decreased their intake of saturated fats over the
past 100 years.
In traditional diets, saturated fats supplied varying
amounts of vitamin D. Thus, both reduction of saturated
fats and increase of polyunsaturated and
monounsaturated fats contribute to the current
widespread D deficiency.
Trans fatty acids, found in margarine and shortenings
used in most commercial baked goods, should always be
avoided. There is evidence that these fats can interfere
with the enzyme systems the body uses to convert
vitamin D in the liver.
Vitamin D Therapy
Single, infrequent, intense, skin exposure to UV-B light not
only causes sunburn but also suppresses the immune
system. On the other hand, frequent low-level exposure
normalizes immune function, enhancing NK-cell and T-cell
production, reducing abnormal inflammatory responses
typical of autoimmune disorders, and reducing
occurrences of infectious disease.26;67;68-71 Thus it is important
to sunbathe frequently for short periods of time, when
UV-B is present, rather than spend long hours in the sun at
infrequent intervals. Adequate UV-B exposure and
vitamin-D production can be achieved in less time than it
takes to cause any redness in the skin. It is never
necessary to burn or tan to obtain sufficient vitamin D.
If you have symptoms of vitamin-D insufficiency or are
unable to spend time in the sun, due to season or lifestyle
or prior skin cancer, consider adding a supplement of
1,000 IU daily. Higher levels may be needed but should be
recommended and monitored by your health care
practitioner after testing serum 25(OH)D. 1,000 iu can be
obtained from a concentrated supplement or from 2
teaspoons of high quality cod liver oil. Both Carlson Labs
and Solgar make a 1,000 IU vitamin-D supplement
naturally derived from fish oil. (Do not attempt to obtain
large amounts of vitamin D from cod liver oil alone, as this
would supply vitamin A in excessive and possibly toxic
Supplementation is safe as long as sarcoidosis, liver or kidney
disease is not present and the diet contains adequate calcium,
magnesium and other minerals.
Adequate calcium and magnesium, as well as other minerals,
are critical parts of vitamin D therapy. Without calcium and
magnesium in sufficient quantities, vitamin-D supplementation
will withdraw calcium from the bone and will allow the uptake
of toxic minerals. Do not supplement vitamin D and do not
sunbathe unless you are sure you have sufficient calcium and
magnesium to meet your daily needs. Weston Price suggested a
minimum of 1,200-2,400 mg of calcium daily. Research suggests
that 1,200-1,500 mg is adequate as a supplement for most
adults, both men and women. (Magnesium intake should be half
that of calcium.)
Vitamin programs usually omit vitamin D
because of concerns about toxicity. These
concerns are valid because vitamin D in all
forms can be toxic in pharmacological (druglike) doses. The dangers of toxicity have not
been exaggerated, but the doses needed to
result in toxicity have been ill defined with
the unfortunate result that many people
currently suffer from vitamin-D deficiency or
EXTREMITIES - CARIES of bone
Ars. ASAF. aur. calc-f. calc-p. Calc. Con. Fl-ac.
graph. Guaj. Hep. LYC. MERC. Mez. NIT-AC.
Ph-ac. Phos. Puls. ruta sec. Sep. SIL. Staph.