This document discusses vitamin D, including its functions, sources, daily requirements, deficiency, toxicity, and management. Some key points: - Vitamin D promotes calcium absorption and is important for bone health. Deficiency can cause rickets in children and osteomalacia in adults. - Good dietary sources include fatty fish, fish liver oils, eggs, and dairy. Sun exposure also enables vitamin D production. - Recommended daily intake is 10-20 micrograms for adults. Deficiency is managed with high dose vitamin D supplementation. Toxicity risks include excessive intake.

1. VITAMIN D
DR.HARIVANSH CHOPRA
M.D.,DCH
PROFESSOR
DEPT.OF COMMUNITY MEDICINE
L.L.R.M.MEDICAL COLLEGE,MEERUT
harichop@gmail.com

2. OBJECTIVES
1) What is Vitamin D,
its functions, rich
sources and its daily
requirement?
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3. OBJECTIVES
2. What are the
diagnostic
features of
deficiency and its
management?
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4. What is vitamin D?
1. VITAMIN D was earlier referred to as
"fat-soluble factor D”.
2. The vitamin was also called "calciferol,"
since it was found to boost calcium
deposits in bone.
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5. What is vitamin D?
There are two basic types of vitamin D:
Ergosterol is the basic building block of vitamin D
in plants.
2.17-dehydro-cholesterol is the basic building block
of vitamin D in humans.
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6. What is vitamin D?
When ultraviolet light
from the sun hits the
leaf of a plant,
ergosterol is
converted into
ergocalciferol, or
vitamin D2.
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7. What is vitamin D?
Both of these
substances -
ergocalciferol in
plants and
cholecalciferol in
humans - are usually
referred to as
"provitamin D“.
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8. PHYSIOLOGICAL ACTION OF VITAMIN D
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9. Functions of Vitamin D
Intestine:
1. Promotes
absorption of
Calcium and
Phosphorus.
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10. Functions of Vitamin D
Bone:
Stimulates normal
mineralization.
Enhances bone resorption.
Affects collagen
maturation.
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11. Functions of Vitamin D
Kidney:
• Increases tubular
resorption of
phosphate.
• Variable effect on
calcium resorption.
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12. Functions of Vitamin D
Other:
Promotes
normal
growth.
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13. Food Sources
1. Fish
2. Liver
3. Oils
4. Egg yolk
5. Butter
6. Hen
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14. Impact of Cooking,
Storage and Processing
How do cooking, storage, or processing
affect vitamin D?
Vitamin D is a stable compound. Neither
cooking nor long-term storage significantly
reduce vitamin D levels in food.
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15. PREDISPOSING FACTORS
FOR DEFICIENCY
 Breast feeding, if
the mother is
vitamin D deficient
 Obesity
 Insufficient dietary
fat or inability to
absorb dietary fat
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16. PREDISPOSING FACTORS
FOR DEFICIENCY
4. Health conditions that
involve the
parathyroid gland or
kidney.
5. Ageing
6. Genetic susceptibility
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17. Deficiency Symptoms
In addition, breast milk may not
contain a sufficient amount of
vitamin D so exclusively breast-
fed infants may require
supplemental vitamin D.
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18. Predisposing factors for Deficiency
Although vitamin D deficiency
is relatively rare, it is important
for individuals with limited sun
exposure to include good
sources of vitamin D in their
diets.
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19. Predisposing factors for Deficiency
1. Homebound
individuals.
2. People living in
northern latitudes.
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20. Predisposing factors for Deficiency
3. Individuals who
wear clothing that
completely
covers the body.
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21. Predisposing factors for Deficiency
4. Individuals
working in
occupations that
prevent exposure
to sunlight.
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22. Drug-Nutrient Interactions
The following medications
impact the absorption,
utilization and/or activation
of vitamin D:
Anticonvulsant medications,
including Dilantin,…
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23. Drug-Nutrient Interactions
2) Cimetidine
3) HRT may blood levels of vit.D.
4) corticosteroids
5) Heparin
6) Bile acid sequestrants
(Cholestyramine, Colestipol)
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24. Drug-Nutrient Interactions
1. Vitamin D may
interfere with the
effectiveness of
calcium channel-
blockers.
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25. Drug-Nutrient Interactions
Taking supplemental
vitamin D and calcium
along with thiazide
diurectics can cause
blood levels of
calcium to increase
above normal levels.
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26. RECOMMENDED DAILY ALLOWANCE
1. Infants & Children : 10 μgm. (400 I.U.)
2. Adults : 10-20 μgm. (400-800 I.U.)
3. Pregnancy and Lactation : 10 μgm(400 I.U.)
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27. Age Prevention Tolerable Upper Limit Treatment
Premature
neonates
400 IU / day 1000 IU / day 1000 IU / day
Neonates (< 1
months)
Infants (1-12
months)
400 IU / day
400 IU / day
1000 IU / day
1000 – 1500 IU/day
2000 IU/day
2000 IU/day
1 – 18 years 600 IU/day
3000 IU day till 9
years
4000 IU/day from 9 –
18 years
60000 IU weekly
for 6 weeks
At risk groups
400 – 1000
IU/day
As per age group
As per age
group
TABLE I RECOMMENDATIONS FOR VITAMIN D DEFICIENCY –
PREVENTION AND TREATMENT
IAP Guidelines: July 2017

28. Age Prevention Tolerable Upper Limit Treatment
Premature
neonates
150 - 220
mg/kg/day
1000 mg / day
175 – 200 mg/kg/
day
Neonates (< 1
months)
Infants (1-12
months)
200 mg/day
250 - 500
mg/day
1000 mg / day
1000 – 1500 mg/day
500 mg/day
500 mg/day
1 – 18 years
600 - 800
mg/day
2500 mg/day till 8
years
3000 mg/day from 9 –
18 years
600 - 800 mg/day
At risk groups
As per age
group
As per age group
As per age
group
TABLE II RECOMMENDATIONS FOR CALCIUM DEFICIENCY –
PREVENTION AND TREATMENT
IAP Guidelines: July 2017

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Dietary sources of vitamin D
µg/100 g µg/100 g
Butter
Eggs
Milk; whole
Fish fat
0.5-1.5
1.25-1.5
0.1
5-30
Shark liver oil
Cod liver Oil
Halibut liver
oil
30-100
200-750
500-10 000

30. Health Conditions
What health conditions require special
emphasis on vitamin D?
Atherosclerosis
Breast cancer
Depression
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31. Health Conditions
4) Epilepsy
5) Hypertension
6) Inflammatory bowel
disease
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32. Health Conditions
7) Kidney disease
8) Liver disease
9) Multiple sclerosis
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33. Health Conditions
10. Osteoporosis
11. Periodontal disease
12. Pre-eclampsia
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34. Health Conditions
13) Psoriasis
14) Tinnitus
15) Ulcerative colitis
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35. Deficiency Symptoms
In infants and children,
such a deficiency
manifests itself as rickets,
a condition characterized
by bone deformities and
growth retardation.
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36. Deficiency Symptoms
Adults with vitamin D
deficiency may
experience bone pain
and/or osteomalacia (soft
bone).
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37. CLINICAL FEATURES
OF VITAMIN D DEFICIENCY
 Clinical manifestation of
RICKETS in children
usually manifest in the
latter half of the first year or
in second year.
 Rickets is unusual below
the age of three months.
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38. EARLY SIGNS OF RICKETS
Increased sweating
over face and
forehead.
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1. Clinical Assessment
CRANIOTABES

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WIDENING OF WRIST
JOINT

41. CLINICAL FEATURES
Delayed closure
of anterior
fontanelle.
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42. CLINICAL FEATURES
Bossing of
skull
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43. CLINICAL FEATURES
4. Delayed irregular eruption
of primary teeth.
5. Rachitic rosary.
6. Pigeon shaped chest.
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44. CLINICAL FEATURES
7. Harrisons groove.
8. Pot belly
abdomen.
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45. CLINICAL FEATURES
9. Kyphosis, Lordosis &
Scoliosis.
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46. CLINICAL FEATURES
10. Rachitic pelvis, resulting in
difficulty in normal delivery.
11. Epiphyses of long bones
widened.
12. Deformity of long bones.
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47. CLINICAL FEATURES
13. Anterior bowing of legs.
14. Knock knee.
15. Coxa vara.
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48. DIAGNOSIS
 The diagnosis of Rickets is based on:
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49. RADIOLOGICAL PICTURE
1. Early radiological
changes are
observed in lower
ends of radius and
ulna.
2. A cup or saucer like
depression is seen at
the growing end of
bone.
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50. RADIOLOGICAL PICTURE
3. Cupping and fraying
of the distal ends of
the radius and ulna.
4. Double contour along
the lateral outline of
the radius (Periosteal
Osteoid).
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51. RADIOLOGICAL PICTURE
5. Increase distance
between epiphysis
and ends of
metacarpals.
6. Greenstick fractures.
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52. BIOCHEMICAL FINDINGS
1. Decreased Serum Vit D
Levels.
2. Serum calcium may be
low or normal.
3. Alkaline phosphatase is
high (>500mg/dL)
4. Serum phosphorus is
low.
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53. MANAGEMENT
1. Administration of 15,000
micrograms or 600,000 I.U. of Vit.D
orally.
2. Wait for 4 weeks.
3. Look for ZPC (Zone of Proliferating
Calcification).
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54. RADIOLOGICAL FINDINGS
1. A) Active rickets
showing cupping &
fraying of distal ends
of radius & ulna.
1. B) Healing rickets
after 12 days of
treatment showing
ZPC.
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A B

55. RADIOLOGICAL FINDINGS
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1. C) Healing rickets after 18
days of treatment, ZPC
well defined.
2. Epiphysis of radius
becomes well calcified. C D

56. RADIOLOGICAL FINDINGS
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1. D) Healing rickets after
29 days of treatment.
2. ZPC,rachitic
metaphysis and shafts
have become united. C D

57. MANAGEMENT
1. If ZPC is not seen in X-ray within 3-4
weeks, repeat the dose of 6 lakh I.U.
2. Wait for another 4 weeks.
3. Look for ZPC.
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58. MANAGEMENT
1. Cases who respond to this
therapy are further put on 400
units or 10 micrograms of Vit.
D/day after healing has started.
2. Deformities of bones are
treated by orthopedic
measures.
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59. MANAGEMENT
 If two massive doses of 6 lakh I.U. of Vit. D
does not result in production of ZPC, then it
is not a case of Nutritional Rickets.
 It may be “Vit. D Dependant Rickets” or
“Vit. D Resistant Rickets”.
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60. MANAGEMENT
1. Child should be encouraged
to play outdoors.
1. Diet should be
supplemented by vit. D.
1. Steatorrhoea or
malabsorption of fat, when
present, should be treated.
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61. Toxicity Symptoms
Individual with hyperparathyroidism,
Overactivity of the parathyroid gland,
are at increased risk for vitamin D
toxicity, and should not take
supplemental vitamin D without
consulting a physician.
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62. Toxicity Symptoms
1. Excessive dietary intake of vitamin D can be
toxic. Symptoms include:
2. loss of appetite,
3. nausea,
4. vomiting,
5. high blood pressure,
6. kidney malfunction, and
7. failure to thrive.
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63. Management of Toxicity symptoms
PREVENTION: By
careful evaluation of
vitamin D dosage.
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64. Management of Toxicity symptoms
TREATMENT:
Discontinue Vit D intake.
Decrease intake of calcium.
For severely involved infants, aluminum hydroxide
by mouth, cortisone, or sodium versenate is used.
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65. Conclusion
1. Vitamin D acts as a double-edged sword.
2. Deficiency leads to rickets, while excess
results in metabolic bone disease.
3. Deficiency cannot be corrected by dietary
supplements; massive Vit. D dose is
required.
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66. 1). Richest source of Vit. D is –
 Shark liver oil
 Cod liver oil
 Halibut liver oil
 Safflower oil
Ans.- 3
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67.  2). All the following vitamins are
antioxidants except –
1. Vit A
2. Vit C
3. Vit D
4. Vit E
Ans.- 3
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68.  3). Which of the following vitamin is needed in
excess of normal daily requirement in
pregnancy? –
1. Vitamin A
2. Vitamin D
3. Vitamin C
4. ALL of the above.
Ans. – 4
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69.  4). Which joint shows the best radiological
features of Rickets? –
1. Knee.
2. Wrist.
3. Elbow.
4. All of the above.
Ans. – 2
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70.  5). Which of the following is the earliest
sign of Rickets? –
1. Increased sweating on forehead and face.
2. Rachitic Rosary.
3. Rachitic pelvis.
4. Delayed closure of anterior fontanelle.
Ans. – 1
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71.  6). The dose of Vit. D in treatment of
Rickets is –
1. 600 IU.
2. 6000 IU.
3. 60000 IU.
4. 600000 IU.
Ans. – 4
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