Summary
Definition
History and exam
Key diagnostic factors
- inadequate sunlight exposure
- increased skin pigmentation
- age >50 years
- history of inadequate dietary and supplemental vitamin D intake
- history of malabsorption
- obesity
- medication use (e.g., dexamethasone, phenytoin, carbamazepine, ritonavir)
- history of chronic kidney disease
- history of benign or malignant tumor
- bowing of the legs
- widening of the ends of the long bones
- delayed tooth eruption and early dental caries
- chest deformity
- throbbing, aching bone discomfort and/or irritability
- head sweating
- localized or generalized bone tenderness
- proximal muscle weakness
- rachitic rosary
- frontal bossing
- waddling gait
Other diagnostic factors
- faltering growth
- delayed achievement of motor milestones
- fatigue and malaise
- symptoms of hypocalcemia
Risk factors
- inadequate sunlight exposure
- increased skin pigmentation
- age >50 years
- inadequate dietary and supplemental vitamin D intake
- malabsorption
- obesity
- medication use
- genetic mutations
- tumor
- chronic kidney disease
- granulomatous disorders
- primary hyperparathyroidism
- hyperthyroidism
Diagnostic tests
1st tests to order
- serum 25-hydroxyvitamin D
- serum calcium
- fasting serum phosphate
- serum alkaline phosphatase
- plain film radiographs of knees and wrists
Tests to consider
- intact PTH
- serum 1,25-dihydroxyvitamin D
- bone density (DEXA) scan
Treatment algorithm
insufficiency
deficiency
Contributors
Authors
Michael F. Holick, PhD, MD
Director Vitamin D, Skin, and Bone Research Laboratory
Director Ehlers-Danlos Clinical Research Program
Professor of Medicine, Physiology, and Biophysics and Molecular Medicine
Departments of Medicine, Physiology, and Biophysics
Section of Endocrinology, Diabetes, Nutrition and Weight Management
Boston University School of Medicine
Boston
MA
Disclosures
MFH has a clinical research contract and consultant for Solius Inc., clinical and basic research contract and grant from Carbogen-Amcis, and is a consultant for Faes Farma. He is a speaker for Pulse Ltd, Abbott Inc., Sanofi Inc., Menarini Inc., and a board member Bridge to Life. He also chaired the Endocrine Society’s practice guidelines on vitamin D. MFH is an author of references cited in this topic.
Peer reviewers
Vin Tangpricha, PhD, MD
Professor of Medicine
Division of Endocrinology
Metabolism and Lipids
Emory University School of Medicine
Atlanta
GA
Disclosures
VT is an author of references cited in this topic.
Stefan Pilz, MD
General Practitioner
Resident at the Department of Internal Medicine
Division of Endocrinology and Nuclear Medicine
Medical University of Graz
Graz
Austria
Disclosures
SP is an author of references cited in this topic.
References
Key articles
Hossein-Nezhad A, Holick MF. Vitamin D for health: a global perspective. Mayo Clin Proc. 2013 Jul;88(7):720-55.Full text Abstract
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. 2011 Jul;96(7):1911-30.Full text Abstract
Chanchlani R, Nemer P, Sinha R, et al. An overview of rickets in children. Kidney Int Rep. 2020 Jul;5(7):980-90.Full text Abstract
Cashman KD. Global differences in vitamin D status and dietary intake: a review of the data. Endocr Connect. 2022 Jan 11;11(1):e210282.Full text Abstract
Charoenngam N, Holick MF. Immunologic effects of vitamin D on human health and disease. Nutrients. 2020 Jul 15;12(7):2097.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Primary hyperparathyroidism
- Multiple myeloma
- Fibromyalgia
More DifferentialsGuidelines
- Nutritional interventions update: vitamin D supplements during pregnancy
- KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder
More GuidelinesPatient information
Vitamin D deficiency
Osteoporosis: what is it?
More Patient informationLog in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer