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Vitamin D deficiency

Last reviewed: 7 Apr 2025
Last updated: 25 Feb 2025

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
Full details

Other diagnostic factors

  • faltering growth
  • delayed achievement of motor milestones
  • fatigue and malaise
  • symptoms of hypocalcemia
Full details

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
Full details

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
Full details

Tests to consider

  • intact PTH
  • serum 1,25-dihydroxyvitamin D
  • bone density (DEXA) scan
Full details

Treatment algorithm

ACUTE

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

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

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.
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