Vitamin D deficiency

Last reviewed: 30 Aug 2023
Last updated: 22 Jun 2023



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
More key diagnostic factors

Other diagnostic factors

  • faltering growth
  • delayed achievement of motor milestones
  • fatigue and malaise
  • symptoms of hypocalcemia
Other diagnostic factors

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
More risk factors

Diagnostic investigations

1st investigations to order

  • serum 25-hydroxyvitamin D
  • serum calcium
  • fasting serum phosphate
  • serum alkaline phosphatase
  • plain film radiographs of knees and wrists
More 1st investigations to order

Investigations to consider

  • intact PTH
  • serum 1,25-dihydroxyvitamin D
  • bone density (DEXA) scan
More investigations to consider

Treatment algorithm






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




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




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




SP is an author of references cited in this topic.

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