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Vitamin D Deficiency

(Rickets; Osteomalacia)


Larry E. Johnson

, MD, PhD, University of Arkansas for Medical Sciences

Reviewed/Revised Nov 2022
Topic Resources

Vitamin D deficiency is most commonly caused by a lack of exposure to sunlight. Some disorders can also cause the deficiency.

  • The most common cause is lack of exposure to sunlight, usually when the diet is deficient in vitamin D, but certain disorders can also cause the deficiency.

  • Without enough vitamin D, muscle and bone weakness and pain occur.

  • Infants develop rickets: The skull is soft, bones grow abnormally, and infants are slow to sit and crawl.

  • Blood tests and sometimes x-rays are done to confirm the diagnosis.

  • From birth, breastfed infants should be given vitamin D supplements because breast milk contains little vitamin D.

  • Vitamin D supplements taken by mouth or given by injection usually result in a complete recovery.

Two forms of vitamin D are important for nutrition:

  • Vitamin D2 (ergocalciferol): This form is synthesized from plants and yeast precursors. It is also the form usually used in high-dose supplements.

  • Vitamin D3 (cholecalciferol): This form is the most active form of vitamin D. It is formed in the skin when the skin is exposed to direct sunlight. The most common food source is fortified foods, mainly cereals and dairy products. Vitamin D is also present in fish liver oils, fatty fish, egg yolks, and liver.

Vitamin D is stored mainly in the liver. Vitamin D2 and D3 are not active in the body. Both forms must be processed (metabolized) by the liver and kidneys into an active form called active vitamin D or calcitriol. This active form promotes absorption of calcium and phosphorus from the intestine. Calcium and phosphorus, which are minerals, are incorporated into bones to make them strong and dense (a process called mineralization). Thus, calcitriol is necessary for the formation, growth, and repair of bones.

Requirements for vitamin D increase as people age.

Vitamin D deficiency is common worldwide. In vitamin D deficiency, the body absorbs less calcium and phosphate. Because not enough calcium and phosphate are available to maintain healthy bones, vitamin D deficiency may result in a bone disorder called rickets in children or osteomalacia in adults. In osteomalacia, the body does not incorporate enough calcium and other minerals into bones, resulting in weak bones.

In a pregnant woman, vitamin D deficiency causes the deficiency in the fetus, and the newborn has a high risk of developing rickets. Occasionally, the deficiency is severe enough to cause osteomalacia in the woman. Vitamin D deficiency makes osteoporosis Osteoporosis Osteoporosis is a condition in which a decrease in the density of bones weakens the bones, making breaks (fractures) likely. Aging, estrogen deficiency, low vitamin D or calcium intake, and... read more Osteoporosis worse.

Vitamin D deficiency results in a low calcium level in blood. To try to increase the low calcium level, the body may produce more parathyroid hormone. However, as the parathyroid hormone level becomes high (a condition called hyperparathyroidism Hyperparathyroidism In hypercalcemia, the level of calcium in blood is too high. A high calcium level may result from a problem with the parathyroid glands, as well as from diet, cancer, or disorders affecting... read more Hyperparathyroidism ), the hormone draws calcium out of bone to increase the calcium level in blood. Parathyroid hormone also causes more phosphate to be eliminated in urine. Both calcium and phosphate are necessary to maintain healthy bones. As a result, bones are weakened.

Did You Know...

  • Lack of exposure to sunlight can cause vitamin D deficiency.

Causes of Vitamin D Deficiency

Vitamin D deficiency usually occurs in people who are not exposed to sunlight and who do not consume enough vitamin D in their diet. Natural (unfortified) foods alone rarely provide enough vitamin D to prevent deficiency. Foods that are fortified with vitamin D and supplements of vitamin D can help prevent deficiency when exposure to sunlight is inadequate.

Inadequate exposure to sunlight

The most common cause of vitamin D deficiency is

  • Inadequate exposure to sunlight

Thus, vitamin D deficiency occurs mainly among people who do not spend much time outdoors: older people and people who live in an institution such as a nursing home. The deficiency can also occur in the winter at northern and southern latitudes or in people who keep their bodies covered, such as Muslim women.

Because breast milk contains only small amounts of vitamin D, breastfed infants who are not exposed to enough sunlight are at risk of the deficiency and rickets.

Some experts recommend that the arms and legs or the face, arms, and hands should be exposed to direct sunlight for 5 to 15 minutes at least 3 times a week, but some people, such as those who have darker skin or are older, may need more exposure to sunlight. However, many dermatologists do not recommend increased sunlight exposure because risk of skin cancer is increased.

Other causes

When the skin is exposed to enough sunlight, the body usually forms enough vitamin D. However, certain circumstances increase the risk of vitamin D deficiency even when there is exposure to sunlight:

Symptoms of Vitamin D Deficiency

Vitamin D deficiency can cause muscle aches, weakness, and bone pain in people of all ages.

Muscle spasms (tetany) may be the first sign of rickets in infants. They are caused by a low calcium level Hypocalcemia (Low Level of Calcium in the Blood) In hypocalcemia, the calcium level in blood is too low. A low calcium level may result from a problem with the parathyroid glands, as well as from diet, kidney disorders, or certain medications... read more in the blood in people with severe vitamin D deficiency. If pregnant women have vitamin D deficiency, their newborn may have spasms. The spasms may affect the face, hands, and feet. If the spasms are severe, they may cause seizures.

In young infants who have rickets, the entire skull may be soft.

Older infants may be slow to sit and crawl, and the spaces between the skull bones (fontanelles) may be slow to close.

For older children and adolescents, walking is painful. Severe vitamin D deficiency can cause bowlegs or knock-knees. The pelvic bones may flatten, narrowing the birth canal in adolescent girls.

In adults, the bones, particularly the spine, pelvis, and leg bones, weaken. Affected areas may be painful to touch, and fractures may occur.

Diagnosis of Vitamin D Deficiency

  • Blood tests

  • Sometimes x-rays

Doctors suspect vitamin D deficiency in the following people:

  • People who report an inadequate diet or inadequate exposure to sunlight

  • Newborns with tetany (a type of muscle spasms)

  • Children with signs of rickets

  • Older adults, especially those with decreased bone density (for example, with osteoporosis) or broken bones

Blood tests to measure vitamin D can confirm the deficiency. Levels of calcium and phosphate are measured. Levels of other substances may be measured to rule out other causes of decreased bone density.

X-rays may also be taken. The characteristic changes in bone may be seen on x-rays before symptoms become noticeable.

The diagnosis of rickets or osteomalacia due to vitamin D deficiency is based on symptoms, the characteristic appearance of bones on x-rays, and a low level of vitamin D in the blood.

Prevention of Vitamin D Deficiency

Many people need to take vitamin D supplements. Getting enough exposure to sunlight may be difficult, especially because the skin also needs to be protected from sun damage. Natural foods rarely contains enough vitamin D to compensate for lack of sunlight.

Vitamin D supplements are particularly important for people who are at risk (such as people who are older, housebound, or living in long-term care facilities). To prevent deficiency, older people should usually take 20 micrograms [800 units] of vitamin D daily in supplements. Higher doses are rarely needed.

Commercially available liquid milk (but not cheese or yogurt) is fortified with vitamin D in the United States and Canada. Many other countries do not fortify milk with vitamin D. Breakfast cereals may also be fortified.

In breastfed infants, starting vitamin D supplements at birth is particularly important because breast milk contains little vitamin D. Supplements are given until infants are 6 months old, when they begin to eat a more varied diet. For formula-fed infants, commercial infant formulas contain enough vitamin D.

Treatment of Vitamin D Deficiency

  • Vitamin D supplements

  • Sometimes calcium and phosphate supplements

Treatment of vitamin D deficiency involves taking high doses of vitamin D, usually daily by mouth, for about 1 month. After 1 month, the dose is usually reduced gradually to the usual recommended dose.

If muscle spasms are present or calcium is thought to be deficient, calcium supplements are also given. If phosphate is deficient, phosphate supplements are given. Usually, this treatment leads to a complete recovery.

People with a chronic liver or kidney disorder may require special formulations of vitamin D supplements.

Spotlight on Aging: Vitamin D Deficiency

Older people are more likely to develop vitamin D deficiency for several reasons:

  • Their requirements are higher than those of younger people.

  • They tend to spend less time outdoors and thus are not exposed to enough sunlight.

  • They may not be exposed to enough sunlight because they are housebound, live in long-term care facilities, or need to stay in the hospital for a long time.

  • When exposed to sunlight, their skin does not form as much vitamin D.

  • They may consume so little vitamin D in their diet that even taking vitamin D supplements in low doses (such as 10 micrograms [400 units] per day) does not prevent the deficiency.

  • They may have disorders or take drugs that interfere with the processing of vitamin D.

Older people should take 20 micrograms [800 units] of vitamin D each day to keep their bones healthy.

Vitamin D has not been shown to prevent cancer or other disorders or to prevent falls in older people. Research to look for other benefits of vitamin D is ongoing.

Older people who take high doses of vitamin D supplements need to have periodic blood tests to check their levels of calcium, vitamin D, and parathyroid hormone.

Drugs Mentioned In This Article

Generic Name Select Brand Names
Calcidol, Calciferol, D3 Vitamin, DECARA, Deltalin, Dialyvite Vitamin D, Dialyvite Vitamin D3, Drisdol, D-Vita, Enfamil D-Vi-Sol, Ergo D, Fiber with Vitamin D3 Gummies Gluten-Free, Happy Sunshine Vitamin D3, MAXIMUM D3, PureMark Naturals Vitamin D, Replesta, Replesta Children's, Super Happy SUNSHINE Vitamin D3, Thera-D 2000, Thera-D 4000, Thera-D Rapid Repletion, THERA-D SPORT, UpSpring Baby Vitamin D, UpSpring Baby Vitamin D3, YumVs, YumVs Kids ZERO, YumVs ZERO
Rifadin, Rifadin IV, Rimactane
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