Defining Hypovitaminosis D Hypovitaminosis D is a deficiency of vitamin D.

It can result from inadequate nutritional intake of vitamin D coupled with inadequate sunlight exposure (in particular sunlight with adequate ultraviolet B rays), disorders that limit vitamin D absorption, and conditions that impair the conversion of vitamin D into active metabolites including certain liver, kidney, and hereditary disorders.[1] Deficiency results in impaired bone mineralization and leads to bone softening diseases including rickets in children and osteomalacia and osteoporosis in adults.[1]

Vitamin D Metabolism Vitamin D has two main forms: D2 (ergocalciferol) and D3 (cholecalciferol). Vitamin D3 is synthesized in skin by exposure to sunlight (ultraviolet radiation) and obtained in the diet chiefly in fish liver oils and egg yolks. In some developed countries, milk and other foods are fortified with vitamin D. Human breast milk is low in vitamin D, containing an average of only 10% of the amount in fortified cow's milk. Requirements for vitamin D increase with aging. Vitamin D is a prohormone with several active metabolites that act as hormones. Vitamin D3 is metabolized by the liver to 25(OH)D, which is then converted by the kidneys to 1,25(OH)2D (1,25-

dihydroxycholecalciferol, calcitriol, or active vitamin D hormone). 25(OH)D, the major circulating form, has some metabolic activity, but 1,25(OH)2D is the most metabolically active. Inadequate exposure to sunlight may cause vitamin D deficiency. Deficiency impairs bone mineralization, causing rickets in children and osteomalacia in adults and may contribute to osteoporosis.

Measure of Vitamin D Status Hypovitaminosis D is typically diagnosed by measuring the concentration in blood of the compound 25-hydroxyvitamin D (calcidiol), which is a precursor to the active form 1,25dihydroxyvitamin D (calcitriol).[3] One 2008 review has proposed the following four categories for hypovitaminosis D:[4] Insufficient 50100 nmol/L (2040 ng/mL) Mild 2550 nmol/L (1020 ng/mL) Moderate 12.525.0 nmol/L (510 ng/mL) Severe < 12.5 nmol/L (< 5 ng/mL)

Risk Factor for Hypovitaminosis D Elderly Related to housebound status and decreased Vitamin D absorption Comorbid illness Malnourished Lack of Sun Exposure (or thorough sun screen use) Those with darker skin require 3-6 fold more exposure Renal disease (Renal Failure, Nephrotic Syndrome) Hepatic disease (Cirrhosis) Gastric surgery (resection or Gastric Bypass) Small Bowel Resection Medications Anticonvulsant use (e.g. Phenobarbital, Phenytoin) Requires 2-5 fold more Vitamin D intake daily Corticosteroids (long-term use) Rifampin Total Parenteral Nutrition