e-SPEN Journal 7 (2012) e215ee218

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journal homepage: http://www.elsevier.com/locate/clnu

Original article

Awareness of vitamin D deciency states and recommended supplementation

doses: Survey of faculty and staff at a medical school
J.E. Agens a, *, G.T. Galasko b, A.V. Purandare c, J. Lin d
a

Department of Geriatrics, Florida State University College of Medicine, Suite 4313, 1115 West Call Street Tallahassee, FL 32306-4300, United States
Department of Biomedical Sciences, Florida State University College of Medicine, United States
c
Florida State University College of Medicine, United States
d
Florida State University, United States
b

a r t i c l e i n f o

s u m m a r y

Article history:
Received 21 December 2011
Accepted 10 September 2012

Background & aims: Adequate vitamin D is essential for good health. It is important that physicians are
aware that deciency occurs even in areas with plentiful sunshine.
Methods: We used e-mail distribution lists to anonymously survey physicians (MDs) and non-physicians
(non-MDs) of a Southeastern USA medical school in order to determine awareness of conditions associated with vitamin D deciency, percentage of subjects who had had their vitamin D levels checked,
percentage of subjects who were aware they had low vitamin D, MD-recommended doses for supplementation, and MD factors associated with recommending doses >800 IU/day.
Results: A minority (21%) of all subjects had their vitamin D level checked and two thirds of those who
knew their level reported it low. Multivariate logistic regression showed: 1) having vitamin D checked
was associated with personally taking vitamin D, 2) MDs were more likely to take vitamin D than nonMDs, and 3) a trend that MDs who had their vitamin D level checked recommended higher supplementary doses (
800 IU/day) for their patients.
Conclusions: Low self-reported vitamin D levels are prevalent in our sample of MDs and non-MDs living
in an area of the USA with plentiful sunshine.
2012 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights
reserved.

Keywords:
Vitamin D
25-Hydroxyvitamin D
Survey
Awareness
Physicians
Supplementation

1. Background and purpose

Vitamin D is a fat soluble vitamin, long known to affect bone
health. Cholecalciferol (D3) is synthesized in the skin from 7dehydrocholesterol by exposure to ultraviolet B (UVB) rays from
sunlight. D3 is converted in the liver to 25-hydroxy vitamin D
(25OHD), which is the form commonly measured to determine
blood levels. The primary active metabolite, calcitriol (1,25(OH)2
D3), is then formed by metabolic activation in the kidney. The
amount of calcitriol formed depends on both the amount of
exposure to sunlight and on renal function. Because sunlight is
important in the formation of vitamin D, both climate and

Abbreviations: D3, cholecalciferol; 25OHD, 25-hydroxyvitamin D; MDs, physicians; non-MDs, non-physicians; UVB, ultraviolet B; IOM, Institute of Medicine; DRI,
dietary reference intakes; RDA, recommended daily allowance; UL, tolerable upper
intake level.
* Corresponding author. Tel.: 1 850 644 2250.
E-mail addresses: john.agens@med.fsu.edu (J.E. Agens), gail.galasko@
med.fsu.edu (G.T. Galasko), avp08@med.fsu.edu (A.V. Purandare), jlin@stat.fsu.edu
(J. Lin).

behaviors affecting sun exposure have an important role in determining whether sufcient vitamin D is formed. While it is well
known that UVB intensity (necessary for 25OHD formation)
decreases with increasing latitude and that populations in
Northern latitudes are at risk for hypovitaminosis D, it is often
overlooked that this may occur even in the sunniest climates due to
behaviors that modify sun exposure to the skin. Examples include
indoor lifestyle with less time spent outdoors, increased sunscreen
use, and, in some cultures, wearing of heavy veiling, such as burqas,
by women. Few foods contain appreciable amounts of vitamin D.
Low vitamin D status occurs even in sunny areas, such as the
Southeastern USA,1 as a result of sun avoiding behaviors. However,
since low vitamin D is associated with higher latitudes where there
is less sunshine, the question arose as to physicians knowledge of
vitamin D deciency in sunshine states.
Vitamin D has classically been used therapeutically for its effect
on bone, originally for prophylaxis and treatment of rickets and
osteomalacia, and later in prevention and treatment of osteoporosis.
A 25OHD level of less than 25 nmol/L is internationally recognized as
the level at which risk for rickets and osteomalacia occurs (<10 ng/
ml in the USA, with a conversion factor of 2.5X to convert to nmol/L);

2212-8263/$36.00 2012 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.clnme.2012.09.003

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however, parathyroid hormone elevation begins to occur at vitamin

D levels below 50 nmol/L (20 ng/ml) leading some to recommend
the latter as the level of vitamin D deciency.2
Over the past few years, epidemiological studies have shown
that multiple conditions and syndromes are associated with low
25OHD levels. These include, inter alia, frailty in older persons;3
respiratory infections;4,5 cognitive decline;6 hypertension;7,8
increased circulating renin-angiotensin; heart failure;9 and
cancer.10 Vitamin D has immune modulating effects,11 and deciency exacerbates experimental autoimmune diseases including
inammatory bowel disease.12 Many organs and tissues have
vitamin D receptors. A recent review suggests vitamin D has antiinammatory properties (down-regulation of TNF alpha, IL6, and
IL1) in autoimmune conditions such as multiple sclerosis, inuencing the proliferation and differentiation of B cells and T cells.13 In
addition, vitamin D (700e1000 mg/day) has been shown to prevent
falls in the elderly.14 The conuence of this newer epidemiologic
data has led some to suggest optimal 25OHD levels should be
higher than previously thought, viz. 100 nmol/L to 175 nmol/L
(40 ng/ml to 70 ng/ml).15,16 Concentrations between these levels
and deciency would then be termed vitamin D insufciency.
These ndings suggest that vitamin D has multiple roles in
maintaining good health. In the last few years, it has become
increasingly evident that correcting low vitamin D has multiple
benecial effects 17,18,19,20 and that low vitamin D blood levels are
associated with multiple conditions and syndromes.16 Relatively
few adverse effects have been reported for daily doses up to
2000 IU per day;21 however, a study using a single annual dose of
500,000 IU of vitamin D supplementation showed increased risk of
falls and fractures.22 In addition, care needs to be taken since
overdose of vitamin D can lead to hypercalcemia.23 Thus, knowledge of an individuals vitamin D status is an important factor in
determining appropriate supplementation.
Recently the Institute of Medicine (IOM) determined that
enough new and relevant scientic data exist to recommend a new
nutrient review on vitamin D24 since the Dietary Reference Intakes
(DRI) were published in 1997. The evidence was felt to be particularly strong in the elderly. It is therefore important that medical
practitioners are aware of the consequences of both vitamin D
insufciency and deciency and that this can occur even in areas
with plentiful sunshine.
There is little literature addressing physicians knowledge of
vitamin D deciency.25,26,27 The only article of relevance to this
study concerned physician ordering of vitamin D levels as a function of knowledge of their own vitamin D status.25 We found no
literature concerning non-physicians awareness of vitamin D
deciency states or awareness of their own vitamin D status.
The purpose of this research was to determine, through the use of
an anonymous and condential survey, the level of awareness of
possible vitamin D deciency in a sunny Southeastern region of the
USA; to determine what physician factors are associated with
recommendations of adequate doses of vitamin D supplementation
to their patients; to determine what percentage of physicians are
aware of their vitamin D status and how this compares to educated
non-MDs; and to determine what percentage of physicians personally take vitamin D supplements as compared to educated non-MDs.
We also sought to nd factors that correlate with a MD recommendation to supplement vitamin D at a dose 800 IU or greater.
2. Materials and methods
2.1. Study design
Faculty and staff of a Southeastern USA medical school with
a geographically distributed, community-based campus model

were asked to participate in an anonymous survey concerning

vitamin D awareness (see Supplementary materials). The parent
universitys institutional review board for research with human
subjects approved this study. The e-mail distribution lists of the
medical school were used for survey distribution. All subjects gave
informed consent and results were collected on surveymonkey.com
then exported to an electronic spread sheet for analysis. The survey
was administered in early spring.
2.2. Participants
There are over 1,800 faculty and staff on the e-mail distribution
lists at the medical school. The main campus employs mostly fulltime MD and PhD faculty in teaching rst- and second-year medical
students. There are six regional campuses teaching third- and fourthyear medical students. At the regional campuses, community faculty
physicians, who are not full time faculty, teach under the direction of
their respective regional campus deans and clinical clerkship directors. Rural areas and small to medium cities are well represented.
Over two thirds of the physician responses were from regional
campuses, ensuring both clinical and academic practice.
Two hundred and nine subjects responded to the survey;
however, not all subjects answered all questions. Just over half of
the respondents who answered the question Are you a physician?
(104/205) were physicians (MDs). The remaining non-MDs were
more likely to be female (79% versus 29%, p < 0.001) and more
likely to be under 40 years of age (58% versus 43% of MDs,
p < 0.001). Of the 196 who answered the race/ethnicity question,
84 percent were Caucasian, 5 percent Hispanic, 5 percent Asian or
Pacic Islander, 4 percent African American, with the remainder
answering Other. There were no signicant differences between
the MDs and non-MDs. Of the MDs, 50 (48%) reported themselves
as follows: internal medicine, family practice, pediatrics, geriatrics,
or obstetrics gynecology. These primary care physicians are typically able to longitudinally monitor dietary supplement use. The
remainder reported a variety of other specialties.
2.3. Data analysis
The following measures were treated as categorical independent variables: MD versus non-MD, gender, age greater than or
equal to 50 versus less than 50 years, and Caucasian race versus
other races or ethnicities. Non-MD faculty (n 20) and staff
(n 71) were combined for chi-square analysis because of the
relatively small number of non-MD faculty and the similarity of
their survey responses to staff. This combined category is termed
non-MD. The numbers of non-Caucasian races as well as the
numbers of ethnicities are too small for statistical analysis.
Dependent variables were analyzed using chi-square analysis.
MDs as well as non-MDs had the opportunity to free text as many as
ve conditions or syndromes they thought were associated with
vitamin D deciency. These were sorted and ranked according to
how often MDs and non-MDs noted each. The total number of
conditions listed by each subject was also counted (0, 1, 2, 3, 4, or 5).
The following measures were also treated as categorical dependent
variables: vitamin D level ever checked (yes/no), personally taking
calcium (yes/no), personally taking daily vitamin D (yes/no),
vitamin D level known to be low (yes/no), and less than 20 minutes
of sunlight versus more than 20 minutes exposure per day. MDs
were specically asked about the supplementation dosages of
vitamin D they recommend for patients for prevention (200 IU,
400 IU, 800 IU, 1000 IU, or greater than 1000 IU) as well as the
dosages they recommend for treatment of patients with deciency
(200 IU, 400 IU, 800 IU, 1000 IU, or greater than 1000 IU). We did not
allow a treatment choice for vitamin D insufciency in this inquiry.

J.E. Agens et al. / e-SPEN Journal 7 (2012) e215ee218

3. Results
Osteomalacia, osteoporosis, and rickets were each noted by at
least 15 percent of those surveyed. Conditions such as muscle
weakness, fatigue, falling, fractures, cardiovascular disease, breast
cancer, and colon cancer were each listed by less than 15 percent.
MDs noted osteoporosis, osteomalacia, and rickets (65%, 81%, and
84% respectively) signicantly more frequently than non-MDs (35%,
22%, and 16%, p < 0.001). MDs noted osteoporosis signicantly less
than osteomalacia or rickets (p 0.010), but non-MDs noted
osteoporosis signicantly more frequently than those two conditions (p < 0.050). MDs also noted a greater number of total
conditions associated with vitamin D deciency versus the total
number of conditions noted by the non-MDs (p < 0.050). MDs
tended to note three or more conditions. Non-MDs noted zero to
two conditions. There were no statistically signicant differences
based on gender or age.
A signicantly higher percentage of female MDs reported taking
vitamin D compared to male MDs (70% versus 42%, p < 0.050).
There were no signicant gender differences for non-MDs. For MDs
and non-MDs, the percentage of females having their vitamin D
level checked was slightly higher than that for males, but the
difference was not signicant (20% versus 19% for MDs and 23%
versus 17% for non-MDs).
Fig. 1 shows the dosages of vitamin D recommended for
prevention and treatment by MDs. For prevention, responses were
approximately evenly distributed between doses of 400 IU, 800 IU,
and 1000 IU with the small remainder either unsure (10%) or recommending doses greater than 1000 IU (11%). A minority (27%)
recommended 400 IU or less for prevention. For the treatment of
deciency, a majority (71%) recommended 1000 IU per day or
more; but the rest were either unsure or recommending less.
Differences between prevention and treatment recommended
doses were statistically signicant (p < 0.001).
3.1. Multivariate logistic regression
Multivariate logistic regression was performed on survey
response characteristics most likely to be associated with personal
vitamin D supplementation as a dependent variable. MDs were
signicantly more likely to take vitamin D than non-MDs
(p < 0.050). Those respondents having had their vitamin D
checked and those on a calcium supplement were each signicantly
more likely to be taking vitamin D (p < 0.001, p < 0.001). No other
independent variables were signicantly associated with taking
vitamin D. This includes gender and age.

Fig. 1. MD recommended daily dose of vitamin D. Doses of vitamin D in International

Units recommended by MDs for both prevention (represented by the darkly shaded
bars) and treatment (represented by the lightly shaded bars). Chi-Square analysis
showed MDs recommended signicantly higher doses for treatment of deciency
compared to doses they recommended for prevention of deciency (p < 0.001).

e217

Multivariate logistic regression was also performed on survey

response characteristics most likely to be associated with respondents having had a vitamin D level checked. Older age was associated with having had a vitamin D level checked. With age 20e29
as the reference decade, each decade of age beginning with 40e49
was signicantly associated with having had a vitamin D level
checked: 30e39, p 0.159 NS (not signicant); 40e49, p 0.035;
50e59, p 0.010; 60e79, p 0.005; and age >80 p 0.011. Less
than 20 min of sun exposure per day (p < 0.001) and being on
calcium supplementation (p 0.003) were both signicantly
associated with having had a vitamin D level checked. No other
variables were independently, signicantly associated with having
had a vitamin D level checked.
Finally, a multivariate logistic regression analysis was performed
to nd out which variables were associated with a physician recommending a dose of greater than or equal to 800 IU/day of vitamin
D for prevention of deciency. MDs who had their own vitamin D
level checked were 4.5 times more likely to recommend greater
than or equal to 800 IU/day, a non-signicant trend (p 0.056). A
majority (56%) of the 104 MDs said they would like to have their
vitamin D level checked. For non-MDs, 74 percent said they would
like to have their vitamin D level checked.
3.2. Self-reported vitamin D levels
Twenty one percent of all subjects had their vitamin D level
checked. Of those, 73 percent said they knew their level. Two thirds
said the level was low and one third said it was normal. While this
is a small percentage of the total survey sample, a very high
percentage of those having their vitamin D level checked knew it to
be low.
4. Discussion
The results obtained in this study showed that knowledge of
bone conditions traditionally associated with vitamin D deciency
was well entrenched in our survey sample; however, it is noteworthy that MDs listed rickets and osteomalacia more frequently
than osteoporosis. Knowledge of other associations, such as low
vitamin D levels being associated with falls in the elderly, was
demonstrated by less than 15 percent of the sample.
Knowledge of MD factors associated with taking vitamin D for
themselves and with recommending it for their patients may help
us better understand what inuences such decisions. MDs were
more likely to take a vitamin D supplement than non-MDs
(p < 0.050). This was due predominantly to female MDs who
took vitamin D. Having vitamin D checked and taking a calcium
supplement were associated with personally taking vitamin D in
the multivariate analysis. Given that the multivariate analysis did
not show a gender bias, perhaps one or both of those variables
accounted for the fact that more female MDs took vitamin D in the
simple chi-square analysis.
On November 30, 2010, new DRI for vitamin D were published
by the IOM. The Recommended Daily Allowance (RDA) was revised
upward and the Tolerable Upper Intake Level (UL) was established.
The UL is the intake at which harm is unlikely. The RDA for adults is
now 600 IU/day and 800 IU/day for adults 71 and older. In addition,
the UL was set at 4,000 IU/day for ages nine and older.28 While
there is debate on whether vitamin D supplementation is recommended too rarely or too often,28,29 a full 27 percent of our MD
sample recommended a supplementation dose of 400 IU or less,
which is low according to some authors.29
The survey suggested a non-signicant trend that having ones
vitamin D level checked increased a MDs chance of recommending 800 or more IU/day or higher by 4.5 times (p 0.056

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J.E. Agens et al. / e-SPEN Journal 7 (2012) e215ee218

NS). Since 56 percent of our surveyed MDs reported that they

would like to have their own vitamin D level checked, we propose
that offering vitamin D testing to MDs would be of value in
increasing their knowledge about vitamin D deciency and
treatment recommendations to patients. Most non-MDs also reported they would like to have their vitamin D level checked
(74%). Since only 20 percent of both MDs and non-MDs reported
having their levels checked, there is a gap between wanting and
having knowledge of vitamin D status. Like the MDs, many nonMDs were aware of an association between low vitamin D
status and bone diseases.
Although there are limitations with our survey, the results are
valuable because of the uniqueness of this type of survey data in
the published literature on vitamin D deciency. Our survey
response rate is typical for anonymous e-mail surveys at our
institution (about 15%). Since the response rate was low, we
cannot generalize results to the entire population of MDs or nonMDs at our medical school. We have no data on non-responders.
Stepwise, multivariate logistic regression has limitations. The
associations we report do not imply causation. They raise a series
of questions about their causes. For example, personally taking
vitamin D was associated with taking a calcium supplement. Was
it because calcium supplements are often combined with vitamin
D supplements when taken for maintaining bone calcium
content? Having had a vitamin D level checked was associated
with greater age and less sun exposure. Those are both risk factors
for vitamin D deciency. Population screening is not currently
recommended. Were these risk factors used by the subjects care
providers when ordering levels? Two thirds of subjects who knew
their level reported it as low and personally taking a vitamin D
supplement was associated with having had a vitamin D level
checked; however, we did not directly ask subjects why they were
taking vitamin D. We did not independently conrm vitamin D
levels.
We have no data on why MDs chose various vitamin D doses for
prevention or treatment of deciency. We do not know the MDs
assumptions about the prevalence of vitamin D deciency in their
communities or about daily UVB exposure in their patients. We also
performed this study before the new RDIs for vitamin D were
published, so we could not have anticipated the new 600 IU/day
RDA for adults <71 years of age (previously 400 IU/day). Had we
anticipated this, we would have included 600 IU/day as a supplement dose choice.
Statement of authorship
JA conceived of and carried out the study, co-designed the study,
co-supervised the data analysis, and co-drafted the manuscript. GG
co-drafted the manuscript, co-supervised the data analysis, codesigned the study, and participated in carrying out the study. AP
performed the data analysis, including design of the gures and
participated in drafting of the manuscript. JL performed statistical
analyses, participated in analysis of data, and participated in the
drafting of the manuscript.
Conict of interest statement
The authors declare no conicts of interest.
Acknowledgments
There were no external funding sources for this research. The
authors would like to thank Charles Saunders for critique of
statistics, data analysis, and early drafts of the manuscript.

Appendix A. Supplementary material

Supplementary data related to this article can be found at
http://dx.doi.org/10.1016/j.clnme.2012.09.003.

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