Problems of vitamin D deficiency are becoming more evident

The woman had been going to various doctors for years, seeking a solution for seemingly unending generalized pain. Over time, her function had diminished to the point that she could no longer walk without assistance. It was only when her physician tested her vitamin D levels, diagnosed them as low and began treatment that she started to recover.

"She was very deficient in vitamin D," said Gustavo Jurado, MD, an internal medicine resident at the University of Chicago. "It's often overlooked. But if we had picked that up sooner, she could have avoided eight years of suffering."

Dr. Jurado presented this case at last month's American Assn. of Clinical Endocrinologists Annual Meeting and Clinical Congress in Chicago. Physicians are increasingly recognizing that vitamin D deficiency, which was the subject of several of the meeting's presentations, could be the cause of numerous patient ills.

"Vitamin D deficiency has not been well-recognized, but we're becoming progressively more aware of how hugely prevalent it is," said Daniel K. Short, MD, PhD, a staff endocrinologist at Gundersen Lutheran Medical Center in La Crosse, Wis.

Experts say this problem is coming to the fore due to the convergence of several phenomena. Older skin has a harder time synthesizing vitamin D from the sun, the nutrient's primary source, and the population is older than ever. Obese individuals have a harder time getting vitamin D from sunlight, and obesity is also on the rise. Increased awareness of skin cancer may be leading people to shield themselves from the sun so much that they are blocking out the vitamin, too. In addition, few foods contain it, and most of the U.S. population lives where it is not possible to get vitamin D from the sun year-round.

"There are concerns about skin cancer, and, in the winter, if you go out on the streets of New York completely naked, you do not get any vitamin D," said John P. Bilezikian, MD, who presented on the issue and is professor of medicine and pharmacology at the Columbia University's College of Physicians and Surgeons in New York. "Forget about the sun. The sun is not the source of vitamin D anymore."

Difficult to detect

But although recognition that the problem exists is growing, there is also increasing recognition that, although it can be cheap and easy to treat with supplements, it is tough to detect. The main symptoms, such as generalized pain and fatigue, could be markers for numerous disorders.

"The symptoms are very non-specific, so it can be difficult to pick up," Dr. Jurado said.

Lab checks are also not routine. As a result, many physicians may not know how to uncover it. For example, Dr. Jurado presented a survey of physicians along with the case study finding that 75% were not sure which test would diagnose or screen for vitamin D deficiency.

To make it more likely that this problem is detected and treated, the AACE plans to issue a position statement on vitamin D within the next six months and intends to incorporate new data on its use in its osteoporosis treatment guidelines due out before the year's end.

Until additional guidance is delivered, experts are calling on physicians to be alert to the fact that their patients might be vitamin D deficient, particularly those with osteoporosis. Many of these patients are prescribed bisphosphonates, but these drugs actually could cause harm if the patient is vitamin D deficient.

"This can induce fairly significant hypocalcemia and actually make things worse," Dr. Bilezikian said.

In addition to calling for greater attention to the role of using vitamin D to treat patients, some physicians are calling for increased attention to vitamin D as a preventive.

The National Institutes of Health held several conferences on this issue within the past few years, and the American Medical Women's Assn. issued a statement in November 2005 advising that the recommended daily intake be increased -- primarily to promote bone health.

And, because a growing body of literature is suggesting that vitamin D can reduce the risk of a whole host of ills, from multiple sclerosis to several types of cancer and diabetes, some experts are even advocating healthy sun exposure.

"There's no question that excessive exposure and sunburns are bad for you, but 10% of your body should be exposed to the sun for 15 minutes two to three times a week," said Michael Holick, MD, PhD, a professor of medicine, physiology and biophysics at Boston University School of Medicine. "Go out and enjoy yourself. Get the beneficial effect of the sun and then put on sunscreen."

This proposal, however, has been extremely controversial. Dermatologists have expressed concern that the benefits of additional vitamin D from sun exposure might not balance out the possible increased risks of skin cancer. The American Academy of Dermatology has issued several statements in the past several months urging people to get their vitamin D from food or dietary supplements.

"Any individual or organization advocating intentional sun exposure as the preferred means of obtaining vitamin D is doing a tremendous disservice to the public," said Barbara A. Gilchrest, MD, professor and chair of BU's Dermatology Dept.