Vitamin D Deficiency: Difference between revisions

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*IUs= International Units
IUs= International Units


**DV= Daily Values developed by U.S. Food and Drug Administration
DV= Daily Values developed by U.S. Food and Drug Administration


== Differential Diagnosis  ==
== Differential Diagnosis  ==

Revision as of 01:38, 2 April 2013

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors -Nicole Hess & Shannon McMullen from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Definition/Description[edit | edit source]

Vitamin D, also known as calcidiol or 25(OH)D, is a fat-soluble vitamin obtained from sun exposure, food, and supplements. It is not naturally present in many foods but is often used to fortify food or taken as a dietary supplement.Vitamin D is synthesized in the body when cholesterol[1] (7-dehydrocholesterol)[2] activates with UVB rays from sunlight. When ingested the intestines absorbs the vitamin and sends it to the liver and kidneys for further processing. In the liver it converts to 25-hydroxyvitamin D [25(OH)D], also known as calcidiol and in the kidneys it forms the physiologically active 1,25-dihydroxyvitamin D [1,25(OH)2D], also known as calcitriol. It is a necessary vitamin for calcium absorption, maintaining serum calcium and phosphate concentrations to enable normal mineralization of bone and to prevent hypocalcemic tetany. It is also needed for bone growth and bone remodeling by osteoblasts and osteoclasts. Inadequate amounts of vitamin D is associated with many comorbidities and diagnoses such as rickets in children and osteomalacia in adults. [1]

Prevalence[edit | edit source]

A minimum of 25% up to 50% US adult population are vitamin D deficient.[3][4] According to a recent National Health and Nutrition Examination Survey, overall prevalence rate of vitamin D deficiency is approximately 41% in the US adult population. Regarding ethnicity, deficiency is most commonly seen in African Americans followed by Hispanics.[3]


Other common characteristics associated with increased prevalence:

  • Geriatric population[2]
  • Obesity (all ages)[5][6]
  • Gestational diabetes[7]
  • Poor general health status[3]
  • Hypertension[3]
  • Insufficient daily intake of milk[3][8]
  • Depression[9]
  • Burn patients[10]

Characteristics/Clinical Presentation[edit | edit source]

  • General muscle weakness, falls, fractures, and decreased functional status and decreased progress during rehabilitation. 
  • In children with rickets this may present with bowing of the long bones with widening, fraying, and clubbing in areas of active bone growth. This is more prominent around the metaphyseal ends of the long bones and sternal ends of the ribs.[2]

Associated Co-morbidities[edit | edit source]

Hyperparathyroidism[8]

The reduced conversion of 25OHD associated with poor renal function in the kidneys may result in decreased active vitamin D and parathyroid hormone (PTH) concentration in the blood.

Medications[edit | edit source]

add text here

Diagnostic Tests/Lab Tests/Lab Values
[edit | edit source]

A risk marker used to measure defficiency levels is the plasma metabolite of Vitamine D, 25-hydroxyvitamin D (25(OH)D)[4][8]

Various methods available to measure 25OHD concentration include[8]:

  • Competitive Protein Binding Assay (CPBA)
  • Radioimmunoassay (RIA)
  • Enzyme-linked Immunoassay (EIA, ELISA)
  • Random Access Automated Assay using chemiluminescence technology (RAAA)
  • High-Performance Liquid Chromatography (HPLC)
  • Liquid Chromatography-mass Spectrometry (LC-MS)

Etiology/Causes[edit | edit source]

  • Low intake of vitamin D in diet [2]
  • Poor renal function: reduces conversion of 25OHD to active metabolite in kidney [8]
  • Decreased sun exposure [2]
  • Intestinal malabsorption problems, often associated with aging [2]
  • Long-term uses of anticonvulsants, which accelerates breakdown of the active forms of vitamin D[2]

Systemic Involvement[edit | edit source]

  1. Musculoskeletal System: Severe vitamin D deficiency may be associated with non-specific musculoskeletal pain, causing bone, muscle, and/or joint pain. [11][12]

Medical Management (current best evidence)
[edit | edit source]

                                               Recommended Dietary Allowances (RDA's) for Vitamin D[1]

Age Male Female Pregnancy
0-12 months*

400 IU

(10 mcg)

400 IU

(10 mcg)

1-13 years


600 IU

(15 mcg)


600 IU

(15 mcg)

14-18 years

600 IU
(15 mcg)


600 IU
(15 mcg)


600 IU
(15 mcg)


19-50 years

600 IU

(15 mcg)

600 IU

(15 mcg)

600 IU

(15 mcg)

51-71 yeas

600 IU

(15 mcg)

600 IU

(15 mcg)

> 70 years

800 IU 

(20 mcg)

800 IU

(20 mcg)

Physical Therapy Management (current best evidence)[edit | edit source]

add text here

Alternative/Holistic Management (current best evidence)[edit | edit source]

Vitamin D is best treated with holistic methods such as foods high in vitamin D and sun exposure

  • D2 (ergocalciferol) is found in vegetable sources and oral supplements
  • D3 (cholecalciferol) is obtained primarily from skin exposure to ultraviolet B (UVB) radiation in sunlight, ingestion of food sources such as oily fish and variably fortified foods (milk, juices, margarines, yogurts, cereals, and soy), and oral supplements

Most foods contain between 50 and 200 IU per serving, which varies depending on geographical location and use of th fortification process [4]


Food Sources Containing Vitamin D[1]
Food IUs per Serving* Percent DV**
Cod live oil, 1 tablespoon 1,360 340
Swordfish, cooked, 3 ounces 566 142
Salmon (sockeye), cooked, 3 ounces 447 112
Tuna fish, canned in water, drained, 3 ounces 154 39
Orange juice fortified with vitamin D, 1 cup 137 34
Milk, nonfat, reduced fat, and whole, vitamin D fortified, 1 cup 115-124 29-31
Yogurt, fortified with 20% of the DV of vitamin D, 6 ounces 80 20
Margarine, fortified, 1 tablespoon 60 15
Sardines, canned in oil, drained, 2 sardines 46 12
Liver, beef, cooked, 3 ounces 42 11
Egg, 1 large (vitamin D found in yolk) 41 10
Cheese, Swiss, 1 ounce  6 2

IUs= International Units

DV= Daily Values developed by U.S. Food and Drug Administration

Differential Diagnosis[edit | edit source]

  • Fibromyalgia [11]
  • Rheumatic diseases [11]

Case Reports[edit | edit source]

Case Report #1  [Full article available at www.najms.org/article.asp] [13]

Authors:
Clement Z, Ashford M, and Sivakumaran

Abstract:

  • Vitamin D deficiency is extremely common in multiple myeloma, and it represents a surrogate for clinical multiple myeloma disease status. Patients may complain of dull, persistent, generalized musculoskeletal aches and pains with fatigue or decrease in muscle strength.
  • This case highlights that vitamin D deficiency is common in patients with multiple myeloma, and can cause generalized musculoskeletal pain and increase the risk of falls, yet it often goes unrecognized. In patients with non-specific musculoskeletal pain, and inadequate sun-exposure medical practitioners must have a high index of suspicion for vitamin D deficiency.

Patient Characteristics:

  • 63 year old man with multiple myeloma
  • Current reactivation of herpes zoster

Subjective: Chief complaints include:

  • Generalized weakness
  • Nonspecific musculoskeletal pain
  • Reported multiple falls

Examination:

  • Pale presentation with a depressed affect
  •  Resting tremor, generalized bony tenderness, worse on movement and weight bearing
  • Muscle weakness
  • Waddling gait
  • Bone studies showed features of osteomalacia with a very low Vitamin D level of less than 20 nmol/L

Past Medical History:

  • Previously diagnosed with solitary plasmacytoma in 2001, which then progressed to smoldering myeloma in 2004
  • 2007 the indolent version of his myeloma transformed to a more aggressive form of myeloma with non-specific musculoskeletal chest pain, anorexia, weight loss, and tumour-lysis requiring hospital admission and plasmapheresis.
  • June 2010 the patient was admitted to hospital after multiple falls and zoster reactivation including ophthalmic zoster of the right first and second trigeminal branches.

Intervention: Physical Therapy

Co-intervention: Received 3,000 nmol/L daily of Vitamin D supplementation
Outcomes: 4 months later

  • Significant decrease in his generalized musculoskeletal pain
  • Bloods showed a normalized level of Vitamin D of 109 nmol/L
  • Decrease in alkaline phosphatase to 182 U/L
  • Currently undergoing palliative rehabilitation.


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Resources
[edit | edit source]

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Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Office of Dietary Supplements National Institutes of Health. Dietary Supplement Fact Sheet: Vitamin D. Available at: http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/#ref. Accessibility verified March 28, 2013.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. 3rd ed. Missouri: Saunders Elsevier; 2009.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Forrest K, Stuhldreher W. Prevalence and correlates of vitamin D deficiency in US adults. Nutrition Research (New York, N.Y.). January 2011;31(1):48-54. Available from: MEDLINE, Ipswich, MA. Accessed March 29, 2013.
  4. ↑ 4.0 4.1 4.2 Kennel KA, Drake MT, Hurley DL. Vitamin D deficiency in adults: when to test and how to treat. Mayo Clin Proc. 2010;85:752–757. quiz 757-8.
  5. ↑ Turer C, Lin H, Flores G. Prevalence of vitamin D deficiency among overweight and obese US children. Pediatrics [serial online]. January 2013;131(1):e152-e161. Available from: MEDLINE, Ipswich, MA. Accessed March 29, 2013.
  6. ↑ Olson M, Maalouf N, Oden J, White P, Hutchison M. Vitamin D deficiency in obese children and its relationship to glucose homeostasis. The Journal Of Clinical Endocrinology And Metabolism. January 2012;97(1):279-285.
  7. ↑ Alzaim M, Wood R. Vitamin D and gestational diabetes mellitus. Nutrition Reviews [serial online]. March 2013;71(3):158-167. Available from: CINAHL with Full Text, Ipswich, MA. Accessed March 29, 2013.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 Prentice A. Vitamin D deficiency: a global perspective. Nutrition Reviews [serial on the Internet]. (2008, Oct 2), [cited March 29, 2013]; 66S153-S164. Available from: SPORTDiscus with Full Text.
  9. ↑ Högberg G, Gustafsson S, Hällström T, Gustafsson T, Klawitter B, Petersson M. Depressed adolescents in a case-series were low in vitamin D and depression was ameliorated by vitamin D supplementation. Acta Paediatrica (Oslo, Norway: 1992) [serial on the Internet]. (2012, July), [cited March 29, 2013]; 101(7): 779-783. Available from: MEDLINE.
  10. ↑ Schumann A, Paxton R, Solanki N, Kurmis R, Mackie I, Greenwood J, et al. Vitamin D deficiency in burn patients. Journal Of Burn Care & Research: Official Publication Of The American Burn Association [serial on the Internet]. (2012, Nov), [cited March 29, 2013]; 33(6): 731-735. Available from: MEDLINE.
  11. ↑ 11.0 11.1 11.2 Gerber J; Journal of the American Chiropractic Association, 2010 May-Jun; 47 (4): 6-10. (journal article) ISSN: 1081-7166. Accessed 28 March 2013
  12. ↑ Heidari B, Shirvani J, Firouzjahi A, Heidari P, Hajian-Tilaki K. Association between nonspecific skeletal pain and vitamin D deficiency. International Journal Of Rheumatic Diseases [serial online]. October 2010;13(4):340-346. Available from: Academic Search Premier, Ipswich, MA. Accessed March 28, 2013.
  13. ↑ Clement Z, Ashford M, Sivakurmaran S. Vitamin D Deficiency in a Man with Multiple Myeloma. N Am J Med Sci. 2011 October; 3(10): 469–471. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3271427/. Accessed 28 March 2013.

Goodman C, Snyder T. Differential Diagnosis for Physical Therapist: Screening For Referral. Missouri: Saunders Elsevier; 2013.


Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. 3rd ed. Missouri: Saunders Elsevier; 2009.

see adding references tutorial.


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