Critical reappraisal of vitamin D deficiency

The current surge of interest in vitamin D is fuelled not only by evidence that vitamin D supplementation decreases the risk of osteoporotic fractures but also by vast observational studies indicating a variety of beneficial extraskeletal effects (including decreases in the risks of cancer, inflammatory diseases, and even death). Serum 25-hydroxyvitamin D (25(OH)D) assay is now a highly reliable method for evaluating vitamin D stores in individual patients. Nevertheless, the normal or desirable 25(OH)D range for patients seen in everyday clinical practice needs to be more accurately defined. Maintaining serum 25(OH)D above 75 nmol/L is currently recommended to ensure optimal bone health, but higher levels may be required to obtain some of the extraskeletal benefits. Naturally occurring vitamin D is by far the most widely used form for correcting vitamin D deficiency, and the hydroxylated derivatives have only a few highly specific indications. However, controversy persists about the optimal modalities of natural vitamin D supplementation in terms of the type of vitamin (D2 or D3), schedule (once daily or at wider intervals), and route (oral or injectable). For chronic supplementation to protect against bone loss, a daily dosage of at least 800 IU seems required. Higher dosages (e.g., 100,000 to 200,000 IU every 2 months for 6 months) may be needed to correct established vitamin D deficiency; a repeat 25(OH)D assay after 4 to 6 months may help to assess the treatment response and to adjust the subsequent vitamin D dosage. The current emphasis is on the detection of vitamin D deficiency in the general population and in subgroups at risk for osteoporosis followed by an assessment of severity and the initiation of appropriate treatment. From a public health perspective, supplying at least 800 IU per day seems useful and safe.