Vitamin D Screening and Supplementation in Community-Dwelling Adults: Common Questions and Answers

 

Measurement of vitamin D levels and supplementation with oral vitamin D have become commonplace, although clinical trials have not demonstrated health benefits. The usefulness of serum 25-hydroxyvitamin D levels to assess adequate exposure to vitamin D is hampered by variations in measurement technique and precision. Serum levels less than 12 ng per mL reflect inadequate vitamin D intake for bone health. Levels greater than 20 ng per mL are adequate for 97.5% of the population. Routine vitamin D supplementation does not prolong life, decrease the incidence of cancer or cardiovascular disease, or decrease fracture rates. Screening asymptomatic individuals for vitamin D deficiency and treating those considered to be deficient do not reduce the risk of cancer, type 2 diabetes mellitus, or death in community-dwelling adults, or fractures in persons not at high risk of fractures. Randomized controlled trials of vitamin D supplementation in the treatment of depression, fatigue, osteoarthritis, and chronic pain show no benefit, even in persons with low levels at baseline.

Measurement of vitamin D levels and supplementation with oral vitamin D have become commonplace in clinical practice.1,2 In 2014, vitamin D levels were the fifth most common laboratory test ordered for Medicare patients, with a total cost of $323 million.1 Although vitamin D was first identified as a vitamin, it is now considered a prohormone and is unique to other nutrients because it can be synthesized in the skin through exposure to sunlight. Although vitamin D deficiency has been labeled a worldwide problem,3 estimates of disease burden are based on specific laboratory values,4 rather than on health problems that can be reliably attributed to low vitamin D levels or that have been shown to respond to vitamin D supplementation.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Serum 25-OH-D levels of 12 to 20 ng per mL (30 to 50 nmol per L) correlate to the vitamin D exposure necessary to maintain bone health. Individuals with levels less than 12 ng per mL are usually deficient in vitamin D, and 97.5% of individuals with levels higher than 20 ng per mL have adequate vitamin D intake.

C

5

Use of 25-OH-D levels to assess adequate vitamin D exposure is limited by variability in measurement technique and precision.

Routine vitamin D supplementation in community-dwelling adults is not recommended.

A

1622

Routine vitamin D supplementation does not prolong life, decrease the incidence of cancer or cardiovascular disease, or decrease fracture rates.

There is insufficient evidence to recommend screening the general population for vitamin D deficiency. Treating asymptomatic individuals with identified deficiency has not been shown to improve health.

B

2527

The USPSTF found adequate evidence that treating vitamin D deficiency does not reduce risk of cancer, type 2 diabetes mellitus, or death in community-dwelling adults, or fractures in persons not at high risk of fractures. Evidence is insufficient for other outcomes, including psychosocial and physical functioning.

Physicians should not measure 25-OH-D levels or prescribe vitamin D supplementation in the treatment of depression, fatigue, osteoarthritis, or chronic pain.

A

3741, 4648, 5357

Randomized controlled trials do not show benefit for conditions commonly treated with vitamin D. Other nonskeletal conditions have been inadequately studied.


25-OH-D = 25-hydroxyvitamin D; USPSTF = U.S. Preventive Services Task Force.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Serum 25-OH-D levels of 12 to 20 ng per mL (30 to 50 nmol per L) correlate to the vitamin D exposure necessary to maintain bone health. Individuals with levels less than 12 ng per mL are usually deficient in vitamin D, and 97.5% of individuals with levels higher than 20 ng per mL have adequate vitamin D intake.

C

5

Use of 25-OH-D levels to assess adequate vitamin D exposure is limited by variability in measurement technique and precision.

Routine vitamin D supplementation in community-dwelling adults is not recommended.

A

1622

Routine vitamin D supplementation does not prolong life, decrease the incidence of cancer or cardiovascular disease, or decrease fracture rates.

There is insufficient evidence to recommend screening the general population for vitamin D deficiency. Treating asymptomatic individuals with identified deficiency has not been shown to improve health.

B

2527

The USPSTF found adequate evidence that treating vitamin D deficiency does not reduce

The Authors

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MICHAEL L. LEFEVRE, MD, MSPH, is a Future of Family Medicine professor in and vice chair of the Department of Family and Community Medicine at the University of Missouri School of Medicine in Columbia....

NICHOLAS M. LEFEVRE, MD, is on the faculty at the John Peter Smith Family Medicine Residency in Fort Worth, Tex. At the time this article was written, he was a fourth-year resident at Lawrence (Mass.) Family Medicine Residency.

Address correspondence to Michael L. LeFevre, MD, MSPH, University of Missouri School of Medicine, MA 303 Health Sciences Center, Columbia, MO 65212 (e-mail: lefevrem@health.missouri.edu). Reprints are not available from the authors.

Author disclosure: no relevant financial affiliations.

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