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The Vitamin D Deficiency Pandemic: a Forgotten Hormone Important for Health


Early in the twentieth century more than 80 percent of children in industrialized Europe and North America were ravaged by the devastating skeletal consequences of rickets. Finding that exposure to ultraviolet radiation or sunlight treated and prevented rickets led to the ultraviolet irradiation of foods including milk. These practices along with the fortification of a variety of foods including dairy products with vitamin D and widespread use of cod liver oil eradicated rickets as a significant health problem by the late 1930s. Many countries mandated the fortification of milk with vitamin D to prevent rickets during wartime shortages. In the 1950s, in Europe, many countries forbid fortification of dairy and food products except breakfast cereals and margarine because of an outbreak of vitamin D intoxication in neonates.

Vitamin D deficiency has again become a major public health interest with its association with osteoporosis, osteomalacia, fractures, and more recently with prevention of cancer, diabetes, heart disease and other chronic illnesses. Regular sun exposure has decreased due to changing lifestyles. Vitamin D deficiency is especially prevalent in dark skinned children and adults living in Northern latitudes, and obese children and adults. Improving the vitamin D status worldwide would have dramatic effects on public health, and reduce healthcare costs for many chronic diseases. The most cost-effective way to remedy this deficiency is to increase food fortification with higher levels of vitamin D along with sensible sun exposure, and adequate vitamin D supplementation. I review the pathophysiology of vitamin D deficiency and its health consequences and provide recommendations for a new policy approach to this vital public health issue.


  1. 1.

    Holick MF. Resurrection of vitamin D deficiency and rickets. J Clin Invest. 2006; 116:2062–72.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Rajakumar K, Greenspan SL, Thomas SB, Holick MF. Solar ultraviolet radiation and vitamin D: a historical perspective. Am J Public Health. 2007;97:1746–54.

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Sniadecki J. Jerdrzej Sniadecki (1768–1838) on the cure of rickets. (1840) Cited by W. Mozolowski. Nature. 1939;143:121–124.

    Google Scholar 

  4. 4.

    Huldschinsky K. The ultra-violet light treatment of rickets. New Jersey: Alpine Press; 1928. p.3–19.

    Google Scholar 

  5. 5.

    Centers for Disease Control. Achievements in public health, 1900–1999: Safer and healthier foods. MMWR Morb Mortal Wkly Rep. 1999:48:905–13.

    Google Scholar 

  6. 6.

    Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357:266–8.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Dusso AS, Brown AJ, Slatopolsky E. Vitamin D. Am J Physiol Renal Physiol. 2005;289:F8–28.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Bischoff-Ferrari HA, Giovannucci E, Willett WC, Dietrich T, Dawson-Hughes B. Estimation of optimal serum concentrations of 25-hydroxyvitamin D for multiple health outcomes. Am J Clin Nutr. 2006;84:18–28.

    CAS  PubMed  Google Scholar 

  9. 9.

    Moan J, Porojnicu AC, Dahlback A, Setlow RB. Addressing the health benefits and risks, involving vitamin D or skin cancer, of increased sun exposure. Proc Natl Acad Sci U.S.A. 2008;105:668–73.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Grant WB. A critical review of vitamin D and cancer. A report of the IARC Working Group on Vitamin D. Dermatoendocrinol 2009;1:25–33.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Nagpal S, Na S, Rathnachalam R. Noncalcemic actions of vitamin D receptor ligands. Endocr Rev. 2005;26:662–87.

    CAS  Article  PubMed  Google Scholar 

  12. 12.

    Bikle D. Nonclassic actions of vitamin D. J Clin Endocrinol Metab 2009;94:26–34.

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Malabanan A, Veronikis IE, Holick MF. Redefining vitamin D insufficiency. Lancet. 1998;351:805–6.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Chapuy MC, Preziosi P, Maamer M, Arnaud S, Galan P, Hercberg S, et al. Prevalence of vitamin D insufficiency in an adult normal population. Osteoporos Int. 1997;7:439–43.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Heaney RP, Dowell MS, Hale CA, Bendich A. Calcium absorption varies within the reference range for serum 25-hydroxyvitamin D. J Am Coll Nutr. 2003; 22:142–6.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Rovner AJ, O’Brien KO. Hypovitaminosis D among healthy children in the United States: a review of current evidence. Arch Pediatr Adolesc Med 2008: 513–9.

    Google Scholar 

  17. 17.

    Kumar J, Muntner P, Kaskel FJ, Hailpern, SM, Melamed ML. Prevalence and associations of 25-hydroxyvitamin D deficiency in US Children: NHANES 2001–2004. Pediatrics 2009;124:e362–70. Aug 3 [Epub ahead of print]

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Looker AC, Pfeiffer CM, Lacher DA, Schleicher RL, Picciano MF, Yetley EA. Serum 25-hydroxyvitamin D status of the US population: 1988–1994 compared with 2000–2004. Am J Clin Nutr. 2008;88:1519–27.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Hyppönen E, Power C. Hypovitaminosis D in British adults at age 45 y: nationwide cohort study of dietary and lifestyle predictors. Am J Clin Nutr. 2007 Mar;85:860–8.

    PubMed  Google Scholar 

  20. 20.

    Koenig J, Elmadfa I. Status of calcium and vitamin D of different population groups in Austria. Int J Vitam Nutr Res. 2000 Sep;70(5):214–20.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Hintzpeter B, Mensink GB, Thierfelder W, Müller MJ, Scheidt-Nave C. Vitamin D status and health correlates among German adults. Eur J Clin Nutr. 2008 Sep;62(9):1079–89.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Lamberg-Allardt CJ, Outila TA, Kärkkainen MU, Rita HJ, Valsta LM. Vitamin D deficiency and bone health in healthy adults in Finland: could this be a concern in other parts of Europe? Bone Miner Res. 2001 Nov;16:2066–73.

    CAS  Article  Google Scholar 

  23. 23.

    Rockell JE, Skeaff CM, Williams SM, Green TJ. Serum 25-hydroxyvitamin D concentrations of New Zealanders aged 15 years and older. Osteoporos Int. 2006;17:1382–9. Epub 2006 Jul 11.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Sachan A, Gupta R, Das V, Agarwal A, Awasthi PK, Bhatia V. High prevalence of vitamin D deficiency among pregnant women and their newborns in northern India. Am J Clin Nutr. 2005 May;81:1060–4.

    CAS  PubMed  Google Scholar 

  25. 25.

    McKenna MJ. Differences in vitamin D status between countries in young adults and the elderly. Am J Med. 1992 Jul;93:69–77.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Calvo MS, Whiting SJ, Barton CN. Vitamin D fortification in the United States and Canada: current status and data needs. In: Vitamin D and health in the 21st century: bone and beyond. Am J Clin Nutr. 2004;80:1710S–1716S.

    CAS  PubMed  Google Scholar 

  27. 27.

    Garland CF, Gorham ED, Mohr SB, Grant WB, Giovannucci EL, Lipkin M, et al. Vitamin D and prevention of breast cancer: pooled analysis. J Steroid Biochem Mol Biol. 2007;103:708–11.

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Knight JA, Lesosky M, Barnett H, Raboud JM, Vieth R. Vitamin D and reduced risk of breast cancer: a population-based case-control study. Cancer Epidemiol Biomarkers Prev. 2007;16:422–9.

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    Lappe JM, Travers-Gustafson D, Davies KM, Recker RR, Heaney RP. Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial. Am J Clin Nutr. 2007;85:1586–91.

    CAS  PubMed  Google Scholar 

  30. 30.

    International Agency for Research on Cancer. IARC Working Group on Vitamin D. Vitamin D and cancer: a report of the IARC Working Group on Vitamin D. 2008. Lyon France. Available at URL: wrk/wrk5/Report_VitD.pdf (Accessed 28 March, 2010).

    Google Scholar 

  31. 31.

    Hyppönen E, Läärä E, Reunanen A, Jarvelin MR, Virtanen SM. Intake of vitamin D and risk of type 1 diabetes: a birth-cohort study. Lancet. 2001;358: 1500–3.

    Article  PubMed  Google Scholar 

  32. 32.

    Wang TJ, Pencina MJ, Booth SL, Jacques PF, Ingelsson E, Lanier K, et al. Vitamin D deficiency and risk of cardiovascular disease. Circulation. 2008; 117:503–11.

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Liu PT, Stenger S, Li H, Wenzel L, Tan BH, Krutzik SR, et al. Toll-like receptor triggering of a vitamin D-mediated human antimicrobial response. Science 2006;311:1770–3.

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Ginde AA, Mansbach JM, Camargo CA. Association between serum 25- hydroxyvitamin D level and upper respiratory tract infection in the Third National Health and Nutrition Examination Survey. Arch Intern Med. 2009; 169:384–90.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    Czarnecki D, Meehan CJ, Bruce F. The vitamin D status of Australian dermatologists. Clin Experimental Dermatol. 2009;34:624–5.

    CAS  Article  Google Scholar 

  36. 36.

    Holick MF, Biancuzzo RM, Chen TC, Klein EK, Young A, Bibuld D, et al. Vitamin D2 is as effective as vitamin D3 in maintaining circulating concentrations of 25-hydroxyvitamin D. J Clin Endocrinol Metab 2008;93: 677–81.

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Gordon CM, Williams AL, Feldman HA, May J, Sinclair L, Vasquez A, et al. Treatment of hypovitaminosis D in infants and toddlers. J Clin Endocrinol Metab 2008;93:2716–21.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  38. 38.

    Pietras SM, Obayan BK, Cai MH, Holick MF. Vitamin D2 treatment for vitamin D deficiency and insufficiency for up to 6 years. Arch Intern Med 2009;169:1806–8.

    Article  PubMed  Google Scholar 

  39. 39.

    Maalouf J, Nabulsi M, Vieth R, Kimball S, El-Rassi R, Mahfoud Z, et al. Shortand long-term safety of weekly high-dose vitamin D3 supplementation in school children. J Clin Endocrinol Metab 2008;93:2693–701.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Bischoff-Ferrari HA, Shao A, Dawson-Hughes B, Hathcock J, Giovannucci E, Willett WC. Benefit–risk assessment of vitamin D supplementation. Osteoporos Intl. 2009;Dec 3:(Epub ahead of print).

    Google Scholar 

  41. 41.

    Broe KE, Chen TC, Weinberg J, Bischoff-Ferrari HA, Holick MF, Kiel DP. A higher dose of vitamin D reduces the risk of falls in nursing home residents: a randomized, multiple-dose study. J Am Geriatr Soc. 2007;55:234–9.

    Article  PubMed  Google Scholar 

  42. 42.

    Heaney RP, Davies KM, Chen TC, Holick MF, Barger-Lux MJ. Human serum 25-hydroxycholecalciferol response to extended oral dosing with cholecalciferol. Am J Clin Nutr. 2003;77:204–10.

    CAS  PubMed  Google Scholar 

  43. 43.

    Wagner CL, Greer FR; American Academy of Pediatrics Section on Breastfeeding; American Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008 Nov;122:1142–52.

    Article  PubMed  Google Scholar 

  44. 44.

    National Institutes of Health, Office of Dietary Supplements. US Food and Drug Administration: Dietary Supplement Fact Sheet: Vitamin D. Available from URL: (Updated 13 November, 2009 and accessed 24 March, 2010).

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Correspondence to Michael F. Holick PhD, MD.

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Holick, M.F. The Vitamin D Deficiency Pandemic: a Forgotten Hormone Important for Health. Public Health Rev 32, 267–283 (2010).

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Key Words

  • vitamin D deficiency
  • micronutrient deficiency conditions
  • pandemic
  • global health
  • 25-hydroxyvitamin D
  • osteoporosis
  • rickets