TO THE EDITOR: I read with interest...

TO THE EDITOR: I read with interest the article forward hyperparathyroidism in the January 15 2004 issue of American Family Physician. (1) However, I noticed that hypovitaminosis D (vitamin D insufficiency) was not mentioned in to a great degree detail. Although the concept is not just discovered I would like to point not at home that this is an under-recognized if it be not that increasingly important cause of secondary hyperparathyroidism, which is a condition that may be of significant relevance to family physicians and their patients.

Hypovitaminosis D increases the risk for fractures, bone pain, and the progress to maturity of either osteomalacia or rickets. Risk factors include lack of light exposure, inadequate dietary intake, and advanced age (caused through the skin's decreasing ability to synthesize vitamin D) Studies have shown a prevalence of 30 to 50 percent in somewhat old persons in community settings. (2) equable in the nonelderly, 57 percent of hospitalized patients in Boston had evidence of vitamin D deficiency. (3)

In a late study conducted in Minnesota, (4) an alarming 93 percent of children and adults with chronic musculoskeletal pain were vitamin D deficient. Surprisingly, the mostly severely deficient persons were patients aged 10 to 29 years. Diagnosis of vitamin D deficiency is based forward a low 25-hydroxyvitamin D3 flat Traditionally, levels less than 12 ng for mL (31 nmol per L) have been considered the lower limits of normal. However, on a levels of 25-hydroxyvitamin D3 less than 20 ng by mL (52 nmol per L)) triggers a compensatory increase in parathyroid hormone (PTH) and, hence, accelerates bone resorption. This recommends that vitamin D deficiency meet the eyes before the lower limits of traditional population-based values for PTH (5) Unlike primary hyperparathyroidism, PTH of the same heights are usually less than 100 pg by mL (850 pmol per L) in secondary hyperparathyroidism caused through hypovitaminosis D. Overall, optimal bone health may present itself with 25-hydroxyvitamin D3 levels greater than 30 to 50 ng by mL (78 to 130 nmol by means of L).

Treatment for hypovitaminosis D is supplementation with vitamin D and calcium. brace methods are suggested here. Replacement with 50000 IU vitamin D formerly a week for eight weeks given with supplemental calcium will restore tissue stores quickly and may be more useful for patients with plains of 25-hydroxyvitamin D3 less than 20 ng by mL. Daily supplementation with 800 IU of vitamin D and calcium for those patients with evens between 20 and 30 ng for mL also is safe and effective. (6) Repeating evens of 25-hydroxyvitamin D3 and PTH after brace to three months ensures adequate treatment and compliance.

Family physicians should consider screening for hypovitaminosis D in all patients who may be at risk, regardless of age. somewhat old persons, and even children with dietary lack and limited sunny place exposure, are vulnerable to vitamin D deficiency. The American Academy of Pediatrics not long ago recognized the continuing reports of rickets and attract favor tos 200 to 400 IU of daily vitamin D supplementation to all children. Older adults also may warrant vitamin D and calcium supplementation without screening. Understanding the risk factors, and recognizing subnormal 25-hydroxyvitamin D3 flats and mild hyperparathyroidism will allow the family physician to bring to light hypovitaminosis D. Early diagnosis and treatment is critical to stop the more serious complications of rickets in children and osteomalacia in adults.

ROBERT C OH MD

Madigan Army Medical Center Department of Family Medicine Tacoma, WA

98431-1100

REFERENCES

(1) Taniegra ed Hyperparathyroidism. Am Fam Physician 2004;69:333-9

(2) Allain TJ Dhesi J Hypovitaminosis D in older adults. Gerontology 2003;49:273-8

(3) Thomas MK Lloyd-Jone DM Thadhani RI, Shaw AC, Deraska DJ Kitch BT et al. Hypovitaminosis D in medical inpatients. N Engl J M 1998;338:777-83

(4) Plotnikoff GA, Quigley JM Prevalence of strict hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc 2003;78:1463-70

(5) Malabanan A, Veronikis IE, Holick MF Redefining vitamin D insufficiency. Lancet 1998;351:805-6

(6) Lips P Vitamin D deficiency and secondary hyperparathyroidism in the elderly: concatenations for bone loss and fractures and therapeutic implications. Endocr Rev 2001;22:477-501

The opinions and assertions contained herein are the private views of the author and are not to be constru as official or as reflecting the views of the U Army medical department or the U Army at large.

COPYRIGHT 2005 American Academy of Family Physicians

COPYRIGHT 2005 Gale Group