Vitamin D Deficiency in India: Why It Is So Common in Older Adults

What vitamin D does

Vitamin D is a fat-soluble vitamin and a hormone precursor. Its main role is to help the gut absorb calcium and phosphorus, which keeps bones strong. It also supports muscle function, and has roles in immunity and other body systems that researchers are still studying. When vitamin D is very low, adults can develop osteomalacia (soft, painful bones), and low levels worsen osteoporosis, raising the risk of falls and fractures. See calcium and vitamin D after 60: doses, food and sun and osteoporosis at home: preventing fractures and living well.

Why deficiency is so common in older Indians

• Indoor living and clothing: many older adults, particularly women, spend most of the day indoors, and cover most of their skin when outdoors.
• Skin pigmentation: melanin, the pigment that gives darker skin its colour and protects from sunburn, reduces vitamin D production; people with medium to dark skin need longer exposure than light-skinned people.
• Age: the skin of a seventy-year-old makes substantially less vitamin D from the same sunlight than that of a young adult.
• Air pollution and urban living: smog, dust and tall buildings reduce ultraviolet B reaching the skin, especially in northern Indian cities in winter.
• Sunscreen and sun avoidance because of heat or skin lightening preferences.
• Time of day: only midday sun contains enough ultraviolet B; early morning and late afternoon sun produce little.
• Low dietary sources: few Indian foods are rich in vitamin D, vegetarians avoid fish and liver, and fortified foods are not widely used.
• Obesity, which traps vitamin D in fat.
• Chronic diseases of the kidney, liver or gut that impair vitamin D activation or absorption.
• Medicines such as some anticonvulsants, steroids, certain antiretrovirals and anti-tuberculosis drugs.
• Low calcium intake and poor overall nutrition.
• Limited testing and awareness.

What deficiency can feel like

Many people have no symptoms. When present, symptoms are vague and easily blamed on age:

• Bone pain, especially in the back, hips, thighs, ribs and feet, often worse at night or when pressing on bones.
• Muscle weakness, difficulty climbing stairs or rising from a chair, a waddling gait, aching muscles.
• Frequent falls and unsteadiness.
• Tiredness and low mood.
• Fractures after minor injury.
• Muscle cramps or tingling, when calcium is low.
• Height loss.

These symptoms are not specific, and may signal other conditions, so a medical check is needed rather than self-treatment; see sarcopenia: muscle loss, protein and strength, arthritis at home: a complete guide and thyroid problems in older adults.

Who is at higher risk

• Adults over sixty, especially over seventy-five.
• People who stay indoors, are housebound or in care, or are bedridden.
• Women who cover their skin for cultural or religious reasons.
• People with darker skin.
• People with kidney, liver, bowel or malabsorption disease, or after stomach or bowel surgery.
• People who are overweight or obese.
• People who have had fractures, osteoporosis or frequent falls.
• People on medicines affecting vitamin D.
• Strict vegetarians and vegans with low fortified food intake.
• Residents of polluted cities or higher latitudes in winter.

Testing

The usual blood test is 25-hydroxy vitamin D (25-OH D), which reflects stores. Typical interpretation (laboratories and guidelines vary slightly):

• Below about 12 ng/mL (30 nmol/L): deficiency.
• About 12 to 20 ng/mL (30 to 50 nmol/L): insufficiency or inadequate.
• About 20 ng/mL (50 nmol/L) or above: generally adequate for most people.
• Above about 50 ng/mL (125 nmol/L), particularly above 100: possible excess; the doctor reviews.

The doctor may also check calcium, phosphate, parathyroid hormone, alkaline phosphatase, kidney function and sometimes a bone density scan. Routine screening of everyone is not always recommended, but testing makes sense for people with symptoms, fractures, osteoporosis, kidney or bowel disease or high-risk factors. Do not self-medicate with high doses before testing. Results can be affected by the lab method and season.

Getting more vitamin D

### Sunlight, sensibly

• Timing: the best time is around late morning to early afternoon, when ultraviolet B is strongest; early morning and evening sun give little.
• Duration: commonly suggested is about 10 to 30 minutes, several times a week, with face, arms and, where acceptable, legs exposed, without sunscreen for that short period; people with darker skin may need the longer end. This is a guide; the right amount varies.
• Safety: avoid sunburn, heat exhaustion and dehydration; take care for those with skin cancer history, medicines that cause photosensitivity, heart or kidney disease or heat intolerance; sit in shade during the hottest hours when exposure is long. Glass windows block ultraviolet B. See exercise in summer and monsoon indoors and summer heat and bedridden care for heat precautions.
• Mobility: for those who cannot go out, a sunny balcony or terrace with supervision can help; see garden, balcony and terrace safety.
• Not a substitute for supplements in people with confirmed deficiency, particularly in winter or polluted areas.

### Food

• Oily fish: sardines, mackerel, salmon, hilsa and other fatty fish.
• Egg yolk, liver.
• Sun-dried mushrooms or mushrooms exposed to ultraviolet light.
• Fortified milk, oils and cereals, where available; check labels.
• Pair with calcium-rich foods such as milk, curd, ragi, sesame and greens; see 10 food sources of calcium for your bones.

Food alone rarely corrects deficiency.

### Supplements

• Vitamin D3 (cholecalciferol) is commonly used; doses depend on the level.
• For general maintenance, typical label doses are in the range of about 400 to 2,000 IU per day; Indian and international bodies suggest about 600 to 800 IU per day total intake for older adults, and the long-term upper limit is about 4,000 IU per day.
• For treatment of confirmed deficiency, doctors in India commonly prescribe higher doses, often a weekly or monthly sachet or capsule for a few weeks, followed by a lower daily maintenance dose. Follow the prescription and duration exactly, and do not repeat the course without a repeat test and the doctor's advice. Repeated "loading" doses taken for months can cause high calcium and toxicity.
• Take with a meal containing some fat.
• Calcium: many people need adequate calcium too; combination tablets exist; see calcium and vitamin D after 60: doses, food and sun and multivitamins for older adults: helpful or wasteful?.
• Check the label for units (IU versus micrograms); see how to read a supplement label.
• Injections may be used in malabsorption, as the doctor decides.

Safety, interactions and toxicity

• Too much vitamin D can cause high blood calcium (hypercalcaemia), with nausea, vomiting, loss of appetite, constipation, thirst, frequent urination, weakness, confusion, kidney stones and kidney damage and abnormal heart rhythm. Toxicity usually comes from large doses taken for long periods, not from sun. Seek urgent help for confusion, severe vomiting or palpitations.
• Kidney disease, kidney stones, parathyroid disease, sarcoidosis and some cancers: vitamin D must be supervised; see chronic kidney disease: a home care guide.
• Medicines: thiazide diuretics, digoxin, some anticonvulsants, steroids, orlistat and others interact; see supplements and medicine interactions: a safety guide.
• Do not combine multiple vitamin D products without counting the total.
• Do not stop prescribed medicines because of supplements.
• Tell the doctor about all supplements, including multivitamins and herbal products.

Monitoring and follow-up

• Repeat the blood test after about three months of treatment or as the doctor advises, to check levels and calcium.
• Move to maintenance doses once corrected.
• Review bone health, falls risk and osteoporosis treatment; see falls risk assessment at home.
• Keep a record of tests and doses; see keeping a health record at home.

Practical tips for Indian families

• Take a brief daily walk in midday sun with arms and face exposed, with a hat and water, rather than hours of exposure, if the doctor agrees.
• Add ragi, sesame, curd, milk, eggs and fish to meals.
• Use a pill organiser and a calendar for weekly doses; see pill organiser guide.
• Store supplements in a cool, dry place.
• For bedridden or housebound parents, discuss supplements with the doctor, since sunlight is limited.
• Test before starting high doses, and avoid buying "vitamin D shots" or sachets from untrusted sources; see spotting fake or poor-quality care products.
• Combine with exercise, since weight-bearing activity and strength training protect bones; see exercise for osteoporosis.

When to ask a professional

See a doctor for persistent bone or muscle pain, weakness, falls, fractures, height loss or tiredness, and ask about a vitamin D test and bone health review. Ask a dietician about food sources and a pharmacist about interactions and product quality. Seek urgent help for a fall with suspected fracture, confusion, severe vomiting or severe pain; call 112 if severe.