it is freely available to any one who allows adequate exposure of skin to the ultraviolet radiation present in the sunrays . however , vitamin d deficiency is not uncommon even in the sunny land of india . the clinical syndrome vitamin d deficiency consists of osteomalacia in adults and rickets in children . other manifestations of vitamin d deficiency include nonspecific backache , joint pains , and generalized body ache . with the availability of a method to accurately measure 25-hydroxyvitamin d [ 25(oh ) d ] , a state of hypovitaminosis d without overt signs and symptoms of vitamin d deficiency has become apparent [ 1 , 2 ] . the amount of vitamin d provided by sun exposure and diet is difficult to determine as the duration and intensity of sunlight exposure depends on age , clothing , and sunscreens . the insufficient intake of vitamin d has been implicated as one of the factors in the development of bone disease [ 46 ] . various elements contribute to this insufficient vitamin d intake such as skin pigmentation , which presumably interferes with ultraviolet ray transmission through epidermis , genetic factors [ 8 , 9 ] , social customs such as avoidance of sun exposure , consumption of chapattis ( flattened rounded wheat bread ) that is high in phytates which bind calcium in the gut and interfere with calcium absorption , lack of sun exposure and malnutrition to name a few important contributing factors . this is exemplified by the high prevalence of vitamin d deficiency in house bound and elderly patients [ 1113 ] . while osteomalacia and rickets have been studied extensively , there is little information on vitamin d deficiency without obvious bone disease . the aims and objectives of this study were ( a ) to study the clinical symptoms and signs of vitamin d deficiency and their correlation with 25-hydroxyvitamin d [ 25(oh ) d ] levels , ( b ) to study the bone profile of patients of hypovitaminosis d , and ( c ) to observe the response to treatment with vitamin d on these individuals . the patients were seen between 1996 and 2001 at the rheumatology services of the hinduja hospital and medical research centre , mumbai , india . a proforma was prepared to record relevant details ( appendix a - proforma : profile of vitamin d deficiency ) . this included details regarding symptom and signs , dietary history , duration and severity of illness , associated illnesses , sun exposure , renal disease , gastrointestinal tract disease and intake of anticonvulsants such as diphenylhydantoin sodium . the treatments given to these patients were recorded and their responses to treatment were noted . for the details not available in the medical chart , an attempt was made to contact the patients on telephone or in person to get complete information . of these 38%   ( n = 27 ) were in the age group of 3140 years . vitamin d deficiency in this population , while symptomatic , was without any of florid signs ( 63% showed no tenderness  as shown in table 3 ) . the bone profile of patients with vitamin d deficiency is shown in table 4 . the radiological data showing various vitamin d associated changes in the study 's patients are shown in table 6 . taking the normal range of vitamin d , 25(oh ) d in our laboratory as 9.941.5 ng / ml , we classified our patients into 3 grades of vitamin d deficiency . the grades were mild 25-hydroxyvitamin d [ 25(oh ) d ] levels6 to 9.9 ng / ml , moderate 25-hydroxyvitamin d [ 25(oh ) d ] levels2 to 5.9 ng / ml , and   severe 25-hydroxyvitamin d [ 25(oh ) d ] levels   <   2 ng / ml . the distribution of severity of vitamin d amongst these patients is shown in table 7 using these parameters . vitamin d deficiency is variably defined as a 25(oh ) d level less than 1015 g / l [ 16 , 17 ] . the commonness of vitamin d deficiency in an otherwise healthy population was an eye - opener as well as a teaser . at the hinduja hospital and medical research center , mumbai , india , the awareness of vitamin d deficiency started with appreciation of vitamin d deficiency as a complicating factor in rheumatic diseases . a case is briefly described to make the point . a 59year - old male patient with ankylosing spondylitis of more than 30 years duration was admitted with a recurrence of left - sided hemiparesis and a recent increase in  joint pains  . he had diabetes for the past 10 years which was controlled on oral hypoglycemic agents . a year before his admission , he had developed left - sided hemiparesis from which he had recovered completely . the increase in joint pains started six months before he was admitted but he reported no swelling or stiffness at that time . there was no evidence of synovitis of peripheral joints , but he had severe diffuse bony tenderness , especially of his spine and ribs . investigations revealed the following statistics : hemoglobin : 12.2 gm / dl , white blood cell count : 16,700/mm ,   platelets : 2.3 lac / mm , esr : 28 mm / h , serum calcium : 8.3 mg / dl ( normal range : 8 to 10.4 mg / dl ) , phosphorus 2.9 mg / dl ( normal range : 2.54.6 mg / dl ) , alkaline phosphatase : 590 iu / l ( normal range : 40120 iu / l ) , 25(oh ) vitamin d : 4.3 ng / ml ( normal range : 9.941.5 ng / ml ) and parathormone 333 pg / ml ( normal range : 1272 pg / ml ) . a routine   urine test showed trace proteins , 24 hours urinary proteins : 792 mg ( 0165 mg ) and creatinine 1 mg / dl ( normal range : 0.6 to 1.01 mg / dl ) . he was diagnosed with vitamin d deficiency - related osteomalacia with secondary hyperparathyroidism being made and he was initiated on a vitamin d treatment regimen ( alpha d3 and vitamin d 60 000 units ) , along with one gram supplemental calcium . within one week his pains started to decrease and were significantly more manageable in three weeks time and he was discharged . at this man 's medical case was followed by the publication of a small series of letters to the editor in the   journal of association of physicians of india . soon patients with a variety of nonspecific musculoskeletal complaints were tested for vitamin d status . to our surprise thus of the samples tested for vitamin d levels in our hospital laboratory , 80% had low serum 25-hydroxyvitamin d [ 25(oh ) d ] levels , that is ,   < 9.9 ng / ml . it therefore became imperative that we study the significance of low vitamin d levels in adults for clinical , therapeutic , and other aspects . thus the case selection was based upon the presence of low vitamin d levels in individuals attending the clinic , for various nonspecific musculoskeletal symptoms . the present study has its inherent limitations but was thought necessary to understand the phenomenon of low vitamin d levels . all the study patients had musculoskeletal complaints and were suspected to suffer from rheumatoid arthritis , ankylosing spondylitis , or vertebral disc disease . although it is not possible to judge the exact proportion of such patients , vitamin d deficiency is an important differential diagnosis of patients with such complaints . in rheumatology parlance , fibromyalgia and hypothyroidism closely resemble this symptomatology , and hence myalgia and nonspecific pain may be due to vitamin d deficiency . muscle weakness led to inability to get up from squatting position and waddling gait in some patients . vitamin d deficiency is an important consideration in a patient with proximal muscle weakness , ( and may additionally complicate a case of polymyositis - dermatomyositis ) . vitamin d deficiency in this population was without florid signs ( 63% showed no tenderness ) . this is important , as without bony tenderness ( which would suggest osteomalacia ) and without proper awareness on the part of physicians , vitamin d deficiency can easily be overlooked . when we tried to correlate the vitamin d levels with the symptoms ( as shown in table 7 ) , we came to the conclusion that although patients with low vitamin d levels present many nonspecific symptoms like backache , body ache , leg pain , and thigh pain , not all are osteomalacic . how does one explain the absence of clinical osteomalacia in individuals with very low vitamin d levels ? is it likely that even at low vitamin d levels , there is enough 1 , 25 ( oh)2   d3    to maintain homeostasis ? although this current study does not possess the funding to answer this question , it remains an interesting line of inquiry . there may be ( over ) active conversion of 25 ( oh ) d to 1 , 25 ( oh ) 2   d3    to maintain bone mass . a parallel can be drawn with iron deficiency anemia ; until body iron stores are exhausted iron deficiency does not manifest as anemia . an attempt was made to see if the severity of vitamin d deficiency correlated with the number of symptoms recorded ( as shown in table 7 ) . ( unfortunately , the severity of individual symptoms can not be analyzed as this was not recorded using a visual analogue scale . ) still there does not seem to be any such correlation given that only one patient had more than four out of the seven symptoms analyzed . we compared the records of 12 patients who were diagnosed as osteomalacic and found that 50% of the patients had vitamin d levels that measured at levels below 5 ng / ml . it is apparent that individuals with vitamin d deficiency may not suffer from clinical osteomalacia but can have nonspecific musculoskeletal symptoms accompanied with morbidity . it is likely that some may go on to develop frank nutritional osteomalacia unless treated . this is because , compared with the commonness of vitamin d deficiency , clinical osteomalacia is not a common disorder . it is difficult to guess the prevalence of vitamin d deficiency in the community , but it does seem logical to assume that osteomalacia ( as well as rickets ) are only the tip of the iceberg . the common etiological factors of vitamin d deficiency are lack of exposure to sun rays ( solar ultraviolet - b exposure to as much of body surface as possible produces vitamin d ) and decreased intake of foods rich in vitamin d. a specific history was not recorded in all patients studied , but a majority of these patients were vegetarians , with poor intake of milk or milk products and little outdoor activity . none of the patients belonged to a low socioeconomic group and hence likely had access to plenty of food . thus paradoxically , vitamin d deficiency may be a disease of the rich ! the case involves a 50-year - old gentleman , a businessman and an epileptic on diphenylhydantoin sodium living in a house with drawn curtains , and traveling in a car with tainted glass . when seen by the physician , he was nearly crippled by back pain with frank evidence of osteomalacia . the pain was treated as spondylosis , and he was even suspected to be suffering from tuberculosis!. vitamin d , calcium , and regular sun exposure brought him back to normalcy . when we checked the response to vitamin d and calcium therapy , we found that out of 20 patients placed on calcium and/or vitamin d , 13 patients showed significant clinical improvement . also followup information was not provided for 51 of these patients , and so it is impossible to speculate about their response to treatment . it should be noted that the cause for nonresponse to treatment in some patients may be due to factors other than vitamin d deficiency . additionally , the symptoms these patients report , symptoms that indicate a lack of vitamin d , may also be caused by other incidental factors . for example a recent controlled study found that diffuse musculoskeletal pain may not be associated with low vitamin d and that this pain does not respond to treatment with vitamin d . as already stated vitamin d deficiency can complicate a rheumatic disease and make diagnosis difficult [ 18 , 2023 ] . g , a 46-year - old female patient suffering from rheumatoid arthritis for more than 15 years had tried a few disease modifying agents at the initial stages of the disease without beneficial effects . eight years prior to being seen , she had undergone a left hip replacement . for five of those years , she was bed ridden with deformities and complained of severe , debilitating , unbearable aches and pains . she could not even turn in bed , move her legs , or lift her arms due to the pain . investigations revealed undetectable levels of vitamin d , low serum calcium , phosphorus , and increased alkaline phosphatase . a diagnosis of concomitant osteomalacia was made , and she was placed on three weekly bolus of 60 000 units of oral vitamin d followed by a daily supplement of 1.5 grams of calcium . over a period of 1 month , her bone pains reduced significantly . she was able to lift her arms , eat with her own hands , and sit without support . the case was an eye - opener . in every case with pains out of proportion to clinical findings , it would be wise to check for vitamin d deficiency symptoms . since this was a retrospective study where the study participants had to recall their dietary history , type of indoor and outdoor activities performed , and history of sun exposure , a recall bias is evident . furthermore the data on assessment of muscle weakness were incomplete and were not evaluated by another independent rater . this small retrospective study shows that vitamin d deficiency is not uncommon but frank osteomalacia is uncommon . a  subclinical vitamin d state  exists which is characterized by nonspecific musculoskeletal symptoms . this state may complicate a rheumatic disorder , and it is important to consider this diagnosis as the results of treatment are most gratifying . three conclusions can be drawn from this study : ( a ) vitamin d deficiency runs across the board ; importantly it affects individuals in the prime of their life and affects the quality of life and the productivity of those suffering from it ; ( b ) the preponderance of female patients compared to male patients suffering from vitamin d deficiencies possibly reflects social factors like the avoidance of milk and milk products and staying indoors ; ( c ) a large chunk of vitamin d deficiency is  subclinical . if estimation of vitamin d is not possible , a trail of oral vitamin d supplements and calcium is indicated to be beneficial . there is a new and emerging body of literature showing relationship between vitamin d deficiencies and respiratory infections , along with obstetrical conditions such as pre - eclampsia .
vitamin d deficiency is not uncommon even in the sunny land of india . 
 lack of sun 
 exposure and inadequate oral intake are both responsible for vitamin d deficiency . 
 this 
 article provides a retrospective , examining the effects of vitamin d deficiency in 71 
 patients . 
 the study 's inclusion criterion was low vitamin d level combined with 
 musculoskeletal symptoms but without the presence of osteomalacia . 
 all patients in this 
 study were suspected to have vitamin d deficiency . 
 the data were retrieved from the 
 case - charts of patients seen between 1996 and 2001 at the rheumatology services of hinduja 
 hospital , mumbai , india . 
 this study found no correlation between vitamin d levels and 
 symptoms , or between the severity of vitamin d deficiency and the number of symptoms 
 displayed . 
 subclinical vitamin d deficiency or preosteomalacic state was the term 
 coined for individuals with vitamin d deficiency producing nonspecific musculoskeletal 
 symptoms in the absence of clinical osteomalacia .