Elsevier

Mayo Clinic Proceedings

Volume 78, Issue 12, December 2003, Pages 1463-1470
Mayo Clinic Proceedings

Original Article
Prevalence of Severe Hypovitaminosis D in Patients With Persistent, Nonspecific Musculoskeletal Pain

https://doi.org/10.4065/78.12.1463Get rights and content

Objective

To determine the prevalence of hypovitaminosis D in primary care outpatients with persistent, nonspecific musculoskeletal pain syndromes refractory to standard therapies.

Patients and Methods

In this cross-sectional study, 150 patients presented consecutively between February 2000 and June 2002 with persistent, nonspecific musculoskeletal pain to the Community University Health Care Center, a university-affiliated inner city primary care clinic in Minneapolis, Minn (45° north). Immigrant (n=83) and nonimmigrant (n=67) persons of both sexes, aged 10 to 65 years, from 6 broad ethnic groups were screened for vitamin D status. Serum 25-hydroxyvitamin D levels were determined by radioimmunoassay.

Results

Of the African American, East African, Hispanic, and American Indian patients, 100% had deficient levels of vitamin D (=20 ng/mL). Of all patients, 93% (140/ 150) had deficient levels of vitamin D (mean, 12.08 ng/mL; 95% confidence interval, 11.18-12.99 ng/mL). Nonimmigrants had vitamin D levels as deficient as immigrants (P=.48). Levels of vitamin D in men were as deficient as in women (P=.42). Of all patients, 28% (42/150) had severely deficient vitamin D levels (=8 ng/mL), including 55% of whom were younger than 30 years. Five patients, 4 of whom were aged 35 years or younger, had vitamin D serum levels below the level of detection. The severity of deficiency was disproportionate by age for young women (P<.001), by sex for East African patients (P<.001), and by race for African American patients (P=.006). Season was not a significant factor in determining vitamin D serum levels (P=.06).

Conclusion

All patients with persistent, nonspecific musculoskeletal pain are at high risk for the consequences of unrecognized and untreated severe hypovitaminosis D. This risk extends to those considered at low risk for vitamin D deficiency: nonelderly, nonhousebound, or nonimmigrant persons of either sex. Nonimmigrant women of childbearing age with such pain appear to be at greatest risk for misdiagnosis or delayed diagnosis. Because osteomalacia is a known cause of persistent, nonspecific musculoskeletal pain, screening all outpatients with such pain for hypovitaminosis D should be standard practice in clinical care.

Section snippets

Study Population

Six broad categories of ethnic groups were divided into immigrant and nonimmigrant populations. The immigrant ethnic groups considered in this study are East African (primarily Somalian), Hispanic (primarily Mexican), and Southeast Asian (primarily Hmong, Cambodian, or Laotian). The Southeast Asian patients began translocating to Minnesota in 1975, most of whom arrived from refugee camps. The East African and Hispanic patients began arriving in Minnesota in 1995. The nonimmigrant ethnic groups

RESULTS

The prevalence of hypovitaminosis D was unexpectedly high in this population of nonelderly, nonhousebound, primary care outpatients with persistent, nonspecific musculoskeletal pain refractory to standard pharmaceutical agents. Of all patients, 93% (140/150) had deficient levels of vitamin D (mean, 12.08 ng/mL; 95% confidence interval [CI], 11.18-12.99 ng/mL). Among the immigrant populations in this study, 100% of the East African (n=34), 100% of the Hispanic (n=5), and 89% (39/44) of the

DISCUSSION

Severe hypovitaminosis D is not asymptomatic. Before the clinical presentation of osteomalacia bone pain, severe hypovitaminosis D results in a syndrome of persistent, nonspecific musculoskeletal pain, which has been well documented in European immigrants8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and recently in residents of Saudi Arabia.24 In all such studies, women have been particularly at risk.

This study shows that in the United States, the risk of severe hypovitaminosis D extends beyond

CONCLUSION

These results support screening of all outpatients with persistent, nonspecific musculoskeletal pain for hypovitaminosis D. These patients are at high risk for the consequences of unrecognized and untreated hypovitaminosis D, and this risk extends to those now considered at low risk, including nonelderly, nonhousebound, or nonimmigrant persons of either sex. Nonimmigrant women of childbearing age may be at particularly high risk for misdiagnosis or delayed diagnosis. Because osteomalacia is a

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