Medicosnext
Dr. Suyash Timalsina
He is a Consultant Orthopedic Doctor at Frontline Hospital, Old Baneshwor, Kathmandu. He completed his M.B.B.S from Kathmandu Medical College and Teaching Hospital. He served as Founding Medical Director at Raskot Community Hospital, Kalikot, and later contributed during COVID-19 through telemedicine establishing Danphe Care. He completed Orthopaedic and Trauma Surgery from Lumbini Medical College under Kathmandu University where he received the R.P. Singh Gold Medal in 2025 for academic excellence.
Vitamin D remains fundamental to bone health. It promotes intestinal calcium absorption, supports skeletal mineralization, and helps prevent rickets in children and osteomalacia in adults. Few would dispute its importance. The real question today is different: are we prescribing vitamin D too readily, interpreting laboratory reports too literally, and continuing supplementation too long in patients who may not truly benefit?
This question is becoming increasingly relevant in everyday practice. For years, vitamin D was treated almost as a harmless universal tonic, easy to prescribe, easy to repeat, and rarely questioned. But the evidence has become more nuanced. In generally healthy adults, routine high-dose supplementation has not shown the broad skeletal benefits many clinicians once expected. Current guidance also no longer supports indiscriminate screening or blanket supplementation in low-risk individuals [1-3]. That shift matters, especially in settings where vitamin D is often prescribed empirically for fatigue, back pain, generalized body ache, or vague musculoskeletal symptoms.
Nepal presents an interesting paradox. It is a country with abundant sunlight, yet multiple Nepalese studies have reported a high prevalence of low vitamin D levels across different groups, including adults, women, pregnant mothers, and children [4-8]. A tertiary-care study from Kathmandu reported vitamin D deficiency in 69.6% of tested patients, with higher rates among women and older adults [8]. Similar findings have been reported elsewhere in Nepal. At first glance, these numbers seem to justify widespread supplementation. But prevalence figures alone do not tell the whole story. They are shaped by the assay used, the season of testing, the population selected, and the laboratory cut-off chosen to define deficiency. An abnormal report is not always the same as clinically meaningful bone disease.
That distinction becomes even more important when one considers the broader determinants of vitamin D status in Nepal. Data from eastern Nepal suggest that deficiency is more common in individuals with darker skin tones, which is biologically plausible because higher melanin content reduces the efficiency of cutaneous vitamin D synthesis [4]. The same study also found that vitamin D deficiency was less common among people who consumed fish regularly. Although Nepalese studies have generally assessed fish intake rather than fatty fish specifically, this still remains relevant. Fish remains one of the few natural dietary sources of vitamin D, and limited intake may contribute to low vitamin D status in the population [4,10,11]. In rural Nepalese women, more frequent consumption of milk and eggs has also been associated with higher serum 25-hydroxyvitamin D levels, suggesting that the problem cannot be explained by sunlight exposure alone [5].
This is important because low vitamin D in Nepal is often discussed as though it were simply a matter of sun exposure. In reality, skin pigmentation, clothing habits, time spent indoors, seasonal changes, dietary patterns, and overall nutritional status all interact. Many Nepali diets are not rich in vitamin D-containing foods, and fish consumption remains modest by international standards [10,11]. In that context, low vitamin D levels are understandable. But understandable does not mean every case requires aggressive or prolonged supplementation.
For bone health, the evidence is more selective than routine prescribing patterns might suggest. Large randomized trial data show that vitamin D alone does not significantly reduce fractures in generally healthy community-dwelling adults who were not selected for deficiency, osteoporosis, or low bone mass [12]. Evidence from umbrella reviews similarly suggests that
any fracture benefit is more likely to be seen in specific higher-risk groups, particularly when vitamin D is combined with calcium rather than used alone [13]. This point is highly relevant in Nepal, where low dietary calcium intake, under-recognized osteoporosis, delayed presentation after fragility fractures, and limited awareness of bone health may be more important contributors to skeletal risk than an isolated vitamin D value [14-18].
Nepal’s bone-health challenge is therefore broader than a single micronutrient. Studies from Nepal indicate that osteoporosis and fragility fractures are already significant concerns, particularly among older adults and women [15-18]. One recent community-based study reported osteoporosis in about 22.3% of adults aged 50 years and above, with greater burden among women, older adults, people with lower body mass index, and those with lower calcium intake [16]. Another concern is poor awareness. A Nepalese study on osteoporosis awareness found that only a minority of participants identified calcium- and vitamin D-rich foods as preventive measures [18]. In such a setting, vitamin D can easily become an attractive shortcut: a convenient prescription that risks overshadowing the more difficult but equally important work of improving diet, mobility, fall prevention, and osteoporosis assessment.
A further difficulty lies in the interpretation of laboratory reports. Most laboratories continue to use international cutoffs, commonly defining vitamin D deficiency as a serum 25(OH)D level below 20 ng/mL and, in some settings, insufficiency below 30 ng/mL. Yet even internationally, there is no complete uniformity in how these thresholds are applied. The National Academies consider levels around 20 ng/mL sufficient for most people in relation to bone health, whereas the 2024 Endocrine Society guideline does not endorse universal serum targets for healthy adults and advises against routine testing in the general population [1,2]. This uncertainty becomes even more relevant in Nepal, where local validation of these thresholds against fracture risk, bone mineral density, osteomalacia, or other hard skeletal outcomes remains limited.
Nepalese research has already raised this concern. A recent study examining the relationship between 25(OH)D and intact parathyroid hormone in a Nepalese population highlighted the scarcity of locally relevant data to define clinical decision thresholds across age groups and ethnic backgrounds [9]. This is an important point. A laboratory report may flag a value as “insufficient,” but that does not automatically mean the patient has clinically significant skeletal disease or requires repeated high-dose therapy. The report may be technically accurate according to the laboratory reference range, yet still incomplete in its clinical meaning for a given patient. For this reason, vitamin D values in Nepal should be interpreted in clinical context rather than in isolation. Symptoms, dietary history, calcium intake, phosphate status, alkaline phosphatase where relevant, renal and liver function, pregnancy status, fracture history, bone mineral density, and coexisting risk factors such as malabsorption, frailty, chronic illness, or institutionalization all matter. A low vitamin D value in a frail older adult with a fragility fracture is not the same as a borderline low report in an otherwise healthy individual tested during a routine health check. Clinical judgment is still essential.
None of this is an argument against vitamin D. It remains necessary in patients with proven deficiency, osteomalacia, malabsorption, limited sun exposure, chronic kidney or liver disease, institutionalization, and in selected older adults at high skeletal risk [1,13]. The problem is not supplementation itself, but reflex supplementation in everyone. High intermittent doses are especially difficult to defend; annual high-dose vitamin D regimens have even been associated with increased falls and fractures in older women [19]. Excessive supplementation can also cause hypercalcemia, hypercalciuria, nephrolithiasis, and renal injury, although overt toxicity remains uncommon and is usually supplement-related [20].
So, are we overprescribing? In many cases, probably yes. In Nepal, the answer is not to dismiss vitamin D, but to use it more thoughtfully. Low vitamin D is common, and Nepalese studies do support associations with darker skin tone, lower fish intake, and broader nutritional limitations [4,5]. But that does not justify treating every low or borderline laboratory report as a disease in itself. A more balanced approach would reserve supplementation for those with documented deficiency, clear clinical risk, or established bone disease, while paying equal attention to calcium intake, weight-bearing activity, fall prevention, and timely assessment for osteoporosis. Bone health is shaped by far more than one laboratory value. It needs a strategy, not just a capsule.
References
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3.Office of Dietary Supplements, National Institutes of Health. Vitamin D: fact sheet for health professionals [Internet]. Bethesda (MD): NIH; 2025 [cited 2026 Apr 15].
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