In the US, Europe, and East Asia, more than 40% of the adult population are vitamin D deficient, this being the most prominent cause of osteomalacia.[8]Song HR, Kweon SS, Choi JS, et al. High prevalence of vitamin D deficiency in adults aged 50 years and older in Gwangju, Korea: the Dong-gu Study. J Korean Med Sci. 2014 Jan;29(1):149-52.
https://www.doi.org/10.3346/jkms.2014.29.1.149
http://www.ncbi.nlm.nih.gov/pubmed/24431921?tool=bestpractice.com
[9]Cashman KD, Dowling KG, Škrabáková Z, et al. Vitamin D deficiency in Europe: pandemic? Am J Clin Nutr. 2016 Apr;103(4):1033-44.
https://www.sciencedirect.com/science/article/pii/S0002916523119277?via%3Dihub
http://www.ncbi.nlm.nih.gov/pubmed/26864360?tool=bestpractice.com
The incidence of nutritional rickets and osteomalacia is rising globally, including high-income countries where hospitalization for rickets has increased in recent decades.[10]Prentice A. Nutritional rickets around the world. J Steroid Biochem Mol Biol. 2013 Jul;136:201-6.
http://www.ncbi.nlm.nih.gov/pubmed/23220549?tool=bestpractice.com
[11]Goldacre M, Hall N, Yeates DG. Hospitalisation for children with rickets in England: a historical perspective. Lancet. 2014 Feb 15;383(9917):597-8.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60211-7/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/24529462?tool=bestpractice.com
The prevalence of osteomalacia at postmortem in European adults is up to 25%.[12]Priemel M, von Domarus C, Klatte TO, et al. Bone mineralization defects and vitamin D deficiency: histomorphometric analysis of iliac crest bone biopsies and circulating 25-hydroxyvitamin D in 675 patients. J Bone Miner Res. 2010 Feb;25(2):305-12.
https://onlinelibrary.wiley.com/doi/10.1359/jbmr.090728
http://www.ncbi.nlm.nih.gov/pubmed/19594303?tool=bestpractice.com
In some developing countries, such as Tibet and Mongolia, vitamin D deficiency leading to clinical rickets is reported in 60% of infants.[13]Harris NS, Crawford PB, Yangzom Y, et al. Nutritional and health status of Tibetan children living at high altitudes. N Engl J Med. 2001 Feb 1;344(5):341-7.
http://www.nejm.org/doi/full/10.1056/NEJM200102013440504#t=article
http://www.ncbi.nlm.nih.gov/pubmed/11172165?tool=bestpractice.com
In the Middle East, a high prevalence of rickets and osteomalacia has been described in Muslim women and their infants, perhaps due to increased clothing coverage of the skin.[14]Sedrani SH. Are Saudis at risk of developing vitamin D deficiency? Saudi Med J. 1986;7:427-433. Fortification of foods with vitamin D and the use of vitamin supplements has greatly reduced the incidence of osteomalacia in the Western world.[15]Drezner MK, McGuire JL, Marks SC. Metabolic bone disease. In: Kelley W, ed. Textbook of internal medicine. 2nd ed. Philadelphia, PA: Lippincott; 1992. Despite this, vitamin D-related osteomalacia still occurs with the consumption of unfortified foods, especially in the setting of limited sunlight exposure.[16]Finch PJ, Ang L, Eastwood JB, et al. Clinical and histological spectrum of osteomalacia among Asians in South London. Q J Med. 1992;83:439.
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