Vitamin D and Calcium Deficiency in Indian Adults: What Actually Matters

Vitamin D deficiency is common in Indian adults, with studies across cities reporting anywhere from half to four-fifths of those tested falling below the usual thresholds, depending on the population and cut-off used. Dietary calcium intake is also consistently below recommended levels in national dietary surveys. The two compound each other, because vitamin D is what allows the gut to absorb calcium efficiently. Without it, a good calcium intake is partly wasted.

What actually matters is narrower than the internet suggests. Deficiency genuinely causes diffuse bone and muscle pain, weakness of the thigh and shoulder girdle muscles, and in severe cases a softening of bone called osteomalacia. It gets blamed for a great deal else, including fatigue, hair loss, low mood and poor immunity, where trial evidence is weak or negative. The sensible approach is to test people who have a reason to be tested, correct what is genuinely low under medical supervision, fix dietary calcium where it is short, and load the skeleton with weight-bearing and resistance exercise, which is the part almost everyone skips.

Why deficiency is so common in a sunny country

Vitamin D is made in the skin on exposure to UVB radiation. India sits at latitudes where UVB is available for much of the year, so the deficiency is not about the sun failing to arrive. It is about what stands between people and it.

• Indoor lives. Office work, commuting in vehicles and screen-based leisure mean many urban adults get almost no direct midday sun on bare skin on a working day.
• Covered clothing. For cultural, religious or practical reasons a large proportion of the population exposes very little skin outdoors.
• Air pollution. Particulate matter and atmospheric haze scatter and absorb UVB, meaningfully reducing what reaches ground level in polluted cities.
• Skin pigmentation. Melanin is a natural sunscreen, so darker skin needs substantially longer exposure to make the same amount of vitamin D.
• Sun avoidance. Heat and a preference for shade push exposure into early morning and evening, when UVB is weakest. Sunlight through window glass produces none at all.
• Diet and fortification. Very few foods contain meaningful vitamin D naturally, mostly fatty fish, egg yolk and liver. Fortification of staples exists in India but is patchy, so it cannot be relied upon.
• Low dietary calcium. Cereal-based, largely vegetarian diets tend to be low in calcium and high in phytate and oxalate, both of which reduce absorption.

What vitamin D actually does

Vitamin D made in the skin or taken in the diet is converted first in the liver and then in the kidney to its active form, whose main job is to increase absorption of calcium from the intestine. Without it, only a small fraction of dietary calcium is absorbed, and simply eating more calcium does not fix the problem.

When blood calcium starts to fall, the parathyroid glands raise parathyroid hormone, which pulls calcium out of the skeleton to keep the blood level normal. This is why serum calcium can look perfectly normal in someone who is deficient: the body protects the blood level at the expense of the bones. Prolonged, this causes bone loss and, when severe, osteomalacia, in which new bone is not adequately mineralised and becomes soft and painful. In growing children the equivalent is rickets, with bowing of the legs, delayed walking and skeletal deformity; that belongs with a paediatric orthopedic assessment, not an over-the-counter supplement.

Symptoms that are genuinely attributable

Deficiency severe enough to matter clinically produces a recognisable picture:

• Diffuse aching bone pain across the pelvis, lower back, ribs, hips and thighs, not localised to one joint.
• Tenderness when pressing firmly over the shin bone or sternum.
• Proximal muscle weakness, meaning weakness of muscles closest to the trunk. In practice: difficulty rising from a low chair or the floor without using the hands, difficulty climbing stairs, sometimes a waddling walk.
• In advanced osteomalacia, pain on weight bearing and a risk of insufficiency fractures.

Contrast that with the long list of complaints for which vitamin D is routinely blamed and prescribed: general tiredness, hair fall, low mood, frequent infections, weight gain, poor sleep. Trials supplementing people who are not deficient have largely been disappointing for these outcomes. Correcting a genuine deficiency is worth doing; treating an unrelated symptom with vitamin D because it is easy is not.

Who should actually be tested

Testing everyone is not sensible, and the test is not free. It is reasonable when there is a specific reason:

• Symptoms suggesting osteomalacia, particularly bone pain with proximal muscle weakness.
• A fragility fracture, meaning one from a fall from standing height or less.
• Known osteoporosis, or before starting medication for it.
• Conditions impairing absorption: coeliac disease, inflammatory bowel disease, chronic pancreatitis, previous bariatric surgery.
• Chronic kidney disease or chronic liver disease.
• Long-term glucocorticoids or some anti-epileptic drugs.
• Very limited sun exposure, including housebound or institutionalised older adults.
• Recurrent stress fractures, or unexplained delayed fracture healing.
• Children with skeletal deformity, bone pain or delayed motor milestones.

The test to ask for is serum 25-hydroxyvitamin D. Serum calcium alone is often normal and is not a screening test for deficiency.

Why this matters in orthopedic practice

Fracture healing

Bone repair requires mineral. Low vitamin D is associated with delayed union in several studies, though proving that correcting it speeds healing is harder than it sounds. Our position is pragmatic: in a patient with a fracture and clear risk factors, checking and correcting a deficiency is cheap, low-risk and sensible, but supportive rather than curative. What a fracture needs most is correct reduction, adequate stability and sensible loading, as described on our fracture treatment page.

Before and after joint replacement

Deficiency is worth identifying before elective surgery. Proximal muscle weakness slows rehabilitation, because rising from a chair and climbing stairs are exactly the tasks early recovery is built around. Correcting it beforehand is part of routine optimisation, alongside the other factors we discuss when planning a hip replacement.

Osteoporosis and fragility fractures

Bone loss accelerates sharply after menopause, and vitamin D and calcium adequacy is the foundation on which any osteoporosis treatment sits. Older men are the forgotten group: they get osteoporosis too, are diagnosed later, and do worse after hip fracture. A first fragility fracture at any site should trigger a bone health assessment, not just fracture treatment. Coexisting arthritis is common and runs in parallel; see arthritis treatment.

Stress fractures in athletes and new runners

Stress fractures happen when repetitive loading outpaces the bone’s ability to remodel, and low vitamin D, low calcium intake and low overall energy availability all shift that balance the wrong way. The classic case is someone who recently took up running, increased mileage quickly, and developed focal shin or foot pain that worsens through a run and does not settle with rest days. Details are in stress fracture treatment, symptoms and recovery, and these presentations are assessed on our foot and ankle page.

Body weight

Vitamin D is fat-soluble and sequestered in adipose tissue, so measured levels tend to be lower in people with higher body fat. That sits alongside the mechanical load on joints, covered in how obesity affects joint health.

Realistic dietary calcium in an Indian diet

The figures below are approximate food-composition values, given so you can compare foods sensibly. They are not a daily target; your own requirement should be discussed with your doctor.

Food	Typical serving	Approximate calcium	Bioavailability note
Milk (cow or buffalo)	1 cup, about 200 ml	Roughly 240 to 250 mg	Well absorbed; the most reliable everyday source
Curd or dahi	1 cup	Roughly 200 mg	Well absorbed; often better tolerated than milk
Paneer	50 g	Roughly 100 to 200 mg, varies widely	Depends heavily on how it was set
Ragi or finger millet	50 g dry	Roughly 150 to 175 mg	High content but phytate limits absorption; sprouting, soaking and fermenting help
Sesame seeds, til	2 tablespoons	Roughly 200 mg for unhulled seeds	Hulled seeds have far less; small portions in practice
Drumstick and amaranth leaves	1 cooked cup	Roughly 150 to 250 mg	Low-oxalate greens; reasonably well absorbed
Spinach	1 cooked cup	High on paper	Very high oxalate; only a small fraction is actually absorbed. Do not count on it
Almonds	A small handful	Roughly 75 mg	Useful addition, not a primary source
Small fish eaten with bones	Standard portion	Substantial	Very well absorbed; relevant only for non-vegetarians
Calcium-fortified foods	As labelled	Check the label	Fortification varies between products; read what you are buying

Two caveats. Content is not the same as absorbed calcium; oxalate in spinach and phytate in millets and pulses both cut absorption considerably. And the body absorbs calcium better in modest amounts spread through the day, so two or three calcium-containing items across meals does more than one large serving.

How supplementation should be approached

Supplementation belongs after a test, at a dose and duration decided by a doctor, with a plan for rechecking. We deliberately do not publish dosing figures, because the right regimen depends on how low the level is, why it is low, your kidney function, your body weight, whether absorption is impaired and what else you take. What suits a housebound eighty-year-old with a hip fracture is not what suits a thirty-year-old runner.

Three points are worth stating plainly. Mega-doses are not better; more vitamin D does not produce proportionally more benefit, and some trials of very high intermittent dosing in older adults found more falls and fractures, not fewer. Toxicity is real, not theoretical; because the vitamin is fat-soluble it accumulates, and sustained excess causes high blood calcium, kidney stones, kidney damage, nausea, constipation and confusion, and cases from repeated unsupervised high-dose sachets are seen in Indian practice. And calcium supplements are not automatically indicated for everyone; dietary calcium is preferable where achievable, supplements can cause constipation and bloating, and they may raise kidney stone risk in susceptible people.

The intervention most people skip

Bone responds to load. Weight-bearing activity and progressive resistance training stimulate bone formation in a way no supplement does, and they build the strength and balance that prevent the falls which cause fractures in the first place.

In practice that means walking, stair climbing and other upright weight-bearing activity most days, plus resistance work for the legs, hips and back two or three times a week, progressed gradually. Swimming and cycling are excellent for fitness and for painful joints but load the skeleton very little, so they should not be your only exercise if bone health is the goal. For older adults, balance work matters as much as strength. If you have significant arthritis or a previous fracture, have the programme set up properly rather than improvising.

When to see a doctor

Book an assessment for persistent diffuse bone or muscle pain that does not localise to one joint, difficulty rising from a chair or climbing stairs, a fracture from a minor fall, or several of the risk factors listed above. Our guide on when to see an orthopedic surgeon for joint pain covers what warrants review.

Seek medical attention promptly for any of the following:

• A fracture after a fall from standing height or less, at any age over fifty.
• Sudden severe back pain in an older adult, especially with loss of height or a new stoop, which can indicate a vertebral fracture.
• Focal bone pain in a runner or athlete that worsens with activity and has begun to hurt at rest or at night.
• Progressive difficulty standing from a chair or climbing stairs.
• In a child, bowing legs, delayed walking, unusual bone shape or persistent limb pain.
• If you take supplements, symptoms of high blood calcium: persistent nausea, vomiting, marked thirst, frequent urination, constipation, confusion or drowsiness. Stop the supplement and seek review the same day.

This article is general information. Vitamin D and calcium requirements are individual, and any supplement regimen should be started, dosed and monitored by a doctor who has seen your test results.