OBES SURG (2008) 18:145–150
DOI 10.1007/s11695-007-9315-8
RESEARCH ARTICLE
Prevalence of Vitamin D Insufficiency and Deficiency
in Morbidly Obese Patients: A Comparison
with Non-Obese Controls
Whitney S. Goldner & Julie A. Stoner & Jon Thompson &
Karen Taylor & Luann Larson &
Judi Erickson & Corrigan McBride
Received: 30 August 2007 / Accepted: 27 September 2007 / Published online: 4 January 2008
# Springer Science + Business Media B.V. 2007
Abstract
Background Vitamin D deficiency is common in patients
after bariatric surgery. However, obesity itself has also been
associated with decreased vitamin D. The prevalence of
vitamin D deficiency in obese persons has not previously
been compared to non-obese controls when controlling for
factors that could affect vitamin D status.
Methods We evaluated 25 hydroxy vitamin D, iPTH,
calcium, albumin, and creatinine in 41 patients undergoing
Roux-en-Y gastric bypass. We then compared them to
healthy non-obese controls matched for age, sex, race/
ethnicity, and season of vitamin D measurement.
Results Ninety percent of the pre-bariatric surgery patients
had 25-OH-D levels <75 nmol/l, and 61% had 25-OH-D
levels <50 nmol/l versus 32 and 12% in controls, respectively.
Additionally, 49% of the pre-bariatric surgery patients had
secondary hyperparathyroidism versus 2% of controls. These
differences persisted after controlling for sunlight exposure
and dietary intake of calcium and vitamin D. Mean calcium,
W. S. Goldner (*) : J. Erickson
Department of Internal Medicine, Section of Diabetes,
Endocrinology, and Metabolism, University of Nebraska
Medical Center, Omaha, NE 68198-3020, USA
e-mail: wgoldner@unmc.edu
J. A. Stoner
Department of Biostatistics, College of Public Health,
University of Nebraska Medical Center, Omaha, NE, USA
J. Thompson : K. Taylor : C. McBride
Department of Surgery, University of Nebraska Medical Center,
Omaha, NE, USA
L. Larson
Department of Internal Medicine, Clinical Research Center,
University of Nebraska Medical Center, Omaha, NE, USA
corrected for albumin, and creatinine were not significantly
different between the groups, but mean albumin levels were
significantly lower among surgery patients.
Conclusion Vitamin D deficiency is common in obese
patients at the time of bariatric surgery and is also
accompanied by secondary hyperparathyroidism approxi-
mately half the time. These findings suggest that vitamin D
deficiency after bariatric surgery is multifactorial and in part
caused by preoperative vitamin D deficiency rather than
postoperative malabsorption alone. In this study, increased
vitamin D deficiency in obese persons cannot be explained by
a difference in calcium/vitamin D intake or sunlight exposure.
Keywords Vitamin D deficiency . Vitamin D insufficiency .
Obesity . Bariatric surgery . Secondary hyperparathyroidism
Introduction
Vitamin D deficiency is increasingly recognized as being
common in many groups [1] especially after bariatric
surgery. Vitamin D deficiency has been documented in
50–80% of patients after Roux-en-Y gastric bypass or
biliopancreatic diversion [2–5]. Extreme cases of severe
vitamin D deficiency, secondary hyperparathyroidism, met-
abolic bone disease, hypocalcemia, and chronic pain syn-
dromes have also been reported as late complications after
bariatric surgery [6, 7]. It has previously been hypothesized
that the mechanism for vitamin D deficiency after bariatric
surgery was postoperative malabsorption, decreased nutri-
ent and calcium and vitamin D intake, or all of these.
Recent evidence suggests that obesity itself is an indepen-
dent risk factor for vitamin D deficiency and body fat is
inversely proportional to 25 hydroxy vitamin D (25-OH-D)
146
concentrations [8, 9]. Unfortunately, there has not been a
consistent definition for vitamin D deficiency and assays
variably recognize vitamin D forms. Using a variety of
25-OH-D thresholds, vitamin D deficiency has been reported
in 21–81% of obese populations [10–13]. Factors such as
dietary intake of vitamin D, sunlight exposure, latitude,
season, age, and skin color can all affect 25-OH-D levels
[14–17]. None of the previous studies have compared
prevalence of vitamin D deficiency in obese persons to non-
obese persons matched for all of the variables that can affect
vitamin D status. Therefore, we sought to evaluate the preva-
lence of vitamin D deficiency and secondary hyperparathy-
roidism in obese persons at the time of bariatric surgery and
compare them to non-obese controls matched for age, sex,
race/ethnicity, and season of vitamin D measurement.
Materials and Methods
Patient population As part of a larger pilot study to assess
optimal dosing of vitamin D after bariatric surgery, 45
patients planning to undergo Roux-en-Y gastric bypass
were studied. All of the participants needed to be older than
19 and have plans to undergo Roux-en-Y gastric bypass.
Participants were excluded if they planned to undergo
another form of bariatric surgery, had evidence of hyper-
calcemia (calcium>10.5 mg/dl), hypocalcemia (calcium<
7.0 mg/dl), or renal insufficiency (GFR<50 ml/min), or if
they had a history of primary hyperparathyroidism, renal
tubular acidosis, sarcoidosis, granulomatous diseases, or
malignancy. Four patients who had baseline lab draws for
calcium, creatinine, and albumin after bariatric surgery or
had baseline lab draws for 25-OH-D or PTH more than
3 days after bariatric surgery were excluded resulting in a
sample size of 41 surgery patients. Additional information
obtained included age, height (cm), weight (kg), body mass
index (BMI; kg/m2), sex, race/ethnicity, and season of
vitamin D measurement. Full medication list, medical
history detailing comorbid conditions, and assessment of
daily intake of calcium and vitamin D and history of
sunlight exposure was also obtained at baseline. Omaha
Nebraska is located at latitude 41.3N.
A non-obese control group (BMI<30 kg/m2) of similar
age, sex, race/ethnicity, and season of vitamin D measure-
ment was identified. Season of measurement was divided
into summer (April through September) and winter (October
through March). Similar diet, physical, and laboratory
information were obtained from the controls as the study
group. The protocol was approved by the Institutional
Review Board at the University of Nebraska Medical Center.
Laboratory testing The baseline labs obtained included
serum calcium, albumin, phosphorus, creatinine, alkaline
OBES SURG (2008) 18:145–150
phosphatase, 25-OH-D, intact PTH (iPTH), and a spot urine
calcium/creatinine ratio. 25-OH-D was performed by ARUP
Laboratories, (Salt Lake City, UT) using a chemiluminescent
immunoassay. Serum calcium, albumin, phosphorus, creat-
inine, alkaline phosphatase and spot urine calcium/creatinine
ratio were all performed at the Clinical Laboratory of
the Nebraska Medical Center using the VITROS\ assay
(Ortho-Clinical Diagnostics, Inc., Rochester, NY). Intact
PTH assay was performed at the Clinical Laboratory at the
Nebraska Medical Center using the Immulite\ 1000 assay
(DPC\ Diagnostic Products Corporation, Los Angeles, CA).
Serum calcium was adjusted for serum albumin using two
separate equations. The first calculated the corrected calcium
by subtracting the albumin level from 4.44, multiplying the
difference by 0.75, and adding the product to the measured
calcium level. The second formula for corrected calcium
subtracted albumin from 4.0 and multiplied the difference by
0.8, then added the product to the measured calcium level.
Both formulas were used when comparing the measured
calcium to corrected calcium for albumin.
Vitamin D deficiency was defined as 25-OH-D
<50 nmol/l (<20 ng/ml), and vitamin D insufficiency was
defined as 25-OH-D 50-75 nmol/l (20–30 ng/ml). Second-
ary hyperparathyroidism was defined as iPTH≥70 pg/ml.
Statistical analysis Descriptive statistics (mean±SD) were
used to summarize the baseline lab values and patient
characteristics distributions. A two-sample t test was used
to compare the mean values between bariatric surgery
patients and control patients, and a chi-square test or
Fishers exact test was used to compare the distribution of
categorical endpoints between the bariatric surgery and
control patients. A chi-square test for trend was used for
ordered categorical responses. Proportions were estimated
for the following endpoints: the proportion of subjects with
vitamin D levels <75 nmol/l, the proportion of subjects with
vitamin D levels <50 nmol/l, and the proportion of subjects
with iPTH values ≥70 pg/ml. The association between two
continuous measures was summarized using a Spearman’s
rank correlation coefficient. A logistic regression modeling
procedure was used to compare the odds of low 25-OH-D
levels between surgery and control patients while adjusting
for calcium and vitamin D intake. A value of p<0.05 was
considered significant.
Results
The bariatric surgery group and the control group were well
matched and had a mean age of 46.9±10.0 years in the pre-
bariatric surgery group and 46.3±8.3 years in the control
group (Table 1). Fifty-four percent of patients were enrolled
during the summer months (April through September), and
OBES SURG (2008) 18:145–150 147

Table 1 Summary of patient demographic and clinical characteristics

Measurement Subject group P value

Bariatric surgery patients (n=41) Controls (n=41)

Range Mean SD Range Mean SD

Age at screening (years) 25–73 46.9 10.0 27–65 46.3 8.3 0.8
Height (cm) 117.0–198.2 165.2 17.9 149–190 167.8 8.8 0.4
Weight (kg) 109.4–223.0 150.9 30.2 53.6–96.6 70.8 11.7 <0.0001
BMI (kg/m2) 41.8–88.2 56.4 12.3 20.0–29.1 24.7 2.7 <0.0001

Sex 0.8
Male 8 (20%) 9 (22%)
Female 33 (80%) 32 (78%)
Race >0.9
Black/African American 1 (2%) 1 (2%)
White 38 (93%) 40 (98%)
Not provided 2 (5%)

46% were enrolled in the winter months (October through
March) in both groups. As designed, there was a statistical
difference between BMI for the bariatric surgery group
versus controls. Mean BMI for the bariatric surgery group
was 56.4±12.3 kg/m2, and control group BMI mean was
24.7±2.7 kg/m2 (p<0.0001; Table 1).
Overall, the Vitamin D levels were significantly lower,
and the iPTH values were significantly higher in the
bariatric surgery group (Table 2). Mean 25-OH-D in the
bariatric surgery group was 47.7 nmol/l (19.2 ng/ml) versus
90.8 nmol/l (36.3 ng/ml) in controls (p<0.0001). Mean
iPTH in the bariatric surgery group was 87.6 pg/ml versus
controls at 39.8 pg/ml (p<0.0001). The bariatric surgery
group was also evaluated according to time of lab draw in
relation to day of surgery. The pre-surgery labs were com-
pared with post-surgery labs, and there was not a significant
difference between the groups for 25-OH-D and iPTH (data
not shown).
Among the bariatric surgery patients, 61% had 25-OH-D
levels <50 nmol/l (vitamin D deficiency) compared with
12% of the controls (p<0.0001; Table 4). Similarly, when
evaluating vitamin D insufficiency and deficiency (25-OH-
D <75 nmol/l), 90% of surgery patients had levels
<75 nmol/l compared to 32% of controls (p<0.0001;
Table 3). Intact PTH values were elevated ≥70 pg/ml in
49% of the bariatric surgery patients compared with 2% of
the controls (p<0.0001; Table 4).
Serum creatinine was normal in both groups and did not
differ significantly between the surgery and control groups
(Table 2). Serum albumin was also within the normal range
in both groups, but significantly lower in the surgery group
compared with controls (p<0.0001). Mean albumin in the

Table 2 Summary of patient laboratory characteristics

Measurement Subject group P value

Bariatric surgery patients (n=41) Controls (n=41)

Range Mean SD Range Mean SD

25-OH-D (nmol/l) 12.5–129.8 47.7 24.7 32.4–177.2 90.8 34.2 <0.0001

PTH (ng/l) 20.0–284.0 87.6 54.3 3.0–97.0 39.8 18.3 <0.0001
Serum Calcium (mmol/l) 2.3–2.4 2.3 0.08 2.1–2.5 2.3 0.1 <0.0001
Corrected calcium for albumina (mmol/l) 2.1–2.5 2.3 0.08 2.2–2.6 2.4 0.08 0.1
Corrected calcium for albuminb (mmol/l) 2.0–2.4 2.2 0.08 2.8–2.5 2.3 0.08 0.1
Albumin (g/l) 35–46 41.0 3 37–49 43 3 <0.0001
Creatinine (μmol/l) 53.0–106.1 79.6 17.7 53.0–114.9 79.6 17.7 0.3
a
Corrected calcium (formula 1)=(44.4−serum albumin)×0.75+serum calcium.
b
Corrected calcium (formula 2)=(40.0−serum albumin)×0.8+serum calcium.
148 OBES SURG (2008) 18:145–150

Table 3 Summary of dietary calcium and vitamin D intake

Variable count (column %) Surgery patients (n=38) Controls (n=41) P value

How much milk do you drink? 0.3

>2 8 oz glasses/day 3 (8%) 6 (15%)
1 glass per day 12 (32%) 13 (32%)
1 glass every other day 3 (8%) 9 (22%)
<3 glasses/week 12 (34%) 4 (10%)
None 7 (18%) 9 (22%)
How much cheese, cottage cheese, yogurt, calcium and vitamin D enriched orange 0.1
juice do you eat/drink?
>2 servings/day 4 (10%) 3 ( 8%)
1 serving per day 10 (26%) 21 (54%)
1 serving every other day 9 (24%) 7 (18%)
<3 servings/week 14 (37%) 6 (15%)
None 1 (3%) 2 (5%)
How much spinach, broccoli, or other green leafy vegetables do you eat? <0.0001
>2 servings/day 0 (0%) 11 (27%)
1 serving per day 6 (16%) 11 (27%)
1 serving every other day 8 (21%) 11 (27%)
<3 servings/week 20 (53%) 6 (15%)
None 4 (10%) 1 (3%)

bariatric surgery group was 4.1 g/dl versus 4.3 g/dl in the
control group (Table 2).
Mean serum calcium was also significantly lower for the
surgery group when compared with controls (9.0 versus
9.3 mg/dl, p<0.0001), but this difference did not persist
after correction of calcium for albumin using both equa-
tions (Table 2).
BMI was inversely correlated to 25-OH-D levels (r=−0.3,
p=0.06), but no other associations to BMI were significant
in the bariatric surgery group. There was no significant
correlation between BMI and any of the other variables in
the control group (data not shown).
Reported dietary intake of milk, cheese, cottage cheese,
yogurt, and calcium, and vitamin-D-enriched orange juice
was not significantly different between the bariatric surgery
group and the controls. However, there was a significant
difference between reported intake of vegetables containing
vitamin D (Table 3). Sixteen percent, 74 and 10% of the
bariatric surgery group reported consuming at least one
serving per day, less than one serving per day, or no spinach,
broccoli, and green leafy vegetables, respectively, compared
with 55, 43, and 2% of controls, respectively (p<0.0001).
There was also a significant difference between reported
medication administration of calcium and vitamin D
between the two groups. Forty-nine percent of controls
reported taking calcium and/or vitamin D and only 2% of
the bariatric surgery patients reported taking calcium and or
vitamin D (p<0.0001; Table 5). All patients who reported
calcium supplementation were taking less than 2,000 mg of
calcium per day. Most patients could not quantify the
amount of vitamin D they ingested per day; however, all
patients reporting vitamin D supplementation received it as
part of their calcium supplementation. None took vitamin D
as a separate supplement. Hence, the likely maximum
supplementation dose of vitamin D was 800 IU/day. The

Table 5 Supplements and medications

Table 4 Summary of vitamin D deficiency, vitamin D insufficiency,
Medication type count Surgery patients Controls P value
and elevated iPTH
(column %) (n=41) (n=41)
Variable count Surgery patients Controls P value
(column %) (n=41) (n=41) Calcium/vitamin D 1 (2%) 20 (49%) <0.0001
Antihypertensive 13 (32%) 4 (10%) 0.01
25 OH Vitamin D agents
<50 nmol/l 25 (61%) 5 (12%) <0.0001 Estrogen replacement 4 (10%) 10 (24%) 0.08
<75 nmol/l 37 (90%) 13 (32%) <0.0001 therapy
PTH Diabetes medicationsa 6 (15%) 0 0.03
≥70 pg/ml 20 (49%) 1 (2%) <0.0001 a
Includes oral diabetes medications and insulin.
OBES SURG (2008) 18:145–150
Table 6 Association between 25-OH D and season
Variable count Surgery patients Controls P value
(column %)
Summer (n=22) (n=22)
25 OH Vitamin D
<50 nmol/l 12 (55%) 1 (5%) 0.0003
<75 nmol/l 19 (86%) 3 (14%) <0.0001
Winter (n=19) (n=19)
25 OH Vitamin D
<50 nmol/l 13 (68%) 4 (21%) 0.003
<75 nmol/l 18 (95%) 10 (53%) 0.003
bariatric surgery patients also had significantly higher usage
of anti-hypertensive drugs and diabetes medications, but
the controls reported significantly higher usage of estrogen
therapy (Table 5). After adjusting for the reported calcium/
vitamin D intake, the surgery patients were still at increased
risk for vitamin D deficiency (25-OH-D <50 nmol/l; OR=
11.1, 95%CI 2.8–43.4, p=0.0006). Similarly, when com-
bining vitamin D deficiency with vitamin D insufficiency
(25-OH-D <75 nmol/l), the surgery patients were also still at
increased risk for low 25-OH-D (OR=19.0, 95%CI 4.9–73.6,
p<0.0001).
There was no significant difference in the amount of
reported sunlight exposure between the groups (p=0.08),
with approximately 60% of subjects in each group
receiving less than 30 min of sun exposure per day. We
also evaluated the patients according to the season in which
they were studied (Table 6). In each season and for each
endpoint, bariatric surgery patients were more likely to
have low vitamin D levels. When evaluating both vitamin
D deficiency and insufficiency (25-OH-D<75 nmol/l),
significantly more controls had low vitamin D levels in
winter (53%) compared with summer (14%; p=0.008).
There was no significant difference in winter and summer
rates when comparing the outcomes using the vitamin D
deficiency cutoff (25-OH-D<50 nmol/l); however, there
were only four patients in the deficiency category. The
summer and winter rates did not differ for either vitamin D
deficiency or combined vitamin D deficiency and vitamin D
insufficiency in the bariatric surgery group (p>0.4 for each).
When comparing symptoms before bariatric surgery
versus controls, there were significantly more patients who
reported muscle aches in the bariatric surgery group (61%)
compared with controls (10%; p<0.0001). The bariatric
surgery patients also reported more nausea or vomiting and
watery stools or diarrhea pre-surgery. Eighteen percent of
the surgery patients reported nausea or vomiting compared
with none of the controls (p=0.003), and 37% of bariatric
surgery patients reported diarrhea versus 7% of controls
(p=0.001).
149
Discussion
Rates of obesity in the USA have steadily increased over
the last two decades. It is well known that obesity is
associated with diabetes mellitus, coronary artery disease,
hyperlipidemia, and osteoarthritis. It is now clear that
Vitamin D deficiency is also associated with obesity.
Before global screening for vitamin D deficiency after
bariatric surgery, vitamin D deficiency was only rarely
reported many years after bariatric surgery [6, 7], so was
thought to be a rare long-term complication of bariatric
surgery. Recent studies have shown that obesity itself is
associated with vitamin D deficiency, and BMI is inversely
correlated with vitamin D levels and positively correlated
with iPTH, which our study confirmed [8, 9]. Ybarra et al.
[12] demonstrated that the rates of vitamin D deficiency in
obese populations before and after bariatric surgery were
not significantly different, suggesting both pre- and
postoperative factors contribute to vitamin D deficiency
after bariatric surgery. Vitamin D deficiency is known to
contribute to metabolic bone disease. Additionally, vitamin
D deficiency has been associated with autoimmune disease,
certain cancers, insulin resistance, and cardiovascular
disease [1, 8–20]. This raises the question of a possible
association between obesity, vitamin D deficiency, and the
occurrence of these other medical conditions.
The prevalence of vitamin D deficiency (25-OH-D
<50 nmol/l) in obese patients was 61% and combined
vitamin D deficiency and insufficiency (25-OH-D
<75 nmol/l) was 90%. This is consistent with previous
studies showing rates of vitamin D deficiency of 21–81%
before bariatric surgery [10–13]. A possible explanation for
the discrepant range in previous studies could be the
inconsistent vitamin D threshold to define vitamin D
deficiency. Many of the previous reports used much lower
cutoffs ranging from 25 to 50 nmol/l (10–20 ng/ml) to
define vitamin D deficiency, which could result in a lower
reported incidence of vitamin D deficiency in those studies.
In this study, we used a threshold of 75 nmol/l (30 ng/ml) to
define vitamin D sufficiency, which is consistent with
recently published consensus recommendations [21]. We
also found that approximately half of the patients with low
vitamin D levels also had evidence of secondary hyper-
parathyroidism, consistent with previous reports [2].
Serum 25-OH-D is affected by a number of variables,
including vitamin D intake, sunlight exposure, and season.
To evaluate for these potential confounders, we evaluated
reported dietary and medication intake of calcium and
vitamin D. The controls consumed significantly more
calcium and vitamin D via medication supplements and
more vitamin-D-containing vegetables. However, after
adjusting for calcium and vitamin D intake, the risk for
vitamin D deficiency and combination vitamin D deficiency
150
and insufficiency persisted. There was no difference
between reported sunlight exposure between the groups.
This study was performed in Omaha, Nebraska, which is
located at latitude 41.3N. Webb et al. [15] has shown that at
latitudes of 42.2N, there is no cutaneous conversion of
provitamin D3 to previtamin D3 during the winter months
(November through February), and at latitudes of 52N,
there was no conversion from October through March.
Hence, we matched our patients to healthy non-obese
controls to account for this seasonal effect on vitamin D. In
the healthy controls, there was a significant difference
between vitamin D levels in the winter versus the summer
consistent with this effect. However, there was not a
significant difference in vitamin D levels between winter
and summer months in the obese group. As the reported
sunlight exposure was not different between the groups, we
conclude this is not a confounding factor in this study. This
lack of response to sunlight in the bariatric group could be
explained by decreased cutaneous conversion of provitamin
D3 to previtamin D3 as previously suggested by Wortsman
et al. [22] when they demonstrated that obese persons can-
not increase their serum vitamin D levels as efficiently as
non-obese persons when exposed to the same dose of UVB
radiation. Other theories regarding vitamin D deficiency in
obese persons have suggested that there is sequestration of
vitamin D in adipose tissue that results in low circulating
25-OH-D levels despite potentially adequate amounts of
sunlight exposure or oral vitamin D [1].
Myalgias, cramps, and diffuse pain have also been
associated with vitamin D deficiency [23]. We found that
the obese patients had significantly more myalgias than
controls, which may be caused by vitamin D deficiency. We
do not have an explanation for the increase in GI
complaints in the obese group versus controls.
Vitamin D insufficiency and deficiency (25-OH-D
<75 nmol/l) are extremely common in obese populations,
and the combination is present in 90% of morbidly obese
patients at the time of bariatric surgery, unexplained by a
difference in known factors that affect vitamin D. This
study also supports previous reports that obese persons are
less responsive to sunlight exposure as a means of
increasing their vitamin D. These findings underscore the
importance of screening obese persons for vitamin D
deficiency in addition to other medical conditions for
which they are at high risk. It also demonstrates the
importance of vitamin D replacement both pre- and post-
bariatric surgery. Additionally, it will be important to
determine the optimal dose of recommended oral vitamin
D to achieve vitamin D sufficiency in obese as well as non-
obese populations.
Acknowledgment This work was funded by a grant of the Clinical
Research Center at the University of Nebraska Medical Center.
OBES SURG (2008) 18:145–150
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