Low 25(OH)D usually reflects low UVB exposure or intake: limited sun exposure, dark skin pigmentation, high-SPF sunscreen use, winter latitude, low intake of fatty fish or fortified foods, or strict vegan diets.
Other common causes are malabsorption or altered distribution/metabolism: obesity, bariatric surgery, celiac disease, Crohn's disease, cholestasis or pancreatic insufficiency, liver or kidney disease, magnesium insufficiency, and medications such as anticonvulsants, glucocorticoids, rifampin, antiretrovirals, and some antifungals.
High 25(OH)D is most often supplement-driven via excessive vitamin D dose. Sun exposure alone does not usually cause vitamin D toxicity.
Less common: increased active vitamin D production in granulomatous disease or lymphoma, and rare cholecalciferol-containing rodenticide exposure. The main practical concern is hypercalcemia, especially when levels exceed about 100-150 ng/mL.
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