Mandating Vitamin D Availability in Low- and Middle-Income Countries: Time to Act on A Silent Pandemic

Abstract

Vitamin D deficiency impacts over 1 billion individuals globally and qualifies as a pandemic, yet it remains largely unrecognized by healthcare systems in low- and middle-income countries (LMICs). The combined prevalence of serum 25-hydroxyvitamin D levels below 50 nmol/L is 56% in LMICs, with even greater rates among pregnant women, adolescents, and the elderly. South Asia is significantly affected, with adult deficiency rates surpassing 65% in Pakistan, Bangladesh, and India. This Opinion and Analysis advocates for large-scale action to address vitamin D deficiency in LMICs, explores reasons for the ongoing deficiency in sunny regions, and discusses why universal biochemical testing is not the appropriate solution. Drawing on global and regional epidemiology, the Bill & Melinda Gates Foundation and the New York Academy of Sciences expert roadmap, country-level cost-effectiveness modelling, and the Finnish precedent of mandatory food fortification, we argue that three policy instruments used together can shift the population distribution of 25-hydroxyvitamin D within a few years: mandatory fortification of staple foods such as edible oil and milk; targeted supplementation of high-risk groups; and clear public-health communication on sensible sun exposure and dietary sources. This package is biologically sound, operationally feasible, and economically attractive. Cost-effectiveness analyses from India and the United Kingdom suggest that fortification is cost-saving at the population level. The case for ministries of health in Pakistan, India, Bangladesh, and other LMICs to make vitamin D mandatorily available through the foods their populations already eat is now stronger than the case for further delay.