One of the most frustrating things I see in my practice at Prime ENT Center is patients whose BPPV keeps coming back especially in elderly population. I treat them, they get better, and three months later they’re back in my clinic with the same symptoms. After seeing this pattern repeatedly, I started asking: what’s different about patients who have recurrent BPPV versus those who are cured with one treatment? Natural environment also plays a very crucial role in this, In my place (Uttar Pradesh) we have dense fog and low sunlight for almost 2 months in winter.
One factor stood out after a attending neurotology conference 5 years back: vitamin D deficiency. Patients with low vitamin D levels had significantly higher rates of BPPV recurrence. This wasn’t just my observation-research backs it up. Studies show that vitamin D deficiency increases BPPV recurrence risk by up to three times mainly in older population. That’s a huge difference, and it’s something I can actually do something about. Vitamin D Deficiency and BPPV, Can Supplements Prevent Recurrence
The Connection Between Vitamin D Deficiency and BPPV
Let me explain the mechanism. BPPV is about loose otoconia-calcium carbonate crystals in your inner ear. Vitamin D plays a crucial role in calcium metabolism throughout your body, including in the inner ear.
When vitamin D levels are low, your body struggles to maintain proper calcium balance. This affects the otoconia themselves, making them more fragile and more likely to break apart. Additionally, low vitamin D affects the health of the supporting tissues in the inner ear, making them less stable.
Think of vitamin D deficiency as creating a weak foundation. Your inner ear structures become more vulnerable. When something happens-a head movement, a fall, normal wear and tear-the loose crystals form more easily. And once they form, they’re more prone to dislodging again.
On the other hand, adequate vitamin D supports calcium homeostasis and inner ear tissue health, making the otoconia more stable and less likely to break free in the first place.
Research Evidence: The Numbers
Several studies from the past decade have documented this association. A notable study from South Korea (published in 2013) found that BPPV patients with vitamin D deficiency had a significantly higher recurrence rate compared to those with normal vitamin D levels.
The statistics are striking:
- Patients with vitamin D deficiency: approximately 60-70% recurrence rate within 2 years
- Patients with normal vitamin D levels: approximately 20-30% recurrence rate within 2 years
That’s roughly three times higher recurrence risk with low vitamin D. In my practice, I’ve seen similar patterns.
What’s exciting is the corollary: correcting vitamin D levels appears to reduce recurrence. Patients who check their vitamin D after BPPV treatment and supplement if deficient have much lower recurrence rates.
Vitamin D Deficiency in India, An Unexpected Problem
Here’s an irony: India is a sunny country, yet vitamin D deficiency is extremely common, especially in Uttar Pradesh. You’d think abundant sunlight would mean everyone has adequate vitamin D. But the reality is more complex.
Factors contributing to vitamin D deficiency in UP include:
- Limited sun exposure: Many people work indoors. Children spend more time in school, watching screens. Women often have limited outdoor time due to cultural practices or household responsibilities.
- Skin pigmentation: Darker skin requires more sun exposure to produce the same amount of vitamin D as lighter skin
- Seasonal variation: Even in India, winter months (November to February) have reduced sun angle and reduced UV-B intensity
- Dietary intake: Traditional Indian diet, while good overall, is often low in vitamin D sources. Cow’s milk isn’t consumed by many (due to vegetarianism or lactose intolerance), and fish/egg consumption varies
- Age-related factors: Older adults have reduced capacity to synthesize vitamin D from sunlight
Studies show that up to 50-80% of the Indian population has vitamin D deficiency or insufficiency. In my practice in Hardoi, I’d estimate similar or higher rates, especially in winter months.
Who Should Get Vitamin D Tested After BPPV?
Here’s my clinical recommendation: after treating BPPV, I now routinely check vitamin D levels in my patients, particularly:
- Patients over age 50 – Age-related changes in vitamin D metabolism
- Anyone with recurrent BPPV – If they’ve had BPPV before that came back, vitamin D testing is essential
- Patients with limited sun exposure – Those who work indoors, live in northern India, or have other reasons for reduced sun exposure
- Older women – Especially post-menopausal, who have higher osteoporosis risk and often have vitamin D deficiency
- Anyone with multiple health issues – Obesity, kidney disease, malabsorption conditions all affect vitamin D status
For patients at lower risk, vitamin D testing is optional, but I’d argue it’s worth checking. It’s an inexpensive blood test (usually under Rs 500 in Hardoi labs), and if deficient, supplementation is cheap and safe.
Recommended Vitamin D Levels and Supplementation
The standard reference ranges are:
- 30 ng/mL or higher: Sufficient
- 20-29 ng/mL: Insufficient
- Below 20 ng/mL: Deficient
For BPPV prevention, I aim to get my patients to at least 30-35 ng/mL, ideally higher if they’re susceptible to recurrence.
Supplementation dosing:
- Vitamin D supplements as prescribed by your doctor
- Vitamin D supplements as prescribed by your doctor
- Vitamin D supplements as prescribed by your doctor
I typically recommend supplementing for 3-6 months, then retesting. Once levels normalize, many patients can maintain with dietary sources and seasonal sun exposure, though some benefit from continued maintenance doses of Vitamin D supplements as prescribed by your doctor.
Popular Indian combinations include:
- (liquid vitamin D3, easy for kids)
- (combined calcium and vitamin D3)
- vitamin D3 capsules)
- Alendronate + Vitamin D3 combinations (for osteoporosis prevention)
Most are available over-the-counter or with minimal prescription requirement.
Calcium: The Partner to Vitamin D
Vitamin D’s role is helping your body absorb calcium. So adequate calcium intake is equally important. For adults, the recommended dietary allowance is about 1000-.
Good Indian sources of calcium include:
- Dairy: Dahi, milk, paneer, chhena (esp for vegetarians)
- Leafy greens: Mustard greens, fenugreek leaves (methi), spinach (though spinach also has oxalates that reduce absorption)
- Fortified foods: Some Indian brands fortify milk and flour
- Nuts and seeds: Til (sesame) seeds are excellent-just 1 tablespoon provides ~ calcium
- Fish with bones: If you eat non-vegetarian, fish eaten with bones (like canned sardines or some prepared fish) is rich in bioavailable calcium
- Fortified grains: Some modern flours and breakfast cereals
For vegetarians (common in Hardoi), focusing on dahi, paneer, til seeds, and fortified milk products is key.
If dietary intake is inadequate, calcium supplementation (typically 500-) is safe and recommended alongside vitamin D.
Sunlight Exposure Guidelines for Vitamin D Production
The sun is free and the most natural source of vitamin D. Here’s what I tell my patients about sun exposure:
- Timing: Morning sun (6-9 AM) or late afternoon sun (4-6 PM) is generally safer and still produces vitamin D. Avoid peak midday sun (11 AM-3 PM) which increases skin cancer risk
- Duration: About 20-30 minutes of sun exposure on arms and legs (not covered by clothes) most days per week is adequate for most people
- Frequency: Aim for 3-5 days per week. Weekends outdoors, daily short breaks in sunlight
- Barriers to avoid: Sunscreen blocks vitamin D production (though it prevents cancer), so either expose 5-10 minutes without sunscreen, then apply sunscreen, or get vitamin D from other sources if you’re sunscreen-strict
- Seasonal adjustment: In winter, increase duration to 30-40 minutes or more because sun angle is lower and UV-B intensity is reduced
For my patients who work indoors all day, I recommend at least a 20-minute break outdoors during afternoon, even just a short walk in the park or on the street.
Other Factors That Affect BPPV Recurrence
While vitamin D is important, it’s not the only factor affecting recurrence. Other preventive strategies include:
- Avoiding head trauma: Wear helmets when cycling or riding motorcycles, which is common in UP. Even minor head bumps can dislodge crystals in susceptible people
- Managing osteoporosis: If you have osteoporosis or low bone density, this affects inner ear bone health too. Regular weight-bearing exercise and adequate calcium+vitamin D are crucial
- Treating underlying conditions: Diabetes, thyroid disorders, and other metabolic problems can affect inner ear health
- Avoiding medication side effects: Some drugs (certain antibiotics, diuretics) can affect balance. If you’re on medications, ask your doctor if any increase vertigo risk
- Regular vestibular exercises: Some research suggests vestibular rehabilitation exercises may reduce recurrence
Real Patient Case: Recurrent BPPV Fixed by Vitamin D Correction
Mr. Joshi, 58 years old, came to me frustrated. He’d had BPPV five months ago, I treated him with the Epley maneuver, and he was fine. But two months ago it came back. I treated again, fine for six weeks, now it’s back again. He asked, “Doctor, am I going to be stuck with this forever?”
This was a clear recurrence pattern. I checked his vitamin D level: 16 ng/mL-frankly deficient.
I treated the current BPPV episode with the Epley, and I prescribed vitamin D3 Vitamin D supplements as prescribed by your doctor. I explained the vitamin D connection to him.
Six months later, he came for follow-up. No BPPV recurrence. His vitamin D had risen to 32 ng/mL. He said, “I didn’t realize my vitamin D was so low. I feel better overall now, not just the vertigo.”
Last I heard (about a year after), still no recurrence. He continues his vitamin D supplementation and gets outdoor time regularly.
FAQ Section
Q: If I supplement vitamin D, will I never get BPPV again?
Not guaranteed, but it significantly reduces recurrence risk. About 60-70% of vitamin D deficient BPPV patients have recurrence within 2 years, compared to 20-30% with normal vitamin D. So correcting deficiency helps, but some people still have recurrence even with normal vitamin D-it depends on other factors too.
Q: How long should I take vitamin D supplements?
At least 3-6 months initially to correct deficiency, then retest. If levels normalize, many people can continue maintenance doses (Vitamin D supplements as prescribed by your doctor.
Q: Can too much vitamin D be harmful?
Yes, toxicity is possible with very high doses (>Vitamin D supplements as prescribed by your doctor. Standard doses (Vitamin D supplements as prescribed by your doctor. That said, don’t megadose without medical advice.
Q: Should I get vitamin D tested even if I’ve never had BPPV?
Not necessarily, unless you have risk factors for deficiency. But if you have recurrent dizziness, balance issues, or osteoporosis risk, testing is reasonable. Vitamin D deficiency affects overall bone and muscle health too.
Q: Are there vitamin D-rich Indian foods I should eat more of?
If non-vegetarian: fatty fish, egg yolks. If vegetarian: fortified milk, dahi, paneer, and especially til (sesame) seeds. But honestly, most traditional Indian diet doesn’t have abundant natural vitamin D sources, so supplementation is often needed, especially in winter.
Q: What’s the best time to take vitamin D supplements?
With a meal containing fat (vitamin D is fat-soluble), ideally during the day. Morning with breakfast or lunch is fine. Some people prefer one large weekly dose, but daily dosing is more consistent and safer.
Final Thoughts (and research links Pubmed)
If you’ve had BPPV, especially if it’s recurrent, please check your vitamin D level. It’s a simple test that might reveal why you keep having episodes. Correcting vitamin D deficiency is inexpensive, safe, and has been shown to reduce recurrence significantly.
Even if you’ve never had BPPV, adequate vitamin D is important for overall health-bones, immunity, mood, and yes, inner ear health. In a region like Uttar Pradesh where vitamin D deficiency is common despite abundant sunshine, being proactive about checking and correcting levels makes sense.
After I treat your BPPV, don’t just assume you’re done. Ask me about vitamin D testing. It might be the difference between a one-time episode and years of recurrent trouble.
About Dr. Prateek Porwal
Dr. Prateek Porwal is an ENT & Vertigo Specialist with over 13 years of experience, holding MBBS (GSVM Medical College), DNB ENT (Tata Main Hospital), and CAMVD (Yenepoya University). He is the originator of the Bangalore Maneuver for Anterior Canal BPPV.sive approach to vestibular disorders. Dr. Porwal believes in not just treating the acute problem but preventing future episodes through lifestyle optimization and nutritional support.
Book your appointment today: Call 7393062200 or WhatsApp https://wa.me/917393062200
Prime ENT Center, Hardoi, UP | Website: drprateekporwal.com
Medical Disclaimer: This article is for educational purposes only. It does not constitute medical advice or prescribing guidance. All medications mentioned should only be taken under the direct supervision of a qualified physician. Specific doses, durations, and drug choices depend on your individual clinical condition and must be determined by your treating doctor. If you experience severe symptoms, please seek immediate medical attention.