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Diaz-Thomas A, Iyer P. Global Health Disparities in Childhood Rickets. Endocrinol Metab Clin North Am 2023; 52:643-657. [PMID: 37865479 DOI: 10.1016/j.ecl.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
Nutritional rickets is a global health problem reflecting both historical and contemporary health disparities arising from racial, ethnic, environmental, and geopolitical circumstances. It primarily affects marginalized populations and can contribute to long-term morbidity. Deficits in bone health in childhood may also contribute to osteomalacia/osteoporosis. Solutions require a global public health approach.
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Affiliation(s)
- Alicia Diaz-Thomas
- Department of Pediatrics, Division of Pediatric Endocrinology, The University of Tennessee Health Science Center, 910 Madison Avenue, Suite 1010, Memphis, TN 38163, USA.
| | - Pallavi Iyer
- Department of Pediatrics, Division of Endocrinology and Diabetes, Medical College of Wisconsin, Children's Corporate Center, Suite 520, 9000 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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Korkmaz HA, Padidela R, Ozkan B. Approach to nutritional rickets. J Pediatr Endocrinol Metab 2023; 36:335-341. [PMID: 36843296 DOI: 10.1515/jpem-2023-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/09/2023] [Indexed: 02/28/2023]
Abstract
Rickets is the disease of a growing skeleton and results from impaired apoptosis of hypertrophic chondrocytes and mineralization of the growth plate. Nutritionally induced rickets, secondary to vitamin D and/or calcium deficiency, remains a major global problem. In this review, we discuss pathogenesis, clinical signs, investigation and management of nutritional rickets.
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Affiliation(s)
- Hüseyin Anıl Korkmaz
- Department of Pediatrics, Division of Pediatric Endocrinology, Dr. Behçet Uz Pediatric Diseases and Surgery training and Research hospital, İzmir, Türkiye
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital and Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Behzat Ozkan
- Department of Pediatrics, Division of Pediatric Endocrinology, Dr. Behçet Uz Pediatric Diseases and Surgery training and Research hospital, İzmir, Türkiye
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Fischer PR, Sempos CT, Pettifor JM, Fraser DR, Munns CF, Durazo-Arvizu RA, Thacher TD. Serum 1,25-dihydroxyvitamin D levels in the diagnosis and pathogenesis of nutritional rickets - a multivariable re-analysis of a case-control study. Am J Clin Nutr 2023; 117:998-1004. [PMID: 36801463 DOI: 10.1016/j.ajcnut.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND A multivariable logistic regression model resulting from a case-control study of nutritional rickets in Nigerian children suggested that higher levels of serum 25(OH)D may be required to prevent nutritional rickets in populations with low-calcium intakes. OBJECTIVES This current study evaluates if adding serum 1,25-dihydroxyvitamin D [1,25(OH)2D] to that model shows that increased levels of serum 1,25(OH)2D are independently associated with risk of children on low-calcium diets having nutritional rickets. METHODS Multivariable logistic regression analysis was used to model the association between serum 1,25(OH)2D and risk of having nutritional rickets in cases (n = 108) and controls (n = 115) after adjusting for age, sex, weight-for age z-score, religion, phosphorus intake and age began walking and the interaction between serum 25(OH)D and dietary calcium intake (Full Model). RESULTS Serum 1,25(OH)2D levels were significantly higher (320 pmol/L vs. 280 pmol/L) (P = 0.002), and 25(OH)D levels were lower (33 nmol/L vs. 52 nmol/L) (P < 0.0001) in children with rickets than in control children. Serum calcium levels were lower in children with rickets (1.9 mmol/L) than in control children (2.2 mmol/L) (P < 0.001). Dietary calcium intakes were similarly low in both groups (212 mg/d) (P = 0.973). In the multivariable logistic model, 1,25(OH)2D was independently associated with risk of having rickets [coefficient = 0.007 (95% confidence limits: 0.002-0.011)] after adjusting for all variables in the Full Model. CONCLUSIONS Results confirmed theoretical models that in children with low dietary calcium intake, 1,25(OH)2D serum concentrations are higher in children with rickets than in children without rickets. The difference in 1,25(OH)2D levels is consistent with the hypothesis that children with rickets have lower serum calcium concentrations which prompt the elevation of PTH levels resulting in an elevation of 1,25(OH)2D levels. These results support the need for additional studies to identify dietary and environmental risks for nutritional rickets.
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Affiliation(s)
- Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States, Department of Pediatrics, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates and Khalifa University College of Medicine and Health Sciences, Abu Dhabi, United Arab Emirates.
| | | | - John M Pettifor
- Department of Pediatrics, SAMRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - David R Fraser
- Sydney School of Veterinary Science, Faculty of Science, University of Sydney, Sydney, Australia
| | - Craig F Munns
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia and Department of Endocrinology and Diabetes, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Ramon A Durazo-Arvizu
- Biostatistical Core, The Sabin Research Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Tom D Thacher
- Department of Family Medicine, Jos University Teaching Hospital, Jos, Nigeria
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Vlok M, Snoddy AME, Ramesh N, Wheeler BJ, Standen VG, Arriaza BT. The role of dietary calcium in the etiology of childhood rickets in the past and the present. Am J Hum Biol 2023; 35:e23819. [PMID: 36251616 DOI: 10.1002/ajhb.23819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/06/2022] [Accepted: 09/27/2022] [Indexed: 11/11/2022] Open
Abstract
For more than two centuries, lack of sunlight has been understood to cause vitamin D deficiency and documented as a primary cause of rickets. As such, evidence of rickets in the archeological record has been used as a proxy for vitamin D status in past individuals and populations. In the last decade, a clinical global consensus has emerged wherein it is recognized that dietary calcium deficiency also plays a role in the manifestation of rickets and classic skeletal deformities may not form if dietary calcium is normal even if vitamin D is deficient. This disease is now clinically called "nutritional rickets" to reflect the fact that rickets can take calcium deficiency-predominant or vitamin D deficiency-predominant forms. However, there are currently no paleopathological studies wherein dietary calcium deficiency is critically considered a primary etiology of the disease. We review here the interplay of calcium, vitamin D, and phosphorous in bone homeostasis, examine the role of dietary calcium in human health, and critically explore the clinical literature on calcium deficiency-predominant rickets. Finally, we report a case of rickets from the late Formative Period (~2500-1500 years ago) of the Atacama Desert and argue the disease in this infant is likely an example of calcium deficiency-predominant rickets. We conclude that most archeological cases of rickets are the result of multiple micronutrient deficiencies that compound to manifest in macroscopic skeletal lesions. For clinicians, these factors are important for implementing best treatment practice, and for paleopathologists they are necessary for appropriate interpretation of health in past communities.
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Affiliation(s)
- Melandri Vlok
- Sydney Southeast Asia Centre, The University of Sydney, Camperdown, Australia.,Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Anne Marie E Snoddy
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Niranjan Ramesh
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Benjamin J Wheeler
- Department of Women and Children's Health, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Vivien G Standen
- Departamento de Antropología, Universidad de Tarapacá, Arica, Chile
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Fischer PR, Almasri NI. Nutritional rickets - Vitamin D and beyond. J Steroid Biochem Mol Biol 2022; 219:106070. [PMID: 35143980 DOI: 10.1016/j.jsbmb.2022.106070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/25/2022] [Accepted: 02/02/2022] [Indexed: 10/19/2022]
Abstract
Vitamin D deficiency has been considered to be the cause of nutritional rickets for most of the past century. During the past two decades, however, it has become clear that nutritional rickets may be caused by vitamin D deficiency or by dietary insufficiency of calcium. The combined deficiencies of calcium and vitamin D interact, and several other factors are also relevant in the pathogenesis of nutritional rickets.
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Affiliation(s)
- Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA; Department of Pediatrics, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates; Khalifa University, Abu Dhabi, United Arab Emirates.
| | - Neamat I Almasri
- Department of Pediatrics, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
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Mays S, Brickley MB. Is dietary deficiency of calcium a factor in rickets? Use of current evidence for our understanding of the disease in the past. INTERNATIONAL JOURNAL OF PALEOPATHOLOGY 2022; 36:36-44. [PMID: 35139469 DOI: 10.1016/j.ijpp.2021.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/01/2021] [Accepted: 11/25/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Rickets is considered an indicator of vitamin D deficiency in palaeopathology, but a strand of biomedical thought maintains that dietary calcium deficiency may sometimes play a part in its causation. Our aim is to evaluate the extent to which low calcium intake should be considered as a factor in biocultural interpretations of rickets. METHODS We assess published modern epidemiological studies that provide primary data to support claims for a role for dietary calcium deficiency in rickets. We also consider how we might identify, via indicators of calcium intake, populations at risk of calcium deficiency in the past. RESULTS Support for dietary calcium deficiency as a cause of rickets is equivocal. Direct measurement of dietary calcium in the past is not possible, but exposure to risk factors for low calcium intake can to some extent be identified. CONCLUSION Whilst there is little evidence to alter the view that rickets is essentially an indicator of a population's vitamin D status, occasionally, in very low calcium intake groups, dietary calcium deficiency may play a synergistic role by accentuating the need for vitamin D. SIGNIFICANCE The notion that dietary calcium deficiency may be a cause of rickets appears to be gaining currency in bioarchaeological studies. This paper shows that it is unusual for this to be the case, and even then the role of vitamin D remains crucial. LIMITATIONS This paper attempts to summarise the current state of biomedical study in an area that is subject to continuing investigation.
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Affiliation(s)
- S Mays
- Research Department, Historic England, UK; Department of Archaeology, University of Southampton, UK; School of History, Classics and Archaeology, University of Edinburgh, UK.
| | - M B Brickley
- Department of Anthropology, McMaster University, Canada
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Yadav S, Porwal K, Sinha RA, Chattopadhyay N, Gupta SK. Moderate/subclinical calcium deficiency attenuates trabecular mass, microarchitecture and bone growth in growing rats. Biochem Biophys Rep 2021; 26:101033. [PMID: 34124397 PMCID: PMC8175268 DOI: 10.1016/j.bbrep.2021.101033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 04/20/2021] [Accepted: 05/20/2021] [Indexed: 11/30/2022] Open
Abstract
Adequate dietary calcium (Ca) intake is essential for bone accretion, peak bone mass (PBM) attainment, bone quality and strength during the mammalian growth period. Severe Ca deficiency during growing age results in secondary hyperparathyroidism (SHPT) and poor bone quality and strength. However, the impact of moderate Ca deficiency during rats early growth period on bone health and the reversibility with supplementing calcium later in adult life remains unclear. Female Sprague-Dawley (SD) rats (postnatal 28th day, P28) were initiated either with a moderate calcium-deficient diet (MCD, 0.25% w/w Ca) or a control diet (0.8% w/w Ca, control group) till P70. Thereafter, MCD rats were continued either with MCD diet or supplemented with calcium diet (0.8% w/w Ca, calcium supplemented group, CaS) till P150. Another group (control rats) were fed 0.8% w/w Ca containing diet from P28 till P150. MCD group, as compared to the control group, had significantly reduced serum ionized Ca and procollagen type 1 N-terminal propeptide (P1NP) at P70 while no significant change was observed in serum corrected Ca, inorganic phosphate (P), alkaline phosphatase (ALP), 25-hydroxy vitamin D [25(OH)D], intact parathyroid hormone (iPTH), and urinary C-terminal telopeptide of collagen 1 (CTX-1), Ca, and P. Femoral and tibial metaphysis in MCD rats had significantly reduced linear growth, cortical and trabecular volumetric BMD (vBMD), trabecular microarchitecture (BV/TV%, trabecular thickness, separation and number, structural model index and connectivity density), cortical thickness, and bone stiffness despite the absence of secondary hyperparathyroidism (SHPT). Continued MCD at P70–P150 results in persistence of compromised bone strength while calcium supplementation (CaS group) improved all the parameters related to bone strength and microarchitecture. Our results indicate that uncorrected moderate/subclinical calcium deficiency in growing rats can result in poor bone quality and strength despite the absence of SHPT. This finding could have relevance in children with poor calcium intake in childhood and adolescence. Moderate Ca intake impairs bone growth and stiffness in critical growth phase via subclinical Ca deficiency. Ca supplementaion reverses the effects subclinical Ca deficiency on bone health. Conclusively, moderate Ca intake imposes different effects on the bone at different phases of life.
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Affiliation(s)
- Shivmurat Yadav
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow -226014, India
| | - Konica Porwal
- Division of Endocrinology and Centre for ASTHI, CSIR-Central Drug Research Institute, (CSIR-CDRI), BS-10/1, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow 226031, India
| | - Rohit Anthony Sinha
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow -226014, India
| | - Naibedya Chattopadhyay
- Division of Endocrinology and Centre for ASTHI, CSIR-Central Drug Research Institute, (CSIR-CDRI), BS-10/1, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow 226031, India
| | - Sushil Kumar Gupta
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow -226014, India
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Yadav S, Pal S, Singh P, Porwal K, Sinha RA, Kumari N, Chattopadhyay N, Gupta SK. Calcium repletion to rats with calcipenic rickets fails to recover bone quality: A calcipenic "memory". Bone 2020; 141:115562. [PMID: 32730922 DOI: 10.1016/j.bone.2020.115562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 07/02/2020] [Accepted: 07/13/2020] [Indexed: 12/15/2022]
Abstract
Calcipenic rickets is prevalent in underprivileged children in developing countries. Calcipenic rickets resulting from dietary calcium (Ca) deficiency decreases bone mass and deteriorates bone microstructure in humans. The effect of dietary Ca replenishment (CaR) on rachitic bones in animal models depends on the amount, critical period and duration of replenishment, however, the extent of recovery in various bone parameters including bone quality remains unclear. We investigated the effect of CaR in rat skeleton after inducing calcipenic rickets. Female SD rats (postnatal 28 days/P28) were rendered calcipenic by feeding calcium deficient (CaD) diet (0.1% Ca) till P70 while control SD rats were fed Ca sufficient diet (0.8% Ca). At P70, calcipenic rats were switched to 0.8% Ca diet till P150 for one group and P210 for another group (endpoint). The CaD groups received 0.1% Ca diet throughout the study (P210). In the CaD groups, serum Ca and phosphate, and bone mineral density (BMD) were significantly decreased whereas serum alkaline phosphatase (ALP), iPTH and CTX-1 were increased compared to age-matched controls. Moreover, at the endpoint, the CaD group had reduced bone mass, surface referent bone formation parameters, tissue mineralization and strength accompanied by the increased osteoid thickness and microarchitectural decay (measured by trabecular geometric parameters) with poor crystal packing. The CaR group showed complete recovery in serum Ca, iPTH, ALP and CTX-1, and BMD, however, the bone quality parameters including bone strength, microarchitectural decay, tissue mineralization, and crystallinity were incompletely restored. Decreased surface referent bone formation and increased unmineralized bones (osteoid) indicative of osteomalacia were also observed in the CaR group at P210 compared with control despite prolonged replenishment. We conclude that a prolonged Ca repletion following the induction of calcipenic rickets in rats although shows the recovery of biochemical measures of bone metabolism and bone mass, however, the bone quality remains compromised. This suggests that a "memory" of calcipenia occurring at the early growth stage persists in the skeleton of adult rats despite a prolonged Ca replenishment.
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Affiliation(s)
- Shivmurat Yadav
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Subhashis Pal
- Division of Endocrinology and Centre for ASTHI, CSIR-Central Drug Research Institute, (CSIR-CDRI), BS-10/1, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow 226031, India
| | - Priya Singh
- Division of Endocrinology and Centre for ASTHI, CSIR-Central Drug Research Institute, (CSIR-CDRI), BS-10/1, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow 226031, India
| | - Konica Porwal
- Division of Endocrinology and Centre for ASTHI, CSIR-Central Drug Research Institute, (CSIR-CDRI), BS-10/1, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow 226031, India
| | - Rohit Anthony Sinha
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Niraj Kumari
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Naibedya Chattopadhyay
- Division of Endocrinology and Centre for ASTHI, CSIR-Central Drug Research Institute, (CSIR-CDRI), BS-10/1, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow 226031, India.
| | - Sushil Kumar Gupta
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India.
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Bouillon R, Antonio L. Nutritional rickets: Historic overview and plan for worldwide eradication. J Steroid Biochem Mol Biol 2020; 198:105563. [PMID: 31809867 DOI: 10.1016/j.jsbmb.2019.105563] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/10/2019] [Accepted: 12/02/2019] [Indexed: 02/01/2023]
Abstract
Rickets was first described in great detail in the mid 17th century and was affecting a great number of children in major European cities. The disease, however, existed already in the Roman times. The etiology of this disease remained enigmatic until the 1920s when two different mechanisms, lack of exposure to sunlight and lack of a dietary factor were finally solved by the discovery of vitamin D and its dual origin. Soon thereafter, the implementation of vitamin D supplementation for all infants and small children largely eliminated nutritional rickets in Europe and North America. It took nearly a century to elucidate the complex chemistry, metabolism, mode and spectrum of activity of the vitamin D endocrine system. Nutritional rickets, whether due to simple vitamin D or calcium deficiency or both, remains widely ravaging many infants and children around the world. Asian countries and the Middle East are mainly confronted with vitamin D deficiency whereas many African and some Asian countries face calcium deficiency rickets. Immigrants and refugees or in general people with a darker skin living in moderate climate zone are also confronted with this disease. There is great consensus how this disease could be prevented or cured. In collaboration with most international professional societies, we prepare a memorandum, in line with the successful battle against iodine deficiency disorders, to convince the World Health Organization and its member states to start an implementation program to eradicate nutritional rickets by 2030.
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Affiliation(s)
- Roger Bouillon
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, KU, Leuven, Belgium.
| | - Leen Antonio
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, KU, Leuven, Belgium
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Nutritional rickets among children admitted with severe pneumonia at Mulago hospital, Uganda: a cross-sectional study. BMC Pediatr 2018; 18:336. [PMID: 30373538 PMCID: PMC6206941 DOI: 10.1186/s12887-018-1310-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 10/15/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There's abundant sunshine in the tropics but severe rickets is still observed. Nutritional rickets is associated with an increased risk of acute lower respiratory infections. Pneumonia is the leading cause of death in the under 5 -year old children with the highest burden in developing countries. Both Pneumonia and rickets are common in the developing countries and may affect clinical presentation and outcome. This study aimed to determine the prevalence and associated factors of nutritional rickets in children admitted with severe pneumonia. METHODS This was a cross-sectional study of children aged 2-59 months presenting with severe pneumonia at an emergency unit. We enrolled 221 children between February and June 2012 after consent. A pre-coded questionnaire was used to collect data on socio-demographic, nutritional and past medical history. Physical exam was done for signs of rickets and anthropometric measurements. Serum calcium, phosphorus, and alkaline phosphatase (ALP) were assessed. Children with any physical signs of rickets or biochemical rickets (ALP > 400 IU); had a wrist x-ray done. Nutritional rickets was defined as the presence of radiological changes of cupping or fraying and/ or metaphyseal thickening. Severe pneumonia was defined using the WHO criteria. Statistical analysis was performed using the Stata 10 statistical package. P- value < 0.05 was significant. RESULTS The prevalence of nutritional rickets among children with severe pneumonia is 9.5%. However, 14.5% had raised ALP (biochemical rickets). The factors independently associated with rickets was an elevated alkaline phosphatase; p-value < 0.001, or 32.95 95% CI (10.54-102.93). Other factors like breastfeeding, big family size, birth order were not significantly associated with rickets. Low serum calcium was detected in 22 (9.9%) of the 221 participants. Overall few children with rickets had typical clinical features of rickets on physical examination. CONCLUSION Rickets is a common problem in our setting despite ample sunshine. Clinicians should actively assess children for rickets in this setting and screen for rickets in those children at high risk even without clinical features.
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11
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Thandrayen K, Pettifor JM. The roles of vitamin D and dietary calcium in nutritional rickets. Bone Rep 2018; 8:81-89. [PMID: 29955625 PMCID: PMC6019962 DOI: 10.1016/j.bonr.2018.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/04/2018] [Accepted: 01/25/2018] [Indexed: 01/31/2023] Open
Abstract
The etiology and pathogenesis of nutritional rickets are becoming progressively clearer. Vitamin D deficiency has generally been considered the major or only player in the pathogenesis of nutritional rickets. However, recent research into calcium deficiency has now provided clinicians with reasons to investigate and manage patients with nutritional rickets more appropriately. The important question when assessing cases of nutritional rickets is: “Is it calcium or vitamin D deficiency or both that play a major role in the pathogenesis of the disease?” The case presentation in this review highlights the risk factors, clinical presentation and pathophysiology of nutritional rickets in a young South African black child from a semi-urban area in Johannesburg, a city with abundant sunshine throughout the year. Vitamin D and calcium deficiencies play synergistic roles in nutritional rickets. Dietary calcium intake of <300 mg/day increases the risk of nutritional rickets. Vitamin D status is worsened by dietary calcium deficiency itself. Marked elevation of 1,25-dihydroxyvitamin D is characteristic of calcium deficiency. Preventative strategies needed to decrease the prevalence of nutritional rickets.
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Affiliation(s)
- Kebashni Thandrayen
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - John M Pettifor
- Department of Paediatrics, MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Smith TJ, Lanham-New SA, Hart KH. Vitamin D in adolescents: Are current recommendations enough? J Steroid Biochem Mol Biol 2017; 173:265-272. [PMID: 28216151 DOI: 10.1016/j.jsbmb.2017.02.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 02/10/2017] [Accepted: 02/14/2017] [Indexed: 12/16/2022]
Abstract
Vitamin D is essential for bone development during adolescence and low vitamin D status during this critical period of growth may impact bone mineralization, potentially reducing peak bone mass and consequently increasing the risk of osteoporosis in adulthood. Therefore, the high prevalence of vitamin D inadequacy and deficiency in adolescent populations is of great concern. However, there is currently a lack of consensus on the 25-hydroxyvitamin D [25(OH)D] concentration, the widely accepted biomarker of vitamin D status, that defines adequacy, and the vitamin D intake requirements to maintain various 25(OH)D thresholds are not well established. While the current intake recommendations of 10-15μg/day may be sufficient to prevent vitamin D deficiency (25(OH)D<25-30nmol/l), greater intakes may be needed to achieve the higher threshold levels proposed to represent adequacy (25(OH)D>50nmol/l). This review will address these concerns and consider if the current dietary recommendations for vitamin D in adolescents are sufficient.
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Affiliation(s)
- Taryn J Smith
- Department of Nutritional Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, GU2 7XH, UK.
| | - Susan A Lanham-New
- Department of Nutritional Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, GU2 7XH, UK
| | - Kathryn H Hart
- Department of Nutritional Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, GU2 7XH, UK
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Uday S, Högler W. Nutritional Rickets and Osteomalacia in the Twenty-first Century: Revised Concepts, Public Health, and Prevention Strategies. Curr Osteoporos Rep 2017; 15:293-302. [PMID: 28612338 PMCID: PMC5532418 DOI: 10.1007/s11914-017-0383-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Nutritional rickets and osteomalacia are common in dark-skinned and migrant populations. Their global incidence is rising due to changing population demographics, failing prevention policies and missing implementation strategies. The calcium deprivation spectrum has hypocalcaemic (seizures, tetany and dilated cardiomyopathy) and late hypophosphataemic (rickets, osteomalacia and muscle weakness) complications. This article reviews sustainable prevention strategies and identifies areas for future research. RECENT FINDINGS The global rickets consensus recognises the equal contribution of vitamin D and dietary calcium in the causation of calcium deprivation and provides a three stage categorisation for sufficiency, insufficiency and deficiency. For rickets prevention, 400 IU daily is recommended for all infants from birth and 600 IU in pregnancy, alongside monitoring in antenatal and child health surveillance programmes. High-risk populations require lifelong supplementation and food fortification with vitamin D or calcium. Future research should identify the true prevalence of rickets and osteomalacia, their role in bone fragility and infant mortality, and best screening and public health prevention tools.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Wolfgang Högler
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
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Abstract
Calcium and inorganic phosphate are of critical importance for many body functions, thus the regulations of their plasma concentrations are tightly controlled by the concerted actions of reabsorption/excretion in the kidney, absorption in the intestines, and exchange from bone, the major reservoir for calcium and phosphate in the body. Parathyroid hormone (PTH) and 1,25-dihydroxyvitamin D (1,25(OH)2D) control calcium homeostasis, whereas PTH, 1,25(OH)2D, and bone-derived fibroblast growth factor 23 (FGF 23) control phosphate homeostasis. Hypoparathyroidism can cause hypocalcemia and hyperphosphatemia, whereas deficient vitamin D actions can cause osteomalacia in adults and rickets in children. Hyperparathyroidism, alternatively, can cause hypercalcemia and hypophosphatemia. Laboratory tests of calcium, phosphate, PTH, and 25-hydroxyvitamin D are very useful in the diagnosis of abnormalities associated with calcium and/or phosphate metabolisms. Bone is constantly remodeled throughout life in response to mechanical stress and a need for calcium in extracellular fluids. Metabolic bone diseases such as osteoporosis, osteomalacia in adults or rickets in children, and renal osteodystrophy develop when bone resorption exceeds bone formation. Bone turnover markers (BTM) such as serum N-terminal propeptide of type I procollagen (P1NP) and C-terminal collagen cross-link (CTX) may be useful in predicting future fracture risk or monitoring the response to anti-resorptive therapy. There is a need to standardize sample collection protocols because certain BTMs exhibit large circadian variations and tend to be influenced by food intakes. In the United States, a project to standardize BTM sample collection protocols and to establish the reference intervals for serum P1NP and serum CTX is ongoing. We anticipate the outcome of this project to shine lights on the standardization of BTM assays, sample collection protocols, reference intervals in relation to age, sex, and ethnic origins, and clinical utilities of BTMs. This review will briefly discuss the regulations of calcium and phosphate homeostasis, laboratory's role in the diagnosis, and monitoring of bone and calcium metabolism, as well as the usefulness and controversies of the utilities of BTMs in the diagnosis and monitoring of metabolic bone diseases.
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Munns CF, Shaw N, Kiely M, Specker BL, Thacher TD, Ozono K, Michigami T, Tiosano D, Mughal MZ, Mäkitie O, Ramos-Abad L, Ward L, DiMeglio LA, Atapattu N, Cassinelli H, Braegger C, Pettifor JM, Seth A, Idris HW, Bhatia V, Fu J, Goldberg G, Sävendahl L, Khadgawat R, Pludowski P, Maddock J, Hyppönen E, Oduwole A, Frew E, Aguiar M, Tulchinsky T, Butler G, Högler W. Global Consensus Recommendations on Prevention and Management of Nutritional Rickets. Horm Res Paediatr 2016; 85:83-106. [PMID: 26741135 DOI: 10.1159/000443136] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 09/17/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Vitamin D and calcium deficiencies are common worldwide, causing nutritional rickets and osteomalacia, which have a major impact on health, growth, and development of infants, children, and adolescents; the consequences can be lethal or can last into adulthood. The goals of this evidence-based consensus document are to provide health care professionals with guidance for prevention, diagnosis, and management of nutritional rickets and to provide policy makers with a framework to work toward its eradication. EVIDENCE A systematic literature search examining the definition, diagnosis, treatment, and prevention of nutritional rickets in children was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system that describes the strength of the recommendation and the quality of supporting evidence. PROCESS Thirty-three nominated experts in pediatric endocrinology, pediatrics, nutrition, epidemiology, public health, and health economics evaluated the evidence on specific questions within five working groups. The consensus group, representing 11 international scientific organizations, participated in a multiday conference in May 2014 to reach a global evidence-based consensus. RESULTS This consensus document defines nutritional rickets and its diagnostic criteria and describes the clinical management of rickets and osteomalacia. Risk factors, particularly in mothers and infants, are ranked, and specific prevention recommendations including food fortification and supplementation are offered for both the clinical and public health contexts. CONCLUSION Rickets, osteomalacia, and vitamin D and calcium deficiencies are preventable global public health problems in infants, children, and adolescents. Implementation of international rickets prevention programs, including supplementation and food fortification, is urgently required.
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Braithwaite VS, Freeman R, Greenwood CL, Summers DM, Nigdikar S, Lavy CBD, Offiah AC, Bishop NJ, Cashman J, Prentice A. The aetiology of rickets-like lower limb deformities in Malawian children. Osteoporos Int 2016; 27:2367-2372. [PMID: 27059923 PMCID: PMC4901102 DOI: 10.1007/s00198-016-3541-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 02/08/2016] [Indexed: 01/23/2023]
Abstract
UNLABELLED Debilitating rickets-like lower limb deformities are common in children throughout the world, particularly in Malawi, Africa where the causes are unknown. We have identified that Blount disease and calcium deficiency rickets are the likely causes of these deformities and propose calcium supplementation as a potential treatment of Malawian rickets. INTRODUCTION Surgical correction of rickets-like lower limb deformities is the most common paediatric operation performed at Beit Cure Orthopaedic Hospital, Malawi. The aim of this study was to investigate the aetiology of these deformities. METHODS Children with a tibio-femoral angle of deformity >20° were enrolled (n = 42, 3.0-15.0 years). Anthropometric and early life and well-being data were collected. Early morning serum and urine samples were collected on the morning of the operation for markers of calcium and phosphate homeostasis. Knee radiographs were obtained, and the children were diagnosed with either Blount (BD, n = 22) or evidence of rickets disease (RD, n = 20). As BD is a mechanical rather than metabolic disease, BD were assumed to be biochemically representative of the local population and thus used as a local reference for RD. RESULTS There were no differences in anthropometry or early life experiences between BD and RD. Parathyroid hormone (PTH), 1,25-dihydroxyvitamin D, total alkaline phosphatase and urinary phosphate were significantly higher and serum phosphate, 25-hydroxyvitamin D (25OHD) and tubular maximal reabsorption of phosphate significantly lower in RD than BD. There was no difference in serum calcium, fibroblast growth factor 23 or markers of iron status between groups. All children had 25OHD > 25 nmol/L. CONCLUSIONS Vitamin D deficiency is not implicated in the aetiology of RD or BD in Malawian children. The cause of RD in Malawi is likely to be dietary calcium deficiency leading to elevated PTH resulting in increased losses of phosphate from the bone and glomerular filtrate. The causes of BD remain unclear; there was no evidence in support of previously suggested risk factors such as being overweight or starting to walk early. Prior to surgical intervention, supplementation with calcium should be considered for children with RD.
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Affiliation(s)
- V S Braithwaite
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Fulbourn Road, Cambridge, UK.
| | - R Freeman
- Department of Paediatric Orthopaedics, Robert Jones Agnes Hunt NHS Foundation Trust, Oswestry, Shropshire, UK
| | - C L Greenwood
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Fulbourn Road, Cambridge, UK
| | - D M Summers
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - S Nigdikar
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Fulbourn Road, Cambridge, UK
| | - C B D Lavy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| | - A C Offiah
- Department of Oncology and Metabolism, Academic Unit of Child Health, University of Sheffield, Sheffield, UK
| | - N J Bishop
- Department of Oncology and Metabolism, Academic Unit of Child Health, University of Sheffield, Sheffield, UK
| | - J Cashman
- Beit Cure Orthopaedic Hospital, Blantyre, Malawi
| | - A Prentice
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Fulbourn Road, Cambridge, UK
- MRC Keneba, Keneba, The Gambia
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Kisten K, Moodley R, Jonnalagadda SB. Elemental Analysis and Nutritional Value of Seaweed from the East Coast of KwaZulu-Natal, South Africa. ANAL LETT 2016. [DOI: 10.1080/00032719.2016.1182545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Kimona Kisten
- School of Chemistry and Physics, University of KwaZulu Natal, Durban, South Africa
| | - Roshila Moodley
- School of Chemistry and Physics, University of KwaZulu Natal, Durban, South Africa
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18
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Munns CF, Shaw N, Kiely M, Specker BL, Thacher TD, Ozono K, Michigami T, Tiosano D, Mughal MZ, Mäkitie O, Ramos-Abad L, Ward L, DiMeglio LA, Atapattu N, Cassinelli H, Braegger C, Pettifor JM, Seth A, Idris HW, Bhatia V, Fu J, Goldberg G, Sävendahl L, Khadgawat R, Pludowski P, Maddock J, Hyppönen E, Oduwole A, Frew E, Aguiar M, Tulchinsky T, Butler G, Högler W. Global Consensus Recommendations on Prevention and Management of Nutritional Rickets. J Clin Endocrinol Metab 2016; 101:394-415. [PMID: 26745253 PMCID: PMC4880117 DOI: 10.1210/jc.2015-2175] [Citation(s) in RCA: 637] [Impact Index Per Article: 79.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Vitamin D and calcium deficiencies are common worldwide, causing nutritional rickets and osteomalacia, which have a major impact on health, growth, and development of infants, children, and adolescents; the consequences can be lethal or can last into adulthood. The goals of this evidence-based consensus document are to provide health care professionals with guidance for prevention, diagnosis, and management of nutritional rickets and to provide policy makers with a framework to work toward its eradication. EVIDENCE A systematic literature search examining the definition, diagnosis, treatment, and prevention of nutritional rickets in children was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system that describe the strength of the recommendation and the quality of supporting evidence. PROCESS Thirty-three nominated experts in pediatric endocrinology, pediatrics, nutrition, epidemiology, public health, and health economics evaluated the evidence on specific questions within five working groups. The consensus group, representing 11 international scientific organizations, participated in a multiday conference in May 2014 to reach a global evidence-based consensus. RESULTS This consensus document defines nutritional rickets and its diagnostic criteria and describes the clinical management of rickets and osteomalacia. Risk factors, particularly in mothers and infants, are ranked, and specific prevention recommendations including food fortification and supplementation are offered for both the clinical and public health contexts. CONCLUSION Rickets, osteomalacia, and vitamin D and calcium deficiencies are preventable global public health problems in infants, children, and adolescents. Implementation of international rickets prevention programs, including supplementation and food fortification, is urgently required.
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19
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Vitamin D Status in South Africa and Tuberculosis. Lung 2015; 193:975-84. [DOI: 10.1007/s00408-015-9789-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 08/19/2015] [Indexed: 12/11/2022]
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Dabas AG, Khadgawat R. Developing Indigenous Therapeutic Calcium Supplementation for Treating Nutritional Rickets. J Pediatr 2015; 167:12-4. [PMID: 25934070 DOI: 10.1016/j.jpeds.2015.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 04/06/2015] [Indexed: 01/16/2023]
Affiliation(s)
- Aashima G Dabas
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Khadgawat
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India.
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Mangin M, Sinha R, Fincher K. Inflammation and vitamin D: the infection connection. Inflamm Res 2014; 63:803-19. [PMID: 25048990 PMCID: PMC4160567 DOI: 10.1007/s00011-014-0755-z] [Citation(s) in RCA: 174] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 06/04/2014] [Accepted: 06/23/2014] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Inflammation is believed to be a contributing factor to many chronic diseases. The influence of vitamin D deficiency on inflammation is being explored but studies have not demonstrated a causative effect. METHODS Low serum 25(OH)D is also found in healthy persons exposed to adequate sunlight. Despite increased vitamin D supplementation inflammatory diseases are increasing. The current method of determining vitamin D status may be at fault. The level of 25(OH)D does not always reflect the level of 1,25(OH)2D. Assessment of both metabolites often reveals elevated 1,25(OH)2D, indicating abnormal vitamin D endocrine function. FINDINGS This article reviews vitamin D's influence on the immune system, examines the myths regarding vitamin D photosynthesis, discusses ways to accurately assess vitamin D status, describes the risks of supplementation, explains the effect of persistent infection on vitamin D metabolism and presents a novel immunotherapy which provides evidence of an infection connection to inflammation. CONCLUSION Some authorities now believe that low 25(OH)D is a consequence of chronic inflammation rather than the cause. Research points to a bacterial etiology pathogenesis for an inflammatory disease process which results in high 1,25(OH)2D and low 25(OH)D. Immunotherapy, directed at eradicating persistent intracellular pathogens, corrects dysregulated vitamin D metabolism and resolves inflammatory symptoms.
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Affiliation(s)
- Meg Mangin
- Chronic Illness Recovery, Fort Worth, Texas, USA,
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Wang M, Yang X, Ren L, Li S, He X, Wu X, Liu T, Lin L, Li Y, Sun C. Biomarkers identified by urinary metabonomics for noninvasive diagnosis of nutritional rickets. J Proteome Res 2014; 13:4131-42. [PMID: 25051233 DOI: 10.1021/pr500517u] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Nutritional rickets is a worldwide public health problem; however, the current diagnostic methods retain shortcomings for accurate diagnosis of nutritional rickets. To identify urinary biomarkers associated with nutritional rickets and establish a noninvasive diagnosis method, urinary metabonomics analysis by ultra-performance liquid chromatography/quadrupole time-of-flight tandem mass spectrometry and multivariate statistical analysis were employed to investigate the metabolic alterations associated with nutritional rickets in 200 children with or without nutritional rickets. The pathophysiological changes and pathogenesis of nutritional rickets were illustrated by the identified biomarkers. By urinary metabolic profiling, 31 biomarkers of nutritional rickets were identified and five candidate biomarkers for clinical diagnosis were screened and identified by quantitative analysis and receiver operating curve analysis. Urinary levels of five candidate biomarkers were measured using mass spectrometry or commercial kits. In the validation step, the combination of phosphate and sebacic acid was able to give a noninvasive and accurate diagnostic with high sensitivity (94.0%) and specificity (71.2%). Furthermore, on the basis of the pathway analysis of biomarkers, our urinary metabonomics analysis gives new insight into the pathogenesis and pathophysiology of nutritional rickets.
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Affiliation(s)
- Maoqing Wang
- National Key Disciplines of Nutrition and Food Hygiene, Department of Nutrition and Food Hygiene, School of Public Health, Harbin Medical University , 157 Baojian Road, Nangang District, Harbin 150081, P. R. China
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Joy EJM, Ander EL, Young SD, Black CR, Watts MJ, Chilimba ADC, Chilima B, Siyame EWP, Kalimbira AA, Hurst R, Fairweather-Tait SJ, Stein AJ, Gibson RS, White PJ, Broadley MR. Dietary mineral supplies in Africa. PHYSIOLOGIA PLANTARUM 2014; 151:208-29. [PMID: 24524331 PMCID: PMC4235459 DOI: 10.1111/ppl.12144] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 11/25/2013] [Accepted: 11/29/2013] [Indexed: 05/04/2023]
Abstract
Dietary micronutrient deficiencies (MNDs) are widespread, yet their prevalence can be difficult to assess. Here, we estimate MND risks due to inadequate intakes for seven minerals in Africa using food supply and composition data, and consider the potential of food-based and agricultural interventions. Food Balance Sheets (FBSs) for 46 countries were integrated with food composition data to estimate per capita supply of calcium (Ca), copper (Cu), iron (Fe), iodine (I), magnesium (Mg), selenium (Se) and zinc (Zn), and also phytate. Deficiency risks were quantified using an estimated average requirement (EAR) 'cut-point' approach. Deficiency risks are highest for Ca (54% of the population), followed by Zn (40%), Se (28%) and I (19%, after accounting for iodized salt consumption). The risk of Cu (1%) and Mg (<1%) deficiency are low. Deficiency risks are generally lower in the north and west of Africa. Multiple MND risks are high in many countries. The population-weighted mean phytate supply is 2770 mg capita(-1) day(-1). Deficiency risks for Fe are lower than expected (5%). However, 'cut-point' approaches for Fe are sensitive to assumptions regarding requirements; e.g. estimates of Fe deficiency risks are 43% under very low bioavailability scenarios consistent with high-phytate, low-animal protein diets. Fertilization and breeding strategies could greatly reduce certain MNDs. For example, meeting HarvestPlus breeding targets for Zn would reduce dietary Zn deficiency risk by 90% based on supply data. Dietary diversification or direct fortification is likely to be needed to address Ca deficiency risks.
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Affiliation(s)
- Edward J M Joy
- School of Biosciences, University of Nottingham, Sutton Bonington CampusLoughborough LE12 5RD, UK
- British Geological SurveyKeyworth, Nottingham NG12 5GG, UK
| | - E Louise Ander
- British Geological SurveyKeyworth, Nottingham NG12 5GG, UK
| | - Scott D Young
- School of Biosciences, University of Nottingham, Sutton Bonington CampusLoughborough LE12 5RD, UK
| | - Colin R Black
- School of Biosciences, University of Nottingham, Sutton Bonington CampusLoughborough LE12 5RD, UK
| | | | - Allan D C Chilimba
- Ministry of Agriculture and Food SecurityLunyangwa Research Station, P.O. Box 59, Mzuzu, Malawi
| | - Benson Chilima
- Community Health Sciences Unit, Ministry of HealthPrivate Bag 65, Lilongwe, Malawi
| | - Edwin W P Siyame
- Department of Human Nutrition and Health, Lilongwe University of Agriculture and Natural ResourcesP.O. Box 219, Lilongwe, Malawi
| | - Alexander A Kalimbira
- Department of Human Nutrition and Health, Lilongwe University of Agriculture and Natural ResourcesP.O. Box 219, Lilongwe, Malawi
| | - Rachel Hurst
- Norwich Medical School, University of East AngliaNorwich NR4 7TJ, UK
| | | | | | - Rosalind S Gibson
- Department of Human Nutrition, University of OtagoP.O. Box 56, Dunedin, New Zealand
| | - Philip J White
- Ecological Sciences, The James Hutton InstituteInvergowrie, Dundee DD2 5DA, UK
| | - Martin R Broadley
- School of Biosciences, University of Nottingham, Sutton Bonington CampusLoughborough LE12 5RD, UK
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Glorieux FH, Pettifor JM. Vitamin D/dietary calcium deficiency rickets and pseudo-vitamin D deficiency rickets. BONEKEY REPORTS 2014; 3:524. [PMID: 24818008 DOI: 10.1038/bonekey.2014.19] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 02/24/2014] [Indexed: 11/09/2022]
Abstract
This review describes the pathogenesis, clinical presentation and biochemical perturbations found in privational (nutritional) rickets and pseudo-vitamin D deficiency rickets (PDDR), an autosomal recessive condition with loss of function mutations in CYP27B1. It may seem strange to combine a discussion on privational rickets and PDDR as a single topic, but privational rickets and PDDR present with similar clinical signs and symptoms and with similar perturbations in bone and mineral metabolism. Of interest is the characteristic lack of features of rickets at birth in infants with PDDR, a finding which has also been reported in infants born to vitamin D-deficient mothers. This highlights the independence of the fetus and neonate from the need for vitamin D to maintain calcium homeostasis during this period. The variable roles of vitamin D deficiency and dietary calcium deficiency in the pathogenesis of privational rickets are discussed and the associated alterations in vitamin D metabolism highlighted. Although PDDR is a rare autosomal recessive disorder, results of long-term follow-up are now available on the effect of treatment with calcitriol, and these are discussed. Areas of uncertainty, such as should affected mothers breastfeed their infants, are emphasized.
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Affiliation(s)
- Francis H Glorieux
- Genetics Unit, Shriners Hospital for Children-Canada and McGill University , Montreal, Quebec, Canada
| | - John M Pettifor
- MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand , Parktown, South Africa
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Aggarwal V, Seth A, Marwaha RK, Sharma B, Sonkar P, Singh S, Aneja S. Management of nutritional rickets in Indian children: a randomized controlled trial. J Trop Pediatr 2013; 59:127-33. [PMID: 23104564 DOI: 10.1093/tropej/fms058] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Rickets is usually attributed to vitamin D deficiency. However, recent studies have implicated dietary calcium deficiency in its etiology. Information on relative efficacy of calcium, vitamin D or both together in healing of rickets is limited. OBJECTIVE To study effect of treatment with calcium, vitamin D or a combination of these two on healing of nutritional rickets in young children. DESIGN Randomized controlled trial. METHODS Sixty-seven cases of nutritional rickets in the age group of 6 months to 5 years were randomly allocated to receive vitamin D (600 000 IU single intramuscular dose), calcium (75 mg/kg/day elemental calcium orally) or a combination of the above two for a period of 12 weeks. The demographic parameters, nutritional status, dietary calcium and phytate intake were assessed for all. Radiographs (wrist and knee) and biochemical parameters (serum calcium, inorganic phosphate, alkaline phosphatase, 25-hydroxycholecalciferol and parathyroid hormone) were evaluated at baseline, 6 and 12 weeks for evidence of healing. RESULTS Mean dietary intake of calcium in all cases was low (204 ± 129 mg/day). Mean serum 25-hydroxycholecalciferol D level was 15.9 ± 12.4 ng/ml, and 82.1% of patients had serum vitamin D levels <20 ng/ml, indicative of vitamin D deficiency. After 6 and 12 weeks of treatment, radiological and biochemical evidence of healing rickets was observed in all treatment groups, albeit to a variable extent. The combined end point of normal serum alkaline phosphatase and complete radiological healing at 12 weeks was observed in 50% subjects on combination therapy as compared with 15.7% subjects on vitamin D alone and 11.7% on calcium alone. CONCLUSIONS Children with rickets had a low serum vitamin D level and a low dietary calcium intake. The best therapeutic response was seen with a combination of vitamin D and calcium than either of them given alone. TRIAL REGISTRATION NUMBER CTRI/2010/091/000448.
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Affiliation(s)
- Varun Aggarwal
- Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, India
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26
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Hartmann L, Sponholz B. Spatial distribution of calcium in food, water and soil and its possible influence on rickets disease in Northern Nigeria. ENVIRONMENTAL GEOCHEMISTRY AND HEALTH 2012; 34:503-512. [PMID: 22161153 DOI: 10.1007/s10653-011-9440-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 11/24/2011] [Indexed: 05/31/2023]
Abstract
Since the 1990s, children of the Gbagyi tribe in Northern Nigeria have been suffering severe rickets with an incidence of up to 40% in the children's generation. The disease seems to be prevalent in an area of approximately 100 km(2) south-east of Kaduna. According to broad medical studies in that area, there is no evidence for a genetic disposition but for a nutritional cause of the disease. A lack of calcium was found in blood and was calculated to originate from diet. We therefore checked parent material, soil, maize cobs (Zea mays) and drinking water for their specific Ca contents from a region with rickets problem (study area A) and compared the results to Ca amounts in similar samples from a region where rickets is unknown among the Gbagyi population (study area B). It thereby became apparent that there are no differences in mineralogical composition of the parent material between the study areas, but that Ca contents in soil, maize cobs and drinking water are 47.6%, 26.6%, respectively, 79.1% lower in study area A compared to study area B. This result suggests that there may indeed be a nutritionally and/or environmentally influence on rickets disease. Nevertheless, further research on this topic is required.
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Affiliation(s)
- Lena Hartmann
- Institute of Physical Geography, University of Würzburg, Am Hubland, 97074 Würzburg, Germany.
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Agarwal A, Gupta SK, Sukumar R. Hyperparathyroidism and malnutrition with severe vitamin D deficiency. World J Surg 2010; 33:2303-13. [PMID: 19404706 DOI: 10.1007/s00268-009-0044-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Vitamin D deficiency and its associated problems are common in developing Asian countries and countries of the Middle East. Various factors, including poor nutritional status and other compounding factors such as dietary, cultural, ethnic, and environmental factors, play a major role in contributing to the poor calcium and vitamin D homeostasis. Vitamin D deficiency is thought to exacerbate signs and symptoms of hyperparathyroidism (HPT). In this overview, we present evidence of the impact of vitamin D and calcium deficiency on primary HPT (PHPT). METHODS We performed an evidence-based review of articles published in the English language between January 1960 and June 2008. RESULTS Level IV evidence suggests widespread calcium and vitamin D deficiency in developing countries (issue 1). Limited level IV evidence suggests malnutrition as a primary cause of calcium and vitamin D deficiency (issue 2). Level IV evidence suggests that calcium and vitamin deficiencies cause secondary HPT and possibly PHPT as well (issues 3 and 4). A literature search revealed only six studies that correlated vitamin D levels with clinical, biochemical, and pathologic features of PHPT (issue 5). These studies provide level IV evidence suggesting that vitamin D deficiency causes some specific clinical features of PHPT as well as exacerbating other features of the disease. CONCLUSIONS In the developing countries, which have severe vitamin D and calcium deficient population, PHPT patients present with advanced disease and particularly severe bone symptoms. There is presently only level IV evidence of vitamin D status affecting the clinical severity of PHPT.
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Affiliation(s)
- Amit Agarwal
- Department of Endocrine Surgery, SGPGIMS, Lucknow 226014, Uttar Pradesh, India.
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Dayod M, Tyerman SD, Leigh RA, Gilliham M. Calcium storage in plants and the implications for calcium biofortification. PROTOPLASMA 2010; 247:215-31. [PMID: 20658253 DOI: 10.1007/s00709-010-0182-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 07/06/2010] [Indexed: 05/20/2023]
Abstract
Calcium (Ca) is an essential nutrient for plants and animals, with key structural and signalling roles, and its deficiency in plants can result in poor biotic and abiotic stress tolerance, reduced crop quality and yield. Likewise, low Ca intake in humans has been linked to various diseases (e.g. rickets, osteoporosis, hypertension and colorectal cancer) which can threaten quality of life and have major economic costs. Biofortification of various food crops with Ca has been suggested as a good method to enhance human intake of Ca and is advocated as an economically and environmentally advantageous strategy. Efforts to enhance Ca content of crops via transgenic means have had promising results. Overall Ca content of transgenic plants has been increased but in some cases adverse affects on plant function have been observed. This suggests that a better understanding of how Ca ions (Ca(2+)) are stored and transported through plants is required to maximise the effectiveness of future approaches.
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Affiliation(s)
- Maclin Dayod
- Waite Research Institute, School of Agriculture, Food and Wine, University of Adelaide, PMB1, Glen Osmond, SA 5064, Australia
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Thacher TD, Abrams SA. Relationship of calcium absorption with 25(OH)D and calcium intake in children with rickets. Nutr Rev 2010; 68:682-8. [PMID: 20961298 DOI: 10.1111/j.1753-4887.2010.00338.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Nutritional rickets has long been considered a disease caused by vitamin D deficiency, but recent data indicate that inadequate dietary calcium intake is an important cause of rickets, particularly in tropical countries. Children with rickets due to calcium deficiency do not have very low 25(OH)D concentrations, and serum 1,25(OH)(2) D values are markedly elevated. Studies of Nigerian children with rickets demonstrated they have high fractional calcium absorption. A high-phytate diet was demonstrated to increase calcium absorption compared with the fasting state, and enzymatic dephytinization did not significantly improve calcium absorption. When given vitamin D, children with rickets have a marked increase in 1,25(OH)(2) D concentrations without any change in fractional calcium absorption. No positive relationship was found between fractional calcium absorption and serum 25(OH)D concentrations in children on low-calcium diets. More research is needed to understand the interaction between calcium and vitamin D and the role of vitamin D in calcium absorption.
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Affiliation(s)
- Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Salama MM, El-Sakka AS. Hypocalcemic seizures in breastfed infants with rickets secondary to severe maternal vitamin D deficiency. Pak J Biol Sci 2010; 13:437-42. [PMID: 20973397 DOI: 10.3923/pjbs.2010.437.442] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study was done to evaluate if nursing mothers of infants with rickets have vitamin D deficiency, and to evaluate the relationship between maternal vitamin D levels with hypocalcemic seizures in infants with rickets. We selected a cohort of breastfed infants with rickets. Infants were included in this study if they were breastfed and presented with any of the following clinical criteria: delayed motor milestones or delayed teething, were found to have specific rachitic bony signs, or presented with hypocalcemic seizures. We checked serum calcium (Ca), phosphorus (P), alkaline phosphatase, 25 hydroxy vitamin D [25(OH)D] and parathyroid hormone (PTH) levels in both infants and their mothers. Out of 32 children who met the clinical criteria for rickets, 23 (72%) had vitamin D level less than 20 ng mL(-1). Twenty two mothers (69%) had vitamin D deficiency (25 hydroxy vitamin D < 20 ng mL(-1)). Mothers of nine infants who presented with hypocalcemic seizures had severe vitamin D deficiency, (p = 0.005). We conclude that maternal vitamin D deficiency is common in nursing mothers of infants diagnosed with rickets. Invariably mothers of infants presenting with hypocalcemic seizures have severe vitamin D deficiency. Hypocalcemic seizures in infants secondary to maternal vitamin D deficiency might be prevented by supplementation of vitamin D.
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Affiliation(s)
- Mostafa M Salama
- Department of Obstetric and Gynecology, Ain Shams University, Egypt
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31
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Relationship between rickets and incomplete distal renal tubular acidosis in children. Ital J Pediatr 2010; 36:54. [PMID: 20699008 PMCID: PMC2925332 DOI: 10.1186/1824-7288-36-54] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 08/11/2010] [Indexed: 11/10/2022] Open
Abstract
Background In the Sub Saharan Africa Rickets has now been established to be due primarily to calcium deficiency and sometimes in combination with vitamin D deficiency. The main thrust of management is calcium supplementation with or without vitamin D. An observation was made that some children with nutritional rickets do not respond to this management modality. The recently reported high prevalence of Incomplete Distal Renal Tubular Acidosis (idRTA) in adults with osteoporosis as brought to fore the possibility of this being a possible cause of calcium wastage and therefore the poor response in these group of children with rickets. Aim To determine the prevalence of idRTA amongst a cohort of subjects with rickets To show a relationship between rickets and incomplete distal renal acidosis To determine the response of children with rickets and idRTA to addition of Shohl's solution to therapy Methodology Two separate cohorts of children with rickets performed the ammonium chloride loading test to detect those with incomplete renal tubular acidosis. Following identification for idRTA, Shohl's solution was added to therapy of calcium and vitamin D supplementation and their response compared to those without idRTA on calcium and vitamin D supplementation solely. Results 50 children with rickets aged from two to six years of age and composed of 29 females and 21males were investigated. Incomplete renal tubular acidosis was found in 38% of them. Prevalence of idRTA was highest amongst those aged 3-6 years of age. Those with idRTA had worse limb deformities, biochemical and radiological parameters than those who hadn't. Rate of response on those with idRTA treated with Shohl's solution was at par with those without idRTA. Conclusion Incomplete idRTA exist amongst children with rickets and should be looked out for in severe rickets and older children. Treatment of idRTA will lead to optimal response and healing of rickets.
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Abstract
Rickets is a mineralization disorder of the growing bone. Nutritional rickets is still prevalent in many parts of the developing world and is re-emerging in developed countries. Although vitamin D deficiency plays a central role in the pathogenesis of this disease, calcium deficiency and genetic factors may also cause or contribute to the development of rickets. This review will focus on the classical form of nutritional rickets, in other words, vitamin D-deficiency rickets. The epidemiology, ethiopathogenesis, risk factors, clinical picture, diagnosis, treatment and prevention of nutritional rickets are reviewed.
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Affiliation(s)
- Abdullah Bereket
- Marmara University, School of Medicine, Division of Pediatric Endocrinology, Istanbul, Turkey
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Abstract
Africa is heterogeneous in latitude, geography, climate, food availability, religious and cultural practices, and skin pigmentation. It is expected, therefore, that prevalence of vitamin D deficiency varies widely, in line with influences on skin exposure to UVB sunshine. Furthermore, low calcium intakes and heavy burden of infectious disease common in many countries may increase vitamin D utilization and turnover. Studies of plasma 25OHD concentration indicate a spectrum from clinical deficiency to values at the high end of the physiological range; however, data are limited. Representative studies of status in different countries, using comparable analytical techniques, and of relationships between vitamin D status and risk of infectious and chronic diseases relevant to the African context are needed. Public health measures to secure vitamin D adequacy cannot encompass the whole continent and need to be developed locally.
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Fischer PR, Thacher TD, Pettifor JM. Pediatric vitamin D and calcium nutrition in developing countries. Rev Endocr Metab Disord 2008; 9:181-92. [PMID: 18604643 DOI: 10.1007/s11154-008-9085-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Accepted: 06/10/2008] [Indexed: 01/10/2023]
Abstract
Over one billion humans have insufficient circulating levels of vitamin D, and dietary insufficiency of calcium is common in developing countries. Worldwide, nutritional rickets is considered to be the most common non-communicable disease of children. Rickets can be due either to primary deficiencies of vitamin D or calcium or to combined deficiencies of both elements. Vitamin D deficiency is also increasingly linked to non-skeletal complications. Even without laboratory and radiologic resources, the diagnosis of rickets is considered clinically when a child presents with limb deformities and has beaded ribs and widened wrists and ankles. Prevention is possible through increased sun exposure and dietary enhancement. Treatment of nutritional rickets involves provision of adequate vitamin D and calcium. Further research is needed to elucidate the precise epidemiology of vitamin D and calcium deficiencies in developing countries, to determine the roles of additional pathologic factors contributing to the development and morbidity of rickets, to improve affordable and feasible means of diagnosing rickets in resource-limited areas, to better target at-risk populations for preventive interventions, to identify accurate dosing and delivery of therapeutic interventions, and to evaluate the long-term consequences of vitamin D and calcium deficiencies in childhood.
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Affiliation(s)
- Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Rajah J, Jubeh JA, Haq A, Shalash A, Parsons H. Nutritional rickets and z scores for height in the United Arab Emirates: to D or not to D? Pediatr Int 2008; 50:424-8. [PMID: 18937749 DOI: 10.1111/j.1442-200x.2008.02700.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Vitamin D deficiency is still prevalent worldwide, including the Middle East. A cohort of patients with nutritional rickets was treated with vitamin D(2) (ergocalciferol) alone. After this intervention, patients were followed to document changes in z scores for height after treatment. The secondary aim was to determine the proportion of affected children who had vitamin D deficiency or calcium deficiency. METHODS Z score for height was calculated as the difference between the observed value and the median value, divided by the SD of the population. Z scores were compared in patients before and after treatment. RESULTS The improvement in z score after treatment was 0.86 +/- 0.95. The 95% confidence interval for the mean difference was 1.32-0.40 (t = 3.95, P < 0.001). With a diagnostic cut-off for 25 hydroxyvitamin D(3) (25D) deficiency of <25 nmol/L, only half were diagnosed with severe vitamin D deficiency. The remaining patients had presumable calcium deficiency. The alkaline phosphatase (ALP) was negatively correlated to z scores, implying that higher ALP concentrations predicted severe bone disease (lower z scores). The variables 25D and age were moderately and positively correlated (Pearson's r = 0.59, 95%CI: 0.15-0.84; P = 0.01), indicating that younger infants had the lowest 25D levels. CONCLUSION Vitamin D alone was efficient in resolving radiological and biochemical disturbances as well as improving z scores for height in a cohort of children with nutritional rickets, which included patients with 25D deficiency as well as calcium deficiency. The results support the hypothesis of the interplay and continuum of 25D deficiency and calcium deficiency in the pathogenesis of rickets.
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Affiliation(s)
- Jaishen Rajah
- Department of Pediatrics, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
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Baroncelli GI, Bereket A, El Kholy M, Audì L, Cesur Y, Ozkan B, Rashad M, Fernández-Cancio M, Weisman Y, Saggese G, Hochberg Z. Rickets in the Middle East: role of environment and genetic predisposition. J Clin Endocrinol Metab 2008; 93:1743-50. [PMID: 18285415 DOI: 10.1210/jc.2007-1413] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT The Middle East has a high incidence of rickets, and it is also common in Europe-dwelling children of Middle Eastern origin. OBJECTIVE The objective of the study was to explore the mechanisms leading to rickets in children of the Middle East. DESIGN AND SETTING We conducted a prospective study in 98 rachitic and 50 controls (aged 6 months to 4 yr) from university and community outpatient hospitals in Egypt and Turkey. MAIN OUTCOME MEASURES We collected epidemiological, maternal, nutritional, radiographic, and biochemical parameters; markers of bone turnover; and vitamin D receptor (VDR) gene polymorphisms. RESULTS Epidemiological factors had a key role in pursuit of rickets; Egyptian and Turkish patients had lower (P < 0.01) dietary calcium intake than controls and the recommended dietary intakes, and serum 25-hydroxyvitamin D levels were reduced in patients, the difference with controls being significant (P < 0.001) only in Turkey, although rickets was more severe in Egypt as determined by the x-ray score (P < 0.05). In Turkey, the F VDR allele frequency was significantly (P < 0.05) increased in patients. The BB VDR genotype was associated with lower serum 25-hydroxyvitamin D levels in both patients and controls and with severity of rickets. CONCLUSIONS In Turkey most patients had vitamin D deficiency, whereas in Egypt they had mostly calcium insufficiency combined with vitamin D deficiency. In this environ, VDR genotypes may predispose to rickets by increased frequency of the F allele. The unique environs and genetic predisposition have to be accounted for in the design of preventive measures, rather than using European or American recommended dietary intake for calcium and vitamin D.
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Prentice A, Ceesay M, Nigdikar S, Allen SJ, Pettifor JM. FGF23 is elevated in Gambian children with rickets. Bone 2008; 42:788-97. [PMID: 18234575 DOI: 10.1016/j.bone.2007.11.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Revised: 10/11/2007] [Accepted: 11/30/2007] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Fibroblast growth factor 23 (FGF23) is a phosphaturic factor that is elevated in several diseases associated with hypophosphatemia and rickets. Rickets in the absence of vitamin D deficiency has been reported in African and Asian populations with a low calcium intake but the definition of risk factors has proved elusive. The aim of the study was to characterize the biochemical profile and measure FGF23 in a series of Gambian children who had presented with rickets of unknown etiology and a plasma 25-hydroxyvitamin D (25OHD) above the range typical of vitamin D-deficiency rickets. METHODS The 46 patients (30 males, 16 females) had bone deformities typical of rickets and were 1.1-16.4 years old (geometric mean, 3.4 years). Active rickets (on radiographs and/or elevated plasma alkaline phosphatase) was present in 28%. Plasma 25-hydroxyvitamin D was above 20 nmol/l in all patients. Concentrations of plasma FGF23, phosphate and other relevant biochemical analytes were measured in stored samples of fasting, early morning plasma and compared with those measured in samples collected from local children and stored under similar conditions. RESULTS The rickets patients had lower plasma phosphate, lower 25-hydroxyvitamin D, higher 1,25-dihydroxyvitamin D and elevated total alkaline phosphatase than local children. Those with active rickets had raised parathyroid hormone concentration. The patients had significantly higher FGF23 concentration than local children (geometric mean (-1SD, +1SD, range) RU/ml: 367 (87, 1552, 46-7052, n=39) vs 51 (23, 112, 3-130, n=30), p<or=0.001). At presentation, the majority (74%) had an FGF23 concentration that was above the range seen in local children, some grossly so (up to 50-fold). There was no significant difference in FGF23 concentration between those with active rickets and the other patients. Plasma phosphate was significantly and inversely correlated with FGF23 concentration. Some clinical improvements were noted after 6-12 months, during which time calcium and vitamin D had been prescribed, but FGF23 remained elevated in many patients. CONCLUSIONS These data suggest that perturbations of phosphate and FGF23 regulation may be implicated in the pathogenesis of calcium-deficiency rickets in Africa and Asia.
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Combs GF, Hassan N, Dellagana N, Staab D, Fischer P, Hunt C, Watts J. Apparent efficacy of food-based calcium supplementation in preventing rickets in Bangladesh. Biol Trace Elem Res 2008; 121:193-204. [PMID: 18180882 DOI: 10.1007/s12011-007-8053-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2007] [Accepted: 10/01/2007] [Indexed: 11/25/2022]
Abstract
To determine whether increased Ca intakes can prevent rickets in a susceptible group of children living in a rickets-endemic area of Bangladesh, we conducted a 13-month long, double-blind, clinical trial with 1-to 5-year-old children who did not present with rickets but ranked in the upper decile of plasma alkaline phosphatase (AP) activity of a screening cohort of 1,749 children. A total of 158 children were randomized to a milk-powder-based dietary supplement given daily, 6 days/week, and providing either 50, 250, or 500 mg Ca, or 500 mg Ca plus multivitamins, iron, and zinc. Upon initial screening, 194 healthy children presented with no rachitic leg signs and had serum AP in the upper decile (>260 u/dl) of the cohort. When 183 of those subjects were re-screened after a 7-month pre-trial period, 23 (12.6%) had developed rachitic leg signs, suggesting an annual risk of 21.5% in this cohort. Of those still not presenting with leg signs and completing 13 months of dietary intervention, none showed rachitic leg signs, none showed significant radiological evidence of active rickets, and all showed carpal ossification normal for age after that intervention. These results are consistent with even the lowest amount of supplemental Ca (50 mg/day) being useful in supporting normal bone development in this high-risk population.
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Affiliation(s)
- Gerald F Combs
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA.
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Prentice A, Bates CJ. An Appraisal of the Adequacy of Dietary Mineral Intakes in Developing Countries for Bone Growth and Development in Children. Nutr Res Rev 2007; 6:51-69. [DOI: 10.1079/nrr19930006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Arnaud J, Pettifor JM, Cimma JP, Fischer PR, Craviari T, Meisner C, Haque S. Clinical and radiographic improvement of rickets in Bangladeshi children as a result of nutritional advice. ACTA ACUST UNITED AC 2007; 27:185-91. [PMID: 17716446 DOI: 10.1179/146532807x220299] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Calcium-deficiency rickets is common in south-east Bangladesh and responds to calcium supplementation. AIM To evaluate the healing effect on active rickets of a five-component nutritional advice programme aimed at doubling dietary calcium intakes. METHODS Forty-nine children aged <10 years with mild lower limb deformities and active rickets were followed over a period of 12 months. All were provided with a five-component nutritional advice programme advocating (i) the routine addition of 1 g limestone/kg rice, (ii) consuming small fish (including bones) instead of large ones, and (iii) daily consumption of 5 g ground sesame seeds, (iv) 100 g leafy vegetables and, if possible, (v) 100 ml of milk. RESULTS Radiographic scores improved in 90% of children. The response was positively associated with age (r=0.34, n=48, p=0.01) and severity of radiographic score at baseline (r=0.85, n=49, p<0.0001). CONCLUSIONS Despite the lack of a statistically significant association between radiographic improvement and compliance with nutritional advice, in mild calcium-deficiency active rickets, nutritional advice may be a cost-effective treatment and possibly a valuable long-term solution to the problem.
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Affiliation(s)
- J Arnaud
- Department of Integrated Biology, Clinical Biology Unit, University Hospital Grenoble, Grenoble, France.
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41
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Abstract
OBJECTIVE Inadequate sunlight exposure and calcium intake during rapid growth at puberty lead to hypocalcemia, hypovitaminosis D and eventually to overt rickets. To determine serum biochemical findings of rickets in healthy 11-15 yr old girls, the effect of sunlight exposure and oral vitamin D supplementation on serum 25- hydroxy vitamin D and calcium administration in girls with abnormal findings during December 2002 through March 2003 in Tehran, Iran. METHODS Healthy middle school girls were selected for estimation of vitamin D, calcium and phosphorus intake by a three-day food recall. And measurement of serum calcium, phosphorus, parathyroid hormone, alkaline-phosphatase and 25- hydroxyvitamin D concentration. The girls with abnormal findings divided in two groups. Hypovitaminosis D girls subdivided into two groups, supplementary sunlight exposure and vitamin- D administrated for them and calcium administration for the second group for 20 days. RESULTS Of 414 girls, the mean daily vitamin D acquirement and calcium intake were 119 +/- 52 IU and 360 +/- 350 mg among all girls respectively. Mean serum 25-hydroxyvitamin D with two or more abnormal biochemical findings in 15 (3.6%) girls (group I) were 7.8 ng/ml and alkaline phosphatse with normal or low calcium in 29 (7%) girls (group II) was 1187 IU/L. Mean serum calcium was 8.2 mg % in 8 of 29 girls. Serum 25- hydroxyvitamin D before and after sunlight exposure was 7.1 +/- 1.9 ng/ml and 13.9 +/- 2.4 ng/ml and vitamin D administration was 7.4 +/- 1.8 ng/ml (group Ia) and 27.9 +/- 4.2 ng/ml (group Ib) respectively. Serum alkaline phosphatase before and after calcium administration were 1187 IU/L and 666 IU/L respectively. CONCLUSION We conclude that low daily calcium intake and vitamin D acquirement are two important problems in Iranian girls during rapid growth at puberty; therefore, for prevention of overt rickets calcium and vitamin D Supplementation appear to be necessary.
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Affiliation(s)
- Hossein Dahifar
- Shaheed Beheshti University of medical sciences and Health services, Tehran, Iran.
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Mehrotra M, Gupta SK, Kumar K, Awasthi PK, Dubey M, Pandey CM, Godbole MM. Calcium deficiency-induced secondary hyperparathyroidism and osteopenia are rapidly reversible with calcium supplementation in growing rabbit pups. Br J Nutr 2007; 95:582-90. [PMID: 16512945 DOI: 10.1079/bjn20051656] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The reversibility of osteopenia secondary to isolated Ca deficiency (CaDef) is still not clear. We studied the effect of severe CaDef on Ca homeostasis and bone accrual in a ‘hypercalcaemic’ animal, the rabbit, during the post-weaning period and its reversibility on Ca supplementation. Male Belgian 5-week-old rabbit pups were fed CaDef diet (0·026% Ca) for 10 weeks. As compared with those fed with a normal chow diet (0·45% Ca), CaDef pups developed significant hypocalcaemia (P<0·05), hypocalciuria (urinary Ca 76 (sem 12) V 17 (sem 1) mg/l;P<0·005), hypophosphataemia (serum inorganic P 100 (sem 6) V. 65 (sem 4) mg/l; P<0·005), secondary hyperparathyroidism (SHPT) (serum intact parathyroid hormone human equivalent 18·2 (sem 1·4) V. 125·0 (sem 4·5) pg/ml; P<0·001) and elevated serum calcitriol levels (34·0 (sem 3·9) V. 91·0 (sem 1·0) pg/ml; v<0·005). Elevated urinary C-terminal telopeptide of class I collagen (P<0·005) and total serum alkaline phosphatase (P<0·005) suggested increased bone turnover. There was a significantly lower gain in bone mineral density (BMD) and bone mineral content (BMC) in the whole body and lumbar spine in vivo, and various sub-regions of the femur and tibia in vitro.Supplementation of adequate Ca (0·45% Ca) after 15 weeks on the normal diet resulted in rapid catch-up growth, and resolution of SHPT. Rapid gain in various BMD and BMC parameters continued at 30 weeks of age, and both were comparable with those in rabbits on a normal diet. We conclude that Ca deficiency-induced SHPT and poor bone accrual in growing rabbit pups are rapidly reversible with Ca supplementation. The present study indicates that early intervention may be a more appropriate window period for human nutritional corrective measures.
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Affiliation(s)
- Meenal Mehrotra
- Department of Medical Endocrinology, Centre for Endocrine Sciences, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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43
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Abstract
The recent resurgence of the ancient disease of vitamin D deficiency rickets and the widespread presence of hypovitaminosis D across the age spectrum pose significant challenges for today's clinicians. Furthermore, new research into previously unsuspected actions of vitamin D in multiple cell systems offer the possibility that vitamin D will play an increasingly important role in our understanding of a wide variety of disease states.
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Combs GF, Hassan N. The Chakaria food system study: household-level, case-control study to identify risk factor for rickets in Bangladesh. Eur J Clin Nutr 2006; 59:1291-301. [PMID: 16047028 DOI: 10.1038/sj.ejcn.1602242] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE A comprehensive, multiround survey of local food systems in a rickets-endemic area of Bangladesh was conducted to identify household-level risk factors for rickets. DESIGN A household-level, case-control study was conducted in a rickets-endemic area, Chakaria, with planned comparisons between households with one or more rachitic child and neighboring households with no affected children. SETTING A rickets-endemic area of southeastern Bangladesh, Chakaria. SUBJECTS AND METHODS An interview-based survey was conducted in six villages in Chakaria with 199 households with at least one child showing physical signs consistent with rickets and 281 households with no affected children. RESULTS Households with rachitic children in Chakaria had more children, more pregnant or lactating women, and fewer adults than unaffected households in that community. Affected households tended to rely on farming for their livelihood and tended to have less economic activity as indicated by less outstanding debt than their neighbors. Households with rickets were at significantly greater risk of pneumonia than were other households. Calcium undernutrition was severe and widespread in Chakaria due to a food system that offered very little of the element in accessible forms. Household diets were based on cereals and starchy vegetables. Rice and fish constituted the major source of calcium for most households, although dairy products, when used, were very important calcium sources, particularly for young children. In fact, the use of dairy products was the only household choice that led to substantial increases in the calcium intakes of children, and households that used dairy products tended to show increased calcium intakes for all of their members. CONCLUSIONS The risk of a Chakarian household having a child with rickets appeared to be related to its economic status. Although this might be expected to be manifest as limitations in food access and/or use, rickets households failed to show a dietary pattern associated with rickets. Calcium undernutrition was prevalent and, thus, would appear to be a predisposing factor for rickets; however, calcium undernutrition was prevalent in Chakarian households with and without rickets. Therefore, it is probable that another precipitating factor(s) play a role(s) in the etiology of rickets in Chakaria.
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Affiliation(s)
- G F Combs
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA.
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45
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Levy Y, Davidovits M. Nutritional rickets in children with cows' milk allergy: calcium deficiency or vitamin D deficiency? Pediatr Allergy Immunol 2005; 16:553. [PMID: 16176406 DOI: 10.1111/j.1399-3038.2005.00270.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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46
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Abstract
This article discusses the pathogenesis, epidemiology, prevention, and treatment of nutritional rickets in children, highlighting the roles of exclusive breastfeeding and low dietary calcium intakes in its pathogenesis. The worldwide nature of the problem is described. Preventive strategies are discussed, and various treatment options are provided.
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Affiliation(s)
- John M Pettifor
- Department of Paediatrics, Chris Hani Baragwanath Hospital, Soweto 2013, South Africa.
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47
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Abrams SA, Thacher TD, Fischer PR, Graff M, Stadler DD, Pam SD, Pettifor JM. Reply to RP Heaney. Am J Clin Nutr 2005. [DOI: 10.1093/ajcn/81.6.1451a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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48
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Abstract
Nutritional rickets remains a public health problem in many countries, despite dramatic declines in the prevalence of the condition in many developed countries since the discoveries of vitamin D and the role of ultraviolet light in prevention. The disease continues to be problematic among infants in many communities, especially among infants who are exclusively breast-fed, infants and children of dark-skinned immigrants living in temperate climates, infants and their mothers in the Middle East, and infants and children in many developing countries in the tropics and subtropics, such as Nigeria, Ethiopia, Yemen, and Bangladesh. Vitamin D deficiency remains the major cause of rickets among young infants in most countries, because breast milk is low in vitamin D and its metabolites and social and religious customs and/or climatic conditions often prevent adequate ultraviolet light exposure. In sunny countries such as Nigeria, South Africa, and Bangladesh, such factors do not apply. Studies indicated that the disease occurs among older toddlers and children and probably is attributable to low dietary calcium intakes, which are characteristic of cereal-based diets with limited variety and little access to dairy products. In such situations, calcium supplements alone result in healing of the bone disease. Studies among Asian children and African American toddlers suggested that low dietary calcium intakes result in increased catabolism of vitamin D and the development of vitamin D deficiency and rickets. Dietary calcium deficiency and vitamin D deficiency represent 2 ends of the spectrum for the pathogenesis of nutritional rickets, with a combination of the 2 in the middle.
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Affiliation(s)
- John M Pettifor
- Medical Research Council Mineral Metabolism Research Unit, Department of Paediatrics, Chris Hani Baragwanath Hospital and the University of the Witwatersrand, Johannesburg, South Africa.
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Abstract
Nutritional rickets remains a public health problem in many countries, despite dramatic declines in the prevalence of the condition in many developed countries since the discoveries of vitamin D and the role of ultraviolet light in prevention. The disease continues to be problematic among infants in many communities, especially among infants who are exclusively breast-fed, infants and children of dark-skinned immigrants living in temperate climates, infants and their mothers in the Middle East, and infants and children in many developing countries in the tropics and subtropics, such as Nigeria, Ethiopia, Yemen, and Bangladesh. Vitamin D deficiency remains the major cause of rickets among young infants in most countries, because breast milk is low in vitamin D and its metabolites and social and religious customs and/or climatic conditions often prevent adequate ultraviolet light exposure. In sunny countries such as Nigeria, South Africa, and Bangladesh, such factors do not apply. Studies indicated that the disease occurs among older toddlers and children and probably is attributable to low dietary calcium intakes, which are characteristic of cereal-based diets with limited variety and little access to dairy products. In such situations, calcium supplements alone result in healing of the bone disease. Studies among Asian children and African American toddlers suggested that low dietary calcium intakes result in increased catabolism of vitamin D and the development of vitamin D deficiency and rickets. Dietary calcium deficiency and vitamin D deficiency represent 2 ends of the spectrum for the pathogenesis of nutritional rickets, with a combination of the 2 in the middle.
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Affiliation(s)
- John M Pettifor
- Medical Research Council Mineral Metabolism Research Unit, Department of Paediatrics, Chris Hani Baragwanath Hospital and the University of the Witwatersrand, Johannesburg, South Africa.
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Graff M, Thacher TD, Fischer PR, Stadler D, Pam SD, Pettifor JM, Isichei CO, Abrams SA. Calcium absorption in Nigerian children with rickets. Am J Clin Nutr 2004; 80:1415-21. [PMID: 15531695 DOI: 10.1093/ajcn/80.5.1415] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Nutritional rickets is common in Nigerian children and responds to calcium supplementation. Low dietary calcium intakes are also common in Nigerian children with and without rickets. OBJECTIVE The objective was to assess intestinal calcium absorption in Nigerian children with rickets. DESIGN Calcium absorption was assessed in 15 children with active rickets (2-8 y of age) and in 15 age- and sex-matched children without rickets by using a dual-tracer stable-isotope method. The children with rickets were supplemented with calcium for 6 mo; calcium absorption was reevaluated 12 mo after the baseline study. Fractional calcium absorption could be determined in 10 children with rickets and in 10 children without rickets. RESULTS The children with and without rickets had dietary calcium intakes of approximately 200 mg/d. Compared with the control children, the children with rickets had lower serum 25-hydroxyvitamin D and calcium concentrations and greater 1,25-dihydroxyvitamin D and parathyroid hormone concentrations. In fact, there were 15 rachitic and 15 control children in the study. Mean (+/-SD) fractional calcium absorption did not differ between those with (61 +/- 20%) and without (63 +/- 13%) rickets (P = 0.47). Calcium absorption was not associated with serum concentrations of calcium, alkaline phosphatase, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, or parathyroid hormone. Mean fractional calcium absorption was significantly greater after (81 +/- 10%) than before (61 +/- 20%) calcium supplementation for the treatment of rickets (P = 0.035). CONCLUSIONS In Nigerian children with rickets, the capacity to absorb calcium is not impaired; however, fractional calcium absorption increases after the resolution of active disease. Calcium absorption may be inadequate to meet the skeletal demands of children with rickets during the active phase of the disease, despite being similar to that of control children.
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Affiliation(s)
- Mariaelisa Graff
- Department of Foods and Nutrition, University of Utah, Salt Lake City and Chemical Pathology, University of Jos, Jos, Nigeria
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