Severe bone deformities in young children from vitamin D deficiency and fluorosis in Bihar-India

Metals on the Menu-Analyzing the Presence, Importance, and Consequences

Metals are integral components of the natural environment, and their presence in the food supply is inevitable and complex. While essential metals such as sodium, potassium, magnesium, calcium, iron, zinc, and copper are crucial for various physiological functions and must be consumed through the diet, others, like lead, mercury, and cadmium, are toxic even at low concentrations and pose serious health risks. This study comprehensively analyzes the presence, importance, and consequences of metals in the food chain. We explore the pathways through which metals enter the food supply, their distribution across different food types, and the associated health implications. By examining current regulatory standards for maximum allowable levels of various metals, we highlight the importance of ensuring food safety and protecting public health. Furthermore, this research underscores the need for continuous monitoring and management of metal content in food, especially as global agricultural and food production practices evolve. Our findings aim to inform dietary recommendations, food fortification strategies, and regulatory policies, ultimately contributing to safer and more nutritionally balanced diets.

Global Health Disparities in Childhood Rickets

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.

Vitamin D may assist the UPR against sodium fluoride-induced damage by reducing RIPK1, ATG5, BECN1, oxidative stress and increasing caspase-3 in the osteoblast MC3T3-E1 cell line

BACKGROUND

Out of all measure systemic exposure to fluorides can cause defect of skeletal and dental fluorosis. Endoplasmic reticulum (ER) stress is caused by fluorine-induced oxidative stress and importance of vitamin D in its prevention is not known enough in bone cells. This study was carried out to investigate fluorine-induced oxidative stress, ER stress, and death pathways and the effect of vitamin D on them.

METHODS

MC3T3-E1 mouse osteoblast cell line was used as the material of the study. The NaF and vitamin D concentrations were determined by the MTT assay. NaF treatments and vitamin D supplementation (pre-add, co-add, and post-add) was administered in the cell line at 24th and 48th hours. The expression of the genes in oxidative stress, ER stress, and death pathways was determined using RT-qPCR and Western blotting techniques.

RESULTS

Vitamin D significantly reduced mRNA expression levels of SOD2, CYGB, ATF6, PERK, IRE1, ATG5 and BECN1 whereas caused an increase in levels GPX1, SOD1, NOS2 and Caspase-3 in MC3T3-E1 mouse osteoblast cell line of NaF-induced. In addition, GPX1, SOD1, ATF6, PERK, IRE1, BECN1, Caspase-3 and RIPK1 protein levels were examined by Western blot analysis, and it was determined that vitamin D decreased IRE1 and PERK protein levels, but increased GPX1, SOD1, ATF6 and Caspase-3 protein levels.

CONCLUSION

The findings of the study suggest that vitamin D has protective potential against NaF-induced cytotoxicity reasonably through the attenuation of oxidative stress, ER stress, ATG5, IRE1 and by increasesing caspase-3 in vitro conditions.

First Clinical Nutrition Outpatient Consultation: A Review of Basic Principles in Nutritional Care of Adults with Hematologic Disease

Methods

A bibliographic survey was carried out between 2020 and 2022 using two databases: PubMed/MEDLINE and Scientific Electronic Library Online (SciELO) and the information source Academic Google, irrespective of language or geography.

Results

In the first nutrition consultation (FNC), there should be an investigative direction focused on nutritional interventions in the short, medium, and long term. The record in the patient's medical record is relevant for carrying out the consultation, according to the recommendations of the normative councils of medicine and nutrition. The main steps to be followed are the investigation of the presence of food allergies and intolerances; the drugs/nutritional supplements in use; changes in the digestive tract; the presence or absence of picamalacia; and socioeconomic and lifestyle data. In addition, it is necessary to carry out laboratory evaluations, semiological assessment, anthropometric assessment, and assessment of food consumption. In the end, the nutritional approach should be composed of calculation of energy and macronutrient and micronutrient needs, intervention in nutritional status deviations, nutritional guidelines, and nutritional therapeutic planning of return, focusing on adherence to treatment.

Conclusion

The first nutrition consultation may represent investigative steps that help the clinical nutritionist in the management, allowing a longitudinal and specific nutritional therapeutic planning for patients assisted in large reference centers for hematological disease.

Enamel Hypoplasia and Dental Fluorosis in Children With Special Healthcare Needs: An Epidemiological Study

Background Children with cerebral palsy, intellectual difficulties, or hearing deficiencies may have enamel hypoplasia. Moreover, as the child begins to walk, the fluorosis progresses to bone malformations in the lower limbs, and it fully manifests as the child grows up. Methodology An epidemiological study was conducted to assess the prevalence of dental caries, oral hygiene status, enamel opacities, and oral hygiene habits among children 4-15 years of age from various schools for special healthcare needs including government schools and non-government organizations. Results The study sample comprised 1,047 children with special healthcare needs in the age group of 4-15 years, with 608 males and 439 females. It was seen that 29.79% of vegetarian children were affected with caries, while only 16.14% of children with a mixed diet were affected with caries. Conclusions There is no significant association between enamel hypoplasia and the physical and mental disabilities of children with special healthcare needs.

Possible Association Between Polymorphisms in ESR1, COL1A2, BGLAP, SPARC, VDR, and MMP2 Genes and Dental Fluorosis in a Population from an Endemic Region of West Bengal

Dental fluorosis (DF) is the most prevalent form of fluorosis in India affecting millions of people all over the country. As estrogen receptor 1 (ESR1), collagen type 1 alpha 2 (COL1A2), bone γ-carboxyglutamic acid protein (BGLAP), secreted protein acidic and cysteine-rich (SPARC), vitamin D receptor (VDR), and matrix metallopeptidase 2 (MMP2) genes play critical roles in bone metabolism, bone formation, mineral metabolism, and mineralization, variants in these genes could influence susceptibility to DF. The present study was aimed at evaluating the association between 15 single-nucleotide polymorphisms (SNPs) in the six candidate genes (namely, ESR1, COL1A2, BGLAP, SPARC, VDR, and MMP2) and DF among 132 individuals (case = 71 and control = 61) living in a fluoride endemic region of West Bengal, India. No statistically significant association with disease risk was found when the genotypes and allele frequencies of each of the 15 SNPs was analyzed individually using odd's ratio with 95% confidence interval. "CC" and "AG" haplotypes of the COL1A2 gene showed a borderline association with DF. The present study is the first in India to use multifactor dimensionality reduction (MDR) analysis for identifying gene-gene and gene-environment interactions in fluorosis. The biomarker of serum fluoride showed a significant association with the disease state among the 17 attributes (15 SNPs and 2 biomarkers of urine fluoride and serum fluoride) (P value = 0.011). The best model of MDR analysis with maximized testing accuracy involved two SNPs from the ESR1 gene (rs9340799 and rs2077647) and one SNP from BGLAP gene (rs1543294) (P value < 0.0001).

Calcium and Vitamin D Supplementation Effectively Alleviates Dental and Skeletal Fluorosis and Retain Elemental Homeostasis in Mice

Fluoride (F) is an essential trace element, but chronic exposure beyond the permissible limit (1.5 ppm) effectuates dental and skeletal fluorosis. Although 200 million people across the world are suffering from toxic manifestations of F, till now proper treatment is not available. In this study, we assessed the effectiveness of calcium and vitamin D supplementation for alleviation of fluorosis. Swiss albino mice were divided into 6 groups; group I-control group (received drinking water ˂ 0.5 ppm F; within the permissible limit), group II-treated with 15 ppm of sodium fluoride (NaF) for 4 months, group III-treated with 15 ppm of NaF for 8 months through drinking water. Group IV-orally treated with 15 ppm NaF for 4 months, thereafter received only drinking water for next 4 months, group V-orally treated with 15 ppm NaF for 4 months, thereafter received drinking water supplemented with calcium and vitamin D (2.5-g calcium kg^-1 diet and 1000 IU vitamin D kg^-1 diet) for next 4 months, and group VI was treated with 15 ppm of NaF through drinking water as well as supplemented with calcium and vitamin D for 4 months. NaF treatment caused dental fluorosis, skeletal fluorosis, and alteration of bone's metal profile. Substitution of NaF-containing water with normal drinking water reduced the severity of fluorosis but supplementation of calcium and vitamin D effectively alleviated dental and skeletal fluorosis, reduced F deposition, and retained elemental homeostasis of the bone. Our findings strongly support that calcium and vitamin D act as redeemer of fluorosis. Graphical Abstract.

Supplementation of Calcium and Fluoride-Free Water Mitigates Skeletal Fluorosis in Fluoride-Intoxicated Rats

Fluorosis is a public health concern in 25 countries around the globe. The present study is about the mitigation of fluoride (F) toxicity by giving F-free water (FFW) and calcium (Ca). A study was conducted by taking 76 Wistar rats in two phases, phase I (6 months), where rats were randomly divided into four groups: normal-Ca diet (NCD) 0.5%; low-Ca diet (LCD) 0.25%; NCD + 100 ppm F and LCD + 100 ppm F in groups 1, 2, 3 and 4, respectively. F and Ca were given through water and diet respectively. Phase II is the reversal of fluorosis for 3 months, where LCD group 2 was treated with NCD. Groups 3 and 4 were divided into two subgroups each: 3X and 3Y, and 4X and 4Y, respectively. Groups 3X and 4X received FFW with NCD. Group 3Y continued as phase I and 4Y NCD and F. The biochemical expression, gene expression, biomechanical properties and DXA were studied by standard methods. The results revealed that in phase I, bone turnover was significantly increased whereas bone mineral content and biomechanical properties of group 4 were significantly decreased (p ≤ 0.05) as compared with that of all other groups. Trabecular separation and total porosity increased in groups 2 and 4. Expression of osteocalcin, osteonectin and osteopontin genes was significantly downregulated in group 4. Bone turnover in group 4X was normalised. Expressions of osteocalcin, osteonectin and osteopontin were upregulated after providing NCD and FFW. In conclusion, low calcium aggravates skeletal fluorosis which could be mitigated on supplementation of Ca and FFW.

Chemical Aspects of Human and Environmental Overload with Fluorine

Over the last 100-120 years, due to the ever-increasing importance of fluorine-containing compounds in modern technology and daily life, the explosive development of the fluorochemical industry led to an enormous increase of emission of fluoride ions into the biosphere. This made it more and more important to understand the biological activities, metabolism, degradation, and possible environmental hazards of such substances. This comprehensive and critical review focuses on the effects of fluoride ions and organofluorine compounds (mainly pharmaceuticals and agrochemicals) on human health and the environment. To give a better overview, various connected topics are also discussed: reasons and trends of the advance of fluorine-containing pharmaceuticals and agrochemicals, metabolism of fluorinated drugs, withdrawn fluorinated drugs, natural sources of organic and inorganic fluorine compounds in the environment (including the biosphere), sources of fluoride intake, and finally biomarkers of fluoride exposure.

Apoptotic and Degenerative Changes in the Enteric Nervous System Following Exposure to Fluoride During Pre- and Post-natal Periods

Children born in fluorosis endemic areas usually suffer from gastrointestinal complications and are unable to attain normal growth as per their age group. The enteric nervous system (ENS) controls gut movement and functions. It is highly vulnerable to any ingested toxins. Based on observations, it was hypothesized that fluoride exposure during pregnancy and lactation might induce ENS developmental defects. The aim of this study is to investigate the effects of fluoride exposure during pregnancy and lactation on ENS of the first-generation rat pups. After confirmation of pregnancy, female rats were divided into 3 groups and kept on normal water (group 1), 50 ppm of fluoride (group 2), and 100 ppm of fluoride (group 3). The fluoride exposure started at the start of pregnancy and continued until lactation. On the 21st post-natal day, the pups were euthanized and the gut tissue and blood were harvested and subjected to fluoride measurement, oxidative stress estimation, histopathological and ultrastructural analysis, TUNEL, and immunofluorescence. The quantitative expressional analysis of embryonic lethal abnormal vision-like 4 (ELAVL4) (a pan-neuronal marker) and glial fibrillary acidic protein (GFAP) (a glial cell marker) genes was performed by RT-qPCR. An increase in oxidative stress, subcellular and cellular injuries, and apoptosis in enteric neuronal, glial, and epithelial cells was observed in the distal colon of the first-generation pups. Ganglionic degeneration, reduced expression of HuC/D and GFAP, altered colon muscle layer thickness, and tissue edema were observed in the fluoride-treated groups compared with the control. Fluoride exposure during prenatal and lactation period leads to subcellular and cellular injuries due to increased oxidative stress and apoptosis in the ENS. The reduction in the number of neurons and glia due to increased apoptosis may cause alterations in ENS development.

Chronic exposure to environmentally relevant concentration of fluoride alters Ogg1 and Rad51 expressions in mice: Involvement of epigenetic regulation

Chronic exposure to fluoride (F) beyond the permissible limit (1.5 ppm) is known to cause detrimental health effects by induction of oxidative stress-mediated DNA damage overpowering the DNA repair machinery. In the present study, we assessed F induced oxidative stress through monitoring biochemical parameters and looked into the effect of chronic F exposure on two crucial DNA repair genes Ogg1 and Rad51 having important role against ROS induced DNA damages. To address this issue, we exposed Swiss albino mice to an environmentally relevant concentration of fluoride (15 ppm NaF) for 8 months. Results revealed histoarchitectural damages in liver, brain, kidney and spleen. Depletion of GSH, increase in lipid peroxidation and catalase activity in liver and brain confirmed the generation of oxidative stress. qRT-PCR result showed that expressions of Ogg1 and Rad51 were altered after F exposure in the affected organs. Promoter hypermethylation was associated with the downregulation of Rad51. F-induced DNA damage and the compromised DNA repair machinery triggered intrinsic pathway of apoptosis in liver and brain. The present study indicates the possible association of epigenetic regulation with F induced neurotoxicity.

Vitamin D and tibiofemoral joint orientation angles in children

Vitamin D is an important component in musculoskeletal development and function in children. The aim of our study was to investigate serum vitamin D levels and tibiofemoral joint orientation angles in children. We performed a retrospective review on a consecutive series of children presenting with lower limb complaints. The children underwent an assessment of serum vitamin D level and full-length standing lower limb anteroposterior radiographs, and were divided into normal and deficient vitamin D groups. Tibiofemoral angles (TFAs) [lateral distal femoral angle (LDFA); medial proximal tibial angle (MPTA)] were measured by three independent observers and compared between the groups. Correlation tests between serum vitamin D level and TFAs were also performed. Sixty (39 boys, 21 girls) children were reviewed. The mean serum vitamin D level for the entire group was 26.8 ng/ml and 75% of the children were deficient. The mean serum vitamin D levels in the normal (11 boys, four girls) and deficient (28 boys, 17 girls) groups were 46.7 ng/ml (range: 32-100) and 20.2 ng/ml (range: 4-29), respectively. The mean right and left LDFAs were significantly higher in the normal compared to the deficient vitamin D group (right LDFA: 98.7° vs. 92.2°, P=0.031; left LDFA: 99.1° vs. 92.6°, P=0.018). We also found a correlation between serum vitamin D level and LDFAs (right ρ=0.29, P=0.03; left ρ=0.30, P=0.02). We found no difference in the right and left MPTAs in the normal and deficient vitamin D groups. In addition, we could not find a correlation between serum vitamin D level and MPTAs. The majority of children were vitamin D deficient. Serum vitamin D level was associated with a change and correlation to the LDFAs compared to MPTAs. Further work is required to investigate the effect of vitamin D supplementation on TFAs in children.

Association between leg bowing and serum alkaline phosphatase level regardless of the presence of a radiographic growth plate abnormality in pediatric patients with genu varum

When children around 2 years of age show leg bowing and diseases are ruled out based on radiographic findings without conducting blood tests, they are classified as "physiologic" genu varum. Since whether or not physiologic genu varum is associated with bone metabolism is unclear, this study was conducted to clarify the association between genu varum and bone metabolism in children. Thirty-five pediatric patients with genu varm who visited our out-patient clinic were enrolled. While two of the 35 children had nutritional rickets, showing abnormalities on both blood test (ALP, ≥1000 IU/L; iPTH, >65 pg/mL and 25(OH)D, ≤20 ng/mL) and radiographs (such as cupping, fraying or splaying), five of 35 children showed abnormalities on blood tests but not radiographs. While metaphyseal-diaphyseal angle (MDA) correlated with serum 25-hydroxy vitamin D (r = -0.35, p = 0.04) and magnesium (r = -0.36, p = 0.04), MDA and femorotibial angle (FTA) correlated with alkaline phosphatase (r = 0.43, p = 0.01 and r = 0.51, p = 0.006, respectively). A ridge regression analysis adjusted for age and body mass index indicated that ALP was associated with MDA and FTA. A logistic regression analysis adjusted for age and BMI indicated that higher ALP influenced an MDA >11°, which indicates the risk for the progression of genu varum (odds ratio 1.002, 95% confidence interval 1.0003-1.003, p = 0.021). The higher ALP (+100 IU), the higher risk of an MDA >11° (odds ratio 1.22). In conclusion, genu varum is associated with the alkaline phosphatase level regardless of the presence of radiographic abnormalities in the growth plate in children.

Dose-dependent effect of fluoride on clinical and subclinical indices of fluorosis in school going children and its mitigation by supply of safe drinking water for 5 years: an Indian study

Fluorosis is a public health problem in India; to know its prevalence and severity along with its mitigation measures is very important. The present study has been undertaken with the aim to assess the F dose-dependent clinical and subclinical symptoms of fluorosis and reversal of the disease by providing safe drinking water. For this purpose, a cross-sectional study was undertaken in 1934 schoolgoing children, Nalgonda district. Study villages were categorized into control (category I, F = 0.87 mg/L), affected (category II, F = 2.53 mg/L, and category III, F = 3.77 mg/L), and intervention categories (category IV, F = < 1.0 mg/L). School children were enrolled for dental grading by modified Dean Index criteria. Anthropometric measurements (height and weight) were used to assess nutritional status of the children. The biochemical parameters like serum T3, T4, TSH, PTH, ALP, 25-OH vitamin D, and 1,25-(OH)₂ vitamin D were analyzed. The results showed a positive correlation between the drinking water and urinary fluoride (UF) in different categories. However, there was a significant decrease in the UF levels in the intervention category IV compared to affected group (category III). Fluoride altered the clinical (dental fluorosis and stunting) and subclinical indices (urine and blood) of fluorosis in a dose-dependent manner. In conclusion, the biochemical indices were altered in a dose-dependent manner and intervention with safe drinking water for 5 years in intervention group-mitigated clinical and subclinical symptoms of fluorosis.

Effects of Fluoride on Bone in an Animal Model of Vitamin D Deficiency

We investigated the combined effect of fluoride exposure and Vitamin D deficiency in causing bone damage as a precursor to development of Fluorotoxic Metabolic Bone Disease. Thirty-six male Sprague-Dawley rats were divided into 6 groups of six; 3 groups received a Vitamin D deficient diet whereas the other 3 received a Vitamin D adequate diet. Serum total 25-hydroxyvitamin D (25OHD), calcium, phosphorus, creatinine, Alkaline phosphatase (ALP), albumin, Parathyroid hormone (PTH), Osteocalcin and C terminal telopeptide (CTx) were measured following exposure to varying levels of fluoride in drinking water (< 1.0, 15 and 50 ppm). Full body Dual-energy X-ray Absorptiometry (DXA) scans were used to examine changes in bone morphology pre and post exposure to fluoride. Renal tubular function was assessed using serum creatinine and urine Cystatin C. Histopathological examination of sections of bone and kidney tissues were also performed. Prior to fluoride exposure, DXA scans revealed a significant decrease in Bone Mineral Density (BMD) and Bone Mineral content (BMC) (p < 0.05) but a significant increase in fat mass (p < 0.05) and fat percentage (p < 0.01) among Vitamin D deficient rats, with no significant change in biochemical parameters. Following exposure to fluoride, BMD was significantly increased (p < 0.05) in both groups with a corresponding increase in serum ALP, bone fluoride content, Osteocalcin, CTx and urine fluoride with increasing levels of fluoride exposure. Serum creatinine calcium and phosphate and urinary cystatin C levels showed no significant changes. Light microscopy examination revealed mild thickening and increased osteoid in 80% of the Vitamin D deficient rats exposed to high levels of fluoride but renal tubular changes were found only in one experimental and one control animal. Fluoride deposited in rat bone affects both osteoblastic and osteoclastic activity. Also, these effects are accentuated in the presence of Vitamin D deficiency.

Dental fluorosis, nutritional status, kidney damage, and thyroid function along with bone metabolic indicators in school-going children living in fluoride-affected hilly areas of Doda district, Jammu and Kashmir, India

A case-control study was undertaken among the school children aged 8-15 years to know the presence and severity of dental fluorosis, nutrition and kidney status, and thyroid function along with bone metabolic indicators in Doda district situated at high altitude where drinking water was contaminated and heat stress. This study included 824 participants with an age of 8-15 years. The results of the study reviled that dental fluorosis was significantly higher in affected than control area children. Urinary fluoride was significantly higher (p < 0.05) in affected children as compared to the control area school children. Nutritional status of affected children was lower than control area children. The chronic kidney damage (CKD) was higher in affected than control school children. Thyroid function was affected more in affected than control area schools. Serum creatinine, total alkaline phosphatase, parathyroid hormone, 1, 25(OH)₂ vitamin D, and osteocalcin were significantly higher in affected school children (p < 0.05) as compared to control school children, whereas there was no significant difference in triiodothyronine (T3), thyroxine (T4), and 25-OH vitamin D among the two groups. There was a significant decrease in thyroid-stimulating hormone (TSH) in the affected area school children compared to control. In conclusion, fluorotic area school children were more affected with dental fluorosis, kidney damage, along and some bone indicators as compared to control school children.

Association of dental and skeletal fluorosis with calcium intake and serum vitamin D concentration in adolescents from a region endemic for fluorosis

CONTEXT

Fluorosis is controlled by the duration of fluoride exposure and calcium and Vitamin D nutrition status.

AIM

To examine (a) prevalence of dental and skeletal fluorosis in adolescents from upper, middle, and lower socioeconomic strata (SES) and (b) association of fluorosis with calcium intake and Vitamin D status.

SETTINGS AND DESIGN

A cross-sectional study conducted in 10-13.9 years apparently healthy adolescents (n = 90), from different SES of Patan (Gujarat, India).

MATERIALS AND METHODS

Dental fluorosis was graded as mild, moderate, and severe. Radiographs of the right hand and wrist were examined and graded. Serum 25 hydroxyvitamin D3 (25OHD) and parathyroid hormone concentrations were measured. Diet was recorded (24 h recall) and calcium intake was computed (C-diet V-2.1, 2013, Xenios Technologies Pvt. Ltd).

STATISTICAL ANALYSIS

Generalized linear model was used to analyze relationships between fluorosis, SES, serum 25OHD concentration, and calcium intake.

RESULTS

Fluorosis was predominant in lower SES (17% had both dental and radiological features whereas 73% had dental fluorosis); no skeletal deformities were observed. Mean 25OHD concentrations and dietary calcium were 26.3 ± 4.9, 23.4 ± 4.7, and 18.6 ± 4 ng/ml and 441.2 ± 227.6, 484.3 ± 160.9, and 749.2 ± 245.4 mg/day, respectively, for lower, middle, and upper SES (P < 0.05). Fluorosis and SES showed a significant association (exponential β = 2.5, P = 0.01) as compared to upper SES, middle SES adolescents were at 1.3 times while lower SES adolescents were at 2.5 times higher risk. Serum 25OHD concentrations (P = 0.937) and dietary calcium intake (P = 0.825) did not show a significant association with fluorosis.

CONCLUSION

Fluorosis was more common in lower SES adolescents, probably due to the lack of access to bottled water. Relatively adequate calcium intake and serum 25OHD concentrations may have increased the efficiency of dietary calcium absorption, thus preventing severe fluorosis.

Compact DD generator-based neutron activation analysis (NAA) system to determine fluorine in human bone in vivo: a feasibility study

The subject of whether fluorine (F) is detrimental to human health has been controversial for many years. Much of the discussion focuses on the known benefits and detriments to dental care and problems that F causes in bone structure at high doses. It is therefore advantageous to have the means to monitor F concentrations in the human body as a method to directly assess exposure. F accumulates in the skeleton making bone a useful biomarker to assess long term cumulative exposure to F. This study presents work in the development of a non-invasive method for the monitoring of F in human bone. The work was based on the technique of in vivo neutron activation analysis (IVNAA). A compact deuterium-deuterium (DD) generator was used to produce neutrons. A moderator/reflector/shielding assembly was designed and built for human hand irradiation. The gamma rays emitted through the (19)F(n,γ)(20)F reaction were measured using a HPGe detector. This study was undertaken to (i) find the feasibility of using DD system to determine F in human bone, (ii) estimate the F minimum detection limit (MDL), and (iii) optimize the system using the Monte Carlo N-Particle eXtended (MCNPX) code in order to improve the MDL of the system. The F MDL was found to be 0.54 g experimentally with a neutron flux of 7   ×   10(8) n s(-1) and an optimized irradiation, decay, and measurement time scheme. The numbers of F counts from the experiment were found to be close to the (MCNPX) simulation results with the same irradiation and detection parameters. The equivalent dose to the irradiated hand and the effective dose to the whole body were found to be 0.9 mSv and 0.33 μSv, respectively. Based on these results, it is feasible to develop a compact DD generator based IVNAA system to measure bone F in a population with moderate to high F exposure.

Haematological changes in fluorotic adults and children in fluoride endemic regions of Gaya district, Bihar, India

Groundwater used for drinking and cooking was analysed for fluoride (F), and health surveys were conducted in Bodh Gaya, Amas and Bankebazaar blocks of the Gaya district, Bihar, India. Amas and Bankebazaar blocks were F endemic areas with mean F = 2.36 ± 0.23 mg/L (N = 27). Bodh Gaya was considered as control area with mean F = 0.59 ± 0.03 mg/L (N = 11). Health survey showed that more than 50 % of adults and more than 55 % of children had complaints of gastro-intestinal (GI) disturbances in the F endemic areas, while less than 20 % of adults and less than 10 % of children complained of GI problems in the control areas. Haematological analyses were conducted on age- and sex-matched fluorotic subjects (N = 93) of F endemic areas, and non-fluorotic subjects (N = 52) of control area showed lowered haemoglobin, haematocrit, mean corpuscular volume, mean corpuscular haemoglobin, and mean corpuscular haemoglobin concentration in the fluorotic subjects, suggesting the occurrence of anaemia in the fluorotic subjects.

Vitamin D insufficiency in a sunshine-sufficient area: southern Ethiopia

Background. Although the photosynthesis and bioavailability of vitamin D are influenced by various factors, vitamin D is produced in the skin by ultraviolet B (UVB) radiation from sunlight. However, vitamin D insufficiency is being recognized as a common problem, even in areas with abundant sunshine.

OBJECTIVE

This study assessed vitamin D status by measuring plasma 25(OH)D concentrations in rural women in southern Ethiopia living in the Rift Valley at 7 degree3' N latitude. Methods. Nonpregnant women (n = 202) living in three adjacent rural communities volunteered to participate in this cross-sectional study. Demographic, socioeconomic, health, and food frequency data were acquired by questionnaire. Anthropometric measurements and a fasting venipuncture blood sample were obtained by qualified professionals. Body mass index (BMI) was calculated. ELISA kits from ImmunoDiagnostic Systems were used to determine concentrations of 25(OH)D with external quality control standards from UTAK Laboratories.

RESULTS

The self-reported mean +/- SD age was 30.8 +/- 7.8 years. The mean number of pregnancies was 4.7 +/- 2.7, household size was 6.0 +/- 2.6, and BMI was 20.0 +/- 2.2. None of the participants reported ever consuming vitamin D-rich foods, fortified foods, or dietary supplements. Only 15.8% of the participants had 25(OH) D levels above 50 nmol/L, and 14.8% were below 30 nmol/L, which represents risk of deficiency relative to bone health.

CONCLUSIONS

Vitamin D insufficiency is a serious problem in the study population, and living near the Equator does not assure adequate vitamin D status.

Vitamin D deficiency in India: prevalence, causalities and interventions

Vitamin D deficiency prevails in epidemic proportions all over the Indian subcontinent, with a prevalence of 70%-100% in the general population. In India, widely consumed food items such as dairy products are rarely fortified with vitamin D. Indian socioreligious and cultural practices do not facilitate adequate sun exposure, thereby negating potential benefits of plentiful sunshine. Consequently, subclinical vitamin D deficiency is highly prevalent in both urban and rural settings, and across all socioeconomic and geographic strata. Vitamin D deficiency is likely to play an important role in the very high prevalence of rickets, osteoporosis, cardiovascular diseases, diabetes, cancer and infections such as tuberculosis in India. Fortification of staple foods with vitamin D is the most viable population based strategy to achieve vitamin D sufficiency. Unfortunately, even in advanced countries like USA and Canada, food fortification strategies with vitamin D have been only partially effective and have largely failed to attain vitamin D sufficiency. This article reviews the status of vitamin D nutrition in the Indian subcontinent and also the underlying causes for this epidemic. Implementation of population based educational and interventional strategies to combat this scourge require recognition of vitamin D deficiency as a public health problem by the governing bodies so that healthcare funds can be allocated appropriately.

Suppression of Sclerostin and Dickkopf-1 levels in patients with fluorine bone injury

Evidence has been accumulating for the role of Sclerostin and Dickkopf-1 as the antagonists of Wnt/β-Catenin signaling pathway, which suppresses bone formation through inhibiting osteoblastic function. To get deep-inside information about the expression of the antagonists in patients with fluorine bone injury, a case-control study was conducted in two counties in Hubei Province. Urinary and serum fluoride were significantly higher in patients with fluorine bone injury than in healthy controls. Additionally, patients with fluorine bone injury had significantly lower serum Sclerostin and Dickkopf-1 levels compared with healthy controls (P<0.001). Serum Sclerostin and Dickkopf-1 levels were significantly correlated with serum fluoride in all studied subjects (n=186). Low Sclerostin and Dickkopf-1 levels were associated with a significantly increased risk of fluorine bone injury. In conclusion, serum Sclerostin and Dickkopf-1 might be used as important markers of bone metabolism change and potential therapeutic targets to treat fluorine bone injury.

Drinking water fluoride levels for a city in northern Mexico (durango) determined using a direct electrochemical method and their potential effects on oral health

Fluoride is ingested primarily through consuming drinking water. When drinking water contains fluoride concentrations>0.7 parts per million (ppm), consuming such water can be toxic to the human body; this toxicity is called "fluorosis." Therefore, it is critical to determine the fluoride concentrations in drinking water. The objective of this study was to determine the fluoride concentration in the drinking water of the city of Durango. The wells that supply the drinking water distribution system for the city of Durango were studied. One hundred eighty-nine (189) water samples were analyzed, and the fluoride concentration in each sample was quantified as established by the law NMX-AA-077-SCFI-2001. The fluoride concentrations in such samples varied between 2.22 and 7.23 ppm with a 4.313±1.318 ppm mean concentration. The highest values were observed in the northern area of the city, with a 5.001±2.669 ppm mean value. The samples produced values that exceeded the national standard for fluoride in drinking water. Chronic exposure to fluoride at such concentrations produces harmful health effects, the first sign of which is dental fluorosis. Therefore, it is essential that the government authorities implement water defluoridation programs and take preventative measures to reduce the ingestion of this toxic halogen.

Amelioration of chronic fluoride toxicity by calcium and fluoride-free water in rats

The study was undertaken to explore the amelioration of chronic fluoride (F) toxicity (with low and normal Ca) in rats. The study was conducted in two phases. In phase I (6 months), seventy-six Wistar, weanling male rats were assigned to four treatment groups: normal-Ca (0·5 %) diet (NCD), Ca+F - ; low-Ca (0·25 %) diet (LCD), Ca - F - ; NCD +100 parts per million (ppm) F water, Ca+F+; LCD +100 ppm F water, Ca - F+. In phase II (reversal experiment, 3 months), LCD was replaced with the NCD. Treatment groups Ca+F+ and Ca - F+ were divided into two subgroups to compare the effect of continuation v. discontinuation along with Ca supplementation on reversal of chronic F toxicity. In phase I, significantly reduced food efficiency ratio (FER), body weight gain (BWG), faecal F excretion, serum Ca and increased bone F deposition were observed in the treatment group Ca - F+. Reduced serum 25-hydroxy-vitamin D3, increased 1,25-dihydroxy-vitamin D3 and up-regulation of Ca-sensing receptor, vitamin D receptor and S100 Ca-binding protein G (S100G) were observed in treatment groups Ca - F - and Ca - F+. In phase II (reversal phase), FER, BWG and serum Ca in treatment groups Ca - F+/Ca+F - and Ca - F+/Ca+F+ were still lower, as compared with other groups. However, other variables were comparable. Down-regulation of S100G was observed in F-fed groups (Ca+F+/Ca+F+ and Ca - F+/Ca+F+) in phase II. It is concluded that low Ca aggravates F toxicity, which can be ameliorated after providing adequate Ca and F-free water. However, chronic F toxicity can interfere with Ca absorption by down-regulating S100G expression irrespective of Ca nutrition.

Study on blood biochemical diagnostic indices for hepatic function biomarkers in endemic skeletal fluorosis

The aim of the study was to determine the relationship of fluoride in drinking water to liver function in individuals living in normal and seven endemic fluorosis areas of Punjab, India. The concentration of fluoride in drinking water of different areas varied from 5.9 to 24.5 mg/L. Study group consisted of 705 patients in the age group between 20 and 60 years (mean age of 39.35±11.27) affected with osteodental fluorosis were compared with 300 age- and sex-matched controls (with mean age of 35.28±8.25 years). Biochemical data was analyzed by one-way analysis of variance (ANOVA) with post hoc Tukey-Kramer and Bonferroni multiple comparison tests. The relationship between hepatic enzymes was calculated by Pearson's correlation and linear regression. The results revealed significantly (P<0.001) higher concentration of serum fluoride in patients when compared to control. The mean activities of cyclic adenosine monophosphate (AMP), alkaline phosphatase (ALKP), acid phosphatase (ACP), aspartate aminotransaminase (AST), and alanine aminotransaminase (ALT) were significantly (P<0.05-0.001) elevated in patients from all fluoride areas. ANOVA with post hoc Turkey-Kramer and Bonferroni multiple comparison test demonstrated a significant (P<0.0001) variance in the activities of cAMP, ALKP, ACP, AST, and ALT in fluorotic patients, with elevation in water fluoride levels. Maximum elevation of 196.14% (ACP), 99.31% (cyclic adenosine monophosphate; cAMP), 72.08% (ALT), 60.14% (AST), and least 21.35% (ALKP) was recorded in patients exposed to 24.5 mg/L fluoride in drinking water. There was positive correlation between water fluoride, serum fluoride and AST (r=0.77, 0.91), ALT (r=0.82, 0.90), ALKP (r=0.88, 0.97), and ACP (r=0.74, 0.85). Pearson's correlation demonstrated highly significant (P<0.05) positive relationship between water fluoride and cAMP (regression equation: Y=0.9807×+22:081, =0.84; r=0.92, P<0.05). The increased levels of transaminases in fluorotic patients suggest alteration in liver functions. The level of alkaline and acid phosphatase was increased during fluoride intoxication which is also an early marker of hepatic cell damage because of its specificity and catalytic activity. The elevated levels of enzymes are reflective of bone disorders, which are characterized by increased osteoblastic activity. There levels increased several times if cellular damage occurs in the liver. The results suggest that fluoride exposure intensifies the activities of hepatic function enzymes in osteofluorosis.

Substance flow analysis: a case study of fluoride exposure through food and beverages in young children living in Ethiopia

CONTEXT

Dental and skeletal fluorosis is endemic in the Ethiopian Rift Valley. Children are especially vulnerable to excessive fluoride intake because their permanent teeth are still being formed. Strategies to reduce the total fluoride intake by children are thus warranted.

CASE PRESENTATION

By combining the results of field studies in Ethiopia, the relevant pathways for fluoride intake have been identified in 28 children 2-5 years of age living in two villages on the Wonji Shoa Sugar Estate in the Ethiopian Rift Valley. The focus of the present study was to simulate the fluoride intake of the children using the methods of material flow analysis (MFA) and substance flow analysis.

DISCUSSION

With a model based on MFA, we quantified the potential reduction in total fluoride intake given different scenarios-for example, by reducing the fluoride intake from drinking water and cooking water. The results show clearly that only by removing fluoride completely from both drinking and cooking water does the probability of remaining below the daily tolerable upper intake level exceed 50%. Both prepared food and food ingredients must be taken into consideration when assessing the total fluoride intake by children living in high-fluoride areas.

RELEVANCE

This knowledge will help health personnel, the government, and the food authorities to give scientifically based advice on strategies for reducing the total fluoride intake by children living in high-fluoride areas in the Ethiopian Rift Valley.

Modern India and the vitamin D dilemma: evidence for the need of a national food fortification program

India is located between 8.4 and 37.6 degrees N latitude with the majority of its population living in regions experiencing ample sunlight throughout the year. Historically, Indians obtained most of their vitamin D through adequate sun exposure; however, darker skin pigmentation and the changes which have accompanied India's modernization, including increased hours spent working indoors and pollution, limit sun exposure for many. Inadequate sun exposure results in reduced vitamin D synthesis and ultimately poor vitamin D status if not compensated by dietary intake. Dietary vitamin D intake is very low in India because of low consumption of vitamin D rich foods, absence of fortification and low use of supplements. All these factors contribute to poor vitamin D status as measured by low circulating levels of 25-hydroxy vitamin D. Our review searches the published literature specific to India for evidence that would confirm the need to fortify food staples with vitamin D or stimulate public health policies for vitamin D supplementation and dietary guidelines tailored to the Indian diet. This review documents findings of widespread vitamin D deficiency in Indian populations in higher and lower socioeconomic strata, in all age groups, in both genders and people in various professions. Moreover, poor vitamin D status in India is accompanied by increased bone disorders including osteoporosis, osteomalacia in adults and rickets and other bone deformities in children. Without a concerted national effort to screen for vitamin D status, to implement policies or guidelines for vitamin D fortification and/or supplementation and to re-assess recommended dietary intake guidelines, dramatic increase in the number of bone disorders and other diseases may lie ahead.

High prevalence of genu varum/valgum in European children with low vitamin D status and insufficient dairy products/calcium intakes

OBJECTIVE

The prevalence of lower limb deformities physiologically decreases after 5 years of age. It remains high in some tropical and subtropical regions where it has been associated with severe vitamin D deficiency, low calcium/milk intakes, malnutrition, and/or fluoride overexposure. Very little data is available in apparently healthy Caucasian children and adolescents.

DESIGN

We evaluated the prevalence of genu varum/valgum and other clinical symptoms, and assessed vitamin D status and markers of calcium metabolism in 226 apparently healthy European full-time boarders (7-16 years) seen during winter-spring and fed a cereal-based diet with little access to meat, milk, and dairy products. A cohort of 71 white children and adolescents hospitalized for acute illness served as age-matched controls.

RESULTS

Association studies showed a high prevalence of lower limb deformities (36%) and higher alkaline phosphate activities in the 21% of children and adolescent full-time boarders with serum 25-(OH)D levels ≤ 30 nmol/l, and low serum calcium in the 74% of boarders with 25-(OH)D levels ≤ 50 nmol/l, compared with boarders with higher vitamin D status. No such anomalies were found in the control cohort despite lower serum 25-(OH)D levels.

CONCLUSIONS

Low 25-(OH)D levels, at least during winter-spring, combined with additional risk factors such as very low calcium/milk intakes and possibly digestive disorders, are associated with an increased risk of genu varum/valgum in European children and adolescents. Thus, dietary fortification, or supplementation with vitamin D, may be recommended, at least during the winter, to European children and adolescents with either none or insufficient calcium/dairy product intakes.

Vitamin D metabolism and rickets in domestic animals: a review

Rickets and osteomalacia are increasing in prevalence in people because of cultural practices, breast-feeding, decreased sun exposure, and increased sunscreen usage. Several hereditary forms of rickets owing to either renal phosphate wasting or defects in vitamin D metabolism are also reported in people. Rickets is well recognized in domestic animals, but published reports are not always supported by microscopic findings, and diagnoses based on clinical signs and radiology are unreliable. Most cases in domestic animals are caused by dietary deficiency of either vitamin D or phosphorus, but occasional inherited forms are reported in pigs, sheep, cats, and dogs. There is variation between species in susceptibility to dietary vitamin D and phosphorus deficiency and in the ability to manufacture vitamin D in their skin. A number of mouse models have been discovered or created to study human skeletal diseases and skeletal homeostasis. With the discovery that vitamin D is involved in not only calcium and phosphorus homeostasis but also in the immune system and cancer, there is great potential for new and existing animal models to generate valuable information about vitamin D and its many functions. This review presents an overview of vitamin D metabolism and rickets in domestic and laboratory animals and makes comparisons where appropriate with the disease in humans.

Pattern of expression of apoptosis and inflammatory genes in humans exposed to arsenic and/or fluoride

We have assessed whether the combined exposure to arsenic (As) and fluoride (F) exerts a different effect than the exposure to As alone on the pattern of expression of apoptosis and inflammatory genes by immune cells. RNA was extracted from peripheral blood mononuclear cells from twenty individuals exposed or not to As or F or both. Then, cDNA was isolated, and the expression of 180 genes related to apoptosis and inflammation was tested by a cDNA array test. We found significant differences in the expression of 9 apoptosis and 15 inflammation genes in the three exposed groups compared to non-exposed individuals. In addition, subjects exposed to As or F or both showed different patterns of expression of at least 19 genes. Our data indicate that the combined exposure to As and F has a different effect on gene expression than the exposure to As or F alone.

Child skeletal fluorosis from indoor burning of coal in southwestern China

OBJECTIVES

We assess the prevalence and pathogenic stage of skeletal fluorosis among children and adolescents residing in a severe coal-burning endemic fluorosis area of southwest China.

METHODS

We used a cross-sectional design. A total of 1,616 students aged between 7 and 16 years in Zhijin County, Guizhou, China in late 2004 were selected via a cluster sampling of all 9-year compulsory education schools to complete the study questionnaire. Any student lived in a household that burned coal, used an open-burning stove, or baked foodstuffs over a coal stove was deemed high-risk for skeletal fluorosis. About 23% (370) of students (188 boys, 182 girls) were identified as high-risk and further examined by X-ray.

RESULTS

One-third of the 370 high-risk participants were diagnosed with skeletal fluorosis. Overall prevalence of child skeletal fluorosis due to indoor burning of coal was 7.5%. Children aged 12-16 years were significantly more likely to be diagnosed with skeletal fluorosis than children aged 7-11 years (OR = 1.84, 95% CI: 1.17-2.90; P = .0082). Four types of skeletal fluorosis were identified: constrictive (60.7%), raritas (15.6%), mixed (16.4%), and soft (7.4%). Most diagnosed cases (91%) were mild or moderate in severity. In addition, about 97% of 370 high-risk children were identified with dental fluorosis. Dental fluorosis was highly correlated with skeletal fluorosis in this study.

CONCLUSIONS

Skeletal fluorosis among children may contribute to poor health and reduced productivity when they reach adulthood. Further efforts to reduce fluoride exposure among children in southwestern of China where coal is burned indoors are desperately needed.

Level of certain micro and macro minerals in blood of cattle from fluoride polluted localities of Udaipur, India

Analysis of soil, fodder and water samples collected from some localities of Udaipur district, Rajasthan, India revealed high fluoride concentrations indicating the areas endemic for fluoride pollution. Concentration of micro and macro minerals was estimated in blood samples collected from cattle reared in these localities, and with clinical lesions suggestive of chronic fluoride toxicity. In comparison to healthy controls, zinc, copper and manganese levels were significantly (p < 0.05) lower, while cobalt and magnesium concentrations were significantly (p < 0.05) higher in fluoride-intoxicated cattle. Results of the present study suggested that interaction of fluoride with other minerals possibly played a role in pathogenesis of chronic fluoride intoxication.

Skeletal fluorosis from instant tea

INTRODUCTION

Skeletal fluorosis (SF) can result from prolonged consumption of well water with >4 ppm fluoride ion (F(-); i.e., >4 mg/liter). Black and green teas can contain significant amounts of F(-). In 2005, SF caused by drinking 1-2 gallons of double-strength instant tea daily throughout adult life was reported in a 52-yr-old woman.

MATERIALS AND METHODS

A 49-yr-old woman developed widespread musculoskeletal pains, considered fibromyalgia, in her mid-30s. Additionally, she had unexplained, increasing, axial osteosclerosis. She reported drinking 2 gallons of instant tea each day since 12 yr of age. Fluoxetine had been taken intermittently for 5 yr. Ion-selective electrode methodology quantitated F(-) in her blood, urine, fingernail and toenail clippings, tap water, and beverage.

RESULTS

Radiographs showed marked uniform osteosclerosis involving the axial skeleton without calcification of the paraspinal, intraspinal, sacrotuberous, or iliolumbar ligaments. Minimal bone excrescences affected ligamentous attachments in her forearms and tibias. DXA Z-scores were +10.3 in the lumbar spine and +2.8 in the total hip. Her serum F(-) level was 120 microg/liter (reference range, 20-80 microg/liter), and a 24-h urine collection contained 18 mg F(-)/g creatinine (reference value, <3). Fingernail and toenail clippings showed 3.50 and 5.58 mg F(-)/kg (control means, 1.61 and 2.02, respectively; p(s) < 0.001). The instant tea beverage, prepared as usual extra strength using tap water with approximately 1.2 ppm F(-), contained 5.8 ppm F(-). Therefore, the tea powder contributed approximately 35 mg of the 44 mg daily F(-) exposure from her beverage. Fluoxetine provided at most 3.3 mg of F(-) daily.

CONCLUSIONS

SF from habitual consumption of large volumes of extra strength instant tea calls for recognition and better understanding of a skeletal safety limit for this modern preparation of the world's most popular beverage.

Changes in serum seromucoid following compensatory hyperparathyroidism: A sequel to chronic fluoride ingestion

This study was conducted to find out the possible underlying mechanism of various manifestation of fluorosis, a disease caused by excess ingestion of fluoride. For this the fluoride belt of Jaipur district was selected. The parameters selected were serum Parathyroid hormone, the levels of which are directly affected by fluoride intake. The levels of serum seromucoid, serum and leucocyte ascorbic acid, serum sialic acid (SSA) reflects ground substance metabolism. The study was conducted on two hundred children, selected from four areas (50 from each area) consuming water containing 2.4, 4.6, 5.6 and 13.6 mg/l of fluoride. Drinking water fluoride and serum fluoride were measured by Ion selective electrode method. Serum parathyroid by RIA and all other parameters were measured spectrophotometrically. The results revealed an increase in levels of fluoride, parathyroid hormone and seromucoid in serum with increasing water fluoride concentrations. Serum Calcium and serum ascorbic acid were found in normal range, how ever leucocyte ascorbic acid were decreased. A high positive correlation among fluoride concentration in drinking water and serum parathyroid hormone (r=0.967), and, serum parathyroid hormone and serum seromucoid concentration (r=0.935) was also observed The results indicated that secondary hyperparathyroidism due to hypocalcemic stress caused by excess fluoride ingestion disturbs normal metabolism of ground substance in calcified tissues of the body reflected as altered levels of the components of ground substance in the serum.

Vitamin D status and nutrition in Europe and Asia

Vitamin D status is highly different in various countries of Europe, the Middle East and Asia. For this review, vitamin D deficiency is defined as serum 25-hydroxyvitamin D (25(OH)D) <25 nmol/l. Within European countries, serum 25(OH)D is <25 nmol/l in 2-30% of adults, increasing in the elderly and institutionalized to more than 80% in some studies. A north-south gradient was observed for serum 25(OH)D in the Euronut and MORE studies with higher levels in Scandinavia and lower levels in Italy and Spain and some Eastern European countries. This points to other determinants than sunshine, e.g. nutrition, food fortification and supplement use. Mean vitamin D intake in Scandinavia is 200-400IU/d, twice that in other European countries. Very low serum 25(OH)D levels have been reported in the Middle East, e.g. Turkey, Lebanon, Jordan and Iran. In these countries serum 25(OH)D was lower in women than in men and associated with clothing habits. In a Lebanese survey, vitamin D deficiency was observed in the majority and occurred mainly in veiled women. In India, vitamin D deficiency was observed in more than 30%, vitamin D status being poor in school children, pregnant women and large cities. Vitamin D status was much better in Malaysia and Singapore, but lower serum 25(OH)D was observed in Japan and China. Rickets and osteomalacia appear quite common in India, but precise data are lacking. Immigrants in Europe from the Middle East and Asia carry a high risk for vitamin D deficiency, pregnant women being especially at risk. Comparison of vitamin D status between countries is hampered by interlaboratory variation of serum 25(OH)D measurement. In addition, there is a need of population-based data. In conclusion, vitamin D deficiency is common in Southern Europe, the Middle East, India, China and Japan. It is less common in Northern Europe and Southeast Asia. Risk groups are young children, the elderly, pregnant women and non-western immigrants in Europe. Important determinants are skin type, sex, clothing, nutrition, food fortification, supplement use, BMI and degree of urbanization.

Nutritional rickets around the world: causes and future directions

INTRODUCTION

Nutritional rickets has been described from at least 59 countries in the last 20 years. Its spectrum of causes differs in different regions of the world.

METHODS

We conducted a systematic review of articles on nutritional rickets from various geographical regions published in the last 20 years. We extracted information about the prevalence and causes of rickets.

RESULTS

Calcium deficiency is the major cause of rickets in Africa and some parts of tropical Asia, but is being recognised increasingly in other parts of the world. A resurgence of vitamin D deficiency has been observed in North America and Europe. Vitamin D-deficiency rickets usually presents in the 1st 18 months of life, whereas calcium deficiency typically presents after weaning and often after the 2nd year. Few studies of rickets in developing countries report values of 25(OH)D to permit distinguishing vitamin D from calcium deficiency.

CONCLUSIONS

Rickets exists along a spectrum ranging from isolated vitamin D deficiency to isolated calcium deficiency. Along the spectrum, it is likely that relative deficiencies of calcium and vitamin D interact with genetic and/or environmental factors to stimulate the development of rickets. Vitamin D supplementation alone might not prevent or treat rickets in populations with limited calcium intake.

Beneficial effect of copper supplementation on deposition of fluoride in bone in fluoride- and molybdenum-fed rabbits

Fluorosis is a major public health problem in the world, including India. The present study was undertaken to investigate the role of molybdenum (Mo) in the deposition of fluoride (F) in bone and whether copper (Cu) supplementation has any alleviating role when F and Mo are ingested together. For this purpose, four groups of rabbits were used [control (C), fluoride (F), fluoride + molybdenum (F + Mo), and fluoride + molybdenum + copper (F + Mo + Cu)] to find out the effect of these treatments on various bone-related parameters like intact parathyroid hormone (iPTH), alkaline phosphatase and Cu in serum, hydroxyproline and calcium (Ca) in urine, and minerals (F, Cu, manganese, and zinc) in femur bone ash. Bone mineral content (BMC), bone mineral density (BMD) [by dual energy X-ray absorptiometry (DXA)], and strength of femur bones were also assessed. F content in the femur was significantly higher (P < 0.01) in all experimental groups compared to control group. Mo supplementation increased F deposition in femur bone in the F + Mo group, whereas supplementation of Cu reduced F deposition in the F + Mo + Cu group compared to the F + Mo and F groups. Levels of Cu in femurs of the F + Mo and F + Mo + Cu groups were significantly higher (P < 0.05, P < 0.01, respectively) than in the C group, although serum Cu was significantly lower in the F and F + Mo than the C and F + Mo + Cu groups. Magnesium levels in the F + Mo group were significantly higher (P < 0.05) than in the F and F + Mo + Cu groups. Cu supplementation in the F + Mo + Cu group increased deposition of zinc significantly (P < 0.05) compared to the F and F + Mo groups. Serum iPTH, alkaline phosphatase, and urinary hydroxyproline and Ca were significantly higher (P < 0.01) in the F and F + Mo than in the C and F + Mo + Cu groups. However, serum iPTH and urinary hydroxyproline were higher in the F + Mo group than the F group. Alkaline phosphatase was significantly higher in the F + Mo group than the F and F + Mo + Cu groups. Levels of serum Cu in the F and F + Mo groups were lower than in the C group, though serum Cu was significantly higher in the F + Mo + Cu than in all other groups. DXA analysis of femur bone indicated that BMD in the F + Mo group was significantly higher than in the F (P < 0.05), C (P < 0.01), and F + Mo + Cu (P < 0.05) groups. However, there was no significant difference in BMC among the groups. Bone strength was significantly higher (P < 0.05) in the F + Mo group than in the C group. Results of the present study show that ingestion of Mo with F does not create secondary Cu deficiency (due to increased excretion of Cu through urine). However, Cu concentration was decreased in serum in this group (F + Mo) compared to the C and F + Mo + Cu groups. Deposition of F in femur bone was more (22%) when it was given along with Mo compared to F alone, while F deposition in femur bone was less in the F + Mo + Cu group by 80% compared to the F group. Also, deposition of F in the F + Mo + Cu group was 120% less compared to the F + Mo group. The increase in F level due to Mo addition appears to be offset by supplementation with Cu. Supplementation with Cu showed a beneficial effect on bone resorption as well as bone formation.

Nutritional rickets: deficiency of vitamin D, calcium, or both?

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.