Pediatric vitamin D and calcium nutrition in developing countries

Effectiveness of Vitamin D and Alpha-Lipoic Acid in COVID-19 Infection: A Literature Review

Over three years since the World Health Organization (WHO) declared COVID-19 a pandemic, it is still a global burden. Vaccines against COVID-19, caused by SARS-CoV-2, are available and effective for preventing disease. However, their protective effects are not 100%. Currently, the U.S. Food and Drug Administration (FDA) has only approved a limited number of inpatient treatments for COVID-19, such as remdesivir, baricitinib, and tocilizumab. These medications have indications and contraindications applicable to a select patient population. Finding additional effective therapies that are widely available with limited risk could be vital in optimizing treatment strategies for this viral illness. Some vitamins and supplements have been identified as potential options for managing COVID-19. Vitamin D (VD) deficiency has been associated with respiratory tract infections. Moreover, alpha-lipoic acid (ALA) is a powerful antioxidant and helps reduce inflammatory responses in many pathologic conditions. This review aims to analyze the current evidence regarding the effectiveness of VD and alpha-lipoic acid in COVID-19 infection in both outpatient and hospitalized patients. Relevant randomized controlled trials (RCTs) were identified via the PubMed database from January 1, 2021, to December 31, 2023. Inclusion criteria were as follows: the study design was a randomized controlled trial (RCT), the usage of a constant dose during the intervention period without any additional boluses, and a research ethics committee approved it. Exclusion criteria included a lack of an outcome or apparent intervention, additional boluses, or a single-dose regimen in all the interventional groups. There were 11 studies with a total sample size of 35,717 patients that met the criteria for this review. A total of 10 RCTs examined the efficacy of VD, and one RCT that reviewed the efficacy of ALA was identified. All of the articles investigated the use of VD or ALA during the treatment of COVID-19. The endpoints of each study varied, including length of stay in hospital, viral load, SARS-CoV-2 infection rate, mechanical ventilation, inflammatory markers, clinical symptoms, Sequential Organ Failure Assessment (SOFA) score, and mortality. In 8/10 VD supplementation trials, significant differences were identified between the interventional and placebo groups in the aforementioned parameters. In 2/10 VD supplementation trials, no significant differences were identified. The ALA supplementation RCT found no differences between the interventional and placebo groups in the SOFA score and 30-day all-cause mortality rate. The current literature suggests that VD can potentially reduce the SARS-CoV-2 infection rate, oxygen requirements, inflammatory markers, clinical symptoms, and mortality. Regarding ALA, although there was a suggestion of benefit, it was not statistically significant. Common limitations among the different studies included relatively small sample sizes, different geographical patient locations among studies, and differences in dosages. Trials investigating the effects of higher doses of VD supplementation on SARS-CoV-2 infection should be conducted. More research is needed to define best practices and optimal dosing protocols for the use of VD in COVID-19.

Developing feasible healthy diets for Ethiopian women of reproductive age: a linear goal programming approach

OBJECTIVE

To develop a healthy diet for Ethiopian women closely resembling their current diet and taking fasting periods into account while tracking the cost difference.

DESIGN

Linear goal programming models were built for three scenarios (non-fasting, continuous fasting and intermittent fasting). Each model minimised a function of deviations from nutrient reference values for eleven nutrients (protein, Ca, Fe, Zn, folate, and the vitamins A, B1, B2, B3, B6, and B12). The energy intake in optimised diets could only deviate 5 % from the current diet.

SETTINGS

Five regions are included in the urban and rural areas of Ethiopia.

PARTICIPANTS

Two non-consecutive 24-h dietary recalls (24HDR) were collected from 494 Ethiopian women of reproductive age from November to December 2019.

RESULTS

Women's mean energy intake was well above 2000 kcal across all socio-demographic subgroups. Compared to the current diet, the estimated intake of several food groups was considerably higher in the optimised modelled diets, that is, milk and dairy foods (396 v. 30 g/d), nuts and seeds (20 v. 1 g/d) and fruits (200 v. 7 g/d). Except for Ca and vitamin B12 intake in the continuous fasting diet, the proposed diets provide an adequate intake of the targeted micronutrients. The proposed diets had a maximum cost of 120 Ethiopian birrs ($3·5) per d, twice the current diet's cost.

CONCLUSION

The modelled diets may be feasible for women of reproductive age as they are close to their current diets and fulfil their energy and nutrient demands. However, the costs may be a barrier to implementation.

Vitamin D3 Supplementation: Comparison of 1000 IU and 2000 IU Dose in Healthy Individuals

Background: Scientific studies point to a significant global vitamin D deficiency. The recommended dose of vitamin D for the adult population in Central Europe is 800–2000 IU/day. The aim of our study was to determine whether doses of 1000 IU or 2000 IU of vitamin D3 are adequate to achieve the sufficiency reference values of [25(OH)D]. Methods: Seventy-two healthy volunteers, average age twenty-two, took part in the study. The study was conducted from October to March in order to eliminate intra-dermal vitamin D production. Vitamin D3 in an oleaginous mixture was used. The participants used either 1000 IU or 2000 IU/daily for two 60-day periods with a 30-day break. Results: The dose of 1000 IU, taken for 60 days, increased vitamin D levels relatively little. Furthermore, serum vitamin D levels decreased in the 30 days following the cessation of supplementation. Taking 2000 IU daily led to a sharp increase in serum levels which plateaued 30 days after the subjects stopped using vitamin D3 drops. Conclusions: Both doses, taken daily, can help maintain adequate vitamin D levels during the winter months. A daily dose of 2000 IU, however, maintained the desired levels of vitamin D for a longer period.

The Role of Vitamin D in the Relationship Between Gender and Deep Vein Thrombosis Among Stroke Patients

Introduction: Accumulating evidence had demonstrated that females had a higher risk of deep vein thrombosis (DVT) than males, but the mechanism was still unknown. Vitamin D was found to play an essential role in DVT, and gender may influence the serum vitamin D levels. This study aimed to explore whether vitamin D played a role in the gender difference in DVT.

Materials and Methods: A total of 444 patients with acute stroke were recruited, which were divided into the DVT group (n = 222) and the non-DVT group (n = 222). Serum vitamin D levels were measured after admission and were split into three categories, including deficiency (<50 nmol/L), insufficiency (52.5–72.5 nmol/L), and sufficiency (more than 75 nmol/L). Hierarchical regression analysis was adopted to analyze the relationship between gender and DVT, controlling the confounding factors.

Results: Females showed a higher proportion of DVT than males (60.7 vs. 42.5%, p < 0.001), and lower serum vitamin D levels than males (53.44 ± 16.45 vs. 69.43 ± 23.14, p < 0.001). Moreover, serum vitamin D levels were lower in the DVT group than in the non-DVT group (59.44 ± 19.61 vs. 66.24 ± 23.86, p < 0.001). Besides, the DVT group showed a lower proportion of vitamin D sufficiency than the non-DVT group (21.2 vs. 32.9%, p < 0.05). Hierarchical regression analysis showed that females had 2.083-fold (p < 0.001, unadjusted model) and 1.413-fold (p = 0.155, adjusted model) risk to develop DVT. In addition, the sufficiency status of vitamin D showed an independent protective effect on DVT (unadjusted model OR, 0.504, p = 0.004; adjusted model OR, 0.686, p = 0.011).

Conclusion: Females had a higher risk of DVT than males, and vitamin D may play an essential role in this relationship. Further studies are needed to explore whether vitamin D supplementation could reduce DVT risk in stroke patients, especially females.

Composition of nutrients, heavy metals, polycyclic aromatic hydrocarbons and microbiological quality in processed small indigenous fish species from Ghana: Implications for food security

The triple burden of malnutrition is an incessant issue in low- and middle-income countries, and fish has the potential to mitigate this burden. In Ghana fish is a central part of the diet, but data on nutrients and contaminants in processed indigenous fish species, that are often eaten whole, are missing. Samples of smoked, dried or salted Engraulis encrasicolus (European anchovy), Brachydeuterus auritus (bigeye grunt), Sardinella aurita (round sardinella), Selene dorsalis (African moonfish), Sierrathrissa leonensis (West African (WA) pygmy herring) and Tilapia spp. (tilapia) were collected from five different regions in Ghana. Samples were analyzed for nutrients (crude protein, fat, fatty acids, several vitamins, minerals, and trace elements), microbiological quality (microbial loads of total colony counts, E. coli, coliforms, and Salmonella), and contaminants (PAH4 and heavy metals). Except for tilapia, the processed small fish species had the potential to significantly contribute to the nutrient intakes of vitamins, minerals, and essential fatty acids. High levels of iron, mercury and lead were detected in certain fish samples, which calls for further research and identification of anthropogenic sources along the value chains. The total cell counts in all samples were acceptable; Salmonella was not detected in any sample and E. coli only in one sample. However, high numbers of coliform bacteria were found. PAH4 in smoked samples reached high concentrations up to 1,300 μg/kg, but in contrast salted tilapia samples had a range of PAH4 concentration of 1 μg/kg to 24 μg/kg. This endpoint oriented study provides data for the nutritional value of small processed fish as food in Ghana and also provides information about potential food safety hazards. Future research is needed to determine potential sources of contamination along the value chains in different regions, identify critical points, and develop applicable mitigation strategies to improve the quality and safety of processed small fish in Ghana.

Measurement of Bone Mineral Density in Children with Cerebral Palsy from an Ethical Issue to a Diagnostic Necessity

Introduction

Due to concerns about cumulative radiation exposure in the pediatric population, it is not standard practice to perform dual-energy X-ray absorptiometry (DXA) analysis in the diagnostic process of musculoskeletal disorders, such as cerebral palsy (CP). This study aimed to evaluate the bone mineral density (BMD) in children with CP and the ethical justification of applying DXA analysis in these children. Material and Methods. In this monocentric retrospective analysis, data were collected from children and adolescents with CP who were treated for a primary illness for three years. A clinical examination, which included a DXA analysis, recommended by the multidisciplinary team, was performed. After applying inclusion and exclusion criteria, 60 scans remained for statistical analysis. BMD and Z-scores for the lumbar spine (LS), and hip right and left femoral neck (RFN and LFN, respectively), and total hip (TH) were recorded.

Results

The average age of children with CP when DXA analysis was first performed was about 7 years. The BMD (mean ± SD) at LS (LS-BMD) of all patients was 0.612 ± 0.12, at RFN 0.555 ± 0.11, at LFN 0.572 ± 0.1, and at TH (TH-BMD) 0.581 ± 0.13. The values of the Z-score (mean ± SD) at LS of all patients were −2.5 ± 0.22, at RFN −2.2 ± 0.21, at LFN -2.25 (SD = 0.2), and at TH -2.3 (SD = 0.23). There was no statistical significance between age and gender; however, BMI, walking ability, fracture history, and pattern of CP had a significant impact on BMD and Z-score values of these children.

Conclusion

The results of our study clearly indicate that children with CP have a higher risk of low BMD, osteoporosis, and bone fractures, which makes it ethically justifiable to perform the DXA analysis in these children.

Genetic predisposition to increased serum calcium, bone mineral density, and fracture risk in individuals with normal calcium levels: mendelian randomisation study

OBJECTIVE

To determine if genetically increased serum calcium levels are associated with improved bone mineral density and a reduction in osteoporotic fractures.

DESIGN

Mendelian randomisation study.

SETTING

Cohorts used included: the UK Biobank cohort, providing genotypic and estimated bone mineral density data; 25 cohorts from UK, USA, Europe, and China, providing genotypic and fracture data; and 17 cohorts from Europe, providing genotypic and serum calcium data (summary level statistics).

PARTICIPANTS

A genome-wide association meta-analysis of serum calcium levels in up to 61 079 individuals was used to identify genetic determinants of serum calcium levels. The UK Biobank study was used to assess the association of genetic predisposition to increased serum calcium with estimated bone mineral density derived from heel ultrasound in 426 824 individuals who had, on average, calcium levels in the normal range. A fracture genome-wide association meta-analysis comprising 24 cohorts and the UK Biobank including a total of 76 549 cases and 470 164 controls, who, on average, also had calcium levels in the normal range was then performed.

RESULTS

A standard deviation increase in genetically derived serum calcium (0.13 mmol/L or 0.51 mg/dL) was not associated with increased estimated bone mineral density (0.003 g/cm2, 95% confidence interval -0.059 to 0.066; P=0.92) or a reduced risk of fractures (odds ratio 1.01, 95% confidence interval 0.89 to 1.15; P=0.85) in inverse-variance weighted mendelian randomisation analyses. Sensitivity analyses did not provide evidence of pleiotropic effects.

CONCLUSIONS

Genetic predisposition to increased serum calcium levels in individuals with normal calcium levels is not associated with an increase in estimated bone mineral density and does not provide clinically relevant protection against fracture. Whether such predisposition mimics the effect of short term calcium supplementation is not known. Given that the same genetically derived increase in serum calcium is associated with an increased risk of coronary artery disease, widespread calcium supplementation in the general population could provide more risk than benefit.

Vitamin D Levels in Patients with Recurrent Herpes Labialis

Recurrent infections of herpes simplex virus in the orolabial area are known as recurrent herpes labialis (RHL). Vitamin D has been shown to have an important immunomodulatory role and to be associated with several infectious diseases. This hospital-based case-control study aimed at investigating the association between vitamin D and RHL by comparing vitamin D levels in individuals with and without RHL. Individuals who presented to the dermatology clinic at a state hospital due to RHL (n = 50) and matching control group of healthy volunteers (n = 51) were studied. Their vitamin D levels were measured, stratified based on clinical guidelines, and compared. The average serum vitamin D (25-hydroxyvitamin D) levels were 23.8 ± 15.5 and 42.0 ± 26.3 nM in the patient and control groups, with significant differences between their average serum vitamin D levels and vitamin D status. The studied population had serious vitamin D deficiency regardless of having RHL, with vitamin D levels below the adequate limits in more than 96% of the population. Most importantly, the study established a significant association between low serum vitamin D levels and the presence of RHL. Further interventional and pathophysiological studies should clarify the nature and mechanism of the relationship.

Relationship between Clinical Indicators of Periodontal Disease and Serum Level of Vitamin D

Background: Vitamin D is obtained through food and nutritional supplements, or is synthesized in the skin by sunshine. It is then transferred to the liver and kidney through the bloodstream and hydroxylated by a specific enzyme (cytochrome P450 family 27 subfamilies A member 1, cytochrome P450 family 27 subfamily B member 1) to form 25-hydroxyvitamin D and 1,25-dihydroxy vitamin D. The vitamin D synthesis facilitates calcium and phosphorus absorption from the intestines. The parathyroid hormone helps to synthesize 1,25-dihydroxy vitamin D to aid calcium absorption. Objectives: Many researchers have investigated the relationship between serum vitamin D levels and periodontal disease. And periodontal disease indicators such as bleeding on probing, pocket depth, clinical attachment level, gingival index, and cementoenamel junction-alveolar cresthave been used to identify the effects of vitamin D on periodontal disease. The effects of vitamin D on bacteria or cytokines have also been investigated. In this review article, vitamin D levels according to the status of periodontal disease were summarized. Data sources: PubMed was searched electronically, and randomized clinical trials, cross-sectional studies, and case-control studies were included in the review. Study appraisal and synthesis methods: Articles that the classification of periodontitis was accurately described, indicators for identifying periodontitis was clearly marked, and the form of vitamin D measured in the study was accurately described were selected. Only highly relevant journals were selected and summarized. Results: Most of the research has found positive associations between the serum 25-hydroxyvitamin D level and periodontal health, and the clinical parameters of periodontal disease were reduced by vitamin D. Limitations: Detailed categorization of the characteristics associated with the 25-hydroxyvitamin D level should be needed in future studies. Conclusions: This review article can be used as a guide by clinicians and as a reference book for patients’ education.

Calcium Deficiency Rickets in African Adolescents: Cortical Bone Histomorphometry

Rickets due to dietary calcium deficiency has been well described in black African children, but less is known about this condition in black adolescents. We investigated 26 black adolescents (19 males aged 11 to 19 years and 7 females aged 12 to 15 years) with rachitic leg deformities and 20 controls by routine iliac crest undecalcified cortical bone histomorphometry for disturbances of bone turnover and for mineralization defects, including severity of osteocytic osteolysis (Ot.Olysis) and periosteocytic osteolysis (Peri.Ot.Olysis) of the lacunar‐canalicular space. Serum levels of calcium (sCa), 25‐hydroxyvitamin D (25OHD), 1,25‐dihydroxyvitamin D (1,25(OH)₂D), and total alkaline phosphatase (ALP) were measured. Histomorphometry showed varying degrees of severity of secondary hyperparathyroidism (2⁰ HPT) characterized by hyperosteoidosis, increased erosion, and porosis. Because osteoid was neither being mineralized nor eroded (osteoclasts cannot erode osteoid), it increasingly blocked bone surface needed for osteoclastic resorption. Where osteoid covered >50% of bone surface, osteoid thickness, severity of Ot.Olysis, and extent of Peri.Ot.Olysis increased, sCa and 25OHD declined, and 1,25(OH)₂D and ALP increased. At 80% osteoid cover, bone remodeling had all but ceased, secondary HPT had changed to osteomalacia, and serum biochemical results had deteriorated further. Disease severity was greater in males than in females, likely because males grow faster and for longer than females. In conclusion, this cross‐sectional clinical case study presents cortical bone histomorphometric data of secondary HPT and its transition to osteomalacia in black adolescents with rickets attributable to dietary calcium deficiency. The bone disease was most severe in older adolescent males. Importantly, bone pathology of calcium deficiency rickets in adolescents was not confined to bone surfaces but also manifested at osteocyte level as Ot.Olysis and Peri.Ot.Olysis. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Immunomodulatory Effect of Vitamin D and Its Potential Role in the Prevention and Treatment of Type 1 Diabetes Mellitus-A Narrative Review

Type 1 diabetes mellitus is a chronic autoimmune disease associated with degeneration of pancreatic β-cells that results in an inability to produce insulin and the need for exogenous insulin administration. It is a significant global health problem as the incidence of this disorder is increasing worldwide. The causes are still poorly understood, although it certainly has genetic and environmental origins. Vitamin D formed profusely in the skin upon exposure to sunlight, as well as from dietary sources, exhibits an immunomodulatory effect based on gene transcription control. Indeed, vitamin D can downregulate mechanisms connected with adaptive immunity, induce immunological tolerance and decrease auto-aggression-related inflammation. These properties provide the basis for a preventive and therapeutic role of vitamin D. As many studies have demonstrated, appropriate supplementation with vitamin D reduces the risk of autoimmune diseases, including type 1 diabetes mellitus, and alleviates disease symptoms in patients. The aim of this narrative review is to present the molecular mechanisms for the vitamin D immunomodulatory effect as well as review human clinical studies on the use of vitamin D as adjuvant therapy in type 1 diabetes mellitus.

The vitamin D deficiency pandemic: Approaches for diagnosis, treatment and prevention

Vitamin D deficiency and insufficiency is a global health issue that afflicts more than one billion children and adults worldwide. The consequences of vitamin D deficiency cannot be under estimated. There has been an association of vitamin D deficiency with a myriad of acute and chronic illnesses including preeclampsia, childhood dental caries, periodontitis, autoimmune disorders, infectious diseases, cardiovascular disease, deadly cancers, type 2 diabetes and neurological disorders. This review is to put into perspective the controversy surrounding the definition for vitamin D deficiency and insufficiency as well as providing guidance for how to treat and prevent vitamin D deficiency.

Vitamin D deficiency among smear positive pulmonary tuberculosis patients and their tuberculosis negative household contacts in Northwest Ethiopia: a case-control study

Background

Vitamin D is a fat-soluble vitamin that increases the immunity against tuberculosis (TB), decreases the re-activation of latent TB and reduces the severity of active TB disease. Epidemiological studies on the prevalence of vitamin D deficiency, and its association with TB showed inconsistent results in different countries. This study was aimed to determine the prevalence of vitamin D deficiency and its association with TB in Northwest Ethiopia.

Methods

A case–control study was conducted among smear positive pulmonary tuberculosis patients and their household contacts without symptoms suggestive of TB. Study participants were recruited at 11 TB diagnostic health facilities in North and South Gondar zones of Amhara region between May 2013 and April 2015. The spot-morning-spot sputum samples and 5 ml blood sample were collected prior to commencing TB treatment for the diagnosis of TB and serum vitamin D assay, respectively. The diagnosis of TB was performed using smear microscopy and GeneXpert. Serum vitamin D level was analyzed using VIDAS 25 OH Vitamin D Total testing kits (Biomerieux, Marcy I’Etoile, France) on mini VIDAS automated immunoassay platform. Vitamin D status was interpreted as deficient (<20 ng/ml), insufficient (20–29 ng/ml), sufficient (30–100 ng/ml) and potential toxicity (>100 ng/ml).

Results

Of the total study participants, 134 (46.2%) were vitamin D deficient, and only 56 (19.3%) had sufficient vitamin D level. A total of 59 (61.5%) TB patients and 75 (38.7%) non TB controls were vitamin D deficient. Results of multivariate logistic regression analyses showed a significantly higher vitamin D deficiency among tuberculosis cases (p < 0.001), females (p = 0.002), and urban residents (p < 0.001) than their respective comparison groups. Moreover, age groups of 35–44 (p = 0.001), 45–54 (p = 0.003) and ≥55 (p = 0.001) years had significantly higher vitamin D deficiency compared with age group <15 years.

Conclusions

Vitamin D deficiency is highly prevalent among TB patients and non TB controls in Ethiopia where there is year round abundant sunshine. Study participants with tuberculosis, females, older age groups, and urban residents had significantly higher prevalence of vitamin D deficiency. These findings warrant further studies to investigate the role of vitamin D supplementation in the prevention and treatment of tuberculosis in high TB burden countries like Ethiopia.

Nutritional rickets around the world: an update

Worldwide, nutritional rickets continues to be an evolving problem with several causes. This paper provides an updated literature review characterising the prevalence, aetiology, pathophysiology and treatment of nutritional rickets worldwide. A systematic review of articles on nutritional rickets from various geographical regions was undertaken. For each region, key information was extracted, including prevalence, cause of rickets specific to the region, methods of confirming the diagnosis and current treatment and preventive measures. Calcium deficiency continues to be a major cause of rickets in Africa and Asia. Vitamin D deficiency rickets is perhaps increasing in the Americas, Europe and parts of the Middle East. There continues to be a distinct presentation of calcium-predominant versus vitamin D predominant rickets, although there are overlapping features. More careful diagnosis of rickets and reporting of 25-OHD concentrations has improved accurate knowledge of rickets prevalence and better delineated the cause. Nutritional rickets continues to be an evolving and multi-factorial problem worldwide. It is on a spectrum, ranging from isolated vitamin D deficiency to isolated calcium deficiency. Specific areas which require emphasis include a consistent community approach to screening and diagnosis, vitamin D supplementation of infants and at-risk children, prevention of maternal vitamin D deficiency and the provision of calcium in areas with low calcium diets.

Calcium and vitamin D metabolism in children in developing countries

Low dietary calcium intakes and poor vitamin D status are common findings in children living in developing countries. Despite many of the countries lying within the tropics and subtropics, overcrowding, atmospheric pollution, a lack of vitamin D-fortified foods, and social customs that limit skin exposure to sunlight are major factors in the development of vitamin D deficiency. Low dietary calcium intakes are typically observed as a consequence of a diet limited in dairy products and high in phytates and oxalates which reduce calcium bioavailability. Calcium intakes of many children are a third to a half of the recommended intakes for children living in developed countries, yet the consequences of these low intakes are poorly understood as there is limited research in this area. It appears that the body adapts very adequately to these low intakes through reducing renal calcium excretion and increasing fractional intestinal absorption. However, severe deficiencies of either calcium or vitamin D can result in nutritional rickets, and low dietary calcium intakes in association with vitamin D insufficiency act synergistically to exacerbate the development of rickets. Calcium supplementation in children from developing countries slightly increases bone mass, but the benefit is usually lost on withdrawal of the supplement. It is suggested that the major effect of calcium supplementation is on reducing the bone remodelling space rather than structurally increasing bone size or volumetric bone density. Limited evidence from one study raises concerns about the use of calcium supplements in children on habitually low calcium intakes as the previously supplemented group went through puberty earlier and had a final height several centimetres shorter than the controls.

Preventable but neglected: rickets in an informal settlement, Nairobi, Kenya

SETTING

The primary care clinics of Médecins Sans Frontières within the informal settlement of Kibera, Nairobi, Kenya.

OBJECTIVE

To describe the demographic and clinical characteristics of children clinically diagnosed with rickets from September 2012 to October 2013.

DESIGN

Descriptive retrospective case review of diagnosis and treatment course with vitamin D and calcium using routine programme data.

RESULTS

Of the 82 children who met the clinical diagnosis of rickets, 57% were male, with a median age of 12 months and 14 months for females. Children with rickets were found to have ⩽3 hours/week sunlight exposure for 71% of the children and malnutrition in 39%. Clinical findings on presentation revealed gross motor developmental delays in 44%. The loss to follow-up rate during treatment was 40%.

CONCLUSIONS

This study found that rickets is a common clinical presentation among children living in the informal settlement of Kibera and that there are likely multiple factors within that environment contributing to this condition. As rickets is a simply and inexpensively preventable non-communicable disease, we suggest that routine vitamin D supplementation be formally recommended by the World Health Organization for well-child care in Africa, especially in the contexts of informal settlements.

Vitamin D status among pulmonary TB patients and non-TB controls: a cross-sectional study from Mwanza, Tanzania

BACKGROUND

Little is known about vitamin D status in low-income populations burdened with infectious diseases. Hence, there is a need for data on correlates of serum 25-hydroxy vitamin D (S-25(OH)D) and its validity during infections.

OBJECTIVE

To assess the role of pulmonary TB (PTB) and HIV as correlates of S-25(OH)D.

DESIGN

Age-sex-matched cross-sectional study among PTB patients and non-TB controls.

METHODS

PTB patients were categorized as sputum negative (PTB-) and positive (PTB+) by culture. Non-TB controls were randomly selected among age-sex-matched neighbours to PTB+ patients. Height, weight, arm circumference and triceps skinfold were measured, and body mass index (BMI), arm fat (AFA) and muscle area (AMA) computed. HIV status, and S-25(OH)D, C-reactive protein (S-CRP) and α1-acid glycoprotein (S-AGP) were determined. Linear regression analysis with controls and PTB patients combined was used to identify correlates of S-25(OH)D.

RESULTS

S-25(OH)D data were available on 97.8% (1570) of 1605 participants. Mean (SD) S-25(OH)D was 84.4 (25.6) nmol/L with 39.6% <75 nmol/L among 347 non-TB controls. Time of recruitment, sex, PTB and HIV, and elevated S-AGP were correlates of S-25(OH)D. S-25(OH)D was 24.8 (95% CI 18.6;30.9) nmol/L higher in PTB compared to controls among females, but only 9.8 (95% CI:4.5;15.2) nmol/L among males (interaction p<0.0001). Females had 13.8 (95% CI:8.2;21.9) nmol/L lower S-25(OH)D than males, and HIV infected individuals had 8.5 (95% CI:4.9;12.1) higher S-25(OH)D compared to uninfected. Elevated S-AGP was a positive correlate of S-25(OH)D. Low BMI was associated with S-25(OH)D, but not with infections or S-AGP in the model.

CONCLUSION

While S-25(OH)D may decline transiently during a mild acute phase response, it may increase if the acute phase response leads to loss of fat. The validity of S-25(OH)D as a marker of vitamin D status may be affected by infections.

Vitamin D₃supplementation and childhood diarrhea: a randomized controlled trial

OBJECTIVE

To investigate the effect of vitamin D3 supplementation on the incidence and risk for first and recurrent diarrheal illnesses among children in Kabul, Afghanistan.

METHODS

This double-blind placebo-controlled trial randomized 3046 high-risk 1- to 11-month-old infants to receive 6 quarterly doses of oral vitamin D3 (cholecalciferol 100000 IU) or placebo in inner city Kabul. Data on diarrheal episodes (≥ 3 loose/liquid stools in 24 hours) was gathered through active and passive surveillance over 18 months of follow-up. Time to first diarrheal illness was analyzed by using Kaplan-Meier plots. Incidence rates and hazard ratios (HRs) were calculated by using recurrent event Poisson regression models.

RESULTS

No significant difference existed in survival time to first diarrheal illness (log rank P = .55). The incidences of diarrheal episodes were 3.43 (95% confidence interval [CI], 3.28-3.59) and 3.59 per child-year (95% CI, 3.44-3.76) in the placebo and intervention arms, respectively. Vitamin D3 supplementation was found to have no effect on the risk for recurrent diarrheal disease in either intention-to-treat (HR, 1.05; 95% CI, 0.98-1.17; P = .15) or per protocol (HR, 1.05; 95% CI, 0.98-1.12; P = .14) analyses. The lack of preventive benefit remained when the randomized population was stratified by age groups, nutritional status, and seasons.

CONCLUSIONS

Quarterly supplementation with vitamin D3 conferred no reduction on time to first illness or on the risk for recurrent diarrheal disease in this study. Similar supplementation to comparable populations is not recommended. Additional research in alternative settings may be helpful in elucidating the role of vitamin D3 supplementation for prevention of diarrheal diseases.

The plasma proteome identifies expected and novel proteins correlated with micronutrient status in undernourished Nepalese children

Micronutrient deficiencies are common in undernourished societies yet remain inadequately assessed due to the complexity and costs of existing assays. A plasma proteomics-based approach holds promise in quantifying multiple nutrient:protein associations that reflect biological function and nutritional status. To validate this concept, in plasma samples of a cohort of 500 6- to 8-y-old Nepalese children, we estimated cross-sectional correlations between vitamins A (retinol), D (25-hydroxyvitamin D), and E (α-tocopherol), copper, and selenium, measured by conventional assays, and relative abundance of their major plasma-bound proteins, measured by quantitative proteomics using 8-plex iTRAQ mass tags. The prevalence of low-to-deficient status was 8.8% (<0.70 μmol/L) for retinol, 19.2% (<50 nmol/L) for 25-hydroxyvitamin D, 17.6% (<9.3 μmol/L) for α-tocopherol, 0% (<10 μmol/L) for copper, and 13.6% (<0.6 μmol/L) for selenium. We identified 4705 proteins, 982 in >50 children. Employing a linear mixed effects model, we observed the following correlations: retinol:retinol-binding protein 4 (r = 0.88), 25-hydroxyvitamin D:vitamin D-binding protein (r = 0.58), α-tocopherol:apolipoprotein C-III (r = 0.64), copper:ceruloplasmin (r = 0.65), and selenium:selenoprotein P isoform 1 (r = 0.79) (all P < 0.0001), passing a false discovery rate threshold of 1% (based on P value-derived q values). Individual proteins explained 34-77% (R(2)) of variation in their respective nutrient concentration. Adding second proteins to models raised R(2) to 48-79%, demonstrating a potential to explain additional variation in nutrient concentration by this strategy. Plasma proteomics can identify and quantify protein biomarkers of micronutrient status in undernourished children. The maternal micronutrient supplementation trial, from which data were derived as a follow-up activity, was registered at clinicaltrials.gov as NCT00115271.

Promoting excellence in the care of pediatric endocrine diseases in the developing world

On behalf of the Global Pediatric Endocrinology and Diabetes group, the authors provide a perspective on the rights of a child as enshrined in the United Nations Convention on the Rights of the Child (1989) concerning the care of pediatric endocrine disorders and diabetes mellitus, throughout the world, with particular reference to care in resource-constrained settings. In this article, we define the spectrum of health care needs of the child with an endocrine disorder and how they may be addressed, in terms of education, research, and development of sustainable programs for improved health outcomes. We emphasize the responsibilities of medical communities, the pharmaceutical industry, and relevant governments in promoting and supporting such concepts.

Frequency of vitamin D insufficiency in healthy children between 1 and 16 years of age in Turkey

BACKGROUND

The aim of this study was to establish the frequencies of vitamin D deficiency and insufficiency among healthy children aged 1-16 years and also to determine the factors affecting the levels of vitamin D in Turkey.

METHODS

A total of 849 healthy individuals whose ages ranged from 1 to 16 years were included in the study. Serum 25(OH)D, calcium, phosphorous and alkaline phosphatase l levels were measured at the end of the winter period. The approximate daily calcium intake was calculated by using a 1-week diet history.

RESULTS

We determined that the prevalence of vitamin D deficiency (<20 ng/mL) was 8% and that of vitamin D insufficiency (20-29 ng/mL) was 25.5% in the population investigated. The average daily intake of calcium was especially low in the >8-year-old age group (<1300 mg/day).

CONCLUSION

Vitamin D insufficiency was found to be very common in the population investigated. The daily calcium intake was below the adequate levels especially in school children. Vitamin D supplementation after the first year of life could be beneficial especially for school children and adolescents. The government must develop public policies for the fortification of milk, milk products, and fruit juices with vitamin D.

The effect of calcium supplementation on blood lead levels in Nigerian children

OBJECTIVE

To determine whether calcium supplementation alters the risk of lead toxicity.

STUDY DESIGN

Children aged 12-18 months from 3 communities in Nigeria were assigned to receive daily calcium supplementation, as either calcium carbonate (400 mg) or ground dried fish (529 ± 109 mg), or placebo. All children received 2500 IU of vitamin A. Levels of blood lead, calcium, and vitamin D metabolites were measured at baseline and after 12-18 months (n = 358).

RESULTS

The mean (± SD) baseline lead level was 11.1 ± 7.8 μg/dL (range, 1-43 μg/dL; median, 9 μg/dL); 44.7% of subjects had a lead level >10 μg/dL. After 12-18 months, the mean lead level was 8.1 ± 6.3 μg/dL (range, 1-48 μg/dL; median, 6 μg/dL), with 22.6% with a level >10 μg/dL. Lead levels at baseline varied among communities (P = .01) and were higher in children who used eye cosmetics or lived near a lead-acid battery melter (both P < .001). In a multiple regression model, the decrease in blood lead level was predicted by age, baseline lead level, and time of final lead value at 12-18 months (R(2) = 31%), but not by calcium supplementation (P = .98).

CONCLUSIONS

Lead toxicity is common in Nigerian children, but calcium supplementation does not affect blood lead levels.

Failure of alphacalcidol (1alpha-hydroxyvitamin D3) in treating nutritional rickets and the biochemical response to ergocalciferol

It has been previously documented that alphacalcidol (1alpha-hydroxyvitamin D3) is inefficient in healing rickets, partly because it results in a suboptimal rise in 1,25-dihydroxyvitamin D (1,25-(OH)2D) and partly because it fails to replenish the store of 25-hydroxyvitamin D (25-OHD). However, very few studies have actually documented this outcome. The aim was to document biochemically the response to alphacalcidol and subsequently the change in response to ergocalciferol. This study was conducted at our institution from January 2005 till December 2008. We included all patients referred to our clinic with active rickets after a failed course of alphacalcidol. At baseline the median (IQR) for PTH l7.1 (4.5-35.3) pmol/L, 25-OHD 29.0 (18-66.2) nmol/L, 1,25-(OH)2D 205 (158.2-311.2) pmol/L and ALP 676 (462.5-1101.7) IU/L. After 3 months treatment with ergocalciferol the concentrations changed markedly with biochemical healing: PTH 4.5 (3.9-7.5), 25-OHD 143.5 (101.5-206.5), 1,25-(OH)(2)D 277 (221.0-572.7), ALP 369 (302.2-438.0). The results confirm the biochemical and physiological basis for using ergocalciferol (or cholecalciferol) in nutritional rickets. Unfortunately these forms are not readily available in many geographic areas. This supply problem together with marketing strategies forces physicians to make an incorrect choice of medication. Treatment with ergocalciferol was either with intramuscular stosstherapy or drops for 3 months. The former ensures compliance and is associated with higher 25-OHD and 1,25-(OH)2D concentrations.