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Demay MB, Pittas AG, Bikle DD, Diab DL, Kiely ME, Lazaretti-Castro M, Lips P, Mitchell DM, Murad MH, Powers S, Rao SD, Scragg R, Tayek JA, Valent AM, Walsh JME, McCartney CR. Vitamin D for the Prevention of Disease: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2024; 109:1907-1947. [PMID: 38828931 DOI: 10.1210/clinem/dgae290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Numerous studies demonstrate associations between serum concentrations of 25-hydroxyvitamin D (25[OH]D) and a variety of common disorders, including musculoskeletal, metabolic, cardiovascular, malignant, autoimmune, and infectious diseases. Although a causal link between serum 25(OH)D concentrations and many disorders has not been clearly established, these associations have led to widespread supplementation with vitamin D and increased laboratory testing for 25(OH)D in the general population. The benefit-risk ratio of this increase in vitamin D use is not clear, and the optimal vitamin D intake and the role of testing for 25(OH)D for disease prevention remain uncertain. OBJECTIVE To develop clinical guidelines for the use of vitamin D (cholecalciferol [vitamin D3] or ergocalciferol [vitamin D2]) to lower the risk of disease in individuals without established indications for vitamin D treatment or 25(OH)D testing. METHODS A multidisciplinary panel of clinical experts, along with experts in guideline methodology and systematic literature review, identified and prioritized 14 clinically relevant questions related to the use of vitamin D and 25(OH)D testing to lower the risk of disease. The panel prioritized randomized placebo-controlled trials in general populations (without an established indication for vitamin D treatment or 25[OH]D testing), evaluating the effects of empiric vitamin D administration throughout the lifespan, as well as in select conditions (pregnancy and prediabetes). The panel defined "empiric supplementation" as vitamin D intake that (a) exceeds the Dietary Reference Intakes (DRI) and (b) is implemented without testing for 25(OH)D. Systematic reviews queried electronic databases for publications related to these 14 clinical questions. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology was used to assess the certainty of evidence and guide recommendations. The approach incorporated perspectives from a patient representative and considered patient values, costs and resources required, acceptability and feasibility, and impact on health equity of the proposed recommendations. The process to develop this clinical guideline did not use a risk assessment framework and was not designed to replace current DRI for vitamin D. RESULTS The panel suggests empiric vitamin D supplementation for children and adolescents aged 1 to 18 years to prevent nutritional rickets and because of its potential to lower the risk of respiratory tract infections; for those aged 75 years and older because of its potential to lower the risk of mortality; for those who are pregnant because of its potential to lower the risk of preeclampsia, intra-uterine mortality, preterm birth, small-for-gestational-age birth, and neonatal mortality; and for those with high-risk prediabetes because of its potential to reduce progression to diabetes. Because the vitamin D doses in the included clinical trials varied considerably and many trial participants were allowed to continue their own vitamin D-containing supplements, the optimal doses for empiric vitamin D supplementation remain unclear for the populations considered. For nonpregnant people older than 50 years for whom vitamin D is indicated, the panel suggests supplementation via daily administration of vitamin D, rather than intermittent use of high doses. The panel suggests against empiric vitamin D supplementation above the current DRI to lower the risk of disease in healthy adults younger than 75 years. No clinical trial evidence was found to support routine screening for 25(OH)D in the general population, nor in those with obesity or dark complexion, and there was no clear evidence defining the optimal target level of 25(OH)D required for disease prevention in the populations considered; thus, the panel suggests against routine 25(OH)D testing in all populations considered. The panel judged that, in most situations, empiric vitamin D supplementation is inexpensive, feasible, acceptable to both healthy individuals and health care professionals, and has no negative effect on health equity. CONCLUSION The panel suggests empiric vitamin D for those aged 1 to 18 years and adults over 75 years of age, those who are pregnant, and those with high-risk prediabetes. Due to the scarcity of natural food sources rich in vitamin D, empiric supplementation can be achieved through a combination of fortified foods and supplements that contain vitamin D. Based on the absence of supportive clinical trial evidence, the panel suggests against routine 25(OH)D testing in the absence of established indications. These recommendations are not meant to replace the current DRIs for vitamin D, nor do they apply to people with established indications for vitamin D treatment or 25(OH)D testing. Further research is needed to determine optimal 25(OH)D levels for specific health benefits.
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Affiliation(s)
- Marie B Demay
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Anastassios G Pittas
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Tufts Medical Center, Boston, MA 02111, USA
| | - Daniel D Bikle
- Departments of Medicine and Dermatology, University of California San Francisco, San Francisco VA Medical Center, San Francisco, CA 94158, USA
| | - Dima L Diab
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Mairead E Kiely
- Cork Centre for Vitamin D and Nutrition Research, School of Food and Nutritional Sciences and INFANT Research Centre, University College Cork, Cork, T12 Y337, Ireland
| | - Marise Lazaretti-Castro
- Department of Internal Medicine, Division of Endocrinology, Universidade Federal de Sao Paulo, Sao Paulo 04220-00, Brazil
| | - Paul Lips
- Endocrine Section, Amsterdam University Medical Center, Internal Medicine, 1007 MB Amsterdam, Netherlands
| | - Deborah M Mitchell
- Pediatric Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN 55905, USA
| | - Shelley Powers
- Bone Health and Osteoporosis Foundation, Los Gatos, CA 95032, USA
| | - Sudhaker D Rao
- Division of Endocrinology, Diabetes and Bone & Mineral Disorders, Henry Ford Health, Detroit, MI 48202, USA
- College of Human Medicine, Michigan State University, Lansing, MI 48824, USA
| | - Robert Scragg
- School of Population Health, The University of Auckland, Auckland 1142, New Zealand
| | - John A Tayek
- Department of Internal Medicine, Harbor-UCLA Medical Center, Torrance, CA 90509, USA
- The Lundquist Institute, Torrance, CA 90502, USA
| | - Amy M Valent
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Judith M E Walsh
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Christopher R McCartney
- Department of Medicine, University of Virginia, Charlottesville, VA 22908, USA
- Department of Medicine, West Virginia University, Morgantown, WV 26506, USA
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2
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Wechsung K, Schnabel D, Wiegand S. Longitudinal analysis of vitamin D levels considering sunshine duration and suggestion for a standardised approach for vitamin D supplementation in children and adolescents with obesity. BMC Pediatr 2024; 24:337. [PMID: 38750418 PMCID: PMC11094954 DOI: 10.1186/s12887-024-04823-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 05/09/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Children with obesity have low 25 hydroxy-vitamin D (25-OH-D3) levels compared to lean children. Recommendations on when to start vitamin D supplementation differ largely between countries. Longitudinal data on 25-OH-D3 levels to guide treatment decisions are scarce since they are largely influenced by solar radiation and are difficult to compare. METHODS We carried out a retrospective analysis of multiple 25-OH-D3 and parathyroid hormone (PTH) measurements in a cohort of 543 patients without vitamin D supplementation. All measurements were taken at the local paediatric obesity clinic as documented in the German-Austrian-Swiss APV (Prospective Documentation of Overweight Children and Adolescents) registry from 2009 to 2019. Serial 25-OH-D3 and PTH levels were adjusted for sunshine duration over the last 30 days to account for seasonal variation, as well as for sex and body mass index (BMI). We further performed an exploratory analysis of the association of sunshine duration, sex, BMI SDS (standard deviation score), abnormal lipid levels or dysglycemia with the 25-OH-D3 trend. RESULTS 229 obese patients (mean BMI SDS: 2,58 (± 0,56), 53% females, mean age: 12 (± 3) years, range: 2-21 years) with two, 115 with three and 96 with four repeated 25-OH-D3 measurements were identified. Mean adjusted 25-OH-D3 (48.2 nmol/l) and PTH (34.9 ng/l) levels remained stable over 120 weeks. 5% of the patients had an elevated PTH > 65 ng/l. High total cholesterol ≥ 200 mg/dl and high triglycerides ≥ 130 mg/dl were associated with higher 25-OH-D3 levels. CONCLUSION We propose a simple method to include sunshine duration in the analysis of 25-OH-D3 levels to minimise the bias of seasonal variation. Based on our data we established the pragmatic strategy of limiting vitamin D supplementation to patients with biochemical signs of mineralisation disorders such as elevated PTH and alkaline phosphatase (AP). In children with normal PTH and AP we recommend adjustment of calcium intake and increase of outdoor activity instead.
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Affiliation(s)
- Katja Wechsung
- Department for Pediatric Endocrinology and Diabetology, Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Dirk Schnabel
- Department for Pediatric Endocrinology and Diabetology, Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Susanna Wiegand
- Department for Pediatric Endocrinology and Diabetology, Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
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3
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Giustina A, Bilezikian JP, Adler RA, Banfi G, Bikle DD, Binkley NC, Bollerslev J, Bouillon R, Brandi ML, Casanueva FF, di Filippo L, Donini LM, Ebeling PR, Fuleihan GEH, Fassio A, Frara S, Jones G, Marcocci C, Martineau AR, Minisola S, Napoli N, Procopio M, Rizzoli R, Schafer AL, Sempos CT, Ulivieri FM, Virtanen JK. Consensus Statement on Vitamin D Status Assessment and Supplementation: Whys, Whens, and Hows. Endocr Rev 2024:bnae009. [PMID: 38676447 DOI: 10.1210/endrev/bnae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Indexed: 04/28/2024]
Abstract
The 6th International Conference, "Controversies in Vitamin D," was convened to discuss controversial topics, such as vitamin D metabolism, assessment, actions, and supplementation. Novel insights into vitamin D mechanisms of action suggest links with conditions that do not depend only on reduced solar exposure or diet intake and that can be detected with distinctive noncanonical vitamin D metabolites. Optimal 25-hydroxyvitamin D (25(OH)D) levels remain debated. Varying recommendations from different societies arise from evaluating different clinical or public health approaches. The lack of assay standardization also poses challenges in interpreting data from available studies, hindering rational data pooling and meta-analyses. Beyond the well-known skeletal features, interest in vitamin D's extraskeletal effects has led to clinical trials on cancer, cardiovascular risk, respiratory effects, autoimmune diseases, diabetes, and mortality. The initial negative results are likely due to enrollment of vitamin D-replete individuals. Subsequent post hoc analyses have suggested, nevertheless, potential benefits in reducing cancer incidence, autoimmune diseases, cardiovascular events, and diabetes. Oral administration of vitamin D is the preferred route. Parenteral administration is reserved for specific clinical situations. Cholecalciferol is favored due to safety and minimal monitoring requirements. Calcifediol may be used in certain conditions, while calcitriol should be limited to specific disorders in which the active metabolite is not readily produced in vivo. Further studies are needed to investigate vitamin D effects in relation to the different recommended 25(OH)D levels and the efficacy of the different supplementary formulations in achieving biochemical and clinical outcomes within the multifaced skeletal and extraskeletal potential effects of vitamin D.
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Affiliation(s)
- Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCCS Hospital, Milan 20132, Italy
| | - John P Bilezikian
- Department of Medicine, Vagelos College of Physicians and Surgeons, New York, NY 10032, USA
| | - Robert A Adler
- Richmond Veterans Affairs Medical Center and Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Giuseppe Banfi
- IRCCS Galeazzi Sant'Ambrogio Hospital, Milano 20161, Italy
- San Raffaele Vita-Salute University, Milan 20132, Italy
| | - Daniel D Bikle
- Department of Medicine, University of California and San Francisco Veterans Affairs Health Center, San Francisco, CA 94121-1545, USA
- Department of Endocrinology, University of California and San Francisco Veterans Affairs Health Center, San Francisco, CA 94121-1545, USA
| | - Neil C Binkley
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53726, USA
| | | | - Roger Bouillon
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, 3000 Leuven, Belgium
| | - Maria Luisa Brandi
- Italian Foundation for the Research on Bone Diseases (F.I.R.M.O.), Florence 50129, Italy
| | - Felipe F Casanueva
- Department of Medicine, Instituto de Investigación Sanitaria (IDIS), Complejo Hospitalario Universitario and CIBER de Fisiopatologia de la Obesidad y Nutricion (CIBERobn), Santiago de Compostela University, Santiago de Compostela 15706, Spain
| | - Luigi di Filippo
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCCS Hospital, Milan 20132, Italy
| | - Lorenzo M Donini
- Department of Experimental Medicine, Sapienza University, Rome 00161, Italy
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton 3168, Australia
| | - Ghada El-Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, WHO CC for Metabolic Bone Disorders, Division of Endocrinology, American University of Beirut, Beirut 1107 2020, Lebanon
| | - Angelo Fassio
- Rheumatology Unit, University of Verona, Verona 37129, Italy
| | - Stefano Frara
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCCS Hospital, Milan 20132, Italy
| | - Glenville Jones
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, ON K7L 3N6, Canada
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy
| | - Adrian R Martineau
- Faculty of Medicine and Dentistry, Queen Mary University of London, London E1 4NS, UK
| | - Salvatore Minisola
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome 00161, Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes Campus Bio-Medico, University of Rome, Rome 00128, Italy
| | - Massimo Procopio
- Division of Endocrinology, Diabetology and Metabolic Diseases, "Molinette" Hospital, University of Turin, Turin 10126, Italy
| | - René Rizzoli
- Geneva University Hospitals and Faculty of Medicine, Geneva 1205, Switzerland
| | - Anne L Schafer
- Department of Medicine, University of California and San Francisco Veterans Affairs Health Center, San Francisco, CA 94121-1545, USA
| | | | - Fabio Massimo Ulivieri
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCCS Hospital, Milan 20132, Italy
| | - Jyrki K Virtanen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio FI-70211, Finland
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4
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Çömlek FÖ, Toprak A, Birbilen AZ, Dilek SÖ, Coşkun F. Evaluation of vitamin D levels in children and adolescents after the first year of the COVID-19 pandemic: 1-year results of a secondary-level state hospital. Arch Pediatr 2024; 31:179-182. [PMID: 38538466 DOI: 10.1016/j.arcped.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/21/2023] [Accepted: 11/21/2023] [Indexed: 04/07/2024]
Abstract
BACKGROUND The COVID-19 pandemic caused a global public health problem with high morbidity and mortality rates. In this study, we aimed to evaluate the 25-hydroxyvitamin D (25(OH)D) status of patients presenting to the Pediatrics Department of Gaziantep Maternity and Children's Hospital in the 1-year period after the onset of the COVID-19 pandemic according to ethnicity, age, and gender. METHOD This cross-sectional study included the data of 7640 patients whose 25(OH)D levels were assessed at our hospital between March 2021 and March 2022. Vitamin D levels, age, gender, and the ethnic origin of the patients were retrospectively scanned and recorded from the laboratory results system. Based on the World Health Organization (WHO) classification of vitamin D levels, patients were divided into three groups: <10 ng/mL = vitamin D deficiency; 10-19 ng/mL = vitamin D insufficiency, and 20 ng/mL and over = normal vitamin D status. RESULTS The mean age of the 7640 patients who presented to the pediatrics department was 7.47 (±5.3) years. Of these patients, 48 % (3665) were male and 52 % (3975) were female. The mean vitamin D level of girls was 18.1 (±15.2) ng/mL, and of boys it was 20.2 (±15.4) ng/mL, with a statistically significant difference (p < 0.001). In total, 21.2 % (1650) of patients had deficient, 43.3 % (3310) of patients had insufficient, and 35.5 % (2710) of patients had normal 25(OH)D levels. Overall, 21.8 % of the patients (1667) were immigrants, and in this group the deficiency was found to be statistically significantly higher at 27.4 % (n = 456; p < 0.001). There was a low negative correlation between the age of the patients and their 25(OH)D levels (r=-0.35; p < 0.001). CONCLUSIONS Vitamin D deficiency remains a serious public health problem. Since the most important production source is exposure to the sun, it must be kept in mind that vitamin D should be supported during lockdown pandemic processes.
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Affiliation(s)
| | - Ali Toprak
- Biostatistics, Bezmialem Vakıf University, İstanbul, Turkey
| | | | | | - Fatma Coşkun
- Anesthesia and Reanimation, Gaziantep Children Hospital, Gaziantep, Turkey
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5
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Biasucci G, Donini V, Cannalire G. Rickets Types and Treatment with Vitamin D and Analogues. Nutrients 2024; 16:416. [PMID: 38337700 PMCID: PMC10857029 DOI: 10.3390/nu16030416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
The definition of "Vitamin D" encompasses a group of fat-soluble steroid compounds of different origins with similar chemical structures and the same biological effects. Vitamin D deficiency and/or a defect in the process of its synthesis or transport predispose individuals to several types of rickets. In addition to cholecalciferol, ergocalciferol, and vitamins D3 and D2, there are also active metabolites for the treatment of this condition which are commercially available. Calcitriol and aphacalcidiol are active metabolites that do not require the renal activation step, which is required with calcifediol, or hepatic activation. The purpose of this review is to summarize current approaches to the treatment of rickets for generalist physicians, focusing on the best vitamin D form to be used in each type, or, in the case of X-linked hypophosphatemic rickets (XLH), on both conventional and innovative monoclonal antibody treatments.
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Affiliation(s)
- Giacomo Biasucci
- Pediatrics and Neonatology Unit, University of Parma, Gugliemo da Saliceto Hospital, 29121 Piacenza, Italy;
- Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy
| | - Valentina Donini
- Unit of Pediatrics, Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy;
| | - Giuseppe Cannalire
- Pediatrics and Neonatology Unit, University of Parma, Gugliemo da Saliceto Hospital, 29121 Piacenza, Italy;
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Benameur T. Seasonal Variations in 25-Hydroxyvitamin D Levels among Pediatric Patients Attending the Healthcare Centre. Nutrients 2024; 16:379. [PMID: 38337664 PMCID: PMC10856968 DOI: 10.3390/nu16030379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/17/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Vitamin D plays an essential role in maintaining bone density, building the immune system, and regulating cell growth alongside other key biological functions. Limited data are available about the seasonal variation in vitamin D levels in the pediatric population in Saudi Arabia. This study aimed to investigate the seasonal influence on the pediatric circulating levels of 25(OH)D. A total of 1790 pediatric outpatients who visited the University healthcare centre were included in this study. Overall, there was a noticeably high prevalence (69%) of both combined 25(OH)D deficiency and insufficiency. The highest mean serum concentration of 25(OH)D was recorded in summer (29 ng/mL) and autumn (27 ng/mL). The deficient and insufficient categories were predominant, accounting for 33% and 36%, respectively. Comparable patterns were recorded during autumn, winter, and spring. Interestingly, the 25(OH)D level was significantly associated with the four seasons (p = 0.001), with females having a higher prevalence of 25(OH)D deficiency in the spring and summer than males. Furthermore, only in autumn and winter, we found a significant association between gender and 25(OH)D status (p < 0.001 for both). Another association between nationality and the circulating levels 25(OH)D was found during autumn and winter (p < 0.001 and p = 0.01), respectively. In all seasons, age had a negative impact on serum (OH)D levels. However, this relationship was statistically significant (p < 0.05) only in summer, autumn, and winter. Gender was a significant predictor, with 25(OH)D levels in autumn and winter and an odds ratio of 1.67 in autumn and 2 in winter, indicating that being men had a positive influence on circulating 25(OH)D levels. There were highly significant differences in 25(OH)D concentrations among different age categories. The Saudi population experiences low levels of vitamin D, particularly in autumn and winter periods. This study showed that seasonality, age category, nationality, and gender influence vitamin D status, suggesting the need for tailored intervention and monitoring of 25(OH)D status to reach adequate levels of vitamin D. Healthcare practitioners and policymakers may consider the interplay between age, nationality, gender, and seasonal variations when addressing vitamin D status and a targeted supplementation approach for high-risk groups that may develop health issues.
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Affiliation(s)
- Tarek Benameur
- Department of Biomedical Sciences, College of Medicine, King Faisal University, Al Ahsa 31982, Saudi Arabia
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Naranjo L, Williams Y, Levy J, Obando R, González JA, Pachar M, Chen R, Franco-Paredes C, Higuita NA, Henao-Martínez A, Diaz Y, Suárez JA. The Endless Vulnerability of Migrant Children In-Transit across the Darién Gap. Am J Trop Med Hyg 2023; 109:515-519. [PMID: 37487560 PMCID: PMC10484268 DOI: 10.4269/ajtmh.22-0765] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 05/22/2023] [Indexed: 07/26/2023] Open
Abstract
Many people from poverty-stricken countries are migrating across South and Central America to reach the México-United States border, a movement exacerbated by the COVID-19 pandemic. Migrant people who begin their northbound journey in South America must transit across a significant geographic bottleneck, the Darién Gap, a mountainous rainforest region between Colombia and Panama. Most migrant people crossing this region originate from Cuba, Haiti, and Venezuela. Other people reach the shores of South American countries from west and central Africa or central and southeastern Asia and continue to the Darién Gap. Poverty and violence drive families with children to flee their homes and endure incalculable risks in their path. Children traveling with their families or as unaccompanied minors across the Darién Gap are exposed to life-threatening situations and human rights violations, including abuse, exploitation, malnourishment, and limited access to medical care. In addition to experiencing untreated medical illnesses, children experience mental health disorders during migration and after they reach their destination as a result of victimization and adverse traumatic experiences. Therefore, providing migrants, especially children, with rapid medical screenings and mental health support when they arrive at their destination is critical to reduce health inequities. Furthermore, making these interventions available during their transit and ensuring their safety may prevent further human rights abuses in children and families. Latin American governments must address the ongoing humanitarian crisis endured by migrants throughout their migratory path by offering access to essential healthcare services and safeguarding the rights and security of children and vulnerable groups.
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Affiliation(s)
- Laura Naranjo
- GlaxoSmithKline Vaccines CARICAM, Panama City, Republic of Panama
- Sistema Nacional de Investigación, SNI-Senacyt, Panama City, Republic of Panama
| | - Yesenia Williams
- Hospital de Niños José Renán Esquivel, Panama City, Republic of Panama
| | - Jacqueline Levy
- Hospital de Niños José Renán Esquivel, Panama City, Republic of Panama
| | - Rosela Obando
- Caja del Seguro Social, Panama City, Republic of Panama
| | - José A. González
- Hospital Irma De Lourdes Tzanetato, Panama City, Republic of Panama
| | - Mónica Pachar
- Hospital Santo Tomás, Panama City, Republic of Panama
- Hospital Oncológico, Panama City, Republic of Panama
| | - Roderick Chen
- Instituto Conmemorativo Gorgas, Panama City, Republic of Panama
| | - Carlos Franco-Paredes
- Hospital Infantil de México, Federico Gómez, Mexico DF, Mexico
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado
| | - Nelson Agudelo Higuita
- Department of Medicine, Section of Infectious Diseases, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Andrés Henao-Martínez
- Department of Medicine, Division of Infectious Diseases, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Yamilka Diaz
- Instituto Conmemorativo Gorgas, Panama City, Republic of Panama
| | - José A. Suárez
- Sistema Nacional de Investigación, SNI-Senacyt, Panama City, Republic of Panama
- Facultad de Ciencias Exactas, Universidad de Panama, Panama City, Republic of Panama
- Facultad de Ciencias de la salud, Uisek, Ecuador
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Bustamante VH, Estrada A, Merchant N. Characteristics of vitamin D deficiency hypocalcemia inpatient admissions at a single tertiary center. J Pediatr Endocrinol Metab 2023; 36:749-752. [PMID: 37436141 DOI: 10.1515/jpem-2023-0201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/30/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVES Severe 25-hydroxyvitamin D (25(OH)D) deficiency can result in life-threatening presentations due to hypocalcemia leading to seizures and cardiac arrhythmias. vitamin D deficiency is a common cause of hypocalcemia and rickets in children; however, there are no recent studies on the burden of inpatient admissions in the United States. Our study aims to describe the clinical characteristics and risk factors of inpatient admissions due to severe hypocalcemia and 25(OH)D deficiency at a freestanding academic children's hospital. METHODS A descriptive retrospective chart review was completed on all inpatient admissions from 2016 to 2021 for children 0-18 years of age with corrected calcium <8 mg/dL and 25(OH)D <10 ng/mL during admission. RESULTS Thirty-eight patients met the inclusion criteria (74 % Black/African American). Neurological signs described in 49 %, bone abnormalities in 17 % and EKG abnormalities in 42 % of the patients. The mean calcium serum level was 6.0 mmol/L (range 5.0-7.9 mmol/L), the mean iCa 0.77 mmol/L (range 0.54-0.99 mmol/L). The mean level of 25(OH)D was 5.5 ng/mL (range 2.1-9.7 ng/mL). The median length of stay was 4.5 (range 1-59 days). CONCLUSIONS In this retrospective observational study, risk factors identified: (1) Black/African American race (2) age less than two years (3) lack of supplementation of vitamin D and (4) dietary restrictions. Inpatient admissions are preventable through the implementation of education at the community and healthcare levels.
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Affiliation(s)
| | - Andrea Estrada
- Division of Endocrinology and Diabetes, Children's National Hospital, Washington, DC, USA
- Division of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
| | - Nadia Merchant
- Division of Endocrinology and Diabetes, Children's National Hospital, Washington, DC, USA
- Division of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
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Tanna NK, Karki M, Webber I, Alaa A, El-Costa A, Blair M. Knowledge, attitudes, and practices associated with vitamin D supplementation: A cross-sectional online community survey of adults in the UK. PLoS One 2023; 18:e0281172. [PMID: 37549145 PMCID: PMC10406322 DOI: 10.1371/journal.pone.0281172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 07/21/2023] [Indexed: 08/09/2023] Open
Abstract
OBJECTIVE Assess knowledge, attitudes, and practices (KAPs) of a diverse population. Identify barriers and facilitators that inform routine vitamin D supplementation and self-care in the community setting. DESIGN Cross-sectional online voluntary survey. Electronic survey link published on college Qualtrics platform and advertised widely. Study information provided with Participant Information Sheet. SETTING AND PARTICIPANTS 556 community dwelling adults across the UK. METHODS The overarching study included two phases, incorporating quantitative and qualitative methodologies. This paper reports findings from the first phase of the FABCOM-D (Facilitators and Barriers to Community (Healthy) Vitamin D status) study. Online survey questions were iteratively developed after background literature searches and piloted to ensure clarity and ease of understanding. Survey responses summarised using frequencies and percentages, and univariable and multivariable logistic regression models explored for any association. A p-value less than 0.05 was considered statistically significant. The Checklist for Reporting Results of Internet E-Surveys guided reporting. Statistical analysis performed using IBM SPSS software. MAIN OUTCOME MEASURES Awareness of vitamin D information sources, health benefits and testing. Attitudes to supplementation, sun exposure and fortification. RESULTS Three quarters of the community had some awareness of vitamin D and around half were taking supplements. The two most trusted sources of information included health professionals and the NHS website. Participants were willing to pay for supplements, supporting a self-care agenda. With increasing age, there was significant reduced intake of vitamin D supplements. This aspect needs to be explored further as this could be a concern in deficiency status in the elderly. There was acceptance of food fortification but uncertainty on how to balance food intake with supplementation. CONCLUSION We were successful in eliciting views on KAPs around vitamin D from a community population including a large proportion of Black and Minority Ethnic individuals. The community wanted information and guidance to help manage individual vitamin D status, especially for high-risk groups, and on balancing supplementation, food fortification and sun exposure.
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Affiliation(s)
- Nuttan Kantilal Tanna
- Department of Primary Care & Public Health, Imperial College London, London, United Kingdom
- River Island Paediatric and Child Health Academic Unit, Northwick Park Hospital, London North-West University Healthcare NHS Trust, London, United Kingdom
| | - Manisha Karki
- Self-Care Academic Research Unit (SCARU), School of Public Health, Imperial College London, London, United Kingdom
| | - Iman Webber
- Self-Care Academic Research Unit (SCARU), School of Public Health, Imperial College London, London, United Kingdom
| | - Aos Alaa
- Self-Care Academic Research Unit (SCARU), School of Public Health, Imperial College London, London, United Kingdom
| | - Austen El-Costa
- Self-Care Academic Research Unit (SCARU), School of Public Health, Imperial College London, London, United Kingdom
| | - Mitch Blair
- Department of Primary Care & Public Health, Imperial College London, London, United Kingdom
- River Island Paediatric and Child Health Academic Unit, Northwick Park Hospital, London North-West University Healthcare NHS Trust, London, United Kingdom
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Wójcik M, Jaworski M, Płudowski P. 25(OH)D Concentration in Neonates, Infants, Toddlers, Older Children and Teenagers from Poland-Evaluation of Trends during Years 2014-2019. Nutrients 2023; 15:3477. [PMID: 37571414 PMCID: PMC10420956 DOI: 10.3390/nu15153477] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023] Open
Abstract
INTRODUCTION Local and international guidelines have provided schedules for the vitamin D supplementation of general populations of different ages, including children. Our study aimed to assess 25(OH)D concentration and its potential change during a growth and maturation period, adding parameters that reflect the risk of hypercalcemia. MATERIALS AND METHODS The available 25(OH)D concentration values (n = 17,636; 7.8 ± 6.0 years), calcium (n = 2673; 16.3 ± 6.1 years) and phosphate (n = 2830; 3.8 ± 5.2 years) metabolism markers were analyzed in a studied group of patients (0-18 years). RESULTS In the studied group the mean 25(OH)D concentration was 29.4 ± 11.7 ng/mL. Concentrations of 25(OH)D < 10 ng/mL were observed in 1.7% of patients (n = 292), 10-20 ng/mL in 17.2% (n = 3039), 20-30 ng/mL in 39.5% (n = 6960) and 30-50 ng/mL in 37.2% (n = 6567). In patients with a 25(OH)D concentration <10 ng/mL, normal calcemia (2.25-2.65 mmol/L) was observed in 29.5% of cases (n = 86). Three patients had 25(OH)D concentrations above 100 ng/mL with co-existing hypercalcemia; the mean was Ca = 3.40 mmol/L. Hypocalcemia (Ca < 2.25 mmol/L) was observed in 10,4% of patients (n = 2797). Furthermore, 5.0% of patients showed an increased calcium concentration >2.65 mmol/L (n = 1327). The highest mean 25(OH)D concentration of 32.1 ng/mL ± 12.9 was noted in the years 2018-2019 (n = 3931) and the lowest in the year 2015 (27.2 ng/mL ± 11.0; n = 2822). CONCLUSIONS Vitamin D deficiency (<20 ng/mL) was noted in 18,9% of subjects in the years 2014-2019. An effective prevention of vitamin D deficiency was observed in children aged 3 years and younger. A relationship between the concentrations of calcium and 25(OH)D was not observed.
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Affiliation(s)
| | | | - Paweł Płudowski
- Department of Biochemistry, Radioimmunology and Exerimental Medicine, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (M.W.); (M.J.)
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Pereira A, Adekunle RD, Zaman M, Wan MJ. Association Between Vitamin Deficiencies and Ophthalmological Conditions. Clin Ophthalmol 2023; 17:2045-2062. [PMID: 37489231 PMCID: PMC10363387 DOI: 10.2147/opth.s401262] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/12/2023] [Indexed: 07/26/2023] Open
Abstract
Vitamin deficiencies can have adverse effects on health, including on the visual system. The ocular manifestations of a vitamin deficiency are related to the underlying biochemical function of the particular nutrient. While vitamin deficiencies are not common in developed counties, they are still prevalent in parts of the developing world and in specific, vulnerable populations. Vitamin deficiencies can cause or contribute to many ophthalmological conditions and eye diseases may even be the first presenting finding of a vitamin deficiency. As such, it is important for ophthalmologists to be aware of the ocular manifestations of vitamin deficiencies, especially given that the complications can be severe and effectively treated if identified early. This review summarizes the literature on the main vitamins known to have characteristic ocular manifestations: vitamins A, B1, B2, B9, B12, C, D, E and K. The function, epidemiology, manifestations, workup, and management of each vitamin is discussed in detail.
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Affiliation(s)
- Austin Pereira
- University of Toronto Department of Ophthalmology & Vision Sciences, Toronto, Ontario, Canada
| | - R Damilola Adekunle
- Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Michele Zaman
- Queen’s School of Medicine, Kingston, Ontario, Canada
| | - Michael J Wan
- University of Toronto Department of Ophthalmology & Vision Sciences, Toronto, Ontario, Canada
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12
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Pieridou C, Uday S. Nutritional rickets presenting with developmental regression: a rare presentation of rickets. BMC Pediatr 2023; 23:330. [PMID: 37386483 PMCID: PMC10308663 DOI: 10.1186/s12887-023-04127-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 06/11/2023] [Indexed: 07/01/2023] Open
Abstract
Rickets is a disorder of defective mineralisation of the growth plate. Vitamin D deficiency remains the leading cause of nutritional rickets worldwide.We present the case of a 3.5-year-old breastfed boy who presented with dental abscess when a history of developmental regression was noted. Clinical assessment revealed hypotonia, poor growth and stunting. Biochemistry identified hypocalcaemia (1.63mmol/L, [normal range (NR) 2.2-2.7mmol/L]), severe vitamin D deficiency (25hydroxyvitamin D 5.3nmol/L, [NR > 50nmol/L]) with secondary hyperparathyroidism (Parathormone 159pmol/L, [NR 1.6-7.5pmol/L]) and rickets on radiographs. Growth failure screening suggested hypopituitarism with central hypothyroidism and low IGF1 at baseline, however, dynamic tests confirmed normal axis. Management included nasogastric nutritional rehabilitation, cholecalciferol and calcium supplementation and physiotherapy. A good biochemical response in all parameters was observed within 3 weeks and reversal of developmental regression by 3 months from treatment. Developmental regression as a presentation of nutritional rickets is rare and requires a high index of suspicion.
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Affiliation(s)
- Chariklia Pieridou
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, UK
| | - Suma Uday
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, UK.
- Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, UK.
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Diaz-Thomas AM, Golden SH, Dabelea DM, Grimberg A, Magge SN, Safer JD, Shumer DE, Stanford FC. Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement. J Clin Endocrinol Metab 2023; 108:1533-1584. [PMID: 37191578 PMCID: PMC10653187 DOI: 10.1210/clinem/dgad124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Indexed: 05/17/2023]
Abstract
Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions-growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.
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Affiliation(s)
- Alicia M Diaz-Thomas
- Department of Pediatrics, Division of Endocrinology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Sherita Hill Golden
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Dana M Dabelea
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Adda Grimberg
- Department of Pediatrics, Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Sheela N Magge
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Joshua D Safer
- Department of Medicine, Division of Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10001, USA
| | - Daniel E Shumer
- Department of Pediatric Endocrinology, C.S. Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
| | - Fatima Cody Stanford
- Massachusetts General Hospital, Department of Medicine-Division of Endocrinology-Neuroendocrine, Department of Pediatrics-Division of Endocrinology, Nutrition Obesity Research Center at Harvard (NORCH), Boston, MA 02114, USA
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Cui A, Zhang T, Xiao P, Fan Z, Wang H, Zhuang Y. Global and regional prevalence of vitamin D deficiency in population-based studies from 2000 to 2022: A pooled analysis of 7.9 million participants. Front Nutr 2023; 10:1070808. [PMID: 37006940 PMCID: PMC10064807 DOI: 10.3389/fnut.2023.1070808] [Citation(s) in RCA: 54] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 02/27/2023] [Indexed: 03/19/2023] Open
Abstract
BackgroundVitamin D deficiency causes the bone hypomineralization disorder osteomalacia in humans and is associated with many non-skeletal disorders. We aim to estimate the global and regional prevalence of vitamin D deficiency in people aged 1 year or older from 2000 to 2022.MethodsWe systematically searched Web of Science, PubMed (MEDLINE), Embase, Scopus, and Google databases on December 31, 2021, and updated them on August 20, 2022, without language and time restrictions. Meanwhile, we identified references of relevant system reviews and eligible articles and included the latest and unpublished data from the National Health and Nutrition Examination Survey (NHANES, 2015–2016 and 2017–2018) database. The studies investigating the prevalence of vitamin D deficiency in population-based studies were included. A standardized data extraction form was used to collect information from eligible studies. We used a random-effects meta-analysis to estimate the global and regional prevalence of vitamin D deficiency. We stratified meta-analyses by latitude, season, six WHO regions, the World Bank income groups, gender, and age groups. This study was registered with PROSPERO (CRD42021292586).FindingsOut of 67,340 records searched, 308 studies with 7,947,359 participants from 81 countries were eligible for this study, 202 (7,634,261 participants), 284 (1,475,339 participants), and 165 (561,978 participants) studies for the prevalence of serum 25(OH)D <30, <50, and <75 nmol/L, respectively. We found that globally, 15.7% (95% CrI 13.7–17.8), 47.9% (95% CrI 44.9–50.9), and 76·6% (95% CrI 74.0–79.1) of participants had serum 25-hydroxyvitamin D levels less than 30, 50, and 75 nmol/l, respectively; the prevalence slightly decreased from 2000–2010 to 2011–2022, but it was still at a high level; people living in high latitude areas had a higher prevalence; the prevalence in winter-spring was 1.7 (95% CrI 1.4–2.0) times that in summer-autumn; the Eastern Mediterranean region and Lower-middle-income countries had a higher prevalence; females were vulnerable to vitamin D deficiency; gender, sampling frame, detection assays, sampling region, time of data collection, season, and other factors contributed to heterogeneity between the included studies.InterpretationGlobally, vitamin D deficiency remained prevalent from 2000 to 2022. The high prevalence of vitamin D deficiency would increase the global burden of disease. Therefore, governments, policymakers, health workers, and individuals should attach importance to the high prevalence of vitamin D deficiency and take its prevention as a public health priority.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021292586, PROSPERO CRD42021292586.
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Affiliation(s)
- Aiyong Cui
- Department of Orthopaedics, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Tiansong Zhang
- Jing'an District Hospital of Traditional Chinese Medicine, Shanghai, China
| | - Peilong Xiao
- Department of Orthopaedics, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Zhiqiang Fan
- Department of Pelvic and Acetabular Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Hu Wang
- Department of Pelvic and Acetabular Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
- Hu Wang
| | - Yan Zhuang
- Department of Pelvic and Acetabular Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
- *Correspondence: Yan Zhuang
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15
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Establishing the Prevalence of Osteomalacia in Arab Adolescents Using Biochemical Markers of Bone Health. Nutrients 2022; 14:nu14245354. [PMID: 36558513 PMCID: PMC9784134 DOI: 10.3390/nu14245354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/08/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Nutrition-acquired osteomalacia is a bone mineralization disorder associated with dietary calcium and/or solar vitamin D deficiency, risk factors considered common in the Middle Eastern region. Establishing less invasive, cheap, and widely available diagnostic markers for this underdiagnosed entity is essential, in particular for screening in high-risk groups. This study assessed the prevalence of biochemical osteomalacia in Arab adolescents. In this cross-sectional study performed between September 2019 and March 2021, adolescents aged 12−17 years from 60 different secondary and preparatory year schools in Riyadh, Saudi Arabia were included. Anthropometrics and fasting blood samples were collected. Biochemical osteomalacia was defined as any two of the following four serum markers of hypomineralization, namely low 25 hydroxyvitamin D (25OHD < 30 nmol/L), high alkaline phosphatase (ALP), low calcium (Ca), and/or inorganic phosphorous (Pi). A total of 2938 Arab adolescents [1697 girls; mean age (years) 14.8 ± 1.8; 1241 boys; mean age 15.1 ± 1.6] were recruited. Vitamin D deficiency was noted in 56.2% (n = 953) of girls and 27.1% (n = 336) of boys (p < 0.001). The overall prevalence of biochemical osteomalacia was 10.0% (n = 295/2938) and was higher in girls than boys (14.7% vs. 3.6%, p < 0.001). The prevalence of low serum Ca and/or Pi was also higher in girls than in boys (24.2% vs. 12.5%, respectively, p < 0.001), as well as elevated ALP (5.1% vs. 1.5%, p < 0.001). Overall, girls were 4.6 times (95% CI 3.3−6.4) more likely to have biochemical osteomalacia than boys. Screening of apparently healthy Arab adolescents revealed a high prevalence of deranged mineralization markers suggestive of biochemical osteomalacia, which was significantly more common in girls than boys and was likely associated with Arab traditional clothing and diet. The proposed combination of typically altered mineralization markers for the diagnosis of osteomalacia is, at best, suggestive until further comparisons with established diagnostic tools (histological analysis of bone biopsies) are conducted.
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Meyer SC, Montez K, McClung R, Michael L, Namak S, Brown CL. Growth of Pediatric Refugees after Resettlement to the Southeastern United States. Acad Pediatr 2022; 22:777-781. [PMID: 34637931 PMCID: PMC8993936 DOI: 10.1016/j.acap.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 09/25/2021] [Accepted: 10/04/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To compare weight status and body mass index z-scores (BMIz) of refugee children upon arrival to the Southeastern US and after resettlement with age- and sex-matched controls of nonrefugee children. METHODS We identified refugee children resettled between July 2014 and June 2018 to Forsyth County, NC. Refugees were assigned age- and sex-matched controls (3 controls:1 refugee) who received care at the same health care site, were Medicaid insured, and had height and weight recorded at time of their matched refugee's resettlement plus at least 2 additional visits. BMI and BMIz were calculated. Pearson chi-square test assessed differences in weight status at the time of refugee resettlement and at the last measured time point. Multilevel linear mixed-effects regression models assessed change in BMIz by refugee status, adjusting for sex, race/ethnicity, age, and time since resettlement. RESULTS This study examined 139 pediatric refugees and 417 nonrefugee controls; 46% were female. At the time of resettlement, refugees had a higher rate of underweight (3.3% vs 1.9%), higher rate of healthy weight (68.9% vs 48.2%), and lower rate of overweight/obesity (27.8% vs 50%), compared to controls P < .001. At the last available time point, compared to controls, refugees had higher rates of underweight (3.3% vs 3.0%) and healthy weight (69.5% vs 54.2%) and lower rates of overweight/obesity (27.2% vs 42.7%), P = .005. Refugees had a lower predicted BMIz compared with controls (adjusted β: -0.78; 95% confidence interval -0.91, -0.66). CONCLUSIONS Resettled pediatric refugees were found to have significantly lower predicted BMIz than their age- and sex-matched nonrefugee controls.
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Affiliation(s)
- Stephanie C Meyer
- Department of Student Affairs (SC Meyer), Wake Forest School of Medicine, Winston-Salem, NC
| | - Kimberly Montez
- Department of Pediatrics (K Montez and CL Brown), Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC
| | - Rachel McClung
- Novant Health, Robinhood Pediatrics (R McClung), Winston-Salem, NC
| | - Lemaat Michael
- Department of Student Affairs (L Michael), Wake Forest School of Medicine, Winston-Salem, NC
| | - Shahla Namak
- Department of Family and Community Medicine (S Namak), Wake Forest School of Medicine, Winston-Salem, NC
| | - Callie L Brown
- Department of Pediatrics (K Montez and CL Brown), Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC; Department of Epidemiology and Prevention (CL Brown), Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC.
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Seismic Resilience Assessment in Optimally Integrated Retrofitting of Existing School Buildings in Italy. BUILDINGS 2022. [DOI: 10.3390/buildings12060845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Modern society requires that structures exhibit greater levels of resilience, especially under earthquakes. The seismic resilience of buildings is thus gaining increased attention as a particular, beyond-code approach. Seismically retrofitted buildings behave satisfactorily under expected earthquake scenarios; however, this does not guarantee operativity after a seismic event. This study critically reviews several methods currently available in the literature that quantify the seismic resilience level of buildings from different perspectives. An existing reinforced concrete school building, retrofitted according to four distinct strategies, is first evaluated in terms of seismic resilience levels. The overview and critical analysis of available resilience assessment frameworks determine the most suitable parameters to measure the seismic resilience for buildings. Subsequently, this metric is incorporated as an additional decision variable into an integrated seismic and energy retrofitting set of strategies. A multicriteria decision-making analysis is performed to select the optimally combined seismic and energy retrofitting alternative under social, technical, environmental evaluation, and seismic resilience aspects. We show how resilience impacts the preference for integrated seismic and energy retrofitting strategies, especially when this metric is considered as an annualized expected value.
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Rosenthal T, Touyz RM, Oparil S. Migrating Populations and Health: Risk Factors for Cardiovascular Disease and Metabolic Syndrome. Curr Hypertens Rep 2022; 24:325-340. [PMID: 35704140 PMCID: PMC9198623 DOI: 10.1007/s11906-022-01194-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE OF REVIEW To summarize results of recent studies of migrants in Europe and North America and ongoing efforts to adapt strategies to provide them with inclusive sensitive health care. RECENT FINDINGS Major predisposing factors for developing hypertension, obesity, diabetes, and the metabolic syndrome in migrating populations and refugees were identified. Susceptibility to the metabolic syndrome is predominantly due to environmental factors and psychological stress. Acculturation also contributes to the emergence of cardiovascular (CV) risk factors in first-generation adult immigrants. Increased risk for later development of hypertension and dyslipidemia has also been detected in adolescent immigrants. Targets for public health efforts were based on data that show important differences in CV risk factors and prevalence of the metabolic syndrome among ethnic immigrant groups. Studies in young adults focused on lifestyle and dietary behaviors and perceptions about weight and body image, while the focus for older adults was end-of-life issues. Two important themes have emerged: barriers to health care, with a focus on cultural and language barriers, and violence and its impact on immigrants' mental health.
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Affiliation(s)
- Talma Rosenthal
- Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rhian M Touyz
- Research Institute of McGill University Health Centre, Montreal, QC, Canada
| | - Suzanne Oparil
- Vascular Biology & Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294-0007, USA.
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A Better Integration of Industrial Robots in Romanian Enterprises and the Labour Market. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12126014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this paper is to illustrate the opportunities for adopting robotic applications, through a marketing mix perspective, as well as depicting the current state of industrial robot integration in Romanian enterprises and the labor market, in contrast to other economies of the European Union. In this research, we highlight the impact of industrial robots within enterprises, while also considering the perceived standard of living through GDP per capita. For this, we conducted exploratory research based on secondary data regarding the evolution of the robotics sector in Romania, in connection to the dynamics of the global and European Union robotics market. We also performed a principal components analysis, which revealed the main factors that contributed to the dynamics of nation-level enterprise statistics. Our analysis revealed that a higher integration of industrial robots contributed to the reduction of employment rates amongst all six EU countries considered, while also having positive correlations with the GDP per capita and apparent labor productivity. Mixed results were only observed for the impact of industrial robots on remuneration growth, suggesting the potential adverse effects automation could have on incomes.
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20
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Empirical Research on the Influence Mechanisms of Digital Resources Input on Service Innovation in China’s Finance Industry. SUSTAINABILITY 2022. [DOI: 10.3390/su14127143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In today’s era, digital technology and the digital economy are the forerunners of the scientific and technological revolution and industrial transformation in the world. This paper chooses the organization and executive integration perspectives, studies the effects of relationship between digital resources input and service innovation in China’s finance industry, and the path and the mechanism of the transmission process. Through empirical research, we find that digital resource input has a significant positive impact on service innovation, and information sharing and value creation have significant mediating effects on the relationship between digital resource input and service innovation. Network openness significantly promotes the positive relationship between digital resource input and value creation, while big data technical ability significantly promotes the positive relationship between information sharing and service innovation. Our findings have some significant meanings for China’s financial enterprises.
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21
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Turbidity and Estimated Phosphorus Retention in a Reconnected Lake Erie Coastal Wetland. WATER 2022. [DOI: 10.3390/w14121853] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Nearly all of the wetlands in the coastal zone of Lake Erie have been degraded or destroyed since the 1860s, and most of those that remain are separated from their watersheds by earthen dikes. Hydrologic isolation of these wetlands disrupts ecosystem benefits typical to Great Lakes coastal wetlands, particularly the ability to trap sediments and retain nutrients when inundated by runoff and lake water. High-frequency measurements of turbidity and discharge were taken in 2013 and 2014 to observe turbidity and water flow dynamics to estimate total phosphorus flux of a hydrologically reconnected diked wetland pool in the Crane Creek-Lake Erie wetland complex. Modeled estimates suggest the reconnected pool retained 8% of the total phosphorus loading in 2013 and 10% in 2014, which included short periods of phosphorus export to Lake Erie. Water flowing out of the wetland generally had lower turbidity than inflowing water, but flux in and out of the pool varied seasonally and was linked to changes in lake-levels, seiche dynamics, and weather conditions. More frequent storms, higher winds, and stronger seiches in the spring and fall created turbidity patterns that suggest more phosphorus retention than in summer or winter. Estimates suggest that phosphorus was released during the summer when higher lake levels and the absence of frequent storms, larger short-term seiche oscillations, and potentially soil oxygen availability were driving flux dynamics. This study demonstrated that reestablishing lake hydrology through reconnection of wetland pools can reduce loading and alter timing of delivery of total phosphorus to Lake Erie.
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Al-Qahtani SM, Shati AA, Alqahtani YA, Dawood SA, Siddiqui AF, Zaki MSA, Khalil SN. Prevalence and Correlates of Vitamin D Deficiency in Children Aged Less than Two Years: A Cross-Sectional Study from Aseer Region, Southwestern Saudi Arabia. Healthcare (Basel) 2022; 10:healthcare10061064. [PMID: 35742114 PMCID: PMC9222582 DOI: 10.3390/healthcare10061064] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 05/31/2022] [Accepted: 06/06/2022] [Indexed: 12/13/2022] Open
Abstract
Background: Vitamin D is an essential nutrient for bone growth, mineralization, and other metabolic processes in the human body. Hence, insufficiency or deficiency of this vitamin can have long-term effects, particularly for children. Objectives: The aims of this study were to determine the prevalence of vitamin D deficiency in children up to 2 years of age and investigate the independent predictors of vitamin D deficiency. Methodology: This cross-sectional study was conducted among 484 children aged up to two years who were admitted to the hospital for the treatment of any acute condition from January to November 2021. Serum 25(OH)D was used to determine the level of vitamin D. The serum 25(OH)D was categorized into 3 groups: Sufficiency (>30 ng/mL), insufficiency (20−30 ng/mL), and the deficiency (<20 ng/mL). Results: Overall, vitamin D deficiency was observed in 70.5% of the children, of whom 45.9% had insufficient levels, and one-fourth (24.6%) showed deficiency. The children aged 2−12 months (infants) were more likely to be vitamin deficient compared to children aged 12 months and above. The children who lived in urban areas had a threefold increased risk of vitamin D deficiency (aOR = 3.0, 95% CI 1.78−5.08). The children who were exposed to sunlight for less than 3 days per week experienced a higher risk of developing vitamin D deficiency (aOR = 4.17, 95% CI 2.04−10.88). Children who had received only breast milk were more than two times more likely to experience vitamin D deficiency (aOR = 2.42, 95% CI 1.12−5.23) compared to their counterparts. Conclusion: Our study reveals a high prevalence of vitamin D deficiency among children aged up to two years. Infants, urban dwellers, only breastfed, and exposure to sunlight for less than three days per week were identified to be the independent risk factors for vitamin D deficiency. The results of this work call for enhancing awareness to ensure adequate levels of vitamin D for better health of the children in this region of Saudi Arabia.
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Affiliation(s)
- Saleh M. Al-Qahtani
- Department of Child Health, College of Medicine, King Khalid University, Abha P.O. Box 62529, Saudi Arabia; (S.M.A.-Q.); (Y.A.A.); (S.A.D.)
| | - Ayed A. Shati
- Department of Child Health, College of Medicine, King Khalid University, Abha P.O. Box 62529, Saudi Arabia; (S.M.A.-Q.); (Y.A.A.); (S.A.D.)
- Correspondence:
| | - Youssef A. Alqahtani
- Department of Child Health, College of Medicine, King Khalid University, Abha P.O. Box 62529, Saudi Arabia; (S.M.A.-Q.); (Y.A.A.); (S.A.D.)
| | - Samy A. Dawood
- Department of Child Health, College of Medicine, King Khalid University, Abha P.O. Box 62529, Saudi Arabia; (S.M.A.-Q.); (Y.A.A.); (S.A.D.)
| | - Aesha F. Siddiqui
- Department of Family and Community Medicine, College of Medicine, King Khalid University, Abha P.O. Box 62529, Saudi Arabia; (A.F.S.); (S.N.K.)
| | - Mohamed Samir A. Zaki
- Department of Anatomy, College of Medicine, King Khalid University, Abha P.O. Box 62529, Saudi Arabia;
- Department of Histology and Cell Biology, College of Medicine, Zagazig University, Zagazig P.O. Box 31527, Egypt
| | - Shamsun N. Khalil
- Department of Family and Community Medicine, College of Medicine, King Khalid University, Abha P.O. Box 62529, Saudi Arabia; (A.F.S.); (S.N.K.)
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Gallo S, Gahche J, Kitsantas P, Makwana P, Wang Y, Chen X, Rajbhandari-Thapa J. Vitamin D Intake and Meeting Recommendations Among Infants Participating in WIC Nationally. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2022; 54:499-509. [PMID: 35288058 PMCID: PMC9149040 DOI: 10.1016/j.jneb.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To report and examine associations with infant vitamin D intake and meeting recommendations among a national sample participating in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). DESIGN Secondary analysis from the 2013-2015 WIC Infant Toddler Feeding Practices Study-2. PARTICIPANTS US Infants. VARIABLES MEASURED Total reported vitamin D intake from diet and supplementation at the time of data collection. ANALYSIS Descriptive statistics and generalized estimating equations. RESULTS The median total vitamin D intake ranged from 5.43 (95% confidence interval, 5.40-5.46) mcg/d at month 1 to 8.18 (95% confidence interval, 8.11-8.20) mcg/d at month 13, with 16% to 36% of infants meeting the infant vitamin D recommendation over that time. Overall, 6% to 12% of all participants reported supplementation across all time points. Although most (between 78% to 98%) of supplemented breastfed infants met the recommendation, very few were supplemented as a group. Hence, breastfed infants were less likely to meet the recommendation than those who were formula fed across at time points except month 1 (P < 0.001 for all). Whereas infant age, feeding type, and/or their interaction were significant predictors of both receiving supplementation and meeting the recommendation, mother/caregiver nativity (P = 0.006) and parity (P = 0.01 and P < 0.001) predicted receiving supplementation, and child sex (P < 0.001) and mother/caregiver race/ethnicity (P < 0.001) predicted meeting the recommendation. CONCLUSIONS AND IMPLICATIONS Among a national sample of infants participating in WIC between 2013-2015, a high proportion were not meeting the current vitamin D recommendation. The WIC program is 1 resource for promoting strategies for increasing the number of American infants meeting D recommendations, but a coordinated approach involving other health care providers is likely needed. Future research exploring the reason for lack of supplementation, from both the perspective of parents and providers and the clinical impact of low vitamin D intake, is warranted.
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Affiliation(s)
- Sina Gallo
- Department of Nutritional Sciences, University of Georgia, Athens, GA.
| | - Jaime Gahche
- Office of Dietary Supplements, National Institutes of Health, Bethesda, MD
| | - Panagiota Kitsantas
- Department of Health Administration and Policy, George Mason University, Fairfax, VA
| | - Priyal Makwana
- Department of Health Administration and Policy, George Mason University, Fairfax, VA
| | - Yu Wang
- Department of Statistics, University of Georgia, Athens, GA
| | - Xianyan Chen
- Department of Statistics, University of Georgia, Athens, GA
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Buttriss JL, Lanham-New SA, Steenson S, Levy L, Swan GE, Darling AL, Cashman KD, Allen RE, Durrant LR, Smith CP, Magee P, Hill TR, Uday S, Kiely M, Delamare G, Hoyland AE, Larsen L, Street LN, Mathers JC, Prentice A. Implementation strategies for improving vitamin D status and increasing vitamin D intake in the UK: current controversies and future perspectives: proceedings of the 2nd Rank Prize Funds Forum on vitamin D. Br J Nutr 2022; 127:1567-1587. [PMID: 34284830 PMCID: PMC8376911 DOI: 10.1017/s0007114521002555] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 04/22/2021] [Accepted: 06/08/2021] [Indexed: 12/28/2022]
Abstract
A multi-disciplinary expert group met to discuss vitamin D deficiency in the UK and strategies for improving population intakes and status. Changes to UK Government advice since the 1st Rank Forum on Vitamin D (2009) were discussed, including rationale for setting a reference nutrient intake (10 µg/d; 400 IU/d) for adults and children (4+ years). Current UK data show inadequate intakes among all age groups and high prevalence of low vitamin D status among specific groups (e.g. pregnant women and adolescent males/females). Evidence of widespread deficiency within some minority ethnic groups, resulting in nutritional rickets (particularly among Black and South Asian infants), raised particular concern. Latest data indicate that UK population vitamin D intakes and status reamain relatively unchanged since Government recommendations changed in 2016. Vitamin D food fortification was discussed as a potential strategy to increase population intakes. Data from dose-response and dietary modelling studies indicate dairy products, bread, hens' eggs and some meats as potential fortification vehicles. Vitamin D3 appears more effective than vitamin D2 for raising serum 25-hydroxyvitamin D concentration, which has implications for choice of fortificant. Other considerations for successful fortification strategies include: (i) need for 'real-world' cost information for use in modelling work; (ii) supportive food legislation; (iii) improved consumer and health professional understanding of vitamin D's importance; (iv) clinical consequences of inadequate vitamin D status and (v) consistent communication of Government advice across health/social care professions, and via the food industry. These areas urgently require further research to enable universal improvement in vitamin D intakes and status in the UK population.
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Affiliation(s)
- Judy L. Buttriss
- British Nutrition Foundation, London, UK
- Department of Nutrition, Food and Exercise Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Susan A. Lanham-New
- Department of Nutrition, Food and Exercise Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | | | | | | | - Andrea L. Darling
- Department of Nutrition, Food and Exercise Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Kevin D. Cashman
- Cork Centre for Vitamin D and Nutrition Research, School of Food and Nutritional Sciences, University College Cork, Cork, Republic of Ireland
| | | | - Louise R. Durrant
- Department of Nutrition, Food and Exercise Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
- Yakult, London, UK
| | - Collin P. Smith
- School of Pharmacy and Biomolecular Sciences, University of Brighton, Brighton, UK
| | - Pamela Magee
- Nutrition Innovation Centre for Food & Health, Ulster University at Coleraine, Coleraine, UK
| | - Tom R. Hill
- Human Nutrition Research Centre, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Suma Uday
- University of Birmingham, Birmingham, UK
| | - Mairead Kiely
- Cork Centre for Vitamin D and Nutrition Research, School of Food and Nutritional Sciences, University College Cork, Cork, Republic of Ireland
| | | | | | | | | | - John C. Mathers
- Human Nutrition Research Centre, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Ann Prentice
- MRC Nutrition and Bone Health Group, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
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Kurnaz E, Çetinkaya S, Elmaoğulları S, Araslı Yılmaz A, Muratoğlu Şahin N, Keskin M, Savaş Erdeve Ş. A major health problem facing immigrant children: nutritional rickets. J Pediatr Endocrinol Metab 2022; 35:223-229. [PMID: 34610231 DOI: 10.1515/jpem-2021-0420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/22/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Nutritional rickets (NR) is still an important problem and one which increasing influxes of immigrants are further exacerbating. This study evaluated cases of mostly immigrant children followed up with diagnoses of NR in our pediatric endocrinology clinic. METHODS Details of 20 cases diagnosed with NR between 2017 and 2020 were retrieved from file records. RESULTS Twenty (11 male) cases were included in the study. Three (15%) were Turkish nationals and the others (85%) were immigrants. Hypocalcemia and hypophosphatemia were detected in 17 and 13, respectively. Alkaline phosphatase (ALP) values were normal in two cases, while ALP and parathyroid hormone (PTH) values were elevated in all other cases, and PTH levels were very high (473.64 ± 197.05 pg/mL). 25-hydroxyvitamin D levels were below 20 ng/mL in all cases. Patients with NR received high-dose long-term vitamin D or stoss therapy. Six patients failed to attend long-term follow-up, while PTH and ALP levels and clinical findings improved at long-term follow-up in the other 14 cases. CONCLUSIONS The elevated PTH levels suggest only the most severe cases of NR presented to our clinic. Clinically evident NR is therefore only the tip of the iceberg, and the true burden of subclinical rickets and osteomalacia remains unidentified. Public health policies should therefore focus on universal vitamin D supplementation and adequate dietary calcium provision, their integration into child surveillance programs, adequate advice and support to ensure normal nutrition, exposure to sunlight, and informing families of the increased risk not only for resident populations but also for refugee and immigrant children.
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Affiliation(s)
- Erdal Kurnaz
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Semra Çetinkaya
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Selin Elmaoğulları
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Aslıhan Araslı Yılmaz
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Nursel Muratoğlu Şahin
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Melikşah Keskin
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Şenay Savaş Erdeve
- Clinic of Pediatric Endocrinology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
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Verminderte Mineralisation des Knochens: Rachitis und Osteomalazie. Monatsschr Kinderheilkd 2022. [DOI: 10.1007/s00112-021-01392-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ZusammenfassungDie Mineralisation der Wachstumsfuge und des Knochens benötigt suffiziente Mengen an Kalzium und Phosphat, um ein adäquates Körperwachstum und eine adäquate Knochenstärke zu gewährleisten. Bei Mangelzuständen nehmen Härte und Stärke des Knochens ab (Osteomalazie), mit typischen Veränderungen an der Wachstumsfuge (Rachitis). Die vermeidbaren Komplikationen einer erworbenen Rachitis können lebensbedrohlich sein und sind auch deshalb ein global wichtiges Public-Health-Thema. Typische klinische Zeichen, Laborparameter und radiologische Veränderungen sollten zur unverzüglichen Diagnose führen. Erbliche und erworbene Formen der Rachitis wie X‑chromosomale Hypophosphatämie oder Hypophosphatasie werden, wie oftmals bei seltenen Erkrankungen, spät diagnostiziert. Diagnose, Therapie und Management von Rachitiden sollten durch tertiäre kinderosteologische Spezialisten erfolgen, die in internationalen „Rare-diseases“-Netzwerken arbeiten und in enger Kooperation mit Selbsthilfegruppen stehen.
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27
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Ogunmwonyi I, Adebajo A, Wilkinson JM. The genetic and epigenetic contributions to the development of nutritional rickets. Front Endocrinol (Lausanne) 2022; 13:1059034. [PMID: 36619587 PMCID: PMC9815715 DOI: 10.3389/fendo.2022.1059034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Nutritional rickets is an important disease in global health. Although nutritional rickets commonly manifests as bony deformities, there is an increased risk of life-threatening seizures secondary to hypocalcaemia. Dietary vitamin D deficiency is associated with the development of nutritional rickets among children and infants. This is especially true in populations of darker skinned individuals in high-latitude environments due to decreased ultraviolet light exposure, and in populations in tropical and subtropical climates due to cultural practices. A growing body of evidence has demonstrated that genetic factors might influence the likelihood of developing nutritional rickets by influencing an individual's susceptibility to develop deficiencies in vitamin D and/or calcium. This evidence has been drawn from a variety of different techniques ranging from traditional twin studies to next generation sequencing techniques. Additionally, the role of the epigenome in the development of rickets, although poorly understood, may be related to the effects of DNA methylation and non-coding RNAs on genes involved in bone metabolism. This review aims to provide an overview of the current evidence that investigates the genetic and epigenetic determinants of nutritional rickets.
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Thacher TD, Sempos CT, Durazo-Arvizu RA, Fischer PR, Munns CF, Pettifor JM. The Validity of Serum Alkaline Phosphatase to Identify Nutritional Rickets in Nigerian Children on a Calcium-Deprived Diet. J Clin Endocrinol Metab 2021; 106:e3559-e3564. [PMID: 33982091 DOI: 10.1210/clinem/dgab328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Nutritional rickets results from the interaction of low vitamin D status and limited calcium intake. Serum alkaline phosphatase (AP) activity is a biomarker of impaired mineralization in rickets. OBJECTIVE To assess the performance of serum AP activity in identifying nutritional rickets in calcium-deprived Nigerian children. METHODS We reanalyzed data from a case-control study of children with active rickets and matched control subjects without rickets, using a multivariate logistic regression to assess the odds of rickets associated with AP activity, adjusting for age, sex, and weight-for-age z-score. RESULTS A total of 122 children with rickets and 119 controls were included. Rachitic children had a mean (±SD) age of 54 ± 29 months, and 55 (45.1%) were male. Cases and controls had low dietary calcium intakes (216 ± 87 and 214 ± 96 mg/day, respectively). Serum AP activity levels in cases and controls were 812 ± 415 and 245 ± 78 U/L, respectively (P < 0.001). AP was negatively associated with 25-hydroxyvitamin D values (r = -0.34; P < 0.001). In the adjusted model, the odds ratio (95% CI) receiver operating characteristic curve was 0.978. AP > 350 U/L identified nutritional rickets in Nigerian children with sensitivity 0.93, specificity 0.92, positive likelihood ratio 11.3, and negative likelihood ratio 0.07. CONCLUSION An AP > 350 U/L effectively discriminated between Nigerian children with and without nutritional rickets. AP is a low-cost biochemical test that could be used to screen for nutritional rickets, but cutoff values require validation in other populations, and laboratory values need to be standardized for widespread population studies.
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Affiliation(s)
| | | | | | - Philip R Fischer
- Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Pediatrics, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Craig F Munns
- Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia
| | - John M Pettifor
- MRC/Wits Developmental Pathways for Health Research Unit, Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
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Affiliation(s)
- Lindsey A Warner
- Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B158, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rachel L Sewell
- Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B158, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nina S Ma
- Bone and Mineral Metabolism Program, Section of Endocrinology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B265, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
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30
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Sempos CT, Durazo-Arvizu RA, Fischer PR, Munns CF, Pettifor JM, Thacher TD. Serum 25-hydroxyvitamin D requirements to prevent nutritional rickets in Nigerian children on a low-calcium diet-a multivariable reanalysis. Am J Clin Nutr 2021; 114:231-237. [PMID: 33742199 DOI: 10.1093/ajcn/nqab048] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 02/09/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Nutritional rickets is believed to result from the interaction of inadequate serum 25-hydroxyvitamin D [25(OH)D] concentration and dietary calcium intake, but this interaction has not been confirmed in children with rickets. Determining the vitamin D requirements to prevent nutritional rickets has been thwarted by inconsistent case definition, inadequate adjustment for calcium intake and other confounders, and 25(OH)D assay variability. OBJECTIVES To model the 25(OH)D concentration associated with nutritional rickets in calcium-deprived Nigerian children, adjusted for confounding factors, and develop a general approach to define vitamin D status while accounting for calcium intake. METHODS Logistic regression was used to model the association of serum 25(OH)D with having rickets adjusted for calcium intake in a reanalysis of a case-control study in Nigerian children. The matching variables age, sex, weight-for-age z score, and 4 additional significant variables were selected [religion, age began walking, phosphorus intake, and the 25(OH)D × calcium intake interaction] using a rigorous 7-step algorithm. RESULTS Cases had significantly (P < 0.0001) lower mean ± SD 25(OH)D than controls (33 ± 13 compared with 51 ± 16 nmol/L, respectively), whereas cases and controls had similarly (P = 0.81) low mean dietary calcium intakes (216 ± 88 and 213 ± 95 mg/d, respectively). There was a significant interaction between 25(OH)D and calcium intake [coefficient (95% CI): -0.0006 (-0.0009, -0.0002)]. Accordingly, as calcium intake increased from 130 to 300 mg/d, the adjusted odds of having rickets decreased dramatically with increasing 25(OH)D such that at 200 mg/d, the adjusted odds of having rickets at 47.5 nmol/L was 0.80, whereas it was 0.2 at 62.5 nmol/L. Moreover, at a calcium intake of 300 mg/d, the adjusted odds was 0.16 at a 25(OH)D concentration of 47.5 nmol/L and 0.02 at 62.5 nmol/L. CONCLUSIONS The vitamin D requirement to prevent nutritional rickets varies inversely with calcium intake and vice versa. Also, application of multivariable modeling is essential in defining vitamin D requirements.
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Affiliation(s)
| | - Ramón A Durazo-Arvizu
- Biostatistical Core, The Sabin Research Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA.,Pediatrics Department, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Craig F Munns
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - John M Pettifor
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
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Abstract
Defective mineralization of the growth plate and preformed osteoid result in rickets and osteomalacia, respectively. The leading cause of rickets worldwide is solar vitamin D deficiency and/or dietary calcium deficiency collectively termed as nutritional rickets. Vitamin D deficiency predominates in high-latitude countries in at-risk groups (dark skin, reduced sun exposure, infants and pregnant and lactating women) but is emerging in some tropical countries due to sun avoidance behaviour. Calcium deficiency predominates in tropical countries, especially in the malnourished population. Nutritional rickets can have devastating health consequences beyond bony deformities (swollen wrist and ankle joints, rachitic rosary, soft skull, stunting and bowing) and include life-threatening hypocalcaemic complications of seizures and, in infancy, heart failure due to dilated cardiomyopathy. In children, diagnosis of rickets (always associated with osteomalacia) is confirmed on radiographs (cupping and flaring of metaphyses) and should be suspected in high risk individuals with the above clinical manifestations in the presence of abnormal blood biochemistry (high alkaline phosphatase and parathyroid hormone, low 25-hydroxyvitamin D and calcium and/or low phosphate). In adults or adolescents with closed growth plates, osteomalacia presents with non-specific symptoms (fatigue, malaise and muscle weakness) and abnormal blood biochemistry, but only in extreme cases, it is associated with radiographic findings of Looser's zone fractures. Bone biopsies could confirm osteomalacia at earlier disease stages, for definitive diagnosis. Treatment includes high-dose cholecalciferol or ergocalciferol daily for a minimum of 12 wk or stoss therapy in exceptional circumstances, each followed by lifelong maintenance supplementation. In addition, adequate calcium intake through diet or supplementation should be ensured. Preventative approaches should be tailored to the population needs and incorporate multiple strategies including targeted vitamin D supplementation of at-risk groups and food fortification with vitamin D and/or calcium. Economically, food fortification is certainly the most cost-effective way forward.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology & Diabetes, Birmingham Women's & Children's NHS Foundation Trust; Institute of Metabolism & Systems Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Wolfgang Högler
- Institute of Metabolism & Systems Research, University of Birmingham, Edgbaston, Birmingham, UK; Department of Paediatrics & Adolescent Medicine, Johannes Kepler University, Kepler University Hospital, Med Campus IV, Linz, Austria
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32
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Uday S, Naseem S, Large J, Denmeade R, Goddard P, Preece MA, Dunn R, Fraser W, Tang JCY, Högler W. Failure of national antenatal vitamin D supplementation programme puts dark skinned infants at highest risk: A newborn bloodspot screening study. Clin Nutr 2020; 40:3542-3551. [PMID: 33358424 DOI: 10.1016/j.clnu.2020.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/07/2020] [Accepted: 12/07/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine the prevalence of vitamin D deficiency on dried blood spots (DBS) obtained at newborn blood spot screening (NBS) and thereby test the efficacy of the UK national antenatal supplementation programme in an increasingly ethnically diverse English population. To evaluate the seasonal and ethnic variation in neonatal plasma 25 hydoxyvitamin D (25OHD) and its determinants. DESIGN Three thousand random DBS samples received at a single regional newborn screening laboratory (52° N) over two one-week periods, one in winter (February 2019) and one in summer (August 2019), were collected. Data was collected from NBS cards on birth weight, gestational age, maternal age, ethnicity, and post code which was replaced with index of multiple deprivation (IMD). 25OHD concentrations were measured on 6 mm sub-punch from DBS using quantitative liquid chromatography tandem mass spectrometry adjusted to equivalent plasma values. 25OHD variation with season was assessed using Mann-Whitney U test and ethnic groups compared using Kruskal-Wallis test. Linear regression was used to assess the determinants of 25OHD concentrations. RESULTS 25OHD measurements were available in 2999 (1580 males) subjects [1499 winter-born and 1500 summer-born]. The majority were white British (59.1%) and born at term (mean ± SD gestational age of 38.8 ± 1.8 weeks) with a mean (±SD) birth weight of 3306 (±565) grams. The overall prevalence of vitamin D deficiency [25OHD<30 nmol/L (12 μg/L)] was 35.7% (n = 1070) and insufficiency [30-50 nmol/L (12-20 μg/L)] 33.7% (n = 1010). The median (IQR) 25OHD concentration was significantly lower in the winter-born compared to summer-born [29.1 (19.8, 40.6) vs 49.2 (34.3, 64.8) nmol/L respectively; p < 0.001]. Across both seasons, when compared to white British babies (41.6 nmol/L), the median 25OHD concentrations were significantly lower in babies of black (30.3 nmol/L; p < 0.001), Asian (31.3 nmol/L; p < 0.001), any other mixed (32.9 nmol/L; p < 0.001), mixed white and black (33.7 nmol/L; p < 0.05) and any other white (37.7 nmol/L; p < 0.05) ethnicity. The proportion of deficiency was also higher in babies of Asian (48%), black (47%) and mixed ethnicity (38-44%) compared to any other white (34%) or white British (30%) ethnicity. Season of birth, ethnicity, gestation and maternal age accounted for almost 24% of the variation in 25OHD concentrations. CONCLUSION The current UK antenatal supplementation programme fails to protect newborns from vitamin D deficiency, especially those from minority ethnic groups who are at high risk of vitamin D deficiency. Nearly 70% of all newborns and 85% of winter-borns had 25OHD concentrations below 50 nmol/L (20 μg/L). Almost 50% of babies of Black or Asian origin were deficient at birth, which explains their high risk of hypocalcaemic complications and rickets if left unsupplemented. Our findings call for an immediate review of the delivery of antenatal and infant vitamin D supplementation programmes and implementation of food fortification in the long term.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK; Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Sunia Naseem
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Jamie Large
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Russell Denmeade
- Department of Newborn Screening and Biochemical Genetics, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Philippa Goddard
- Department of Newborn Screening and Biochemical Genetics, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Mary Anne Preece
- Department of Newborn Screening and Biochemical Genetics, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Rachel Dunn
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7UQ, UK
| | - William Fraser
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7UQ, UK; Departments of Diabetes and Endocrinology and Clinical Biochemistry, Norfolk and Norwich University Hospital, Norwich, NR4 7UY, UK
| | - Jonathan C Y Tang
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7UQ, UK
| | - Wolfgang Högler
- Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK; Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, 4020, Linz, Austria
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Nijman RG, Krone J, Mintegi S, Bidlingmaier C, Maconochie IK, Lyttle MD, von Both U. Emergency care provided to refugee children in Europe: RefuNET: a cross-sectional survey study. Emerg Med J 2020; 38:5-13. [PMID: 32907845 PMCID: PMC7788210 DOI: 10.1136/emermed-2019-208699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/16/2020] [Accepted: 07/02/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Refugee children and young people have complex healthcare needs. However, issues related to acute healthcare provision for refugee children across Europe remain unexplored. This study aimed to describe the urgent and emergency healthcare needs of refugee children in Europe, and to identify obstacles to providing this care. METHODS An online cross-sectional survey was distributed to European healthcare professionals via research networks between 1 February and 1 October 2017 addressing health issues of children and young people aged <18 years fulfilling international criteria of refugee status, presenting to emergency departments. Survey domains explored (1) respondent's institution, (2) local healthcare system, (3) available guidance and educational tools, (4) perceived obstacles and improvements required, (5) countries of origin of refugee children being seen and (6) presenting signs and symptoms of refugee children. RESULTS One hundred and forty-eight respondents from 23 European countries completed the survey, and most worked in academic institutions (n=118, 80%). Guidance on immunisations was available for 30% of respondents, and on safeguarding issues (31%), screening for infection (32%) or mental health (14%). Thirteen per cent reported regular teaching sessions related to refugee child health. Language barriers (60%), unknown medical history (54%), post-traumatic stress disorder (52%) and mental health issues (50%) were perceived obstacles to providing care; severity of presenting illness, rare or drug-resistant pathogens and funding were not. CONCLUSIONS Many hospitals are not adequately prepared for providing urgent and emergency care to refugee children and young people. Although clinicians are generally well equipped to deal with most types and severity of presenting illnesses, we identified specific obstacles such as language barriers, mental health issues, safeguarding issues and lack of information on previous medical history. There was a clear need for more guidelines and targeted education on refugee child health.
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Affiliation(s)
- Ruud Gerard Nijman
- Department of Infectious Diseases, Section of Paediatric Infectious Diseases, Imperial College London, London, UK .,Paediatric Emergency Department, Imperial College Hospital NHS Healthcare Trust, London, UK
| | - Johanna Krone
- Division of Paediatric Infectious Diseases, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Santiago Mintegi
- Emergency Department, Hospital Universitario Cruces, Barakaldo, País Vasco, Spain
| | - Christoph Bidlingmaier
- Department of Paediatric Accident and Emergency, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Ian K Maconochie
- Paediatric Emergency Department, Imperial College Hospital NHS Healthcare Trust, London, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Science, University of the West of England, Bristol, UK
| | - Ulrich von Both
- Division of Paediatric Infectious Diseases, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilian University, Munich, Germany.,German Centre for Infection Research (DZIF), partner site, Munich, Germany
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Güngör A, Çuhacı Çakır B, Ateş S, Dönmez AD, Yakut Hİ, Atou A. Syrian refugee mothers' knowledge levels of childhood wellness: A program evaluation. Avicenna J Med 2020; 10:106-110. [PMID: 32832426 PMCID: PMC7414601 DOI: 10.4103/ajm.ajm_33_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Children are most affected by migration and wars. The health of child asylum seekers is adversely affected due to poor nutrition, malnutrition, insufficient vaccinations, and a lack of preventive health-care services (PHCS). The aim of this study was to determine the knowledge levels of the refugee mothers of child wellness monitoring, child vaccinations, and the importance of breastfeeding before and after implementation of an educational program. Materials and Methods: A questionnaire consisting of 12 statements about the importance of child wellness monitoring, child vaccinations, and breastfeeding was prepared and translated into Arabic. Refugee mothers were asked to complete the questionnaire before and after the education program. Results: Thirty-one (72.1%) of the 43 participating mothers had their children vaccinated regularly. Vitamin D supplementation was given to 58.1%, and 23.1% were started on iron supplementation. The rate of vitamin D supplementation was higher in the literate mothers (P = 0.010). The least correctly answered statement before the education program was related to iron supplementation (n = 24, 55.8%). The mean (standard deviation) number of correct answers given by the participating mothers to the 12 statements before the seminar was 9.16 (±2.05), this increased to 11.16 (±0.99) after the seminar. Conclusion: The resultes of this study show that refugee mothers’ knowledge levels about vitamin D and iron supplementation are quite low. Their knowledge levels can be increased in the short term by providing information in the mothers’ native languages.
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Affiliation(s)
- Ali Güngör
- Department of Pediatric Emergency Medicine, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Kırıkkale, Turkey
| | - Bahar Çuhacı Çakır
- Department of Social Pediatrics, Gazi University Faculty of Medicine, Kırıkkale, Turkey
| | - Sema Ateş
- Department of Pediatrics, Ankara City Hospital, Ankara, Turkey
| | - Arzu D Dönmez
- Department of Pediatrics, Ankara City Hospital, Ankara, Turkey
| | - Halil İ Yakut
- Department of Pediatrics, Ankara City Hospital, Ankara, Turkey
| | - Abdullah Atou
- Department of Interpreting Service, Kırıkkale Yuksek Ihtisas Hospital, Kırıkkale, Turkey
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Julies P, Lynn RM, Pall K, Leoni M, Calder A, Mughal Z, Shaw N, McDonnell C, McDevitt H, Blair M. Nutritional rickets under 16 years: UK surveillance results. Arch Dis Child 2020; 105:587-592. [PMID: 31949032 DOI: 10.1136/archdischild-2019-317934] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/06/2019] [Accepted: 12/11/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The UK national incidence of nutritional rickets is unknown. We aimed to describe the incidence, presentation and clinical management of children under 16 years with nutritional rickets in the UK presenting to secondary care. METHODS Prospective data were collected monthly between March 2015 and March 2017 from 3500 consultant paediatricians using British Paediatric Surveillance Unit methodology. Clinicians completed online clinical questionnaires for cases fitting the surveillance case definition. RESULTS 125 cases met the case definition, an annual incidence of 0.48 (95% CI 0.37 to 0.62) per 100 000 children under 16 years. 116 children were under 5 years (annual incidence of 1.39 (95% CI 1.05 to 1.81) per 100 000. Boys (70%) were significantly more affected than girls (30%) (OR 2.17, 95% CI 1.25 to 3.78). The majority were of Black (43%) or South Asian (38%) ethnicity. 77.6% of children were not taking vitamin D supplements despite being eligible. Complications included delayed gross motor development (26.4%), fractures (9.6%), hypocalcaemic seizures (8%) and dilated cardiomyopathy (3%). Two children died (1.6%). In eight cases, rickets was confirmed radiologically and biochemically [raised serum alkaline phosphatase (ALP) and parathyroid hormone (PTH) levels ] but were excluded from the incidence analysis for not meeting the case definition of 25-hydroxyvitamin D of <25 nmol/L. CONCLUSION The incidence of nutritional rickets in the UK is lower than expected. Serious complications and unexpected deaths, particularly in Black and South Asian children under 5 years, occurred. Both vitamin D deficiency and dietary calcium deficiency are role players in pathogenesis. Uptake of vitamin D supplementation remains low.
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Affiliation(s)
- Priscilla Julies
- Child Health, Royal Free London NHS Foundation Trust, London, UK
| | - Richard M Lynn
- Institute of Child Health, University College London Research Department of Epidemiology and Public Health, London, UK.,BPSU, Royal College of Paedaitrics, London, UK
| | - Karina Pall
- BPSU, Royal College of Paediatrics and Child Health, London, UK
| | - Marina Leoni
- BPSU, Royal College of Paediatrics and Child Health, London, UK
| | - Alistair Calder
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Nick Shaw
- Endocrinology and Diabetes, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, West Midlands, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Ciara McDonnell
- Endocrinology Department, Children's University Hospital, Temple Street, Dublin, Ireland
| | - Helen McDevitt
- Paediatric Bone and Endocrinology, Royal Hospital for Children Glasgow, Glasgow, UK.,Neonatology, Royal Hospital for Children Glasgow, Glasgow, UK
| | - Mitch Blair
- Paediatrics, Imperial College London, Harrow, UK
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Food Insecurity and Major Diet-Related Morbidities in Migrating Children: A Systematic Review. Nutrients 2020; 12:nu12020379. [PMID: 32023929 PMCID: PMC7071308 DOI: 10.3390/nu12020379] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 12/27/2022] Open
Abstract
Children of migrant families are known to be at a higher risk of diet-related morbidities due to complex variables including food insecurity, cultural and religious beliefs, and sociodemographic factors like ethnicity, socioeconomic status, and education. Several studies have assessed the presence of specific diseases related to dietary issues in migrant children. This systematic review aims to highlight the existing body of work on nutritional deficiencies in the specific vulnerable pediatric population of immigrants. Refugees were intentionally excluded because of fundamental differences between the two groups including the reasons for migration and health status at the time of arrival. A total of 29 papers were included and assessed for quality. Most of them described a strong correlation between obesity and migration. A high prevalence of stunting, early childhood caries, iron and vitamin D deficiency was also reported, but the studies were few and heterogeneous. Food insecurity and acculturation were found important social factors (nevertheless with inconclusive results) influencing dietary habits and contributing to the development of morbidities such as obesity and other metabolic disorders, which can cause progressive unsustainability of health systems. Public health screening for diet-related diseases in migrant children may be implemented. Educational programs to improve children’s diet and promote healthy-living behaviors as a form of socioeconomic investment for the health of the new generations may also be considered.
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Aul AJ, Fischer PR, O'Grady JS, Mara KC, Maxson JA, Meek AM, Petterson TM, Thacher TD. Population-Based Incidence of Potentially Life-Threatening Complications of Hypocalcemia and the Role of Vitamin D Deficiency. J Pediatr 2019; 211:98-104.e4. [PMID: 30954245 PMCID: PMC6661008 DOI: 10.1016/j.jpeds.2019.02.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 01/17/2019] [Accepted: 02/13/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To determine the incidence of potentially life-threatening complications of hypocalcemia in infants and children in Olmsted County, Minnesota; and to determine if vitamin D deficiency contributed to these events and was, at the time of clinical presentation, considered as a possible cause. STUDY DESIGN In this population-based descriptive study, data were abstracted from the Rochester Epidemiology Project, a medical record linkage system covering 95% of patients in Olmsted County, Minnesota. Participants were children aged 0-5 years who resided in Olmsted County between January 1, 1996 and June 30, 2017, and who received diagnoses of seizures, cardiomyopathy, cardiac arrest, respiratory arrest, laryngospasm, and/or tetany. The incidence of hypocalcemia plus a potentially life-threatening complication was calculated. RESULTS Among 15 419 patients aged 0-5 years in Olmsted County during the study period, 1305 had eligible complications: 460 had serum calcium checked within 14 days of presentation and 85 had hypocalcemia. Patients were excluded when causes other than hypocalcemia likely triggered the complication, leaving 16 children whose complication was attributed to hypocalcemia. Three of these 16 patients had a serum 25-hydroxyvitamin D measurement and 2 were deficient (≤6 ng/mL [15 nmol/L]). Among children aged 0-5 years, the incidence of hypocalcemia plus a potentially life-threatening complication was 6.1 per 100 000 person-years (95% CI, 3.5-10.0). CONCLUSIONS Vitamin D deficiency is an underinvestigated cause of complications of hypocalcemia in children. Serum calcium and 25-hydroxyvitamin D should be measured in children with these complications to identify possibly life-threatening vitamin D deficiency.
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Affiliation(s)
- Andrea J Aul
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Julie A Maxson
- Department of Family Medicine, Mayo Clinic, Rochester, MN
| | - Alicia M Meek
- Department of Family Medicine, Mayo Clinic, Rochester, MN
| | - Tanya M Petterson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, MN.
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Uday S, Högler W. Spot the silent sufferers: A call for clinical diagnostic criteria for solar and nutritional osteomalacia. J Steroid Biochem Mol Biol 2019; 188:141-146. [PMID: 30654108 DOI: 10.1016/j.jsbmb.2019.01.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 01/02/2019] [Accepted: 01/12/2019] [Indexed: 11/29/2022]
Abstract
Osteomalacia and rickets result from defective mineralization when the body is deprived of calcium. Globally, the main cause of osteomalacia is a lack of mineral supply for bone modeling and remodeling due to solar vitamin D and/or dietary calcium deficiency. Osteomalacia occurs when existing bone is replaced by unmineralized bone matrix (osteoid) during remodeling in children and adults, or when newly formed bone is not mineralized in time during modeling in children. Rickets occurs when hypomineralization affects the epiphyseal growth plate chondrocytes and adjacent bone metaphysis in growing children. Hence, osteomalacia co-exists with rickets in growing children. Several reports in the last decade highlight the resurgence of so-called "nutritional" rickets in the dark-skinned population living in high-income countries. However, very few studies have ever explored the hidden iceberg of nutritional osteomalacia in the population. Rickets presents with hypocalcaemic (seizures, tetany, cardiomyopathy), or hypophosphataemic complications (leg bowing, knock knees, rachitic rosary, muscle weakness) and is diagnosed on radiographs (cupping and fraying of metaphyses). In contrast, osteomalacia lacks distinctive, non-invasive diagnostic laboratory or imaging criteria and the clinical presentation is non-specific (general fatigue, malaise, muscle weakness and pain). Hence, osteomalacia remains largely undiagnosed, as a hidden disease in millions of dark-skinned people who are at greatest risk. Radiographs may demonstrate Looser's zone fractures in those most severely affected, however to date, osteomalacia remains a histological diagnosis requiring a bone biopsy. Biochemical features of high serum alkaline phosphatase (ALP), high parathyroid hormone (PTH) with or without low 25 hydroxyvitamin D (25OHD) concentrations are common to both rickets and osteomalacia. Here, we propose non-invasive diagnostic criteria for osteomalacia. We recommend a diagnosis of osteomalacia in the presence of high ALP, high PTH, low dietary calcium intake (<300 mg/day) and/or low serum 25OHD (<30 nmol/L). Presence of clinical symptoms (as above) or Looser's zone fractures should be used to reaffirm the diagnosis. We call for further studies to explore the true prevalence of nutritional osteomalacia in various populations, specifically the Black and Asian ethnic groups, in order to identify the hidden disease burden and inform public health policies for vitamin D/calcium supplementation and food fortification.
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Affiliation(s)
- Suma Uday
- Department of Diabetes and Endocrinology, Birmingham Women's and Children's Hospital, Birmingham, UK; Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Wolfgang Högler
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Department of Paediatrics and Adolescent Medicine, Johannes Kepler University, Linz, Austria.
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Micronutrient deficiencies and health-related quality of life: the case of children with vitamin D deficiency. Public Health Nutr 2019; 23:1165-1172. [PMID: 30744725 DOI: 10.1017/s1368980018003841] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To explore the extent to which micronutrient deficiencies (MND) affect children's health-related quality of life (HRQoL), using vitamin D deficiency (VDD) as a case study. DESIGN Proxy valuation study to estimate the impact of VDD on the HRQoL of younger (0-4 years) and older (>4 years) children. We used the Child Health Utility 9 Dimension (CHU9D) questionnaire to estimate HRQoL for children within six VDD-related health states: 'hypocalcaemic cardiomyopathy', 'hypocalcaemic seizures', 'active rickets', 'bone deformities', 'pain and muscle weakness' and 'subclinical VDD'. SETTING Sampling was not restricted to any particular setting and worldwide experts were recruited. PARTICIPANTS Respondents were paediatric bone experts recruited through network sampling. RESULTS Thirty-eight experts completed the survey. The health state with the largest detrimental impact (mean score (se)) on children's HRQoL was hypocalcaemic cardiomyopathy (0·47 (0·02)), followed by hypocalcaemic seizures (0·50 (0·02)) and active rickets (0·62 (0·02) in young children; 0·57 (0·02) in older children). Asymptomatic VDD had a modest but noticeable negative impact on HRQoL, attributed mostly to tiredness in both age groups and pain in the older paediatric population. CONCLUSIONS Elicitation of HRQoL from clinical experts suggests a negative impact of VDD on HRQoL, even if there is no recognizable clinical manifestation. HRQoL data from populations of patients with MND will inform public health policy decisions. In some settings, routine collection of HRQoL data alongside national nutrition surveys may help capture the full burden of MND and prioritize resources towards effective prevention.
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Roth DE, Abrams SA, Aloia J, Bergeron G, Bourassa MW, Brown KH, Calvo MS, Cashman KD, Combs G, De-Regil LM, Jefferds ME, Jones KS, Kapner H, Martineau AR, Neufeld LM, Schleicher RL, Thacher TD, Whiting SJ. Global prevalence and disease burden of vitamin D deficiency: a roadmap for action in low- and middle-income countries. Ann N Y Acad Sci 2018; 1430:44-79. [PMID: 30225965 PMCID: PMC7309365 DOI: 10.1111/nyas.13968] [Citation(s) in RCA: 281] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 08/23/2018] [Indexed: 12/15/2022]
Abstract
Vitamin D is an essential nutrient for bone health and may influence the risks of respiratory illness, adverse pregnancy outcomes, and chronic diseases of adulthood. Because many countries have a relatively low supply of foods rich in vitamin D and inadequate exposure to natural ultraviolet B (UVB) radiation from sunlight, an important proportion of the global population is at risk of vitamin D deficiency. There is general agreement that the minimum serum/plasma 25-hydroxyvitamin D concentration (25(OH)D) that protects against vitamin D deficiency-related bone disease is approximately 30 nmol/L; therefore, this threshold is suitable to define vitamin D deficiency in population surveys. However, efforts to assess the vitamin D status of populations in low- and middle-income countries have been hampered by limited availability of population-representative 25(OH)D data, particularly among population subgroups most vulnerable to the skeletal and potential extraskeletal consequences of low vitamin D status, namely exclusively breastfed infants, children, adolescents, pregnant and lactating women, and the elderly. In the absence of 25(OH)D data, identification of communities that would benefit from public health interventions to improve vitamin D status may require proxy indicators of the population risk of vitamin D deficiency, such as the prevalence of rickets or metrics of usual UVB exposure. If a high prevalence of vitamin D deficiency is identified (>20% prevalence of 25(OH)D < 30 nmol/L) or the risk for vitamin D deficiency is determined to be high based on proxy indicators (e.g., prevalence of rickets >1%), food fortification and/or targeted vitamin D supplementation policies can be implemented to reduce the burden of vitamin D deficiency-related conditions in vulnerable populations.
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Affiliation(s)
- Daniel E. Roth
- Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Steven A. Abrams
- Department of Pediatrics, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - John Aloia
- NYU Winthrop Hospital, Mineola, New York
| | - Gilles Bergeron
- The Sackler Institute for Nutrition Science, The New York Academy of Sciences, New York, New York
| | - Megan W. Bourassa
- The Sackler Institute for Nutrition Science, The New York Academy of Sciences, New York, New York
| | | | - Mona S. Calvo
- Retired, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Kevin D. Cashman
- Cork Centre for Vitamin D and Nutrition Research, University College Cork, Cork, Ireland
| | | | | | | | - Kerry S. Jones
- MRC Elsie Widdowson Laboratory, Cambridge, United Kingdom
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Uday S, Högler W. Prevention of rickets and osteomalacia in the UK: political action overdue. Arch Dis Child 2018; 103:901-906. [PMID: 29661756 DOI: 10.1136/archdischild-2018-314826] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 12/26/2022]
Abstract
The consequences of vitamin D and dietary calcium deficiency have become a huge public health concern in the UK. The burden of disease from these deficiencies includes rickets, and hypocalcaemic seizures, dilated cardiomyopathy and mostly occult myopathy and osteomalacia. The increasing burden of the disease is intrinsically linked to ethnicity and the population demographic changes in the UK. Three facts have led to the resurfacing of the English disease: (1) the UK has no ultraviolet sunlight for at least 6 months of the year, (2) dark skin produces far less vitamin D than white skin per unit ultraviolet light exposure, and (3) non-European Union immigration over the last century. To date, the UK government demonstrates incomplete understanding of these three facts, and its failure to adjust its prevention programmes to changing demographics is endangering the health and life of UK residents with dark skin, of whom infants are the most vulnerable. Establishing accountability through the implementation of monitored antenatal and infantile supplementation programmes and mandatory food fortification is overdue.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Wolfgang Högler
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Uday S, Fratzl-Zelman N, Roschger P, Klaushofer K, Chikermane A, Saraff V, Tulchinsky T, Thacher TD, Marton T, Högler W. Cardiac, bone and growth plate manifestations in hypocalcemic infants: revealing the hidden body of the vitamin D deficiency iceberg. BMC Pediatr 2018; 18:183. [PMID: 29940979 PMCID: PMC6019205 DOI: 10.1186/s12887-018-1159-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/25/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Whilst hypocalcemic complications from vitamin D deficiency are considered rare in high-income countries, they are highly prevalent among Black, Asian and Minority Ethnic (BAME) group with darker skin. To date, the extent of osteomalacia in such infants and their family members is unknown. Our aim was to investigate clinical, cardiac and bone histomorphometric characteristics, bone matrix mineralization in affected infants and to test family members for biochemical evidence of osteomalacia. CASE PRESENTATION Three infants of BAME origin (aged 5-6 months) presented acutely in early-spring with cardiac arrest, respiratory arrest following seizure or severe respiratory distress, with profound hypocalcemia (serum calcium 1.22-1.96 mmol/L). All infants had dark skin and vitamin D supplementation had not been addressed during child surveillance visits. All three had severely dilated left ventricles (z-scores + 4.6 to + 6.5) with reduced ejection fraction (25-30%; normal 55-70), fractional shortening (7 to 15%; normal 29-40) and global hypokinesia, confirming hypocalcemic dilated cardiomyopathy. They all had low serum levels of 25 hydroxyvitamin D (25OHD < 15 nmol/L), and elevated parathyroid hormone (PTH; 219-482 ng/L) and alkaline phosphatase (ALP; 802-1123 IU/L), with undiagnosed rickets on radiographs. One infant died from cardiac arrest. At post-mortem examination, his growth plate showed a widened, irregular zone of hypertrophic chondrocytes. Histomorphometry and backscattered electron microscopy of a trans-iliac bone biopsy sample revealed increased osteoid thickness (+ 262% of normal) and osteoid volume/bone volume (+ 1573%), and extremely low bone mineralization density. Five of the nine tested family members had vitamin D deficiency (25OHD < 30 nmol/L), three had insufficiency (< 50 nmol/L) and 6/9 members had elevated PTH and ALP levels. CONCLUSIONS The severe, hidden, cardiac and bone pathology described here exposes a failure of public health prevention programs, as complications from vitamin D deficiency are entirely preventable by routine supplementation. The family investigations demonstrate widespread deficiency and undiagnosed osteomalacia in ethnic risk groups and call for protective legislation.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology & Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Nadja Fratzl-Zelman
- 1st Medical Department Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of WGKK and AUVA Trauma Centre, Meidling, Vienna, Austria
| | - Paul Roschger
- 1st Medical Department Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of WGKK and AUVA Trauma Centre, Meidling, Vienna, Austria
| | - Klaus Klaushofer
- 1st Medical Department Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of WGKK and AUVA Trauma Centre, Meidling, Vienna, Austria
| | - Ashish Chikermane
- Department of Cardiology, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Vrinda Saraff
- Department of Endocrinology & Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Ted Tulchinsky
- Emeritus, Braun School of Public Health and Community Medicine, Hadassah Medical Center, Hebrew University-Hadassah, Ein Karem, Jerusalem, Israel
| | - Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tamas Marton
- Department of Cellular Pathology, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Wolfgang Högler
- Department of Endocrinology & Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK. .,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
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Wójcik M, Jaworski M, Pludowski P. 25(OH)D Concentration in Neonates, Infants, and Toddlers From Poland-Evaluation of Trends During Years 1981-2011. Front Endocrinol (Lausanne) 2018; 9:656. [PMID: 30467494 PMCID: PMC6235911 DOI: 10.3389/fendo.2018.00656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 10/19/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction: The numerous evidence showing spectrum of vitamin D effects on human health resulted in both updates of vitamin D supplementation guidelines for general population and concerns on potential risk of hypercalcaemia. The aim of this study was to analyse trends in serum 25-hydroxyvitamin D concentration (25(OH)D) change over the 30 years of operation of a single pediatric diagnostic unit. Materials and methods: Calcium-phosphate metabolism markers and 25(OH)D concentrations were analyzed in a group that consisted of newborns and infants commissioned for diagnostics due to suspected calcium-phosphate metabolic disturbances (n = 3,163; mean age 8.0 ± 3.0 months). Results: 25(OH)D < 10 ng/ml was noted in 4.5% of patients (n = 163), 10-20 ng/ml in 14.7% (n = 465), 20-30 ng/ml in 23.9% (n = 756) and 30-50 ng/ml in 35.9% (n = 1,136). The mean 25(OH)D concentration in analyzed group was 37.5 ± 24.5 ng/ml. In patients with 25(OH)D concentration < 10 ng/ml a normal calcaemia (2.25-2.65 mmol/l) was noted in 83.4% cases (n = 136). Eighty one patients had 25(OH)D concentrations above 100 ng/ml with co-existing calcaemia in range of 2.6-4.38 mmol/l (mean Ca = 2.69 mmol/l). Hypocalcaemia (Ca < 2.25 mmol/l) was observed in 0.54%, (n = 17). 13.8% patients revealed calcium levels >2.65 mmol/l (n = 435). In general, the mean calcium-phosphate markers values were within the reference range for age. The highest mean 25(OH)D concentration of 51.8 ng/ml ± 38.8 was noted in years 1981-1999 (n = 305). The lowest mean 25(OH)D value was observed in years 2010-2011 (29.0 ng/ml ± 13.6; n = 412). The trend of decreasing 25(OH)D concentration during analyzed time period was significant (r = -0.29, p < 0.0001). Conclusions: Eighty percentage of children aged 0-36 months had 25(OH)D concentration >20 ng/ml, however, during 3 decades a mean 25(OH)D concentrations trended significantly to decrease. A direct relationship between low 25(OH)D concentration and hypocalcaemia was not observed nor between high 25(OH)D concentration and hypercalcemia.
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Pludowski P, Holick MF, Grant WB, Konstantynowicz J, Mascarenhas MR, Haq A, Povoroznyuk V, Balatska N, Barbosa AP, Karonova T, Rudenka E, Misiorowski W, Zakharova I, Rudenka A, Łukaszkiewicz J, Marcinowska-Suchowierska E, Łaszcz N, Abramowicz P, Bhattoa HP, Wimalawansa SJ. Vitamin D supplementation guidelines. J Steroid Biochem Mol Biol 2018; 175:125-135. [PMID: 28216084 DOI: 10.1016/j.jsbmb.2017.01.021] [Citation(s) in RCA: 379] [Impact Index Per Article: 63.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 01/26/2017] [Accepted: 01/30/2017] [Indexed: 01/08/2023]
Abstract
Research carried out during the past two-decades extended the understanding of actions of vitamin D, from regulating calcium and phosphate absorption and bone metabolism to many pleiotropic actions in organs and tissues in the body. Most observational and ecological studies report association of higher serum 25-hydroxyvitamin D [25(OH)D] concentrations with improved outcomes for several chronic, communicable and non-communicable diseases. Consequently, numerous agencies and scientific organizations have developed recommendations for vitamin D supplementation and guidance on optimal serum 25(OH)D concentrations. The bone-centric guidelines recommend a target 25(OH)D concentration of 20ng/mL (50nmol/L), and age-dependent daily vitamin D doses of 400-800IU. The guidelines focused on pleiotropic effects of vitamin D recommend a target 25(OH)D concentration of 30ng/mL (75nmol/L), and age-, body weight-, disease-status, and ethnicity dependent vitamin D doses ranging between 400 and 2000IU/day. The wise and balanced choice of the recommendations to follow depends on one's individual health outcome concerns, age, body weight, latitude of residence, dietary and cultural habits, making the regional or nationwide guidelines more applicable in clinical practice. While natural sources of vitamin D can raise 25(OH)D concentrations, relative to dietary preferences and latitude of residence, in the context of general population, these sources are regarded ineffective to maintain the year-round 25(OH)D concentrations in the range of 30-50ng/mL (75-125nmol/L). Vitamin D self-administration related adverse effects, such as hypercalcemia and hypercalciuria are rare, and usually result from taking extremely high doses of vitamin D for a prolonged time.
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Affiliation(s)
- Pawel Pludowski
- Department of Biochemistry, Radioimmunology and Experimental Medicine, The Children's Memorial Health Institute, Warsaw, Poland.
| | - Michael F Holick
- Boston University Medical Center, 85 East Newton Street M-1033, Boston, MA 02118, USA
| | - William B Grant
- Sunlight, Nutrition, and Health Research Center, P.O. Box 641603, San Francisco, CA 94164-1603, USA
| | - Jerzy Konstantynowicz
- Department of Pediatric Rheumatology, Immunology, and Metabolic Bone Diseases, Medical University of Bialystok, Bialystok, Poland
| | - Mario R Mascarenhas
- Department of Endocrinology, Diabetes and Metabolism, Hospital de Santa Maria, EHLN and Faculty of Medicine, Lisbon, Portugal
| | - Afrozul Haq
- Research and Development, Gulf Diagnostic Center Hospital, Abu Dhabi, United Arab Emirates
| | - Vladyslav Povoroznyuk
- D.F. Chebotarev Institute of Gerontology of National Academy of Medical Sciences of Ukraine, Kiev 04114, Ukraine
| | - Nataliya Balatska
- D.F. Chebotarev Institute of Gerontology of National Academy of Medical Sciences of Ukraine, Kiev 04114, Ukraine
| | - Ana Paula Barbosa
- Department of Endocrinology, Diabetes and Metabolism, Hospital de Santa Maria, EHLN and Faculty of Medicine, Lisbon, Portugal
| | - Tatiana Karonova
- Institute of Endocrinology, Federal North-West Medical Research Centre, St. Petersburg 197341, Russian Federation
| | - Ema Rudenka
- Belarusian Medical Academy of Postgraduate Education, 220013 Minsk, Belarus
| | - Waldemar Misiorowski
- Department of Endocrinology, Medical Center for Postgraduate Education, Warsaw, Poland
| | - Irina Zakharova
- Department of Pediatrics, Russian Medical Academy of Postgraduate Education, Moscow, Russian Federation
| | - Alena Rudenka
- Department of Cardiology and Rheumatology of Belarusian Medical Academy of Postgraduate Education, 220013 Minsk, Belarus
| | - Jacek Łukaszkiewicz
- Department of Biochemistry and Clinical Chemistry, Medical University of Warsaw, Warsaw, Poland
| | - Ewa Marcinowska-Suchowierska
- Department of Geriatric, Internal Medicine and Metabolic Bone Disease, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Natalia Łaszcz
- Department of Biochemistry, Radioimmunology and Experimental Medicine, The Children's Memorial Health Institute, Warsaw, Poland
| | - Pawel Abramowicz
- Department of Pediatric Rheumatology, Immunology, and Metabolic Bone Diseases, Medical University of Bialystok, Bialystok, Poland
| | - Harjit P Bhattoa
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Aguiar M, Andronis L, Pallan M, Högler W, Frew E. Preventing vitamin D deficiency (VDD): a systematic review of economic evaluations. Eur J Public Health 2017; 27:292-301. [PMID: 28204459 DOI: 10.1093/eurpub/ckw270] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background Vitamin D deficiency (VDD) is a public health concern worldwide. If untreated, it can lead to reduced quality of life and escalated costs brought about by ill-health. Preventive programmes to improve population vitamin D status exist but little is known about their cost-effectiveness. This information is vital so that decision-makers adopt efficient strategies and optimise use of public resources. Aims Systematically review and critically appraise economic evaluations of population strategies to prevent VDD. Methods The databases reviewed were MEDLINE, EMBASE, Econlit, NHS EED, CEA, and RepEc. All full economic evaluations of VDD prevention strategies were included. Interventions considered were food fortification, supplementation and public health campaigns. Data extracted included type of evaluation, population, setting, measure of benefit and main results. Results Of the 2492 records screened, 14 studies were included. The majority of studies focused on supplementation within at-risk groups with the primary objective of either preventing fractures or falls in older adults. There was insufficient economic evidence to draw conclusions about the cost-effectiveness of population strategies. No study was identified that offered a direct comparison of the two main alternative population strategies: food fortification vs. supplementation. Conclusions Whilst there is a growing body of evidence on the cost-effectiveness of micro nutrient programmes, there is a paucity of data on vitamin D fortification and how fortification programmes compare to population supplementation programmes. We highlight research gaps, and offer suggestions of what is required to undertake population-based cost-effectiveness analysis.
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Affiliation(s)
- Magda Aguiar
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Lazaros Andronis
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Miranda Pallan
- Department of Public Health, Epidemiology and Biotatistics, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Wolfgang Högler
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Emma Frew
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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46
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Uday S, Kongjonaj A, Aguiar M, Tulchinsky T, Högler W. Variations in infant and childhood vitamin D supplementation programmes across Europe and factors influencing adherence. Endocr Connect 2017; 6:667-675. [PMID: 28924002 PMCID: PMC5655685 DOI: 10.1530/ec-17-0193] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 09/18/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Nutritional rickets is a growing global public health concern despite existing prevention programmes and health policies. We aimed to compare infant and childhood vitamin D supplementation policies, implementation strategies and practices across Europe and explore factors influencing adherence. METHODS European Society for Paediatric Endocrinology Bone and Growth Plate Working Group members and other specialists completed a questionnaire on country-specific vitamin D supplementation policy and child health care programmes, socioeconomic factors, policy implementation strategies and adherence. Factors influencing adherence were assessed using Kendall's tau-b correlation coefficient. RESULTS Responses were received from 29 of 30 European countries (97%). Ninety-six per cent had national policies for infant vitamin D supplementation. Supplements are commenced on day 1-5 in 48% (14/29) of countries, day 6-21 in 48% (14/29); only the UK (1/29) starts supplements at 6 months. Duration of supplementation varied widely (6 months to lifelong in at-risk populations). Good (≥80% of infants), moderate (50-79%) and low adherence (<50%) to supplements was reported by 59% (17/29), 31% (9/29) and 10% (3/29) of countries, respectively. UK reported lowest adherence (5-20%). Factors significantly associated with good adherence were universal supplementation independent of feeding mode (P = 0.007), providing information at neonatal unit (NNU) discharge (P = 0.02), financial family support (P = 0.005); monitoring adherence at surveillance visits (P = 0.001) and the total number of factors adopted (P < 0.001). CONCLUSIONS Good adherence to supplementation is a multi-task operation that works best when parents are informed at birth, all babies are supplemented, and adherence monitoring is incorporated into child health surveillance visits. Implementation strategies matter for delivering efficient prevention policies.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology and DiabetesBirmingham Children's Hospital, Birmingham, UK
| | - Ardita Kongjonaj
- MEAL Specialist at Save the Children InternationalAlbania Country Office, Tirana, Albania
| | - Magda Aguiar
- Health Economics UnitUniversity of Birmingham, Birmingham, UK
| | - Ted Tulchinsky
- Braun School of Public Health and Community Medicineand Ashkelon College, Ashkelon, Israel
| | - Wolfgang Högler
- Department of Endocrinology and DiabetesBirmingham Children's Hospital, Birmingham, UK
- Institute of Metabolism and Systems ResearchUniversity of Birmingham, Birmingham, UK
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Fiscaletti M, Stewart P, Munns CF. The importance of vitamin D in maternal and child health: a global perspective. Public Health Rev 2017; 38:19. [PMID: 29450091 PMCID: PMC5809824 DOI: 10.1186/s40985-017-0066-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/21/2017] [Indexed: 12/12/2022] Open
Abstract
Vitamin D and calcium are important nutrients for skeletal growth and bone health. Children and pregnant women are particularly vulnerable to 25-hydroxy vitamin D deficiency (VDD). VDD, with or without dietary calcium deficiency, can lead to nutritional rickets (NR), osteomalacia, and disturbances in calcium homeostasis. Multiple studies have linked VDD to adverse health outcomes in both children and pregnant women that extend beyond bone health. VDD remains an important global public health concern, and an important differentiation must be made between the impact of VDD on children and adults. Reports of increased incidence of NR continue to emerge. NR is an entirely preventable condition, which could be eradicated in infants and children worldwide with adequate vitamin D and calcium supplementation. The desire and necessity to put in place systems for preventing this potentially devastating pediatric disease should not elicit dispute. VDD and NR are global public health issues that require a collaborative, multi-level approach for the implementation of feasible preventative strategies. This review highlights the history, risk factors, and controversies related to VDD during pregnancy and childhood with a particular focus on global NR prevention.
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Affiliation(s)
- M Fiscaletti
- Institute of Endocrinology, The Children’s Hospital at Westmead, Corner Hawkesbury Road and Hainsworth Street, Locked Bag 4001, Westmead, NSW 2145 Australia
| | - P Stewart
- Institute of Endocrinology, The Children’s Hospital at Westmead, Corner Hawkesbury Road and Hainsworth Street, Locked Bag 4001, Westmead, NSW 2145 Australia
| | - CF Munns
- Institute of Endocrinology, The Children’s Hospital at Westmead, Corner Hawkesbury Road and Hainsworth Street, Locked Bag 4001, Westmead, NSW 2145 Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia
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48
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Uday S, Högler W. Nutritional Rickets and Osteomalacia in the Twenty-first Century: Revised Concepts, Public Health, and Prevention Strategies. Curr Osteoporos Rep 2017; 15:293-302. [PMID: 28612338 PMCID: PMC5532418 DOI: 10.1007/s11914-017-0383-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Nutritional rickets and osteomalacia are common in dark-skinned and migrant populations. Their global incidence is rising due to changing population demographics, failing prevention policies and missing implementation strategies. The calcium deprivation spectrum has hypocalcaemic (seizures, tetany and dilated cardiomyopathy) and late hypophosphataemic (rickets, osteomalacia and muscle weakness) complications. This article reviews sustainable prevention strategies and identifies areas for future research. RECENT FINDINGS The global rickets consensus recognises the equal contribution of vitamin D and dietary calcium in the causation of calcium deprivation and provides a three stage categorisation for sufficiency, insufficiency and deficiency. For rickets prevention, 400 IU daily is recommended for all infants from birth and 600 IU in pregnancy, alongside monitoring in antenatal and child health surveillance programmes. High-risk populations require lifelong supplementation and food fortification with vitamin D or calcium. Future research should identify the true prevalence of rickets and osteomalacia, their role in bone fragility and infant mortality, and best screening and public health prevention tools.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Wolfgang Högler
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
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Abstract
OBJECTIVES Poor vitamin D status has been reported to be highly prevalent in many non-western immigrant groups living in Norway and other western countries. However, data on rickets are scarce, and the aim of the current study was to identify new cases of nutritional rickets in Norway in the period 2008-2012 among children under the age of 5 years. DESIGN Register-based cohort study. SETTING The Norwegian population from 2008 to 2012. PARTICIPANTS Children with nutritional rickets under the age of 5 years. MAIN OUTCOME MEASURE Nutritional rickets. Patients with ICD10 (International Statistical Classification of Diseases and Related Health Problems, 10th revision) diagnosis code E55.0 (active rickets) treated at all Norwegian hospitals were identified in the Norwegian Patient Registry. We were able to review 85% of the medical records for diagnosis confirmation. In addition, we identified patients with the diagnoses E55.9, E64.3 and E83.3 to identify individuals with rickets who had been given other diagnoses. RESULTS Nutritional rickets was confirmed in 39 children aged 0-4 years with the diagnosis of E55.0. In addition, three patients with the diagnosis of unspecified vitamin D deficiency (E55.9) were classified as having nutritional rickets, giving a total of 42 patients. Mean age at diagnosis was 1.40 years (range 0.1-3.5 years), and 93% had a non-western immigrant background. The incidence rate of rickets was estimated to be 0.3 per 10 000 person-years in the total Norwegian child population under the age of 5 years and 3.1 per 10 000 person-years in those with an immigrant background from Asia or Africa. CONCLUSION The number of children with nutritional rickets in Norway remained low in the period 2008-2012. Nearly all children had a non-western immigrant background.
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Affiliation(s)
- Haakon E Meyer
- Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Kristina Skram
- Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | | | - Ahmed A Madar
- Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
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Hsu J, Fischer PR, Pettifor JM, Thacher TD. The relationship of maternal bone density with nutritional rickets in Nigerian children. Bone 2017; 97:216-221. [PMID: 28126634 DOI: 10.1016/j.bone.2017.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 01/03/2017] [Accepted: 01/21/2017] [Indexed: 01/01/2023]
Abstract
Factors that affect maternal bone mineral density may be related to the risk of nutritional rickets in their offspring. Our aim was to determine the relationship between maternal areal bone mineral density (aBMD) and rickets in Nigerian children. Using a case-control design, we measured forearm aBMD in 56 and 135 mothers of children with and without nutritional rickets, respectively. Active rickets was confirmed or excluded in all children radiographically. Using logistic regression, we assessed the association of maternal aBMD, adjusted for parity, pregnancy and lactation status, duration of most recent completed lactation, age of menarche, height, body mass index, and maternal age with nutritional rickets. The median (range) age of all mothers was 30years (17-47years), and parity was 4 (1-12). A total of 36 (19%) were pregnant and 55 (29%) were currently breast feeding. Mean (±SD) metaphyseal forearm aBMDs were 0.321±0.057 and 0.316±0.053g/cm2 in mothers of children with and without rickets, respectively (P=0.60). Diaphyseal forearm aBMDs were 0.719±0.071 and 0.715±0.072g/cm2, respectively (P=0.69). In an adjusted analysis, maternal forearm aBMD, bone mineral content and bone area at metaphyseal and diaphyseal sites were not associated with rickets in the child. In the adjusted analysis, rickets was associated with shorter duration of most recently completed lactation (aOR 0.91 for each additional month; 95% CI 0.83-0.99), older maternal age (aOR 1.07 for each additional year; 1.00-1.14), and less frequent maternal use of lead-containing eye cosmetics (aOR 0.20; 95% CI 0.05-0.64), without any difference in maternal blood lead levels. Maternal age, parity, age of menarche, height, and body mass index were not associated with having had a child with rickets in multivariate analysis. Nutritional rickets in Nigerian children was not associated with maternal forearm aBMD. Other unidentified maternal characteristics and practices likely contribute to the risk of rickets in Nigerian children.
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Affiliation(s)
- Jennifer Hsu
- Mayo Medical School, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, United States; Department of Pediatrics, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, United States.
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, United States.
| | - John M Pettifor
- MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Parktown, 2193 Johannesburg, South Africa.
| | - Tom D Thacher
- Department of Family Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, United States; Department of Family Medicine, Jos University Teaching Hospital, PMB 2076, Jos, Plateau State 930241, Nigeria.
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