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Vitamin D pp 543-561 | Cite as

Vitamin D Deficiency, Rickets, and Fluorosis in India

  • C. V. Harinarayan
  • Shashank R. Joshi
Chapter
Part of the Nutrition and Health book series (NH)

Abstract

Data on the vitamin D status of the populations in a tropical country like India have seldom been documented. Vitamin D deficiency is presumed to be rare. Population studied by the author and others in the country has proved otherwise. Studies were carried out to document the dietary habits, serum calcium, 25-hydroxyvitamin D [25(OH)D], and parathyroid hormone levels of urban and rural population in a state in south India. The daily dietary calcium intake of both the urban and the rural population was low compared to that of recommended daily/dietary allowances (RDA) issued by Indian Council of Medical Research (ICMR). About 85% of the populations have varying degree of vitamin D status – either hypovitaminosis or vitamin D deficiency. The 25(OH)D levels of rural adult subjects were significantly higher (P < 0.001) than that of urban adult subjects in both male and female groups studied. The 25(OH)D levels of both the urban and the rural children were low.

Low dietary calcium intake and 25(OH)D levels are associated with deleterious effects on bone mineral homeostasis. The quality of diets has to be improved with enrichment/supplementation of calcium and vitamin D to suppress secondary hyperparathyroidism-induced bone loss and risk of fractures. Prospective longitudinal studies are required to assess the effect on bone mineral density, a surrogate marker for fracture risk and fracture rates. In the background of low dietary calcium and low vitamin D status an environmental toxin like fluoride has deleterious effects on the bone. The effect of fluoride and its concomitant renal tubular damage affects the bone mineral metabolism in a deleterious way.

Key Words

Vitamin D deficiency rickets fluorosis calcium deficiency India sunlight 25-hydroxyvitamin D 

References

  1. 1.
    Report of the Joint FAO/WHO Expert Consultation on vitamin and mineral requirement in human nutrition: Bangkok 1998. Second Edition FAO Rome, 2004. Available at http://whqlibdoc.who.int/publications/2004/9241546123.pdf.
  2. 2.
    Harinarayan CV, Gupta N, Kochupillai N (1995) Vitamin D status in primary hyperparathyroidism. Clin Endocrinol (oxf) 43:351–358. 28CrossRefGoogle Scholar
  3. 3.
    Goswami R, Gupta N, Goswami D, Marwaha RK, Tandon N, Kochupillai N (2000) Prevalence and significance of low 25- hydroxyvitamin D concentrations in healthy subjects in Delhi. Am J Clin Nutr 72:472–475PubMedGoogle Scholar
  4. 4.
    Harinarayan CV, Ramalakshmi T, Prasad UV, Sudhakar D, Srinivasarao PVLN, Sarma KVS et al (2007) High prevalence of low-dietary calcium, high-phytate consumption, and vitamin D deficiency in healthy south Indians. Am J Clin Nutr 85:1062–1065PubMedGoogle Scholar
  5. 5.
    Parfitt AM, Gallagher JC, Heaney RP, Johnston CC, Neer R, Whedon GD, Vitamin D (1982) and bone health in the elderly. Am J Clin Nutr 35:1014–1031Google Scholar
  6. 6.
    Hollis BW (2005) Circulating 25 hydroxy D levels indicative of vitamin D insufficiency: implications of reestablishing a new effective dietary intake recommendation for vitamin D. J Nutr Biochem 135:317–322Google Scholar
  7. 7.
    Harinarayan CV (2005) Prevalence of vitamin D insufficiency in postmenopausal south Indian women. Osteoporos Int 16:397–402PubMedCrossRefGoogle Scholar
  8. 8.
    Harinarayan CV, Ramalakshmi T, Venkataprasad V (2004) High prevalence of low dietary calcium and low vitamin D status in healthy south Indians. Asia Pac J Clin Nutr 13:359–365PubMedGoogle Scholar
  9. 9.
    Harinarayan CV, Ramalakshmi T, Prasad UV, Sudhakar D (2008) Vitamin D status in Andhra Pradesh: a population based study. Indian J Med Res 127(3):211–218PubMedGoogle Scholar
  10. 10.
    Agarwal KS, Mughal MZ, Upadhyay P, Berry JL, Marwer EB, Puliyel JM (2002) The impact of atmospheric pollution on vitamin D status of infants and toddlers in Delhi, India. Arch Dis Child 87:111–113PubMedCrossRefGoogle Scholar
  11. 11.
    Arya V, Bhambari R, Godbole MM, Mithal A (2004) Vitamin D status and its relationship with bone mineral density in healthy Asian Indians. Osteoporos Int 1:56–61CrossRefGoogle Scholar
  12. 12.
    Recommended Dietary Allowances. In: Essentials of Food and Nutrition. Fundamental aspects. Bappco Pub 1997; 1:50821.Google Scholar
  13. 13.
    Standing Committee on Scientific Evaluation of Dietary Reference Intakes (1999) Calcium. In: Dietary Reference Intakes for calcium. Food and Nutrition Board, National Academy Press, Washington, DC, pp. 71–145Google Scholar
  14. 14.
    Panwar B, Punia D (2000) Analysis of composite diets of rural pregnant women and comparison with calculated values. Nutr Health 14:217–223PubMedCrossRefGoogle Scholar
  15. 15.
    Heaney RP, Dowell MS, Hale CA, Bendich A (2003) Calcium absorption varies within the reference range for serum 25-hydroxyvitamin D. J Am Coll Nutr 22:142–146PubMedGoogle Scholar
  16. 16.
    Heaney RP (2003) Vitamin D depletion and effective calcium absorption. J Bone Miner Res 18:1342PubMedCrossRefGoogle Scholar
  17. 17.
    Clements MR, Johnson L, Fraser DR (1987) A new mechanism for induced vitamin D deficiency in calcium deprivation. Nature 325:62–65PubMedCrossRefGoogle Scholar
  18. 18.
    Rajeswari J, Balasubramanian K, Bhatia V, Sharma VP, Agarwal AK (2003) Aetiology and clinical profile of osteomalacia in adolescent girls in northern India. Natl Med J India 16:139–142PubMedGoogle Scholar
  19. 19.
    Mathew JT, Seshadri MS, Thomas K, Krishnaswami H, Cherian AM (1994) Osteomalacia – Fifty-five patients seen in a teaching institution over a 4-year period. J Assoc Phys India 42:692–694Google Scholar
  20. 20.
    Shatrugna V, Kulkarni B, Kumar PA, Rani KU, Balakrishna N (2005) Bone status of Indian women from low income group and its relationship to the nutritional status. Osteoporos Int 16:1827–1835PubMedCrossRefGoogle Scholar
  21. 21.
    Marwaha RK, Tandon N, Reddy DRHK, Aggarwal R, Singh R, Sawhney RC et al. (2005) Vitamin D and bone mineral density status of healthy school children in northern India. Am J Clin Nutr 82:477–482PubMedGoogle Scholar
  22. 22.
    Sachan A, Gupta R, Das V, Agarwal A, Awasthi PK, Bhatia V (2005) High prevalence of vitamin D deficiency among pregnant women and their new borns in north India. Am J Clin Nutr 81:1060–1064PubMedGoogle Scholar
  23. 23.
    Mellanby E (1919) An experimental investigation on rickets. Lancet 1:407–412Google Scholar
  24. 24.
    Sly MR, van der Walt WH, Du Bruyn D, Pettifor JM, Marie PJ (1984) Exacerbation of rickets and osteomalacia by maize: a study of bone histomorphometry and composition in young baboons. Calcif Tissue Int 36:370–379PubMedCrossRefGoogle Scholar
  25. 25.
    Clements MR (1989) The problem of rickets in UK Asians. J Hum Nutr Diet 2:105–116CrossRefGoogle Scholar
  26. 26.
    Goswami R, Goswami R, Kochupillai N, Gupta N, Goswami D, Singh N, Dudha A (2008) Presence of 25 (OH) D Deficiency in a Rural North Indian Village Despite Abundant Sunshine. J Assoc Phys India 56:755–757Google Scholar
  27. 27.
    Sahu Sahu M, Bhatia V, Aggarwal A, Rawat V, Saxena P, Pandey A, Das V (2008) Vitamin D deficiency in rural girls and pregnant women despite abundant sunshine in northern India. Clin Endocrinol (Oxf) 70(5):680–684Google Scholar
  28. 28.
    Joshi Shashank R (2008) Vitamin D paradox in plenty sunshine in rural India – an emerging threat. J Assoc Phys India 56:749–752Google Scholar
  29. 29.
    John M (March 2008) Pettifor. Vitamin D &/or calcium deficiency rickets in infants & children: a global perspective. Indian J Med Res 127:pp. 245–249Google Scholar
  30. 30.
    Bhattacharyya AK (1992) Nutritional rickets in the tropics. In: Simopoulos AP (ed) Nutritional triggers for health and in disease. Karger, Basel, pp. 140–197Google Scholar
  31. 31.
    Tiwari L, Puliyel JM (2004) Vitamin D level in slum children of Delhi. Indian Pediatr 41:1076–1077PubMedGoogle Scholar
  32. 32.
    Balasubramanian K, Rajeswari J, Gulab GYC, Agarwal AK, Kumar A et al (2003) Varying role of vitamin D deficiency in the etiology of rickets in young children vs. adolescents in northern India. J Trop Pediatr 49:201–206PubMedCrossRefGoogle Scholar
  33. 33.
    Khandare AL, Harikumar R, Sivakumar B (2005) Severe bone deformities in young children from vitamin D deficiency and fluorosis in Bihar-India. Calcif Tissue Int 76:412–418PubMedCrossRefGoogle Scholar
  34. 34.
    Pettifor JM, Schnitzler CM, Ross FP, Moodley GP (1989) Endemic skeletal fluorosis in children:hypocalcemia and the presence of renal resistance to parathyroid hormone. Bone Miner 7:275–288PubMedCrossRefGoogle Scholar
  35. 35.
    Marwaha RK, Tandon N, Reddy DR, Aggarwal R, Singh R, Sawhney RC et al. (2005) Vitamin D and bone mineral density status of healthy schoolchildren in northern India. Am J Clin Nutr 82:477–482PubMedGoogle Scholar
  36. 36.
    Bhatia V (2008) Dietary calcium intake – a critical reappraisal. Indian J Med Res 127:269–273PubMedGoogle Scholar
  37. 37.
    Tandon N, Marwaha RK, Kalra S, Gupta N, Dudha A, Kochupillai N (2003) Bone mineral parameters in healthy young Indian adults with optimal vitamin D availability. Natl Med J India 16(6):298–302PubMedGoogle Scholar
  38. 38.
    Puri S, Marwaha RK, Agarwal N, Tandon N, Agarwal R, Grewal K, Reddy DH, Singh S (2008) Vitamin D status of apparently healthy schoolgirls from two different socioeconomic strata in Delhi: relation to nutrition and lifestyle. Br J Nutr 99(4):876–882PubMedCrossRefGoogle Scholar
  39. 39.
    Zargar AH, Ahmad S, Masoodi SR, Wani AI, Bashir MI, Laway BA, Shah ZA (2007) Vitamin D status in apparently healthy adults in Kashmir Valley of Indian subcontinent. Postgrad Med J 83(985):713–716PubMedCrossRefGoogle Scholar
  40. 40.
    Bhalala U, Desai M, Parekh P, Mokal R, Chheda B (2007) Subclinical hypovitaminosis D among exclusively breastfed young infants. Indian Pediatr 44(12):897–901PubMedGoogle Scholar
  41. 41.
    Paul TV, Thomas N, Seshadri MS, Oommen R, Jose A, Mahendri NV (2008 Sep) Prevalence of osteoporosis in ambulatory postmenopausal women from a semiurban region in Southern India: relationship to calcium nutrition and vitamin D status. Endocr Pract 14(6):665–671PubMedGoogle Scholar
  42. 42.
    Harinarayan CV, Kochupillai N, Madhu V, Gupta N, Meunier PJ (2006) Endemic skeletal fluorosis in India. Fluorotoxic metabolic bone disease: an osteo-renal syndrome caused by excess fluoride ingestion in the tropics. Bone 39:907–914PubMedCrossRefGoogle Scholar
  43. 43.
    Bawaskar HS, Bawaskar PH (2006) Endemic fluorosis in an Isolated Village in Western Maharashtra. India trop Doct 36(4):221–223CrossRefGoogle Scholar
  44. 44.
    A.K. Susheela Treatise on Fluorosis: 3rd Revised Edition. Published by Fluorosis Research & Rural Development Foundation, Delhi, 2006Google Scholar
  45. 45.
    Teotia SPS, Teotia M (2008) Nutritional bone disease in Indian population. Indian J Med Res 127:219–228PubMedGoogle Scholar
  46. 46.
    Krishnamachari KA (1986) Skeletal fluorosis in humans: a review of recent progress in the understanding of the disease. Prog Food Nutr Sci 10(3–4):279–314PubMedGoogle Scholar
  47. 47.
    Shortt HE, McRobert GR, Bernard TW, Nayar ASM (1937) Endemic fluorosis in Madras presidency. Indian J Med Res 25:553–568Google Scholar
  48. 48.
    Teotia SP, Teotia M (1984) Endemic fluorosis in India: a challenging national health problem. J Assoc Phys India 32(4):347–352Google Scholar
  49. 49.
    Siddiqui AH (1955) Fluorosis in Nalgonda District, Hyderabad-Deccan. Br J Med 4953:1408–1413Google Scholar
  50. 50.
    Singh A, Jolly SS, Bansal BC (1961) Skeletal fluorosis and its neurological complications. The Lancet I:197–200CrossRefGoogle Scholar
  51. 51.
    Krishnamachari KA, Krishnaswamy K (1973) Genu valgum and osteoporosis in an area of endemic fluorosis. Lancet 2(7834):877–879PubMedCrossRefGoogle Scholar
  52. 52.
    Christie DP (1980) The spectrum of radiographic bone changes in children with fluorosis. Radiology 136(1):85–90PubMedGoogle Scholar
  53. 53.
    Moudgil A, Srivastava RN, Vasudev A, Bagga A, Gupta A (1986) Fluorosis with crippling skeletal deformities. Indian Pediatr 23(10):767–773PubMedGoogle Scholar
  54. 54.
    Krishnamachari KA (1976) Further observations on the syndrome of endemic genu valgum of South India. Indian J Med Res 64(2):201–284Google Scholar
  55. 55.
    Teotia M, Teotia SP, Kunwar KB (1971) Endemic skeletal fluorosis. Arch Dis Child 46(249):686–691PubMedCrossRefGoogle Scholar
  56. 56.
    Krishnamachari KA, Krishnaswamy K (1974 (Sep.)) An epidemiological study of the syndrome of genu valgum among residents of endemic areas for flurosis in Andhra Pradesh. Indian J Med Res 62(9):1415–1423PubMedGoogle Scholar
  57. 57.
    Narasinga Rao BS, Krishnamachari KA, Vijaya Sarathy C (1979 (Jan)) 47Ca turnover in endemic fluorosis and endemic genu valgum. Br J Nutr 41(1):7–14PubMedCrossRefGoogle Scholar
  58. 58.
    Krishnaramachari KA (1982) Trace elements in serum and bone in endemic genu valgum – manifestation of fluorosis. Fluoride 15:25–31Google Scholar
  59. 59.
    Jolly SS, Singh BM, Mathur OC, Malhotra KC (1968 (Nov. 16)) Epidemiological, clinical, and biochemical study of endemic dental and skeletal fluorosis in Punjab. Br J Med 4(628):427–429CrossRefGoogle Scholar
  60. 60.
    Reggabi M, Khelfat M, Tabet A, Azzoua M, Hamrour S, Alamir B et al (1984) Renal function in residents of an endemic fluorosis area in southern Algeria. Fluoride 17:35–41Google Scholar
  61. 61.
    Myers HM, (ed) (1989) Renal handling of fluoride (Chapter III). In: Metabolism and toxicity of fluoride. Monographs in oral science. Whitford GM (ed). Karger, Basel, pp. 51–66Google Scholar
  62. 62.
    Gaster D, Havivi. E, Guggenheim. K (1967) Interrelations of calcium, fluorine and vitamin D in bone metabolism. Br J Nutr 21:413–418PubMedCrossRefGoogle Scholar
  63. 63.
    Teotia M, Teotia SPS, Singh KP (1998) Endemic chronic fluoride toxicity and dietary calcium deficiency interaction syndromes of bone disease and deformities in India-2000. Indian J Pediatr 65:371–381PubMedCrossRefGoogle Scholar
  64. 64.
    Teotia SPS, Teotia M (1983) Fluoride and calcium interactions: syndromes of bone disease and deformities (human studies).In: Frame B, Potts JT Jr (ed) Clinical disorders of bone and mineral metabolism. Excerpta Medica, Amsterdam, pp. 520–523Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • C. V. Harinarayan
    • 1
  • Shashank R. Joshi
    • 2
  1. 1.Department of Endocrinology and MetabolismSri Venkateswara Institute of Medical SciencesTirupatiIndia
  2. 2.Department of EndocrinologyLilavati Hospital, Bhatia Hospital and Joshi Clinic; Seth GS Medical College and KEM HospitalMumbaiIndia

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