Saturday, June 2, 2012

Vitamin D Deficiency in India may be endemic, Be ware, Campaign for Vitamin D food fortification, a study from Trichy

We have been monitoring Vitamin D levels on a consecutive cohort of patients presenting to our hospital. The unpublished results showed 70 out of 85 consecutive patients tested for Vitamin D are deficient in this vitamin. Alarming Eh!

What does it actually mean? Vitamin D is an essential vitamin for the function of all our tissues and the bone in particular. But remember Vitamin D helps in absorption of calcium and keeps the balance with phosphate in the blood and the bone. Calcium is essential for the function of the bone, muscles, heart and the brain and all the tissues of our body.

If this vitamin is deficient, one would feel tired, body pain, back pain in particular, fracture our bones more easily. This vitamin is fortunately synthesized in our skin should we sufficient sun exposure with UV rays. "Maalai muzhudhum Vilayattu endru Vazhakkappaduthi kollu pappa" was sung by Subramania Bharathiyar makes sense for our children. This vilayattu should be outdoors with exposure to sunlight and not in front of our computers.

Deficiency in Vitamin D is termed, as Hypovitaminosis D. Hypovitaminosis D is also prevalent in children and the elderly living in developing world such as Latin America. Risk factors for Hypovitaminosis D in developing countries are similar to those reported in Western countries and include extremes of age, female sex, winter season, dark skin pigmentation, malnutrition, lack of sun exposure, a covered clothing style and obesity (Arabi et al). 
In a tropical country such as India, it is customary to expect Vitamin D deficiency to be rare due to the abundance of sunlight.  The prevalence of Hypovitaminosis D is considerably high in low latitudes. A survey by pediatricians at New Delhi's Kasturba Hospital earlier this year showed the presence of rickets among city children (Mudur et al). 

Vitamin D deficiency when clinically apparent is picked up by the clinicians though the presentation may not necessarily to one sub specialty..  Although severe vitamin D deficiency leading to rickets or osteomalacia is rare in Brazil, a developing country, there is accumulating evidence of the frequent occurrence of subclinical vitamin D deficiency, especially in elderly people (Bandeira et al). 

This sub clinical deficiency makes it even more difficult to quantify the true incidence of Vitamin D deficiency unless an epidemiological study across the whole nation is carried out. This would not be a priority in the national health planning in a country like India especially when the test itself is cost prohibitive.

In developed countries, food fortification has proven an effective and low-cost way to increase the micronutrient supply and reduce the consequences of micronutrient deficiencies. Fortified foods provide most of the vitamin D in the American diet. For example, almost all of the U.S. milk supply is voluntarily fortified with 100 IU/cup. 

In Canada, milk is fortified by law, “with 35–40 IU/100 mL, as is margarine at ≥530 IU/100 g” (Well et all). Other dairy products made from milk, such as cheese and ice cream, are generally not fortified. Certain breakfast cereals often contain added vitamin D, as do several brands of yogurt, margarine, orange juice, and other food products. Both the United States and Canada mandate the fortification of infant formula with vitamin D: 40–100 IU/100 kcal in the United States and 40–80 IU/100 kcal in Canada (Well et all).

In Europe, countries such as Finland have it mandatory to fortify the milk and milk products since 2003.[ Laaksi et al 2006]. Countries such as United Kingdom, Ireland, Scotland, Australia, and similar countries do not require fortification of foods though they allow optional fortification of staple foods such as breakfast cereals and margarine.

However majority of countries in the world do not use Fortification of foods to prevent Vitamin D deficiency. India is one of them.

Most of the studies have reported vitamin D deficiency in specific groups and speciality of medicine. This is a cohort study across all specialities in a multi speciality Hospital which helps us to understand the true incidence in patients attending a hospital. 

However we feel from this study of a very high incidence of clinical Vitamin D deficiency from a select group of patients presenting to a hospital may only be the tip of the iceberg. Even though an epidemiological study across the whole nation will truly reflect the real situation, would not be cost effective. 

As food fortification has rarely been used in the developing countries, we strongly recommend this as a cost effective option. It would be appropriate for a developing country like India as the risk factors for Vitamin D deficiency are the same as a developed country.

The cohort group showed a very high percentage of abnormality for a single test in a clinical situation. With the possibility of sub clinical Vitamin D deficiency, this study highlights the need for either a multi centric study to assess the true incidence in General population or 
simply Vitamin D fortification. 

Now what should we do? We need to campaign to the Government to bring on mandatory food fortification. This would reduce the incidence of this endemic in not only children but also the growing old age popuation who are often confined indoors. We are not going to get any support from the industry as the pharmaceutical companies are happy in selling vitamin D and Calcium supplements and making more money. 

We like to think that we should be taking medicines for every ailment, but in fact a lot of these ailments are preventable and this Vitamin D deficiency is one of them.

Please refer to the link on the side for the calcium rich foods that we can have but we need Vitamin D to help us to absorb the calcium from our diet.

Something to think about!

Best Wishes