Nutritional Rickets and Osteomalacia in the Twenty-first Century: Revised Concepts, Public Health, and Prevention Strategies

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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.

Summary

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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Most cited references 71

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IOM committee members respond to Endocrine Society vitamin D guideline.

Clifford Rosen, Steven A. Abrams, John F. Aloia … (2012)

In early 2011, a committee convened by the Institute of Medicine issued a report on the Dietary Reference Intakes for calcium and vitamin D. The Endocrine Society Task Force in July 2011 published a guideline for the evaluation, treatment, and prevention of vitamin D deficiency. Although these reports are intended for different purposes, the disagreements concerning the nature of the available data and the resulting conclusions have caused confusion for clinicians, researchers, and the public. In this commentary, members of the Institute of Medicine committee respond to aspects of The Endocrine Society guideline that are not well supported and in need of reconsideration. These concerns focus on target serum 25-hydroxyvitamin D levels, the definition of vitamin D deficiency, and the question of who constitutes a population at risk vs. the general population.

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Micronutrient fortification of food and its impact on woman and child health: a systematic review

Jai K Das, Rehana Salam, Rohail Kumar … (2013)

Background Vitamins and minerals are essential for growth and metabolism. The World Health Organization estimates that more than 2 billion people are deficient in key vitamins and minerals. Groups most vulnerable to these micronutrient deficiencies are pregnant and lactating women and young children, given their increased demands. Food fortification is one of the strategies that has been used safely and effectively to prevent vitamin and mineral deficiencies. Methods A comprehensive search was done to identify all available evidence for the impact of fortification interventions. Studies were included if food was fortified with a single, dual or multiple micronutrients and impact of fortification was analyzed on the health outcomes and relevant biochemical indicators of women and children. We performed a meta-analysis of outcomes using Review Manager Software version 5.1. Results Our systematic review identified 201 studies that we reviewed for outcomes of relevance. Fortification for children showed significant impacts on increasing serum micronutrient concentrations. Hematologic markers also improved, including hemoglobin concentrations, which showed a significant rise when food was fortified with vitamin A, iron and multiple micronutrients. Fortification with zinc had no significant adverse impact on hemoglobin levels. Multiple micronutrient fortification showed non-significant impacts on height for age, weight for age and weight for height Z-scores, although they showed positive trends. The results for fortification in women showed that calcium and vitamin D fortification had significant impacts in the post-menopausal age group. Iron fortification led to a significant increase in serum ferritin and hemoglobin levels in women of reproductive age and pregnant women. Folate fortification significantly reduced the incidence of congenital abnormalities like neural tube defects without increasing the incidence of twinning. The number of studies pooled for zinc and multiple micronutrients for women were few, though the evidence suggested benefit. There was a dearth of evidence for the impact of fortification strategies on morbidity and mortality outcomes in women and children. Conclusion Fortification is potentially an effective strategy but evidence from the developing world is scarce. Programs need to assess the direct impact of fortification on morbidity and mortality.

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Incidence and prevalence of nutritional and hereditary rickets in southern Denmark.

G B Brock, Tina Kold Jensen, Jeppe Gram … (2009)

To estimate the incidence of nutritional rickets and the incidence and prevalence of hereditary rickets. Population-based retrospective cohort study based on a review of medical records. Patients aged 0-14.9 years referred to or discharged from hospitals in southern Denmark from 1985 to 2005 with a diagnosis of rickets were identified by register search, and their medical records were retrieved. Patients fulfilling the diagnostic criteria of primary rickets were included. We identified 112 patients with nutritional rickets of whom 74% were immigrants. From 1995 to 2005, the average incidence of nutritional rickets in children aged 0-14.9 and 0-2.9 years was 2.9 and 5.8 per 100,000 per year respectively. Among immigrant children born in Denmark, the average incidence was 60 (0-14.9 years) per 100,000 per year. Ethnic Danish children were only diagnosed in early childhood and the average incidence in the age group 0-2.9 years declined from 5.0 to 2.0 per 100,000 per year during 1985-1994 to 1995-2005. Sixteen cases of hereditary rickets were diagnosed during the study period giving an average incidence of 4.3 per 100,000 (0-0.9 years) per year. The prevalence of hypophosphatemic rickets and vitamin D-dependent rickets type 1 was 4.8 and 0.4 per 100,000 (0-14.9 years) respectively. Nutritional rickets is rare in southern Denmark and largely restricted to immigrants, but the incidence among ethnic Danish children was unexpectedly high. Hereditary rickets is the most common cause of rickets in ethnic Danish children, but nutritional rickets is most frequent among all young children.

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Author and article information

Contributors

Wolfgang Högler: ++44 121 333 8197 , wolfgang.hogler@bch.nhs.uk

Journal

Journal ID (nlm-ta): Curr Osteoporos Rep

Journal ID (iso-abbrev): Curr Osteoporos Rep

Title: Current Osteoporosis Reports

Publisher: Springer US (New York )

ISSN (Print): 1544-1873

ISSN (Electronic): 1544-2241

Publication date (Electronic): 13 June 2017

Publication date PMC-release: 13 June 2017

Publication date (Print): 2017

Volume: 15

Issue: 4

Pages: 293-302

Affiliations

[1 ]ISNI 0000 0004 0399 7272, GRID grid.415246.0, Department of Endocrinology and Diabetes, , Birmingham Children’s Hospital, ; Steelhouse Lane, Birmingham, B4 6NH UK

[2 ]ISNI 0000 0004 1936 7486, GRID grid.6572.6, Institute of Metabolism and Systems Research, , University of Birmingham, ; Birmingham, UK

Article

Publisher ID: 383

DOI: 10.1007/s11914-017-0383-y

PMC ID: 5532418

PubMed ID: 28612338

SO-VID: 6cdc42b2-6a7d-4667-85b0-baeb2d83e6e8

License:

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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Funding

Funded by: University of Birmingham

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ScienceOpen disciplines: Orthopedics

Keywords: nutritional rickets,osteomalacia,vitamin d,supplementation policy,food fortification,dietary calcium

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ScienceOpen disciplines: Orthopedics

Keywords: nutritional rickets, osteomalacia, vitamin d, supplementation policy, food fortification, dietary calcium

Nutritional Rickets and Osteomalacia in the Twenty-first Century: Revised Concepts, Public Health, and Prevention Strategies

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Abstract

Purpose of Review

Recent Findings

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Orthopedics

Most cited references 71

IOM committee members respond to Endocrine Society vitamin D guideline.

Micronutrient fortification of food and its impact on woman and child health: a systematic review

Incidence and prevalence of nutritional and hereditary rickets in southern Denmark.

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