Prevalence and determinates of vitamin D deficiency in India By V.S. Deepika rani

M.Sc. I year (Applied Nutrition)Reg. no. 15MSAN16

PUBLIC HEALTH AND COMMUNITY NUTRITIONMentor- Dr. A Laxmaiah Sir

Scientist ‘F’ (Sr. Deputy Director)&

HOD of community studiesNational Institute of Nutrition, ICMR

Introduction• Prevalence in India - 70 - 100%.

• Factors like lifestyle changes, socio religious and cultural practices etc. do not facilitate adequate sun exposure .

• most under- diagnosed and under- treated .Wide spread in individuals irrespective of their age, gender, race and geography etc.

• Rickets in children and osteopenia, osteoporosis and fractures in the adults.

-Ritu G and Ajay gupta – Vitamin D deficiency in India: Prevalence, Causalities and interventions. Nutrients, 2014.

Background• Till early 1990’s- VDD was considered to be rare in India - measuring

serum calcium and alkaline phosphatase in Indian population.

• Till the year 2000 there was no systematic study which directly assessed body vitamin D status of Indians.

• A study conducted among apparently healthy subjects to measure their serum 25(OH) D level documented significant hypovitaminosis D & was present in up to 90% of subjects.

• There is a wide spread prevalence in all age groups.

- Goswami R, Gupta N, Goswami D, Marwaha RK, Tandon N and Kochupillai N, 2000 Prevalence and significance of low 25-hydroxyvitamin D concentrations in healthy subjects in Delhi, Am J ClinNutr, 72; 472-5.

Testing of vitamin D status• Plasma concentration of 25(OH) D3,

1, 25 (OH) 2 D3, vitamin D binding protein levels are tested.

• Immunoassays such as RIA, ELISA, chemiluminescence immunoassay and protein binding assays are used in routine testing of 25(OH) D in clinical laboratories.

• LCTMS (liquid chromatography tandem mass spectrometry) is the widely accepted reference method for 25 (OH) D measurements.

To define Vitamin D statusClassification given by Lips : o mild hypovitaminosis D : 10–20 ng/ml,o moderate hypovitaminosis D : 5-10 ng/ml,o severe hypovitaminosis D : less than 5 ng/ml

Usual cut off taken are

*Different cut off’s are taken for different age groups.

- Lips P, 2011 Vitamin D Deficiency and secondary hyperparathyroidism in the elderly: consequences of bone loss and fractures and therapeutic impications. Endocr Rev, 22; 477-501.

Serum conc. Of 25(OH)D(ng/ml)

Vitamin D status

<12 VDD

12-20 insufficiency of vitamin D

>20 sufficiency of vitamin D

>50 (particularly when >60ng/ml)

potential adverse effects in adults

Effects of vitamin D deficiency

In children

In adults

Association of vitamin D with human diseasesVitamin D

association with disease

Author and year

T-2 DM R. Goswami et al, 2008G. Bhanuprakashreddy et al, 2015

CVD Zittermann et al 2008

Autoimmunity R. Goswami et al, 2008

Tuberculosis R. Goswami et al, 2008

Cancer Schwartz et al, 1998Deshmukh. 2013

osteoarthritis R. Goswami et al, 2008Present knowledge in Nutrition by Ekhard

E. Ziegler and L.J Filer, Edition 7. pg. no. 206.

Prevalence of vitamin D deficiency in India

3 months

< 5 years

adolescents

pregnant women

lactating women

adults

elderly

0 10 20 30 40 50 60 70 80 90 100

Prevalence of VDD( %)

67-96

47.8

83.7

80

61.4

94.8

91.2

Details of graph Jain V, Gupta N, Kalaivani M, Jain A, Sinha A and Agarwal R, 2011 Vitamin D

deficiency in healthy breastfed term infants at 3 months and their mothers in India:seasonal variation & determinants, Indian J Med Res, 133(3); 267-71.

Wayse V, Yousafzai A, Mogale K and Filteau S, 2004 Association of subclinical vitamin D deficiency with severe acute lower respiratory infection in Indian children under 5 y. Eur J ClinNutr, 58(4); 563-7.

Garg MK, Marwaha RK, Khadgawat R, Ramot R, Obroi AK, Mehan N, Gupta N and Madan R, 2013 Efficacy of Vitamin D loading doses on serum 25-hydroxy Vitamin D levels in school going adolescents: an open label non-randomized prospective trial, J PediatrEndocrinolMetab, 26(5-6); 515-23.

Calvo MS, Whiting SJ and Barton CN, 2005 Vitamin D intake: a global perspective of current status, J Nutr, 135; 310-316.

Oren Y, Shapira Y, Agmon-Levin N, Kivity S, Zafrir Y, Altman A, Lerner A and Shoenfeld Y, 2010 Vitamin D insufficiency in a sunny environment: a demographic and seasonal analysis, Isr Med Assoc J, 12; 751-756.

McCollum E A, 1957 History of Nutrition, Houghton Mifflin Co., Boston, MA. Hopkins FG, 1906 The analyst and the medical man, Analyst, 31; 385–404. Holick MF, 2007 Vitamin D deficiency. N Engl J Med, 357; 266-281. Mehrotra P, Marwaha RK , Aneja S, Seth A, Singla BM, Ashraf G, Sharma B, Sastry

A and Tandon N, 2010 Hypovitaminosis D and Hypocalcemic Seizures in Infancy, Indian Pediatrics, 47; 581-586.

Marwaha RK, Tandon N, Garg MK, Kanwar R, Narang A, Sastry A, Saberwal A, Bhadra K and Mithal A, 2011 Bone health in healthy Indian population aged 50 years and above, OsteoporosInt, 22(11); 2829-36.

Marwaha RK, Tandon N, Agarwal N, Puri S, Agarwal R, Singh S and Mani K, 2010 Impact of two regimens of Vitamin D supplementation on calcium - Vitamin D – PTH axis of schoolgirls of Delhi, Indian Pediatr, 47(9); 761-9.

Seth A, Marwaha RK, Singla B, Aneja S, Mehrotra P, Sastry A, Khurana ML, Mani K, Sharma B, Tandon N et al. (2009) Vitamin D nutritional status of exclusively breast fed infants and their mothers. J PediatrEndocrinolMetab. 22:241-6

Determinates of VDD Reduced skin synthesis of vitamin D

Use of sunscreenSkin pigmentationAgingSeason, latitude and time of day

Decreased bioavailabilityMalabsorptionObesity

Increased catabolismUse of medications

Mother’s nutrition and breast milk

Decreased synthesis of 25(OH)DLiver failure

Increased urinary lossKidney diseases

Dietary, lifestyle factorsModernization - children in crèche (77%)Increased pollution – toddlers residing in DelhiCultural and traditional habitsRepeated and unplanned pregnanciesClimate in IndiaSources of vitamin DChanging food fads and food habits

- Ekbote VH, Khadilkar AV, Mughal MZ, Hanumante N, Sanwalka N, Khadilkar VV, Chiplonkar SA, Kant S, Ganacharya R et al. (2010) Sunlight exposure and development of rickets in Indian toddlers. Indian J Pediatr. 77:61-5.

- Agarwal KS, Mughal MZ, Upadhyay P, Berry JL, Mawer EB, Puliyel JM et al. (2002) The impact of atmospheric pollution on vitamin D status of infants and toddlers in Delhi, India. Arch Dis Child. 87:111-3.

OthersHeritable disorders - pseduo vitamin d ricketsAcquired disorders – hyperthyroidismGenetic factors- ↑ 25(OH) D-24-hydroxylase etc.

Conclusion

• Wide spread prevalence of VDD in India is undeniable.

• Low Ca intake + VDD make matters worse.

• Though various scientific papers give prevalence % and prove the association of vitamin D with various diseases, such studies where basically from other countries. Only few studies are carried out in India. Hence there is a need for encouragement for studies to be carried out in India to prove the same and to have a valid data for ourselves.

Thus recent recommendation of taking 0.8 to 1gm. of dietary calcium and 400 IU ( 1 to 1.5 g of Ca & 2000 IU of vit - D- western data) of vitamin D/day should be adhered to avoid VDD in Indian population .