An old problem yet to be solved

Abrar Ali (not a real name), a 12 year old boy and the captain of volleyball team of his school who takes regular exercise in his basement found that his arms and legs were constantly aching. Visiting his paediatrician revealed that his body lacked vitamin D from blood test. He was prescribed vitamin D and advised to do exercise under sunlight which relieved his pain.

Vitamin D helps to build and maintain bone health. Our body find it difficult to absorb calcium and phosphate from food or supplement without it. But when that happens, bones become brittle and cause pain.

Rickets causing bony deformity is a clinical expression of extreme vitamin D deficiency and represent only the tip of iceberg of huge vitamin D deficiency in children and women, particularly in the developing world. Vitamin D deficiency affects bone health of children and adolescent girls in developing countries. They may not reach pick bone mass as mature adult and they are at risk of osteoporotic fractures at later life. Vitamin D deficiency is also associated with other diseases like type 2 Diabetes, cardiovascular diseases, SLE, Rheumatoid arthritis, breast and colon cancer etc.

Sunlight is the major source of vitamin D, while diet provides less than 10% of body requirement. Children living in sunny countries like Bangladesh are vulnerable to vitamin D deficiency due to

• Dark pigmented skin synthesises ten times less vitamin D from sunlight

• Adolescent girls of many Asian and African have inadequate sunlight exposure due to covering clothes for cultural and religious reasons

• Such women carry low vitamin D status throughout their fertility life, pregnancy and lactating period

• Infants of such women receive less vitamin D from their mother during fetal life and also from mother's milk

• Many urban children do not get enough time for sun exposure either in school (due to lack of playground) or in residence (due to surrounding high rise buildings in cities)

• High air pollution in cities cut off UV radiation leading to inadequate synthesis of vitamin D

How to prevent calcium and vitamin D deficiency?
• Education regarding availability of vitamin D (sunlight exposure of at least 10% exposed skin for 30 -45 minutes)

• Vitamin supplement to exclusively breast fed child particularly of dark skinned mother and child with inadequate exposure to sunlight and other vulnerable group.

• School children should be allowed to spend an hour in sun

• Outdoor exposure of sunlight of children, adolescent and women under privacy if required

• Fortification of milk and food grains is the way forward

• Intake of calcium rich diet such as milk and dairy products like cheese, yogurt, crushed fish bone (grinded) should be encouraged to offer to children.

• Calcium supplement should be taken either on an empty stomach or hours before or after food rich in carbohydrate (wheat, flour, rice etc).

The writer is a Paediatrician working at United Hospital Ltd. E-mail: shakurs@hotmail.com