Fortifying India against Vitamin D deficiency

  • The article has been authored by Dr Ambrish Mithal, chairman and head of endocrinology and diabetes, Max Healthcare and Dr RK Marwaha, senior consultant, endocrinology and president Society for Endocrine Health of Elderly, Adolescents and Children (SEHEAC)
In India, vitamin D deficiency continues to be seen both in children and adults.(Shutterstock)
In India, vitamin D deficiency continues to be seen both in children and adults.(Shutterstock)
Published on Jun 23, 2022 04:38 PM IST
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ByHindustan Times

Just last month a 30-year-old man presented to me with complaints of severe backache and muscle weakness. He had difficulty in walking and was on the verge of being confined to a wheelchair. While typical orthopaedic evaluation was inconclusive, a metabolic diagnosis revealed severe vitamin D deficiency (osteomalacia--a condition wherein the bones lose mineral and become soft and malleable). Fortunately, the patient is well on the recovery path after a vitamin D treatment.

Any physician who practises medicine in India would have seen such patients of vitamin D deficiency with bone/muscle pains and weakness, often along with fractures. In children, severe vitamin D deficiency presents as rickets--the growing bones get bent and deformed. The condition has been virtually eradicated in Europe and the United States due to systematic public health interventions like fortification of foods with vitamin D. In India, however, vitamin D deficiency continues to be seen both in children and adults. In fact, the last few months have seen an increasing number of patients- children and adults--presenting with such symptoms. This is simply a gift of the pandemic, with people confined indoors.

These cases are but the tip of the proverbial iceberg. A much greater number of Indians suffer from mild to moderate vitamin D deficiency. For many, low-grade deficiency persists for long periods, resulting in poor calcium absorption, and contributing to bone damage that can potentially manifest with low bone density and fractures in older age.

Various studies suggest a high prevalence of low blood levels of vitamin D (25-OHD) among people in India. Depending on the cut-off used and the population studied, the prevalence of vitamin D deficiency varies from 17 to 90% across India. While all ages are affected, deficiency seems to be more prevalent in cities than villages, and more in north than in the south, which is closer to the equator. As recently as 2020, as many as 25 % of patients hospitalised with covid in a large hospital in Delhi had levels below 10 ng/ml!

What is the role of vitamin D in our body? While vitamin D is a hormone that has numerous actions in the body at a cellular and molecular level, its primary, critical role is in helping absorb calcium from our gut. In the absence of vitamin D, dietary calcium does not reach our blood stream and bones. There is also evidence that vitamin D helps in preventing acute upper respiratory tract infections. There are some differences of opinion about the level required for optimal human health. Most experts recommend levels of 20 ng/ml for overall bone health among adults and levels of 12 ng/ml to prevent rickets in children.

The principal source of vitamin D is not our food, it is sunshine. So, why does a sunny country like India have such a high prevalence of D deficiency? The factors responsible are our sun fleeing behaviour (as opposed to the sun seeking behaviour of the people living in Europe and the United States); professional and personal reasons for spending majority of time indoors; cultural reasons to keep our body parts fully covered when we do go out; atmospheric pollution, which has been shown to inhibit synthesis of vitamin D. In cities like Delhi, supervised exposure of children to the mid-day sun for 30 mins daily (the best time to make vitamin D), did not result in a significant rise in blood levels.

A multi-pronged strategy is required to handle this public health problem (diversification of diets, sunlight exposure, consuming fortified milk, and using supplements when indicated). Vitamin D fortification of popular and commonly consumed commodities such as milk and edible oil, as recommended by Food and Safety Standards Authority, is an established approach. The recommended average daily intake of vitamin D through fortified milk and oil (240 IU) may not be sufficient to raise the serum levels of vitamin D in the normal range as shown in a recent study.

However, it is vital step in the right direction and should logically lead to mandatory fortification, and ultimately a revision of the amount of vitamin D to be added. Encouragingly, in 2020 the government issued a gazette notification with guidelines and standards for edible oil and milk fortification with Vitamins A and D with the intention of moving towards mandatory fortification of the two staples. However, not much has happened since.

While food fortification is not a magic bullet, but it remains one of the most tangible and cost-effective way to reach the last mile to improve the health and nutrition outcomes especially in the short-term. It also reinforces and supports ongoing nutrition improvement programmes and is an essential part of a broader, integrated approach to prevent micronutrient malnutrition, thereby complementing other approaches to improve micronutrient status. The World Health Organization and World Bank suggest that fortification is a widely recognised and highly cost-effective strategy for increasing nutrient intake, one that doesn’t require change in eating behaviour or substantial government budgets. The success story of universal salt iodisation and its role in eradicating iodine deficiency is one of independent India’s biggest public health success stories.

Achieving the goal of a malnutrition-free India, calls for a scaling up of efforts like fortification. As was the case with the iodisation of common salt, the time has come for all stakeholders to combine for a push towards fortification to reduce and prevent debilitating conditions caused by vitamin D deficiency.

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