Managing osteomalacia in India

In India, in addition to misdiagnosing vitamin D deficiency, the real issue lies in the fact that nutritional deficiencies are not really recognized as a problem or disease. Lack of education and interest in screening people worsen the situation, says Neesha Patel

Over recent decades, a wealth of evidence has accumulated documenting vitamin D deficiency in Europe, Asia and specifically northern India. According to Dr Narayana Kochupillai, head of endocrinology and metabolism at the All India Institute of Medical Sciences, New Delhi, “There is evidence that vitamin D deficiency continues to be neglected causing severe bone loss in adults in northern India.” Osteomalacia is a bone metabolic disease, a condition characterised by softening of the bones as a result of vitamin D deficiency.

Vitamin D is both a vitamin and a hormone and has diverse actions - the major biologically active metabolite, 1,25-dihydroxycholecalciferol, plays a central part in maintaining calcium and phosphate homoeostasis and also has anti-proliferative, pro-differentiation and immunosuppressive effects. Its receptors are distributed in various tissues, including bone, pancreas, stomach, gonads, brain, skin, and breast.

Primary initiatives to reduce the number of osteomalacia cases, such as health education about exposure to sunlight and fortification of dairy products, should be made an immediate focus of health officials. Deficiency awareness among general practitioners and gynecologists would greatly enhance such compliance. Resolving uncertainties about the optimal method of supplementation is an ongoing research priority

Vitamin D is essential for skeletal health and severe deficiency is associated with defective mineralisation resulting in rickets or its adult equivalent, osteomalacia. More subtle degrees of insufficiency lead to secondary hyper-parathyroidism and increased bone turnover, which play an important part in age-related bone loss and osteoporotic fractures. Vitamin D status is most commonly assessed by measuring serum concentrations of 25-OHD, the major circulating form of the hormone.

Serum 25-OHD concentrations below 20 nmol/l are generally regarded as indicating severe vitamin D deficiency, but circulating concentrations up to 37.5 nmol/l may be associated with adverse skeletal effects.

Deficiency of vitamin D

Difficulties in establishing requirements for vitamin D arise from the limited number of food sources available, lack of knowledge of precise body needs and degree of synthesis in the skin by irradiation. The amount needed can vary between winter and summer in northern climates. In addition, lifestyle determines the degree of exposure to sunlight and would, therefore, influence individual need.

This is especially true of the elderly and invalids who do not go outside and would require supplementary vitamin D. Growth demands in childhood, during pregnancy and during lactation necessitate increased intake. On a biological level, vitamin D deficiency creates a deficient deposition of hydroxyapatite in the bones, which is due to inadequate absorption of calcium from the intestinal tract and from the retention of phosphorus in the kidney.

This inadequate mineralisation of the bones causes rickets in infants and children and osteomalacia in adults. Vitamin D deficiency can cause delayed closure of the fontanelles, softening of the skull, soft fragile bones, enlargement of the wrist, knee, and ankle joints, poorly developed muscles, restlessness and nervous irritability.

Misdiagnosis

Although malnourishment is a curse the less privileged must carry, the real facts are truly surprising. Subhadra Menon, a health writer and author of “No Place to Go” defines osteomalacia in India as a ‘silent high-morbidity disease,’ for which till recently there was a lack of awareness among doctors and patients in addition to the non-availability of proper diagnostic tools.

After pregnancy, Shalu Bhargava developed an excruciating backache that persisted for months. The X-rays showed nothing and doctors in some of Delhi’s biggest and best hospitals searched tried-and-tested paths, it could be rheumatoid arthritis or perhaps a bad case of spondylitis, but were unable to figure out what the real problem was.

Soon Shalu was heavily dosed with painkillers and was completely immobile still bereft of a diagnosis. A year later, two doctors, both endocrinologists, working on an extensive survey of people with bone metabolic disorders guessed Shalu’s problem; a case of acute osteomalacia; and treated her with high dose vitamin D supplements.

Osteomalacia in India

As in Shalu’s case, doctors working on the disease, trying to study its reach, are surprised by its extent in Indian society. In a survey of 800 women from Delhi and Lucknow, Dr Ambrish Mithal, who now works at the Indraprastha Apollo Hospital in New Delhi, and his colleagues found a 20 percent prevalence of severe osteomalacia. Mithal and his colleagues found that 74 per cent of the women they studied ingested just 500mg of calcium a day, while the average daily requirement is 1000-1500mg; fortification with vitamin D is still uncommon in India.

This is perhaps the reason why osteoporotic fractures are four times more common than strokes in India, but the seriousness of this problem has not been communicated to the people.

Age related fractures show up much earlier in India as compared to developed nations. Further, in India, women often cover their faces or heads whey they leave their home; covered and colored skin make the absorption of vitamin D a problem.

Dr Kochupillai reports cases of patients with acute respiratory failure caused by a grossly deformed thoracic cage resulting from advanced bone loss in the spine and neighbouring areas. He stated that pregnant women, particularly those with poor intake of calcium through their diet, have been highly susceptible to bone loss associated with vitamin D. An article by G. Mudur states that, “the excessive requirement of calcium during pregnancy pushes such women towards severe osteomalacia.”

Doctors in several other hospitals also report that their clinical experience has been contrary to the expectations that vitamin deficiency would be rare in India because of an abundance of sunlight. In the words of Dr Mithal, “In urban India, where people do not get enough exposure to sunlight, vitamin deficiency is clearly a major problem.” A survey by pediatricians in New Delhi’s Kasturba Hospital showed the presence of rickets even among city children.

Dr Kochupillai also stated that there was clinical evidence linking osteomalacia with drug treatment for tuberculosis, asthma and epilepsy. Such drugs inactivate 25-OHD in the liver and aggravate vitamin D deficiency in patients who have low baseline levels of vitamin D.

Further, young mothers after delivery often seek medical help for persistent back pains; practitioners often misdiagnose this condition and treat the women with anti-tuberculosis drugs. Within months, their condition deteriorates and they are bedridden with fracture deformities of multiple bones.

Looking Ahead

In India, in addition to misdiagnosing vitamin D deficiency, the real issue lies in the fact that nutritional deficiencies are not really recognized as a problem or disease.

Lack of education and interest in screening people worsen the situation. Primary initiatives to reduce the number of osteomalacia cases, such as health education about exposure to sunlight and fortification of dairy products, should be made an immediate focus of health officials.

Fortification of dairy products with vitamin D would only affect people with adequate dairy consumption and thus supplementation with preformed vitamin D should be made mandatory. Deficiency awareness among general practitioners and gynecologists would greatly enhance such compliance.

Resolving uncertainties about the optimal method of supplementation is an ongoing research priority. However, in the meantime, 200IU is a safe dose, free of side effects and should have an impact on the increasing morbidity and cost attributable to osteomalacia.