ReviewNutritional rickets around the world⋆
Highlights
▸ The greatest burden of nutritional rickets is in Africa, the Middle East and Asia. ▸ It is re-emerging in many industrialized countries especially in some ethnic groups. ▸ D deficiency is the main cause even in sunny places, due to limited skin exposure. ▸ Rickets without severe hypovitaminosis D is associated with very low Ca intakes. ▸ Prevention or cure based on vitamin D status will be ineffective in such cases.
Section snippets
Rickets
Rickets is a disease of children characterized by a failure or delay in endochondral calcification of the growth plates of long bones [1]. This results in widening and splaying of the growth plates and leads to enlargement of the wrists and costochondral junctions, and the characteristic deformities of the lower limbs, notably genu varum (bow legs) and genu valgum (knock-knees). Rickets is generally accompanied by osteomalacia, i.e. defective mineralization of preformed osteoid in bone,
Rickets prevalence world-wide
Rickets was common in Europe until the mid- 20th century and was known as “The English Disease” because of its high prevalence in England. The seminal work of pioneers such as Harriette Chick and Elsie Dalyell demonstrated that this was due to vitamin D deficiency [4]. In their studies in a children's hospital in Vienna immediately after World War I, they demonstrated that rickets could be prevented and cured by being in the sunlight outdoors, in the summer not winter, or by exposure to mercury
Causes of nutritional rickets world-wide
Vitamin D deficiency appears to the major factor underlying nutritional rickets in many countries world-wide [23], [24], even in ‘sun-rich’ countries where there is year-round opportunity for skin exposure to UVB-containing sunlight [25], [26], [27]. Vitamin-D deficiency rickets is often first diagnosed in infancy or young childhood and is frequently associated with limited skin sunshine exposure of the mother and child [1]. There are many reasons for such limitations, including wearing
Calcium-deficiency rickets
Reports from South Africa and Nigeria have suggested that calcium deficiency is a major factor in the etiology of rickets in those countries [2], [29], and have demonstrated that some affected children respond well to treatment with calcium alone [32].
A few years ago we reported a case series of patients in The Gambia with bone deformities consistent with rickets who had a similar clinical profile at presentation to that reported from Nigeria and South Africa [28]. The Gambia is a tropical West
Nutritional rickets of mixed etiology
The hypothesis we proposed to explain the etiology of rickets in The Gambia neatly described the presenting biochemical features and response to vitamin D treatment. However, it could not explain why some Gambian children develop rickets while the majority do not, given that most children in that country have very low calcium intakes, of around 200–300 mg/d [37]. Similarly in Nigeria, low calcium intakes alone were not considered to fully account for the rickets seen in that country [29]. In
Concluding remarks
There is an unacceptably high world-wide prevalence of nutritional rickets, a preventable disabling disease of children. The greatest burden is in Africa, the Middle East and Asia, and, increasingly, in families originating from these countries resident in Europe, Australasia and the Americas. For many children, vitamin D deficiency is the predominant cause and is associated with limited UVB exposure by the mother before and during pregnancy and subsequently by the child. For such children the
Acknowledgements
Funded by the UK Medical Research Council under programmes U105960371 and U123261351. I would like to thank all members of my research group, past and present, my collaborators around the world, and the children and their parents who have contributed to the studies and development of ideas described in this paper.
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2022, Journal of Nutrition Education and BehaviorCitation Excerpt :Hence, the national prevalence of rickets in the US is unknown. Albeit rare, the incidence or prevalence of rickets in developed countries occurs mostly among immigrant/refugee and dark-skinned children,16,17 and commonly because of a vitamin D deficiency.15,18,19 In Olmsted County, MN, the incidence of rickets was 24 per 100,000 as identified from health care facilities data between 2000–2009, with Black children having the highest risk at ∼220 per 100,000.20
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Funded by the UK Medical Research Council, programmes U105960371 and U123261351.