Bone Abstracts

Rickets and osteomalacia are caused by calcium deprivation, meaning the body has insufficient calcium supply and the resulting secondary hyperparathyroidism leads to excessive bone resorption and, via renal phosphate wasting, also to hypomineralization of bone and growth plates. The two main environmental causes of calcium deprivation are dietary calcium deficiency and solar vitamin D deficiency. The environmental nature of rickets and osteomalacia is undisputed. On a global scale, hundreds of millions of people are affected, and most are undiagnosed. The fact that rickets is most prevalent in the developing world might suggest that poverty is an important factor, in countries with lacking prevention programs, limited food supply or limited UV sunlight. However, rickets and osteomalacia have become a global health concern as they affect humans of all ages whose diets are low in calcium or whose cultural traditions block sunlight. Dark skinned people are at greatest risk, and their migration to high latitude countries is testing how well rickets prevention programs are implemented. Governmental policies and societal/consensus recommendations have very limited effect unless policy is implemented by systematic monitoring of adherence and by providing financial incentives for those delivering the prevention program and for parents attending the child surveillance visits. Delivering continued education of doctors, health care professionals, and specifically new parents is also paramount. Vaccinations programs and vitamin D supplementation should go hand-in-hand in infants but some countries chose to only monitor vaccinations, which is one of the explanations for substantial regional differences in adherence to rickets prevention programs. Effective prevention includes provision of calcium-rich food, sunlight exposure and/or vitamin D supplements. We have demonstrated that fortification of wheat flour with vitamin D is cost-saving and the optimal strategy to prevent vitamin D deficiency. Supplementing the at-risk groups combined with a flour fortification policy offers a more effective and cost-effective option. Worldwide, billions are spent on 25OH vitamin D testing when the cost of measuring 25OHD in one blood sample is similar to supplementing someone for a whole year. Since the risk groups for rickets and osteomalacia are easily recognizable, supplementation, not testing, should become the new standard.

Disclosure: The author is in receipt of honoraria or consultation fees and grants/research supports from Internis Pharma, Alexion, Kyowa Kirin, Ultragenyx.

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