Journal of Clinical Nutrition & Dietetics

Vitamin D is endogenously synthesized in human beings from photo conversion of 7-dehydrocholestrol in the skin to cholecalciferol on exposure to ultraviolet radiation of sun. In a tropical country like India, where sunlight exposure is abundant, vitamin D deficiency seems unlikely. However, as opposed to this, various studies have highlighted that 70-100% Indians in different age groups vitamin D insufficient or deficient [1].

In a follow up study in infants, Agarwal et al showed that out of 179 exclusively breastfed infants, 55.67% at 10 weeks and 44.33% infants at 6 months at vitamin D levels <11 ng/ml and 16.49% infants developed rickets [2]. About 43.2% infants aged 2-24 weeks suffer from vitamin D deficiency [3]. Ekbote et al have demonstrated vitamin D deficiency in 83% of toddlers aged 2.7±0.52 years from Pune city (Western India) [4]. Seventy-seven percentages of the children who spent a majority of time in the day in daytime crèche had vitamin D deficiency as they had no exposure to sunlight [5]. Toddlers residing in areas of high levels of atmospheric pollution in Delhi (Central India) have shown to have significantly higher levels of vitamin D deficiency as compared to those from less polluted areas [6]. In older children, 93.7% children aged 6-17 years have shown to be deficient in vitamin D [7]. Prevalence of vitamin D deficiency is noted to be similar in children from both upper (91.9%) and lower (89.6%) socio economic strata [8].

In adults, Harinarayan et al studied vitamin D levels in women of reproductive age and postmenopausal women from South India. Seventy six percentage of reproductive age women and 70% of post-menopausal women were reported to be vitamin D deficient [9]. Studies from Lucknow (Central India) have also shown that 84.3% urban women and 83.6% rural women suffered from vitamin D deficiency [10]. In another study from Kashmir (North India), 58.5% adults have been shown to suffer from vitamin D deficiency [11].

The probable reasons of the wide spread vitamin D deficiency in Indians could be because of low dietary vitamin D intake, high fiber and phytate intake that depletes vitamin D levels [12], reduced exposure to sunlight [5], pollution [6] or reduced exposure of skin to sun light because of cultural and traditional habits like “burkha” or “parda”. However, what is really alarming is that despite the wide spread vitamin D deficiency, Indian Council of Medical Research (ICMR) has not given specific recommendations for daily vitamin D consumption except in specific medical conditions where it recommends a daily supplement of 400 IU [13]. For normal healthy children and adults, ICMR only recommends outdoor activities in sun as a means to acquire adequate vitamin D levels [13] which really doesn’t seem to be sufficient in the current Indian scenario to achieve optimum levels of vitamin D given the wide spread prevalence of deficiency in India.

To elevate the prevalence of vitamin D deficiency in India, it’s very important that public and the private health sector work very closely with each other.

• Firstly, it is very important that the ICMR revise the recommended daily allowance to include daily recommendations for Vitamin D levels

• Educational programs need to be planned to increase public awareness regarding vitamin D deficiency, causes, long term consequences and treatment

• Vitamin D supplementation should be made available at affordable rates that are easy to consume and widely available to the general public. Prophylaxis programme could be planned for vitamin D supplementation especially for vulnerable groups such as infants, toddlers, pregnant and lactating women and elderly

• Public health policies should be devised for fortification of foods such as oil, milk, infant cereals, breakfast cereals with vitamin D

• Daily physical activity of half an hour in sun should be made compulsory part of school curriculum in India

It is thus very evident that vitamin D deficiency is wide spread and prevalent in all age groups in India. The prevalence in most studies is alarmingly very high. Long term vitamin D deficiency has severe consequences. Food fortification, educational programs and public health policies soon need to be formulated to reduce the prevalence of vitamin D deficiency in India.

References

1. G R, Gupta A (2014) Fortification of foods with vitamin D in India. Nutrients. 6:3601-23
2. Agarwal N,Faridi MM, Aggarwal A, Singh O (2010) Vitamin D Status of term exclusively breastfed infants and their mothers from India. ActaPaediatr. 99:1671-4
3. Seth A, Marwaha RK, Singla B, Aneja S, Mehrotra P, Sastry A, KhuranaML, Mani K, Sharma B, Tandon N et al. (2009) Vitamin D nutritional status of exclusively breast fed infants and their mothers. J PediatrEndocrinolMetab. 22:241-6
4. Ekbote VH, Khadilkar AV, Chiplonkar SA, Hanumante NM, Khadilkar VV, Mughal MZ et al. (2011) A pilot randomized controlled trial of oral calcium and vitamin D supplementation using fortified laddoos in underprivileged Indian toddlers. Eur J ClinNutr. 65:440-6
5. Ekbote VH, Khadilkar AV, Mughal MZ, Hanumante N, Sanwalka N, Khadilkar VV, Chiplonkar SA, Kant S, Ganacharya R et al. (2010) Sunlight exposure and development of rickets in Indian toddlers. Indian J Pediatr. 77:61-5.
6. Agarwal KS, Mughal MZ, Upadhyay P, Berry JL, Mawer EB, Puliyel JM et al. (2002) The impact of atmospheric pollution on vitamin D status of infants and toddlers in Delhi, India. Arch Dis Child. 87:111-3.
7. Marwaha RK, Tandon N, Agarwal N, Puri S, Agarwal R, Singh S, Mani K et al.(2010) Impact of two regimens of vitamin D supplementation on calcium - vitamin D - PTH axis of schoolgirls of Delhi. Indian Pediatr. 47:761-9.
8. Puri S, Marwaha RK, Agarwal N, Tandon N, Agarwal R, Grewal K, Reddy DH, Singh S et al. (2008) Vitamin D status of apparently healthy schoolgirls from two different socioeconomic strata in Delhi: relation to nutrition and lifestyle. Br J Nutr. 99:876-882.
9. Harinarayan CV, Sachan A, Reddy PA, Satish KM, Prasad UV, Srivani P et al. (2011) Vitamin D status and bone mineral density in women of reproductive and postmenopausal age groups: a cross-sectional study from south India. J Assoc Physicians India. 59:698-704.
10. Sachan A, Gupta R, Das V, Agarwal A, Awasthi PK, Bhatia V et al. (2005) High prevalence of vitamin D deficiency among pregnant women and their newborns in northern India. Am J ClinNutr. 81:1060-4
11. Daga RA , Laway BA, Shah ZA, Mir SA, Kotwal SK, Zargar AH et al. (2012) High prevalence of vitamin D deficiency among newly diagnosed youth-onset diabetes mellitus in north India. Arq Bras EndocrinolMetabol. 56:423-8.
12. Khadilkar AV. (2010) Vitamin D deficiency in Indian Adolescents. Indian Paediatr47:756-757
13. Nutrient Requirement and Recommended Dietary Allowances for Indians - A report of the expert group of the Indian Council of Medical (2009) Indian Council of Medical Research, National Institute of Nutrition. [accessed on 1st August 2010] 132, 163 – 172, 332.