A pilot randomized controlled trial of oral calcium and vitamin D supplementation using fortified laddoos in underprivileged Indian toddlers.

BACKGROUND/OBJECTIVES: Low habitual dietary calcium intake and vitamin D deficiency are common among Indian children. Using 'laddoo', an Indian snack, as a vehicle for administering calcium and vitamin D supplements, a randomized double-blind controlled trial was conducted for 12 months to assess its efficacy on total body less head (TBLH) bone mineral content (BMC) in underprivileged toddlers. SUBJECTS/METHODS: A total of 60 toddlers (mean age 2.7±0.52 years, boys=31) were randomized to two groups, (i) study group receiving one calcium fortified laddoo (cereal-legume snack) containing 405 mg calcium per day and (ii) control receiving a non-fortified laddoo, containing 156 mg of indigenous calcium. Both groups also received a laddoo fortified with 30,000 IU of vitamin D(3) per month. Outcome measures included TBLH bone area (BA) and TBLH BMC by GE-Lunar DPX Pro Pencil Beam Dual-Energy X-ray absorptiometry. RESULTS: At baseline, mean energy, protein and calcium intakes were 71, 72 and 47% of Indian Recommended Dietary allowances. In all, 87 and 83% toddlers were hypocalcaemia and vitamin D deficient, respectively. Mean TBLH BMC was 289.5±45.8 g. Post supplementation, mean TBLH BMC of study group showed a significantly greater (P<0.01) increase of 35% as against 28% in controls and the difference remained significant after adjusting for vitamin D status, calcium intake, height and TBLH BA. CONCLUSIONS: Daily supplementation with calcium fortified laddoo, and monthly vitamin D supplement resulted in a significant increase in TBLH BMC of underprivileged toddlers. We believe that such strategies have the potential of addressing nutritional problems in developing countries.

Sunlight exposure and development of rickets in Indian toddlers.

OBJECTIVE: To study the role of sunlight exposure in determining the vitamin D status of underprivileged toddlers. METHODS: Height and weight were measured, clinical examination was performed, Food Frequency Questionnaire was administered and history of sunlight exposure was obtained in all (61) toddlers attending daytime crèche (Group B). Ionised calcium (iCa), inorganic Phosphorous (iP), alkaline phosphatase activity (ALP), serum parathyroid hormone (PTH) and 25 Hydroxy vitamin D (25OHD) were measured. Data were compared with results of a survey measuring similar parameters in 51 (of 251 eligible) toddlers from the same slum (Group A). RESULTS: 111 children (mean age 2.6 yr (0.7), boys 56) were studied. Prevalence of hypovitaminosis D was 77% in group B toddlers (46 of 60) and 16.4% (10 of 61) had rickets, while none of the group A toddlers had 25OHD levels below 30 nmol/L. Four children (7.8%) from Group A as against 24 (42.9%) from Group B, had sunshine exposure of < 30 minutes per day. CONCLUSION: Underprivileged toddlers who were deprived of sunlight had a much greater incidence of hypovitaminosis D and frank rickets. The study has important public health implications and underscores the necessity for sunlight exposure in young children.

Oral calcium supplementation reverses the biochemical pattern of parathyroid hormone resistance in underprivileged Indian toddlers.

BACKGROUND: Toddlers in Pune, India, accustomed to low dietary calcium intake but vitamin D replete have low serum ionised calcium and inappropriately raised serum inorganic phosphorus concentrations together with elevated serum parathyroid hormone (PTH) concentrations. We hypothesised that dietary calcium deficiency leads to end organ resistance to PTH, thus resulting in mild hypocalcaemia and hyperphosphataemia, and that this would be reversed by oral calcium supplementation. METHODS: 51 subjects (25 male; mean (SD) age 2.4 (0.8) years) from an urban slum in Pune were randomised to 500 mg of oral calcium supplement or placebo, daily, for 8 weeks. All subjects received 20 mg of oral elemental iron, daily, as 90% had a serum ferritin concentration <12 microg/l. All subjects were examined for clinical stigmata of rickets and had a wrist radiograph performed. Serum concentrations of ionised calcium, phosphorus, PTH and fibroblast growth factor-23 (FGF-23) were measured at the start and end of the trial. RESULTS: No subject had clinical or radiological evidence of rickets. There was a significant increase in mean serum ionised calcium concentration (p<0.001) in the supplemented but not the placebo group (p = 0.32). The decrease in mean serum phosphorus concentration in the supplemented group was greater (p<0.001) than in the placebo group (p = 0.003). Mean serum PTH fell in the calcium supplemented (p = 0.001) but not in the placebo (p = 0.303) group. The mean serum FGF-23 concentration did not change in response to calcium supplementation. CONCLUSIONS: From these data the authors conclude that low dietary calcium intake is associated with resistance to PTH.

Vitamin B12 and homocysteine status in asymptomatic Indian toddlers.

Low serum vitamin B(12) (V B(12)) and hyperhomocysteinemia have been reported in asymptomatic Asian Indian men. We studied the prevalence of V B(12) deficiency and hyperhomocysteinemia in 51 asymptomatic toddlers, from Pune, India. V B(12) levels were low and total serum homocysteine was high in 14% and homocysteine levels were significantly higher in boys. Programming for cardiovascular risk in adulthood possibly starts at a very young age through the homocysteine axis.

Iron deficiency anemia in an urban slum.

OBJECTIVE: Of this pilot study was to assess the iron status and dietary intake of 1-3 year-old apparently healthy toddlers of the lower socio-economic class, and the effect of eight weeks intervention with liquid oral iron in an urban slum in Pune, India. METHODS: 50 toddlers (M= 25, F= 25) with mean age of 2.4 years (SD 0.82) were evaluated. Anthropometry, Food Frequency Questionnaire, a hemogram and ferritin were measured. Twenty mg of elemental iron was given to all toddlers. After 8 weeks clinical examination, anthropometry, hemoglobin (HGB) and Ferritin were measured. RESULTS: Prevalence of anemia was 66% (HGB <11 gm %) and ferritin (iron stores) were low (< 12 microgm/L) in 45 (90%). After therapy prevalence of anemia was 30%. There was a significant difference in the HGB and ferritin levels of children after eight weeks of therapy (p<0.001). CONCLUSION: The prevalence of anemia decreased from 66 to 30% after treatment with liquid iron. We propose that all concerned in the care of toddlers should join the fight against anemia and prescribe iron to all toddlers when they are seen for minor ailments.