Rubina Mandlik

Epidemiology and treatment of osteoporosis in women: an Indian perspective

The number of women with osteoporosis, ie, with reduced bone mass and the disruption of bone architecture, is increasing in India. While data on prevalence of osteoporosis among women in India come from studies conducted in small groups spread across the country, estimates suggest that of the 230 million Indians expected to be over the age of 50 years in 2015, 20%, ie, ~46 million, are women with osteoporosis. Thus, osteoporosis is a major public health problem in Indian women. Low calcium intakes with extensive prevalence of vitamin D deficiency, increasing longevity, sex inequality, early menopause, genetic predisposition, lack of diagnostic facilities, and poor knowledge of bone health have contributed toward the high prevalence of osteoporosis. Bone health may be optimized by creating an environment to achieve peak bone mass during adolescence, maintenance of healthy bone throughout the life cycle, and prevention of bone loss postmenopausal. In Indian women, calcium, vitamin D, and bisphosphonates are the commonest first-line therapies used. The use of other drugs such as hormone replacement therapy, estrogen agonists, calcitonin, parathyroid hormone, and denosumab is decided as per the affordability and availability of treatment options. Major gaps still remain in the diagnosis and management of osteoporosis, thus highlighting the need for more structured research in this area. This review focuses on the epidemiology of osteoporosis in Indian women and available treatments.

Dietary calcium intake influences the relationship between serum 25-hydroxyvitamin D3 (25OHD) concentration and parathyroid hormone (PTH) concentration

Objectives To investigate whether dietary calcium intake will modify the relationship between serum 25-hydroxyvitamin D3 (25OHD) with intact serum parathyroid hormone (PTH) concentrations in apparently healthy Indian adolescents. Study design Cross-sectional study. Setting and participants Apparently healthy adolescents aged 10–14 years (n=181), from Gujarat, western India. Study conducted from January 2012 to March 2014. Methods Serum 25OHD concentrations and intact serum PTH concentrations (both using chemiluminescent microparticle immunoassay) were measured. Diet was recorded through 24 h diet recall and calcium intake was computed (C-diet V.2.1). To assess relationship between 25OHD and PTH, data were dichotomised according to median calcium intakes (520 mg/day) and relationship between serum 25OHD and PTH in the two subgroups was plotted. Results Subjects with calcium intakes above median (>520 mg/day) had lower intact serum PTH values for given serum 25OHD concentration while those with calcium intakes below median (<520 mg/day) had higher intact serum PTH values for given serum 25OHD concentration. Serum 25OHD concentration was negatively correlated with intact serum PTH concentration at lower as well as higher calcium intakes (r=− 0.606 and −0.483, respectively, p<0.01 for both). Using a regression analysis, predicted values for intact serum PTH concentration for the given serum 25OHD concentrations were plotted. The plot revealed a negative shift with increasing calcium intake. Conclusions Dietary calcium intake modifies the relationship between serum 25OHD concentrations and intact serum PTH concentrations. Thus, dietary calcium intake should be taken into account when assessing an individuals vitamin D status.

Reference centile curves for triceps skinfold thickness for Indian children aged 5–17 years and cut-offs for predicting risk of childhood hypertension: A multi-centric study

ObjectivesTo create age- and gender-specific Triceps Skinfold Thickness percentile curves for Indian children; and to determine cut-offs for predicting the risk of childhood hypertension.DesignCross-sectional.SettingMulticentric, school-based, 5 major Indian citiesParticipants13375 children (7590 boys) aged 5-17 yearsProcedureData on height, weight, blood pressure, triceps skinfold thickness (using Harpenden Skinfold caliper) were collected. Reference triceps skinfold thickness percentile curves were derived for boys and girls by LMS (lambda-mu-sigma) method. Receiver operating curve analyses were performed to determine the optimal cut-off of triceps skinfold thickness centile for predicting the risk of hypertension.ResultsPercentile curves for boys plateau around 13 years whereas for girls the curves increase steadily till the age of 17 years. Median triceps skinfold thickness increased by 7% to 9% till the age of 9 years in boys and girls. After 12 years, median triceps skinfold thickness decreased by 1% to 2% in boys but increased by 3% to 4% in girls. The optimal cut-off percentile yielding maximal sensitivity (68%) and specificity (74-78%) for predicting high blood pressure was the 70th triceps skinfold thickness percentile in both genders.ConclusionsPercentile curves for triceps skinfold thickness developed in the present study would be useful in the assessment of adiposity and the risk of hypertension in Indian children.

Validation of Bioelectric Impedance Analysis against Dual-Energy X-ray Absorptiometry for assessment of body composition in Indian children aged 5 to 18 years

ObjectiveTo validate body composition measurements by Bioelectric Impedance Analysis (BIA) against Dual-Energy X-ray Absorptiometry (DXA) as the reference method in healthy children and adolescents.DesignCross-sectionalSettingSchools in and around Pune city, India.ParticipantsA random sample of 210 (114 boys, 96 girls) apparently healthy Indian children and adolescents (5–18 y).MethodsWeight, height, Tanner stage (TS) were recorded. Body composition measures: fat-free mass (FFM), fat mass (FM), lean mass (LM), bone mineral content (BMC) and body fat percentage (%BF) were assessed by BIA and DXA on a single day. Agreement between the methods was estimated by Pearson’s correlation, and Bland and Altman analysis.Main outcome measures%BF, FM, FFM, LM, BMC.ResultsBIA underestimated %BF by 6.7 (3.7)% as compared to DXA. Mean FFM, BMC and LM by BIA were significantly higher than by DXA (P<0.001). These differences remained similar after adjusting for age, BMI and TS. Mean differences between FFM (−2.32 (1.39) kg), BMC (−0.18 (0.15) kg), and LM (−2.15 (1.34) kg) by DXA and BIA were significant (P<0.01). Correlations between BIA and DXA were 0.92 for %BF, 0.96 for LM and 0.98 for FFM and BMC. Both the methods were similar in identifying normal and overfat children as per their respective cut-offs.ConclusionBIA and DXA techniques are not interchangeable for assessment of body composition. However, BIA may be used in the field/clinical setting preferably with ethnicity specific references.

Response of serum 25(OH)D to Vitamin D and calcium supplementation in school-children from a semi-rural setting in India

The objectives of this study were to: 1) Determine the impact of varying baseline serum 25OHD on increase in vitamin D concentrations after daily supplementation with vitamin D and calcium (1000 IU + 500 mg respectively) for six months in school-children from a semi-rural setting 2) Test the efficacy of daily vitamin D-calcium supplementation on improvement in serum vitamin D concentrations to ≥75 nmol/L. Data collected from 106 subjects (58 boys, 48 girls), aged 6-12 years, included anthropometric measures like height and weight, body composition analysis, three one-day dietary recalls and sunlight exposure (by questionnaire). Blood was collected at baseline and endline and estimated for serum vitamin D by ELISA technique using standard kits. Classification of Vitamin D status was performed according to the 2011 Endocrine Society Practice Guidelines: vitamin D deficiency - <50 nmol/L; insufficiency - 50.0-74.9 nmol/L; sufficiency - ≥75 nmol/L. Statistical analysis was performed using SPSS software. Mean baseline serum vitamin D concentration was 59.7 ± 11.2 nmol/L; this rose to 79.8 ± 23.3 nmol/L with no significant differences between genders at the two time-points. Inverse relationship was obtained between baseline serum 25(OH)D concentrations and change in serum concentrations after supplementation, implying that with increasing baseline serum concentrations of 25(OH)D, increase in vitamin D levels post supplementation were significantly lower (r = - 0.96, p < 0.0001). Greatest benefit of change in serum vitamin D concentrations after supplementation was experienced by children with basal concentrations of <45 nmol/L. Daily vitamin D supplementation was effective in improving serum 25(OH)D to ≥75 nmol/L in 44% of children. Significantly higher percentage of children who were deficient at baseline (64%) were able to attain serum concentrations of ≥75 nmol/L as compared to children who were vitamin D insufficient (43%) (p < 0.001). Thus, daily supplementation with 1000 IU of vitamin D along with 500 mg of calcium helped in improving serum vitamin D concentrations to ≥75 nmol/L. Children who were vitamin D deficient particularly experienced these benefits.

Association of dental and skeletal fluorosis with calcium intake and serum vitamin D concentration in adolescents from a region endemic for fluorosis

Context: Fluorosis is controlled by the duration of fluoride exposure and calcium and Vitamin D nutrition status. Aim: To examine (a) prevalence of dental and skeletal fluorosis in adolescents from upper, middle, and lower socioeconomic strata (SES) and (b) association of fluorosis with calcium intake and Vitamin D status. Settings and Design: A cross-sectional study conducted in 10–13.9 years apparently healthy adolescents (n = 90), from different SES of Patan (Gujarat, India). Materials and Methods: Dental fluorosis was graded as mild, moderate, and severe. Radiographs of the right hand and wrist were examined and graded. Serum 25 hydroxyvitamin D3 (25OHD) and parathyroid hormone concentrations were measured. Diet was recorded (24 h recall) and calcium intake was computed (C-diet V-2.1, 2013, Xenios Technologies Pvt. Ltd). Statistical Analysis: Generalized linear model was used to analyze relationships between fluorosis, SES, serum 25OHD concentration, and calcium intake. Results: Fluorosis was predominant in lower SES (17% had both dental and radiological features whereas 73% had dental fluorosis); no skeletal deformities were observed. Mean 25OHD concentrations and dietary calcium were 26.3 ± 4.9, 23.4 ± 4.7, and 18.6 ± 4 ng/ml and 441.2 ± 227.6, 484.3 ± 160.9, and 749.2 ± 245.4 mg/day, respectively, for lower, middle, and upper SES (P < 0.05). Fluorosis and SES showed a significant association (exponential β = 2.5, P = 0.01) as compared to upper SES, middle SES adolescents were at 1.3 times while lower SES adolescents were at 2.5 times higher risk. Serum 25OHD concentrations (P = 0.937) and dietary calcium intake (P = 0.825) did not show a significant association with fluorosis. Conclusion: Fluorosis was more common in lower SES adolescents, probably due to the lack of access to bottled water. Relatively adequate calcium intake and serum 25OHD concentrations may have increased the efficiency of dietary calcium absorption, thus preventing severe fluorosis.

Reference centile curves for wrist circumference for Indian children aged 3–18 years

Abstract Background: Childhood obesity and its consequences have reached alarming proportions worldwide and in India. Wrist circumference is emerging as an easily measurable reproducible parameter for screening children at risk of obesity-related morbidities such as hypertension and insulin resistance. The objectives of this study were: (1) to compute age and gender-specific wrist circumference percentiles for 3–18-year-old apparently healthy Indian children and adolescents; (2) to assess the relationship of wrist circumference with measures of obesity and adiposity such as body mass index (BMI), fat percentage and blood pressure (BP) and (3) to suggest age and gender-specific cut-offs for wrist circumference percentile for the risk of hypertension in Indian children and adolescents. Methods: This was a cross-sectional study on samples of 10,199 3–18-year-old children (5703 boys) from randomly selected schools from five major cities in India. Height, weight, waist and wrist circumference and BP were recorded. Body composition was measured using bioelectrical impedance analysis (BIA). Wrist circumference percentiles were computed using the LMS method. Results: The average wrist circumference of boys and girls was 10.4 cm and 10.0 cm at 3 years and increased to 15.1 cm and 13.9 cm, respectively, at 18 years. Compared to their Caucasian counterparts, Indian children’s wrists were smaller. Receiver operating characteristic (ROC) curve analysis derived the 70th percentile of wrist circumference as the cut-off for identifying the risk of hypertension. Conclusions: Contemporary cross-sectional reference percentile curves for wrist circumference for 3–18-year-old Indian children are presented. The 70th percentile of the current study is proposed as the cut-off to screen children for cardiometabolic risk factors such as hypertension.

Determinants of Vitamin D status in Indian school-children

Introduction: Due to the high prevalence of Vitamin D deficiency in spite of abundant sunshine and scarcity of studies investigating Vitamin D status in Indian children from rural and semirural areas, the objectives of this cross-sectional study were to: (1) assess the Vitamin D status of school-children in a semi-rural setting and (2) identify the determinants of Vitamin D status in these children. Materials and Methods: Data collected included anthropometric measurements (height and weight), body composition, three-one-day dietary recall method, demographic data, and sunlight exposure. Serum 25-hydroxyVitamin D (25(OH)D) was estimated by enzyme-linked immunosorbent assay (ELISA) technique. SPSS software was used for statistical analysis. Results: Anthropometric characteristics of the children were similar and mean serum 25(OH)D concentration was 58.5 ± 10.3 nmol/L with no significant differences between genders. Around 80% children reported sunlight exposure of 2 h or more. A majority (71%) of children were Vitamin D insufficient with serum 25(OH)D concentrations between 50 and 74.9 nmol/L. Determinants of Vitamin D identified were duration of sunlight exposure and body fat percent. Significant (P < 0.05) positive association of duration of sunlight exposure was observed with serum 25(OH)D concentrations, while BF% showed a negative association with serum 25(OH)D (β = –0.307; standard error = 0.1388; P < 0.05). Discussion: We have reported a high prevalence of Vitamin D insufficiency in school-children aged 6–12 years, from a semirural setting, in spite of a majority (80%) reporting >2 h of sunlight exposure. We have also demonstrated that duration of sunlight exposure and body fat percentage are the two important determinants of serum 25(OH)D concentrations in these children.

Reference centile curves for body fat percentage, fat-free mass, muscle mass and bone mass measured by bioelectrical impedance in Asian Indian children and adolescents

ObjectivesTo create gender-specific percentile curves for percent body fat (%BF) by Bio electrical Impedance Analysis (BIA) for screening adiposity and risk of hypertension in Indian children and generate reference curves for percent fat-free mass (%FFM), muscle mass (%LM) and bone mineral content (BMC) by using bioelectrical impedance.DesignSecondary analysis of data from previous multicenter cross-sectional studies.SettingPrivate schools from five regions of India.ParticipantsA random sample of 3850 healthy school children (2067 boys) (5-17 yr) from private schools in five major Indian cities.MethodsAnthropometry, blood pressure (BP) and body composition were measured by bioelectrical impedance. Reference curves were generated by the LMS method.Main outcome measures%BF, %FFM, %LM, BMC and BPResultsMedian %BF increased by 6% from 5 to 13 years of age and declined (around 2%) up to 17 years in boys. In girls, %BF increased by 8% from 5 to 14 years and thereafter declined by 3%. Based upon the risk of hypertension, the new cut-offs of 75th and 85th percentile of %BF were proposed for detecting over fatness and excess fatness in children. Median %FFM was 90% at 5 yrs and decreased till 12 years, and then showed a slight increase to 84% at 17 yrs in boys. In girls, it was 86% at 5 yrs and decreased till 15 yrs, and plateaued at 71.8% at 17 yrs.ConclusionsReference curves for percent body fat for Indian children would be useful to screen children for health risk in clinical set up.

Growth status of small for gestational age (SGA) Indian children from two socioeconomic strata

Aims To assess growth and factors associated with growth in children born SGA from two socio economic strata in comparison to age and gender matched healthy controls. Methods Retrospective study conducted at two hospitals in Pune, 0.5 to 5 years old 618 children – 189 SGA from Upper Socioeconomic Strata (USS), 217 SGA from Lower Socioeconomic Strata (LSS) and 212 appropriate for gestational age (AGA) healthy controls were randomly selected. Birth history, maternal history, socioeconomic status, length/height and weight of children were recorded. Anthropometric data were converted to Z scores (HAZ, WAZ) using WHO AnthroPlus software [1]. Data on neonatal morbidity and feeding history of children were recorded (analysis in progress). Results Mean ages of all 3 groups were similar (2.7 years for USS, 2.8 for LSS and 2.9 for controls). The HAZ and WAZ of the SGA group were significantly lower as compared to the controls (p < 0.05), and that of the LSS SGAs were lower than that of the USS SGAs (p<0.05). The percentage of children who were stunted (HAZ <-2.0) were 32% in USS and 49% in LSS (p< 0.05 for all). The percentage of stunted children in the USS SGA group at 2 years was 29% and at 5 years was 17% while in the LSS SGA group, 54% of children were found to be stunted at 2 years and 46% at 5 years. To determine factors associated with stunting in SGA children, generalized linear model (GLM) was used. GLM revealed that a normal vaginal delivery (b = 0.625) and mothers age (b = 0.072) were positively associated with risk of stunting , high SES (b =-0.830), absence of major illness (b =-1.01), higher birth weight (b =-1.34) were negatively associated (p for all < 0.05). Conclusion Children born SGA showed relatively poor growth as compared to healthy controls. Special attention to growth is necessary especially in children from the lower socio economic strata, very low birth weight babies and those with major illnesses during early years of life. Cite this article as: Khadilkar et al.: Growth status of small for gestational age (SGA) Indian children from two socioeconomic strata. which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver