Spot the silent sufferers: A call for clinical diagnostic criteria for solar and nutritional osteomalacia.
J Steroid Biochem Mol Biol. 2019 Jan 14. pii: S0960-0760(18)30542-9. doi: 10.1016/j.jsbmb.2019.01.004.
Uday S1, Högler W2.
Overview of Rickets and vitamin D contains the following summary
Rate of rickets is usually < 0.1% of births, unless dark skin or breastfed
Rate of rickets has greatly increased with the drop in vitamin D levels during the past 40 years
400 IU can prevent/treat most rickets Turkey gave vitamin D to EVERY child and eliminated Rickets
A low serum level of vitamin D does not indicate rickets
Sometimes rickets is also associated with a poor vitamin D receptor
Giving enough Vitamin D to the mother PREVENTS Rickets
Rate of rickets in some countries varies from 10% to 70% (typically poor health overall)
Rickets has been more than doubling in many countries
Rickets is strongly associated with severe breathing problems (weak ribs)
Bowed legs is not the primary indication of rickets (3 other indications of rickets are seen more often)
Vitamin D and Rickets consensus took 80 years
- Vitamin D receptors get worse with age with osteoporosis – Dec 2018
- Osteoporosis 15 percent more likely if poor Vitamin D receptor – meta-analysis Dec 2018
- Diagnosis and treatment of osteopenia – Holick 2010
- Osteomalacia (soft bones - ricket in children) – Vitamin D occurs 87 times in PDF, but not once in the abstract – March 2018
- Low Calcium and vitamin D makes osteomalacia but either makes osteoporosis – Sept 2010
- Quick, free, self test of vitamin D deficiency
Osteomalacia in children = Rickets
- Rickets needs Vitamin D and Calcium - Global Consensus Jan 2016
- Vitamin D and Rickets consensus took 80 years – how long till consensuses on 30 other health problems – Feb 2016
- Sunshine can prevent rickets – Poland 1822
- Low Vitamin D in infants - video interview of Dr. Holick - May 2017
- Rickets in UK increased 4X in a decade - May 2015
- Rickets reduced 60X - lessons learned by Turkey 2011
- But not yet learned by the rest of the world
- Low vitamin D may account for half of the reasons for osteomalacia – Oct 2010
- Search VitaminDWiki for Osteomalacia 1510 items as of June 2018
- Osteomalacia Wikipedia
"Osteomalacia in children is known as rickets, and because of this, use of the term "osteomalacia" is often restricted to the milder, adult form of the disease"
- Mayo Clinic: Osteomalacia refers to a marked softening of your bones, most often caused by severe vitamin D deficiency
- Arthritis UK Osteomalacia often develops because of a lack of vitamin D.
It can cause bone pain and muscle weakness.
In children it used to be called rickets, but nowadays it more often affects adults
- Could growing pains in a child be a vitamin D deficiency – Sept 2010
- Working other than dayshift reduces vitamin D levels and Bone Mineral Density and increases bone pain – Aug 2013
- Lumbar spinal stenosis pain strongly associated with low vitamin D – March 2013
- Leg pain 7X more prevalent when vitamin D lower than 20 ng – Oct 2010
- Shin splints decrease with vitamin D
Magnesium is also needed to build strong bones
Items in both categories Bones and Magnesium are listed here:
- Magnesium increases Vitamin D, which increases Mg. Both increase bone – Oct 2019
- Vitamin D and Calcium do not increase bone density (also need exercise, Mg, K2, protein etc.) – RCT Aug 2019
- Many seniors do not get enough protein, Vitamin D, Mg, etc. needed for bones – Feb 2019
- More Magnesium makes more bone when there is enough Vitamin D (petri dish) – Jan 2019
- Diagnosis and treatment of osteopenia – Holick 2010
- Adding just vitamin D again failed to add bone density (also need Magnesium, Vitamin K, etc) – RCT Aug 2018
- MAGNESIUM IN MAN - IMPLICATIONS FOR HEALTH AND DISEASE – review 2015
- Stronger bones after 3 generations of tap water (more Ca and Mg) vs bottled water – March 2015
- Bones grow better with high level of magnesium: rat study – Dec 2013
- 20 percent fewer male hip fractures if more Magnesium in the water – July 2013
- Magnesium may be more important to kids’ bone health than calcium – May 2013
- Healthy bones need: Calcium, Vitamin D, Magnesium, Silicon, Vitamin K, and Boron – 2012
- Vitamin D, K2, Magnesium, etc increase bone density when taking together– Jan 2012
- 400 IU of vitamin D Magnesium and Calcium helped Twin bones – Feb 2011
Osteomalacia and rickets result from defective mineralization when the body is deprived of calcium. Globally, the main cause of osteomalacia is a lack of mineral supply for bone modeling and remodeling due to solar vitamin D and/or dietary calcium deficiency. Osteomalacia occurs when existing bone is replaced by unmineralized bone matrix (osteoid) during remodeling in children and adults, or when newly formed bone is not mineralized in time during modeling in children. Rickets occurs when hypomineralization affects the epiphyseal growth plate chondrocytes and adjacent bone metaphysis in growing children. Hence, osteomalacia co-exists with rickets in growing children. Several reports in the last decade highlight the resurgence of so-called "nutritional" rickets in the dark-skinned population living in high-income countries.
However, very few studies have ever explored the hidden iceberg of nutritional osteomalacia in the population.
Rickets presents with hypocalcaemic (seizures, tetany, cardiomyopathy), or hypophosphataemic complications (leg bowing, knock knees, rachitic rosary, muscle weakness) and is diagnosed on radiographs (cupping and fraying of metaphyses).
In contrast, osteomalacia lacks distinctive, non-invasive diagnostic laboratory or imaging criteria and the clinical presentation is non-specific (general fatigue, malaise, muscle weakness and pain). Hence, osteomalacia remains largely undiagnosed, as a hidden disease in millions of dark-skinned people who are at greatest risk. Radiographs may demonstrate Looser's zone fractures in those most severely affected, however to date, osteomalacia remains a histological diagnosis requiring a bone biopsy. Biochemical features of high serum alkaline phosphatase (ALP), high parathyroid hormone (PTH) with or without low 25 hydroxyvitamin D (25OHD) concentrations are common to both rickets and osteomalacia.
Here, we propose non-invasive diagnostic criteria for osteomalacia. We recommend a diagnosis of osteomalacia in the presence of
- high ALP,
- high PTH,
- low dietary calcium intake (<300 mg/day)
- and/or low serum 25OHD (<30 nmol/L).
Presence of clinical symptoms (as above) or Looser's zone fractures should be used to reaffirm the diagnosis. We call for further studies to explore the true prevalence of nutritional osteomalacia in various populations, specifically the Black and Asian ethnic groups, in order to identify the hidden disease burden and inform public health policies for vitamin D/calcium supplementation and food fortification.
From chart in the PDF
- Pregnancy/Birth: Obstructed labour, neonatal hypocalcaemia, low birth weight
- Infant: craniotabes, seizures , dilated cardiomyopathy leading to heart failure and cardiac death, hypotonia, poor feeding, restlessness, irritability, leg bowing
- Child: muscle weakness, delayed development and dentition, swelling of wrists and ankles, leg bowing deformities
- Adolescent: Hypocalcaemic seizures, tetany, bone pain, muscle weakness, fractures
- Young adult/adul: Fatigue, bone pain, muscular pain and weakness, difficulty rising from sitting position, waddling gait
- Old age: fatigue, malaise, muscle weakness, muscle pain, falls and fractures