presented at the annual meeting of the American Society for Nutritional Sciences, April, 1998

NUTRITIONAL RICKETS IN BANGLADESH G. Combs, Jr., C. Meisner, P. Fischer, J. Cimma, A. Rahman, N. Hassan, T. Kyaw-Myint, J. Duxbury, R. Welch, A. Kabir, K. Talukder, B. Manaster, D. Staab, S. Haque, Cornell U., Ithaca, NY 14853; CIMMYT, Dhaka; U.Utah, Salt Lake City, UT; Grenoble, France; SARPV, Dhaka; Dhaka U.; UNICEF, Dhaka; USDA, Ithaca, NY; Inst.Mother Child Health, Dhaka; Mem. Christian Hosp., Chakaria, Bangladesh.

Rickets has been identified in Chakaria, southeastern Bangladesh. Vitamin D therapy has not been beneficial. Rachitic children (9 m, 5 f, 36-98 mos.) showed knock- knees (10), bowed legs (4) and sabre tibae (3). Ten had active serum alk. P-ase >350 U/L; 7 of 12 had radiographic evidence of active rickets. Cases differed significantly from children seen by parents as "unaffected": serum alk. P-ase (: 492 vs. 206 U/l), serum P (: 4.3 vs. 5.2 mg/dl), serum 25OHD3 (: 20 vs. 25 ng/ml), serum 1,25-(OH)2D3 (: 131 vs. 73 pg/ml, P<0.0005), but not serum Ca (: 9.6 mg/dl). Only 2 of 10 children with active rickets had low 25OHD3 levels (1 hypophosphatemic). Cases did not show elevated blood levels of known Ca-antagonists (Al, Ba, Sr, Pb, Cd); nor were local water or foods high in these elements. Three 3 "unaffected" children had physical signs consistent with rickets (beaded ribs, 1 with widened wrists, 1 with knock-knees) without elevated alk. P-ase; such findings and elevated serum 1,25-(OH)2D3 among "unaffected" children suggest that subclinical Ca deficiency may be prevalent in this population. These results indicate Chakaria rickets to resemble the Ca-deficiency rickets described in Africa.

presented at the ASCON IV meetings at ICDDR,B - January, 1998

NUTRITIONAL RICKETS WITHOUT VITAMIN D DEFICIENCY IN THE CHAKARIA REGION OF BANGLADESH PR Fischer, A Rahman, JP Cimma, TO Kyaw-Myint, AL Kabir, K Talukder, N Hassan, BJ Manaster, DB Staab, JM Duxbury, RM Welch, CA Meisner, S Haque and GF Combs, Jr, Chakaria Rickets Prevention Consortium

In the last 15 years, rickets has been identified in children of the Chakaria region of southeastern Bangladesh. Standard vitamin D therapy has not proved beneficial, suggesting that the disorder may resemble the calcium (Ca) deficiency rickets that has been reported to be prevalent in some parts of Africa. In order to explore the etiology and characterize the clinical aspects of the Chakaria rickets, 14 rachitic children and 13 children identified by subjects' families as unaffected were evaluated. Rachitic children (9 males, 5 females) varied from 36-98 (mean 69) months of age; their parents reported them being symptomatic of rickets since an average of 24 (range 0-48) months of age. None reported other chronic illnesses, renal disease, or anticonvulsant use. Rachitic deformities included knock-knees (10), bowed legs (4), and sabre tibae (3). Ten of the 14 affected children had active rickets as determined by serum alkaline phosphatase activities >350 U/L; 7 of 12 subjected to x-rays had radiographic evidence of active rickets. Rachitic children had a mean alkaline phosphatase activity of 492 U/L (range 198-834; controls with mean 206 and range 138-331; p<0.0001), a mean serum Ca level of 9.6 mg/dL (range 8.5-10.4, not significantly different from controls), a mean serum phosphorous level of 4.3 mg/dL (range 1.9-5.6; controls with mean of 5.2, range 4.3-5.8; p<0.003), a mean serum 25-OH- vitamin D level of 20 ng/mL (range 7-65 with two subjects less than 14; controls: mean 25, range 16-35; p<0.008), and a mean serum 1,25-(OH)2-vitamin D level of 131 pg/mL (range 78-190; control mean 73, range 22-144 and 9 of 13 subjects above the upper limit of "normal;" p<0.0005). Of the 10 children with active rickets, only two had low vitamin D levels (one with hypophosphatemia), and one other had hypophosphatemia; Ca deficiency is the most likely etiology of the rickets in at least seven of the affected children. Interestingly, 3 "unaffected" children had physical findings consistent with rickets (each with beaded ribs, one also with widened wrists, another also with knock-knees) without elevated alkaline phosphatase activities. These results demonstrate that active rickets in Chakaria is not usually associated with vitamin D deficiency, and that the clinical presentation of rickets in Bangladeshi children is similar to that of African children with Ca-deficiency rickets. Furthermore, the findings of rachitic deformities and elevated serum 1,25-(OH)2-vitamin D levels among "unaffected" children suggest that subclinical Ca deficiency might be much more prevalent than previously suspected.

presented at the ASCON IV meetings at ICDDR,B - January, 1998

MINERAL STATUS IN RELATION TO RICKETS IN CHAKARIA, BANGLADESH

RM Welch, CA Meisner, N Hassan, JM Duxbury, M Rutzke, PR Fischer, A Rahman, JP Cimma, TO Kyaw-Myint, AL Kabir, K Talukder, DB Staab, S Haque and GF Combs, Jr., Chakaria Rickets Prevention Consortium

The rickets prevalent among children of the Chakaria region of Bangladesh is not usually associated with vitamin D deficiency; therefore Ca-deficiency would appear to be at least a pre-disposing factor in its etiology. That rickets has emerged as a public health problem in Chakaria within the last two decades suggests that changes in food habits and/or environmental exposures may be have contributed to the disease either by reducing Ca intakes (e.g., reduced access to Ca-rich foods) or utilization (e.g., increased exposure to such Ca-antagonistic factors as Al, Pb, Cd, F, Sr, Ba, low P, low-B). Indeed, the Chakarian food system has changed during this time: winter rice (requiring irrigation during the dry season) has been introduced; shrimp production in flooded rice paddies has increased; deep (tube) wells have been drilled to provide potable water. In order to explore the etiology of the Chakaria rickets and to identify opportunities within the local food system to prevent the disease, mineral analyses were performed on samples of whole blood and foods collected in the area in October, 1997. Blood was obtained from children (36-98 months of age) identified by their families as either rachitic (n=11) or unaffected (n=8) who were each given physical and radiographic examinations (results reported separately). Samples of drinking water (tube well), cooking water (pond), and cooked and uncooked rice were collected from three households, one of which had rachitic children. Samples of other foods likely to be sources of Ca and other limiting nutrients (mungbean, grasspea, chickpea, Indian chickpea, cowpea, lentil, black gram, amaranth, red chillies, taro, a sea fish, churie, shrimp, and faishya) were purchased in the market at Chakaria. Water pH was measured at the point of sampling; samples were held frozen (blood) or at ambient temperature (water), or dried (food) prior to analysis. Samples were digested with nitric-perchloric >acids and analyzed for 20 elements (Pb, Cd, Cu, Zn, Co, P, K, Na, Mg, Fe, B, Mo, Ni, V, As, U, Cr, Al, Sr, Ba) by inductively coupled plasma emission spectrometry. Results showed blood mineral values for rickets cases and controls to be similar with the exception of P (serum: cases, 43 mg/l vs. controls, 52 mg/l, P>.05; whole blood: cases, 216 mg/l vs. controls, 235 mg/l, P>.05). All values in both pond well water samples were within normal limits. All elements in rice samples were within safe limits reported for plant foods; rice was very low in Ca (105 mg/kg as eaten). All elements in the local foods were within the normal ranges reported for these elements with two notable exceptions: amaranth and shrimp, both of which foods contained high concentrations of almost all elements (amaranth, mg/kg dry weight: Ca, 26,947; Al, 1455; Pb, 1.5; Sr, 129; Ba, 32; Cr, 9.8; V, 3; As, 0.2; shrimp, mg/kg dry weight: Ca, 37,278; Al, 209; Pb, 0.3; Sr, 322; Ba, 34; V, 0.5; As, 4.3). These results do not indicate wide exposure to antagonists of Ca utilization; but point to a food supply generally low in Ca.

Bodruzzaman, M., Meisner, C.A., Duxbury, J.M., Welch, R.M. and Lauren, J.G. 1998. Effects of micronutrient seed enrichment on rice-wheat production. p. 47. In Agronomy abstracts. Am. Soc. Agron. Madison, WI.

Duxbury, J.M., Lauren, J.G. Kataki, P.K., Meisner, C.A. and Hobbs, P.R. 1998. Soil management research in South Asia's rice-wheat systems. p. 46. In Agronomy abstracts. Am. Soc. Agron. Madison, WI.

Parvin, S., Shaheed, A., Abawi, G.S., Lauren, J.G., Duxbury, J.M., and Meisner, C.A. 1998. Diagnosing soil constraints to rice-wheat production with solarization. p. 46. In Agronomy abstracts. Am. Soc. Agron. Madison, WI.

Singh, Y., Lauren, J.G., Chaudary, M.R., Jead, N. and Panu, P.P.S. 1998. Non-nitrogen benefits from green manures in a rice-wheat production system. p. 46. In Agronomy abstracts. Am. Soc. Agron. Madison, WI.