njm 3/14/04

**[Exclusive Breast-feeding or vitamin D supplementation?]{.underline}**

**[Issue:]{.underline}**

The American Academy of Pediatricians (AAP) Section on Breast-feeding
and Nutrition recommends vitamin D supplementation in Breast fed
infants. A recent report found vitamin D deficiency in Alaskan infants
age 2 to 23 months.

**[Questions:]{.underline}**

Can each of you weigh in on Vitamin D supplementation in your
populations and feasibility and acceptability? Do you think it is an
issue?

The sample size for the Alaska study was small and studied infants age 6
to 23 months. Supplementation would begin at 2 months of age.

Do you have infant vitamins on your formulary? Are you prescribing them?
Do you think moms are compliant with the administering of them -
feasibility\...acceptability\...?

**[Initial references:]{.underline}**

American Academy of Pediatricians (AAP) Section on Breast feeding and
Nutrition

Prevention of Rickets and Vitamin D Deficiency: New Guidelines for
Vitamin D Intake

PEDIATRICS Vol. 111 No. 4 April 2003, pp. 908-910

<http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/4/908>

Vitamin D deficiency is common among otherwise healthy Alaskan Children

State of Alaska Epidemiology Bulletin No. 11, December 11, 2003

<http://www.epi.hss.state.ak.us/bulletins/docs/b2003_37.pdf>

# Discussion

**Murphy, Neil <%5Bmailto:nmurphy@anmc.org%5D>**

**Saturday, February 07, 2004 8:07 PM**

We kind of left this thread hanging quite a while back\....

The issue of exclusive breast feeding in areas with known Vitamin D
deficiency in infants

<http://www.epi.hss.state.ak.us/bulletins/docs/b2003_37.pdf>

I tried to discuss it with some folks from AZ and N Mex and they thought
the concept of Vit D

supplementation was did not strongly enough encourage breastfeeding.

Unfortunately our responsibilities cover the Northern Plains, Pacific
Northwest, and Alaska, not

just the sun-drenched states.

You were going to talk to some AAP folks (or others) and get back to me?

**Thierry, Judith K. (HQE) \[Judith.Thierry@ihs.gov\]**

**Mon 2/9/2004 5:04 AM**

Vit D issue and breastfeeding: questions was raised and not addressed.

Can each of you weigh in on Vit D supplementation in your populations
and feasibility and acceptability? Do you think it is an issue?

The sample size for the Alaska study was small and studied infants age 6
to 23 months, supplementation would begin at 2 months of age.

Do you have infant vitamins on your formulary? Are you prescribing them?
Do you think moms are compliant with the administering of them -
feasibility\...acceptability..?

Here are two responses I wanted to share with the group

**From Mark Butterbrodt at Pine Ridge**

Just had a phone visit with Ekhard Ziegler, one of Sam Fomon's folks at
the University of Iowa where I did my pediatric residency---Ekhard
alerted me to concerns about Vit D in cold weather climates in nursed
infants, and shared the political trickiness of it\--I need to educate
myself more about this---by the way, Mary Story got in touch with Sam,
who assured her (and me) that it's ok to go to 2% milk in the second
year of life (it was Sam and his group who made the original
recommendation to go with whole milk for the essential fats, which
efficient fat storers like Lakota children probably do not need as much
of) good to hear from you Mark Butterbordt, MD

**From roger Gollub at ANMC**

Judy, we do prescribe vitamins ADC for exclusively breastfed infants. It
is on our formula for breastfeeding infants. It seems well accepted by
the parents here and also by the many from the rural (bush) areas who
deliver here. In fact I get calls from moms worried about inadequate
vitamin D intake in their children who later refuse cow's milk. (Just
got off the phone with one 60 seconds ago!) So I think the message is
out there and received. -- Roger

**Murphy, Neil**

**Monday, February 09, 2004 9:56 AM**

Yes, the Alaska State Section of Epidemiology study that I sent, which
started this e-mail thread, was a small sample.

That report was of interest this week because it confirmed the larger
body of data from outside Indian Country, which the AAP Section on
Breastfeeding used to create their statement. The AAP statement is
posted on the IHS Breastfeeding page (URL below)

The AAP Section on Breastfeeding did not think it was only the classic
areas of decreased sun exposure (Northern Plains, Pacific Northwest,
Alaska, etc.) that are effected, but a more universal issue due to
lifestyle changes in areas of potentially high sun exposure\...see Sun
Exposure below

While some Indian Health staff are following that recommendation, e.g.,
Dr. Gollub's comment, I wonder how we can spread this information more
effectively? How do we create a more effective / more universal
management impact?

Neil

SUNLIGHT EXPOSURE (AAP)

"A potential source of vitamin D is synthesis in the skin from the
ultraviolet B light fraction of sunlight. Decreased sunlight exposure
occurs during the winter and other seasons and when sunlight is
attenuated by clouds, air pollution, or the environment (e.g., shade).
Lifestyles or cultural practices that decrease time spent outdoors or
increase the amount of body surface area covered by clothing when
outdoors further limit sunlight exposure. The effects of sunlight
exposure on vitamin D synthesis are also decreased for individuals with
darker skin pigmentation and by the use of sunscreens.5 All of these
factors make it very difficult to determine what is adequate sunshine
exposure for any given infant or child. Furthermore, the Centers for
Disease Control and Prevention, with the support of many organizations
including the AAP and the American Cancer Society, has recently launched
a major public health campaign to decrease the incidence of skin cancer
by urging people to limit exposure to ultraviolet light.6 Indirect
epidemiologic evidence now suggests the age at which direct sunlight
exposure is initiated is even more important than the total sunlight
exposure over a lifetime in determining the risk of skin cancer.7-11
Thus, guidelines for decreasing exposure include directives from the AAP
that infants younger than 6 months should be kept out of direct
sunlight, children's activities that minimize sunlight exposure should
be selected, and protective clothing as well as sunscreens should be
used.11 "

Web sites and references

IHS Breastfeeding page

<http://www.ihs.gov/NonMedicalPrograms/nc4/breastfeed/BF/index.cfm>

on the

Literature based resources page

<http://www.ihs.gov/NonMedicalPrograms/nc4/breastfeed/BF/LitInfo.cfm>

or this direct link

AAP Clinical Report: Prevention of Rickets and Vitamin D Deficiency: New
Guidelines for Vitamin D Intake

<http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/4/908>

PEDIATRICS Vol. 111 No. 4 April 2003, pp. 908-910 (references at the
bottom of this message)

REFERENCES

1\. Kreiter SR, Schwartz RP, Kirkman HN Jr, Charlton PA, Calikoglu AS,
Davenport ML. Nutritional rickets in African American breast-fed
infants. J Pediatr.2000; 137 :153 -157\[ISI\]\[Medline\]

2\. Pugliese MF, Blumberg DL, Hludzinski J, Kay S. Nutritional rickets
in suburbia. J Am Coll Nutr.1998; 17 :637 -641\[Abstract/Free Full
Text\]

3\. Sills IN, Skuza KA, Horlick MN, Schwartz MS, Rapaport R. Vitamin D
deficiency rickets. Reports of its demise are exaggerated. Clin Pediatr
(Phila).1994; 33 :491 -493\[ISI\]\[Medline\]

4\. Institute of Medicine, Food and Nutrition Board, Standing Committee
on the Scientific Evaluation of Dietary Reference Intakes. Vitamin D.
In: Dietary Reference Intakes for Calcium, Phosphorus, Magnesium,
Vitamin D, and Fluoride. Washington, DC: National Academy Press;
1997:250-287

5\. Fuller KE, Casparian JM. Vitamin D: balancing cutaneous and systemic
considerations. South Med J.2001; 94 :58 -64\[ISI\]\[Medline\]

6\. National Coalition for Skin Cancer Prevention. The National Forum
for Skin Cancer Prevention in Health, Physical Education, Recreation and
Youth Sports. Reston, VA: American Association for Health Education;
1998

7\. Marks R, Jolley D, Lectsas S, Foley P. The role of childhood
exposure to sunlight in the development of solar keratoses and
non-melanocytic skin cancer. Med J Aust.1990; 152 :62
-66\[ISI\]\[Medline\]

8\. Autier P, Dore JF. Influence of sun exposures during childhood and
during adulthood on melanoma risk. EPIMEL and EORTC Melanoma Cooperative
Group. Int J Cancer.1998; 77 :533 -537\[ISI\]\[Medline\]

9\. Westerdahl J, Olsson H, Ingvar C. At what age do sunburn episodes
play a critical role for the development of malignant melanoma? Eur J
Cancer.1994; 30A :1647 -1654

10\. Gilchrest BA, Eller MS, Geller AC, Yaar M. The pathogenesis of
melanoma induced by ultraviolet radiation. N Engl J Med.1999; 340 :1341
-1348\[Free Full Text\]

11\. American Academy of Pediatrics, Committee on Environmental Health.
Ultraviolet light: a hazard to children. Pediatrics.1999; 104 :328
-333\[Free Full Text\]

12\. Binet A, Kooh SW. Persistence of vitamin D-deficiency rickets in
Toronto in the 1990s. Can J Public Health.1996; 87 :227
-230\[ISI\]\[Medline\]

13\. Daaboul J, Sanderson S, Kristensen K, Kitson H. Vitamin D
deficiency in pregnant and breast-feeding women and their infants. J
Perinatol.1997; 17 :10 -14\[Medline\]

14\. Reeve LE, Chesney RW, DeLuca HF. Vitamin D of human milk:
identification of biologically active forms. Am J Clin Nutr.1982; 36
:122 -126\[Abstract\]

15\. Hollis BW, Roos BA, Draper HH, Lambert PW. Vitamin D and its
metabolites in human and bovine milk. J Nutr.1981; 111 :1240
-1248\[ISI\]\[Medline\]

16\. Lammi-Keefe CJ. Vitamins D and E in human milk. In: Jensen RG, ed.
Handbook of Milk Composition. San Diego, CA: Academic Press;
1995:706-717

17\. Specker BL, Valanis B, Hertzberg V, Edwards N, Tsang RC. Sunshine
exposure and serum 25-hydroxyvitamin D concentrations in exclusively
breast-fed infants. J Pediatr.1985; 107 :372 -376\[ISI\]\[Medline\]

18\. Greer FR, Marshall S. Bone mineral content, serum vitamin D
metabolite concentrations and ultraviolet B light exposure in human
milk-fed infants with and without vitamin D2 supplements. J
Pediatr.1989; 114 :204 -212\[ISI\]\[Medline\]

19\. Life Sciences Research Office Report. Assessment of nutrient
requirements for infant formulas. J Nutr.1998; 128(11 suppl) :2059S
-2293S\[ISI\]\[Medline\]

20.Tsang RC, Zlotkin SH, Nichols BL, Hansen JW, eds. Nutrition During
Infancy: Principles and

Practice. 2^nd^ ed. Cincinnati, OH: Digital Education Publishing;
1997:467-484

**Avritt, Paul \[pavritt@ABQ.IHS.GOV\]**

**Mon 2/9/2004 10:10 AM**

I have not used the Vit D supplements but living in New Mexico the idea
seems to be a non-issue. I have used the Poly-Visol in the past and find
that MOMS USE IT ONLY FOR A short time saw it smells and stains

**Murphy, Neil**

**Mon 2/9/2004 10:33 AM**

Here is what the AAP Section on Breastfeeding said about sun
exposure\...paradoxically it doesn't seem that living where the sun
shines alone helps all that much\...of course that doesn't make the
medicine taste any better thought

Your thoughts?

AAP Clinical Report: Prevention of Rickets and Vitamin D Deficiency: New
Guidelines for Vitamin

D Intake

<http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/4/908>

PEDIATRICS Vol. 111 No. 4 April 2003, pp. 908-910

SUNLIGHT EXPOSURE (AAP)

"A potential source of vitamin D is synthesis in the skin from the
ultraviolet B light fraction of sunlight. Decreased sunlight exposure
occurs during the winter and other seasons and when sunlight is
attenuated by clouds, air pollution, or the environment (e.g., shade).
Lifestyles or cultural practices that decrease time spent outdoors or
increase the amount of body surface area covered by clothing when
outdoors further limit sunlight exposure. The effects of sunlight
exposure on vitamin D synthesis are also decreased for individuals with
darker skin pigmentation and by the use of sunscreens.5 All of these
factors make it very difficult to determine what is adequate sunshine
exposure for any given infant or child. Furthermore, the Centers for
Disease Control and Prevention, with the support of many organizations
including the AAP and the American Cancer Society, has recently launched
a major public health campaign to decrease the incidence of skin cancer
by urging people to limit exposure to ultraviolet light. Indirect
epidemiologic evidence now suggests the age at which direct sunlight
exposure is initiated is even more important than the total sunlight
exposure over a lifetime in determining the risk of skin cancer.7-11
Thus, guidelines for decreasing exposure include directives from the AAP
that infants younger than 6 months should be kept out of direct
sunlight, children's activities that minimize sunlight exposure should
be selected, and protective clothing as well as sunscreens should be
used.

**Avritt, Paul**

**Mon 2/9/2004 10:44 AM**

I did read the AAP stance on Vitamin D use but find it lacking in
individual populations most studies are done in the urban areas where
kids are dressed more. In the Pueblos it is typical to run around almost
naked till about 8 or 9 years of age. Use of sun blocks has not occurred
in my population so I'm not so sure we need the supplements.

I guess the thing to do is get to the University and see if they have
date that is more specific.

**Mandsager, Richard D \[rmandsag@ANMC.ORG\]**

**Mon 2/9/2004 11:27 AM**

We prescribe vit D supplements for breast feeding moms; beginning at 6
weeks. During the summer time I don't think we worry too much. In the
winter, we try hard to get moms to use Vit. D supplements. We quit as
soon as breast-feeding stops.

**William Green \[greenfamil@YAHOO.COM\]**

**Mon 2/9/2004 12:08 PM**

The policy clearly points out that sunny clime or sunny time or no,
there is no way to predict what amount of sunlight infants are actually
receiving---in fact, if families follow our advice regarding limiting
sun exposure, it may be too little for effective synthesis. In this
situation a little vitamin D supplementation could go a long way to
preventing rickets, which although uncommon, is not unknown and with
supplementation totally preventable. I think the policy is cogently
argued and should probably be followed, even if it violates the dictum
that breast milk is always best milk and therefore totally sufficient
for infant needs. It clearly isn't always for vitamin D.

**Murphy, Neil**

**Mon 2/9/2004 12:19 PM**

To reinforce Dr. Green's comments

Yes, the Alaska State Section of Epidemiology study that I sent, which
started this e-mail thread, was a small sample.

That report was of interest this week because it confirmed the larger
body of data from outside Indian Country, which the AAP Section on
Breastfeeding used to create their statement. The AAP statement is
posted on the IHS Breastfeeding page (URL below)

The AAP Section on Breastfeeding did not think it was only the classic
areas of decreased sun exposure (Northern Plains, Pacific Northwest,
Alaska, etc.) that are effected, but a more universal issue due to
lifestyle changes in areas of potentially high sun exposure\...see Sun
Exposure below

While some Indian Health staff are following that recommendation, e.g.,
Dr. Gollub's comment, I wonder how we can spread this information more
effectively? and create a more effective / more universal management
impact?

Neil

SUNLIGHT EXPOSURE (AAP)

"A potential source of vitamin D is synthesis in the skin from the
ultraviolet B light fraction of sunlight. Decreased sunlight exposure
occurs during the winter and other seasons and when sunlight is
attenuated by clouds, air pollution, or the environment (e.g., shade).
Lifestyles or cultural practices that decrease time spent outdoors or
increase the amount of body surface area covered by clothing when
outdoors further limit sunlight exposure. The effects of sunlight
exposure on vitamin D synthesis are also decreased for individuals with
darker skin pigmentation and by the use of sunscreens.5 All of these
factors make it very difficult to determine what is adequate sunshine
exposure for any given infant or child. Furthermore, the Centers for
Disease Control and Prevention, with the support of many organizations
including the AAP and the American Cancer Society, has recently launched
a major public health campaign to decrease the incidence of skin cancer
by urging people to limit exposure to ultraviolet light.6 Indirect
epidemiologic evidence now suggests the age at which direct sunlight
exposure is initiated is even more important than the total sunlight
exposure over a lifetime in determining the risk of skin cancer.7-11
Thus, guidelines for decreasing exposure include directives from the AAP
that infants younger than 6 months should be kept out of direct
sunlight, children's activities that minimize sunlight exposure should
be selected, and protective clothing as well as sunscreens should be
used.11 "

Web sites and references

IHS Breastfeeding page

<http://www.ihs.gov/NonMedicalPrograms/nc4/breastfeed/BF/index.cfm>

on the

Literature based resources page

<http://www.ihs.gov/NonMedicalPrograms/nc4/breastfeed/BF/LitInfo.cfm>

or this direct link

AAP Clinical Report: Prevention of Rickets and Vitamin D Deficiency: New
Guidelines for Vitamin D Intake

<http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/4/908>

PEDIATRICS Vol. 111 No. 4 April 2003, pp. 908-910 (references at the
bottom of this message)

**Singleton, Rosalyn J. \[ris2@CDC.GOV\]**

**Mon 2/9/2004 1:03 PM**

We do recommend Vitamin D in breastfeeding infants routinely. I'm sure
the emphasis varies from provider to provider. Ken Petersen published 3
cases of rickets in Alaska Native infants years ago. I diagnosed a case
of rickets in an 18-month-old breastfed infant. The State of Alaska did
more evaluation and came out with an article and then a statewide
recommendation for Vitamin D in breastfed infants. I'd be happy to
provide the references if you'd like them.

**Thierry, Judith K. (HQE) \[Judith.Thierry@IHS.GOV\]**

**And Holve, Steve (TCRHCC) \[steve.holve@TCIMC.IHS.GOV\]**

**Mon 2/9/2004 1:18 PM**

Please send references

**Singleton, Rosalyn J. \[ris2@CDC.GOV\]**

**Mon 2/9/2004 5:04 PM**

Gessner BD, DeSchweinitz E, Petersen KM, Lewandowski C. Nutritional
Rickets among Breast-fed Black and Alaska Native Children. Alaska
Medicine 1997;39:72-74.

This presents data on 3 black children and 2 Alaska Native children.

A follow-up article came out from the Alaska DHHS MCH Section Family
Health Data Line - along with a letter to all physicians recommending
Vitamin D supplementation of breastfed infants.

**Murphy, Neil**

**Wed 2/18/2004 9:43 AM**

Rickets in breastfed children vs. osteoporosis in Native women

1.)

Request for references

Here is another article from Brad Gessner from the Journal of
Pediatrics, 2003 in Alaskans, 6 mo -23 mo

OBJECTIVE: To determine vitamin D levels among children 6 to 23 months
old receiving services from Women, Infants, and Children (WIC) programs
in Alaska Study design During 2001 and 2002, we recruited 133 children
receiving services at seven WIC clinics, administered a risk factor
questionnaire, and collected blood.

RESULTS: Fifteen (11%) and 26 (20%) children, respectively, had vitamin
D levels \<15 (considered abnormal) and 15 to \<25 ng/mL (low normal).
Compared with other children, children who still breast-fed were more
likely to have a vitamin D level \<15 ng/mL (relative risk \[RR\], 12;
95% confidence interval \[CI\], 3.6-39) or 15 to \<25 ng/mL (RR, 3.6;
95% CI, 1.9-6.8) than \> or =25 ng/mL. Among 41 still breast-feeding
children, 14 (34%) took supplemental vitamins, and six (18%) were
reported to have received vitamins every day.

CONCLUSIONS: Vitamin D deficiency is prevalent in Alaska. Breast-feeding
in the absence of adequate vitamin D supplementation is the greatest
risk factor.

Gessner BD, Plotnik J, Muth PT. 25-hydroxyvitamin D levels among healthy
children in Alaska. J Pediatr. 2003 Oct;143(4):434-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14571215&dopt=Abstract>

Also, here the url for the abstract from the first Gessner article Ros
Singleton sent earlier

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9368423&dopt=Abstract>

Here are just 2 of the other recent articles in non-Native populations.
There seems to be a plethora of these articles now.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12915633&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12584539&dopt=Abstract>

2.)

Another point that has long-term clinical and financial significance to
our whole Indian Health system is not just the relatively small number
of preventable rickets cases in children, but it is the relationship to
adult osteoporosis.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9556054&dopt=Abstract>

A recent National Indian Women\'s Resource Center found Native
osteoporosis was much more prevalent in our Native Women than originally
suspected.

I can forward that data to you under separate cover, if needed

**David Grossman \[navajo@U.WASHINGTON.EDU\]**

**Mon 2/9/2004 3:22 PM**

In Seattle, we also push vitamin D supplements hard, as there have been
a number of rickets cases among breast-fed infants of dark-skinned moms

**William Green \[greenfamil@YAHOO.COM\]**

**Fri 2/20/2004 7:14 PM**

Very interesting the connection you posit between infantile rickets and
adult osteoporosis, Neil\-\--would like to see those references. It's
hard to grasp that bone is not inert but rather a dynamic metabolic
matrix throughout life, and rickets might have lifelong consequences on
skeletal integrity. I hope this discussion, and particularly the science
behind the many cited references, will get the widest possible
circulation in the IHS Provider, the Postgraduate Course in OB/GYN and
possibly the annual Primary Care Conference in Albuquerque. Perhaps
Vitamin D should have a similar **priority to that we now appropriately
assign to immunizations.**

**Murphy, Neil**

**Sat 2/21/2004 10:05 AM**

Like Yogi Berra is attributed to saying:

\'this is like deja vu all over again\'

The IHS Primary care listserv is going through a big discussion on
osteoporosis in Native women right now

The reason I mention that is that there continues to be some overlap
between these two discussion groups.

It does look like we will be able to combine the two listserv(s) for one
discussion.

We will combine the two listserv(s) for a short time starting May 1\....

May 1 was the time when the Primary Care listserv was going to begin its
discussion of

\....\"Risk taking behaviors in Indian adolescents\" lead by Donna
Perry, Chinle

As I am on my laptop right now, here is what I have now. I can get your
more info later

No, I don\'t have a direct RCT link between exclusive breastfed Native
infants who did not receive the AAP recommended Vit D supplementation
and went on to develop clinically significant osteoporosis as Native
elderly.

As in most IHS sites it can very difficult to even obtain a bone
densitometry exam to fulfill national benchmark screening
recommendations, I don\'t foresee any definitive Native data being
developed soon.

Here are some things we do know:

In addition to the relative decrease in Vit D among Alaskan youth, case
reports of rickets, and other data presented so far in this
discussion\...

-We know from NHANNES II data that calcium levels in a general
population of Alaska Native women are significantly decreased compared
to national standards.

(I have that data if you need it)

-We know that there is significant level of lactose intolerance in our
Native populations

-We know that among children aged 2-14 with diseases involving total or
partial withdrawal from milk products for a prolonged period are a group
at potential risk of defective bone mineralization and should be
monitored through BMD assessment\*

-We think the adequate ingestion of calcium as well as vitamin D and
phosphate in childhood appears essential for adequate skeletal
formation\*\*

-We know Lactose intolerance associated with fractures of weight-bearing
bones in Finnish women aged 38-57 years and long-term premenopausal
calcium deficiency differentially affects bones with weight-bearing
nonankle bones being at the greatest risk of suffering reduced
strength.\*\*\*

-We know that the largest risk factor for osteoporosis is previous
osteopenia

-There is suggestive evidence that inadequate intake of calcium may
contribute to the development of osteomalacia. Among African children
with rickets in whom exposure to sunlight was adequate, the intake of
calcium, with or without vitamin D supplementation, was superior to
vitamin D alone in improving the radiological manifestations of rickets

-Nevertheless, it has been difficult to demonstrate a beneficial effect
upon fracture risk with calcium supplementation in any large
populations\*\*\*\* so the chance of showing this effect in our
relatively small populations is unlikely

-We also don\'t know the effect of other known osteoporosis risk factors
which are prevalent or are at least increasing in our Native population:
sedentary life style, tobacco use, eating disorders

-We also know that in osteoporosis the bone that is present is normally
mineralized, which distinguishes osteoporosis from osteomalacia (more
common in Vit D deficiency, per se)

In summary, while there is certainly suggestive evidence that elements
of these two problems have some overlap, there is no direct link. In the
meantime, I am working with 2 groups nationally to increase our
osteoporosis detection in Indian Country

.

I also know that there is a significant push nationally to address the
bone health of young women. Here is a good website for educating young
women about some of these issues

Powerful girls. Powerful bones

<http://www.cdc.gov/powerfulbones/index2.html>

I can give you more info on this later, but in the short term (and of
the things that I can control)

-I am adding a couple osteoporosis discussions to this year's upcoming
OB/GYN Biennial meeting, August 4-6, in ABQ. Adding new topics to the
ACOG Course takes a much longer lead-time and is much more complicated.

-For my part I initiated the osteoporosis discussion on the Primary Care
listserv\... which has really been interesting to hear how inadequately
we screen for this emerging problem IHS wide

References below

Let me know if you have other questions

Neil

\*Risk of inadequate bone mineralization in diseases involving long-term
suppression of dairy products.\
AU - Infante D; Tormo R\
SO - J Pediatr Gastroenterol Nutr 2000 Mar;30(3):310-3.\
\
BACKGROUND: Eighty percent of peak bone mass should be achieved from
birth through adolescence. An adequate calcium intake is essential, and
it is advisable that 60% of the recommended calcium allowance be dairy
calcium. This study was conducted to examine bone mineral content (BMC)
in patients with diseases that usually involve long-term suppression of
dairy products. METHODS: Thirty patients, aged 2 to 14 years (mean, 7
years), 10 with late-onset, genetically induced lactose intolerance, 7
with cow\'s milk protein allergy, 3 with short-bowel syndrome, and 10
with hypercholesterolemia were involved in the study. They were
receiving various dietary regimens for periods longer than 2 years: 14
patients received special formulas for children (lactose-free cow\'s
milk formula, highly hydrolyzed cow\'s milk protein formula, soy protein
isolate formula), 4 patients received liquid soy beverages, 6 patients
received skim milk (1% fat), and 6 patients had exclusion of dairy
products. Bone mineral density (BMD) was assessed by dual-energy x-ray
absorptiometry. RESULTS: Nine patients had osteoporosis, 6 had
osteopenia, and 15 had results within normal ranges. Overall, the group
had a standard deviation score of -1.3 (osteopenia). The statistical
correlation between the BMD value and the percentage intake of
recommended daily allowance (RDA) of dairy (or substitute) calcium (in
milligrams per day) was highly significant (P \< 0.0001, r = 0.89).
CONCLUSIONS: All patients with diseases involving total or partial
withdrawal from milk products for a prolonged period are a group at
potential risk of defective bone mineralization and should be monitored
through BMD assessment.

\*\*Bishop, N. Rickets today\--children still need milk and sunshine
\[editorial; comment\]. N Engl J Med 1999; 341:602.

\*\*\*Lactose intolerance associated with fractures of weight-bearing
bones in Finnish women aged 38-57 years.\
AU - Honkanen R; Kroger H; Alhava E; Turpeinen P; Tuppurainen M;
Saarikoski S\
SO - Bone 1997 Dec;21(6):473-7.\
\
Lactose intolerance (LI) often results in decreased calcium intake. To
test if long-term low intake of calcium affects bone strength, we
examined fracture risks related to LI in women aged 38-57 years. The
11,619 Finnish women aged 47-56 years who responded to the baseline
postal inquiry of the Kuopio Osteoporosis Risk Factor and Prevention
Study in 1989 formed the study population. In all, 896 women reported LI
and 1299 women reported a fracture in 1980-1989. Current intake of dairy
calcium was lower in women with LI (570 mg/d) than in the other women
(850 mg/d) (p \< 0.0001). The fracture risk in general was slightly
elevated in women with LI compared with the other women, with an odds
ratio (OR) (95% CI) of 1.33 (1.09-1.62). However, the fractures at the
three most common sites (wrist, ankle, and rib) were not related to LI.
In contrast, fractures at the tibia and metatarsal were strongly related
to LI with ORs of 3.31 (1.51-7.24) and 2.84 (1.47-5.50), respectively.
The adjusted OR for nonankle lower body fractures combined was 2.15
(1.53-3.04), whereas that for all upper body fractures combined was 1.15
(0.88-1.54). The 10 women with LI and a tibial or metatarsal fracture
showed a 19% lower femoral BMD than all the other women in the
densitometry subsample of 3222 women (p \< 0.001). Long-term
premenopausal calcium deficiency differentially affects bones with
weight-bearing nonankle bones being at the greatest risk of suffering
reduced strength.

\*\*\*\*Calcium intake and fracture risk: results from the study of
osteoporotic fractures.\
AU - Cumming RG; Cummings SR; Nevitt MC; Scott J; Ensrud KE; Vogt TM;
Fox K\
SO - Am J Epidemiol 1997 May 15;145(10):926-34.\
\
The relation between dietary calcium, calcium, and vitamin D supplements
and the risk of fractures of the hip (n = 332), ankle (n = 210),
proximal humerus (n = 241), wrist (n = 467), and vertebrae (n = 389) was
investigated in a cohort study involving 9,704 US white women aged 65
years or older. Baseline assessments took place in 1986-1988 in four US
metropolitan areas. Dietary calcium intake was assessed at baseline with
a validated food frequency questionnaire. Data on new nonvertebral
fractures were collected every 4 months during a mean of 6.6 years of
follow-up; identification of new vertebral fractures was based on
comparison of baseline and follow-up radiographs of the spine done a
mean of 3.7 years apart. Results were adjusted for numerous potential
confounders, including weight, physical activity, estrogen use, protein
intake, and history of falls, osteoporosis, and fractures. There were no
important associations between dietary calcium intake and the risk of
any of the fractures studied. Current use of calcium supplements was
associated with increased risk of hip (relative risk = 1.5, 95%
confidence interval 1.1-2.0) and vertebral (relative risk = 1.4, 95%
confidence interval 1.1-1.9) fractures; current use of Tums antacid
tablets was associated with increased risk of fractures of the proximal
humerus (relative risk = 1.7, 95% confidence interval 1.3-2.4). There
was no evidence of a protective effect of vitamin D supplements.
Although a true adverse effect of calcium supplements on fracture risk
cannot be ruled out, it is more likely that our findings are due to
inadequately controlled confounding by indications for use of
supplements. In conclusion, this study did not find a substantial
beneficial effect of calcium on fracture risk.

**Murphy, Neil <%5Bmailto:nmurphy@anmc.org%5D>**

**Saturday, February 21, 2004 10:14 AM**

There are a couple of discussions going on the clinical listserv(s) that
seem to have some overlap

The primary care listserv is discussing osteoporosis screening The
pediatric special interest group is discussing the need for vit D
supplementation in breastfed infants

The latter discussion came up most recently because of some recent
reports low vit D levels in Alaskan children 2 mo -23 mo, case reports
of rickets, and the American Academy of Pediatrics policy statement
endorsing vit D supplementation in exclusively breastfed infants

In Alaska we also have notoriously low calcium levels in our adult
Alaska Native women, as documented by NHANNES II data

If osteoporosis is related to low BMD

If we have some increased degree of low calcium in our adult Native
women If we have some increased degree of lactose intolerance If we have
some increased degree of Vit D deficiency in a significant portion or
our infants (the breastfed ones)

Have you heard of any data that there would be a reason to encourage
providers of care to young children, or adolescent girls, to increase
either their calcium intake, vit D intake, or exercise levels?

Let me know

**Rhodes, Charles \[Charles.Rhodes@na.ihs.gov\]**

**Mon 2/23/2004 12:03 PM**

Not really, but I have thoughts\....

I am sure the data and recommendations are there, but I don't have a
bibliography handy. The "Pepsi Generation" ads were a bad joke, because
Pepsi substituted for milk reduces calcium and vitamin D intakes,
increases phosphorus intake (thus, increases PTH which can be osteolytic
under these circumstances) and is commonly associated with decreased
physical activity. Cola for teens is a recipe for osteoporosis.
Adolescence is a time of particular vulnerability to deficiency of
nutrients needed for anabolism, including protein, calcium, vitamin D
and iron. Girls, of course, are at higher risk for such nutritional
deficiencies than boys.

Lab issues: If the calcium levels are low, is it because of decreased
protein binding? Is the ionized calcium low? A truly significant calcium
deficiency should cause some rise in PTH. Direct measurement of ionized
calcium is not terribly difficult, but requires care in specimen
handling. You do it with a pH meter, substituting a calcium electrode
for the hydronium electrode; opening the blood collection tube allows
CO2 to escape, raising the pH and deionizing the calcium.

Today, osteoporosis is defined by BMD, at least by people who own BMD
machines. As an endocrinologist, I cringe at the definition of
osteoporosis as a T-score below -2.5. Osteopenia is lack of bone, and
can come from many causes. BMD can demonstrate osteopenia, not
osteoporosis, as can plain x-ray in severe cases. True diagnosis
requires bone biopsy, which we seldom do. The "T-score \< -2.5"
criterion is just a good working rule-of-thumb, not a definition, and
must be interpreted in the clinical setting. Osteomalacia can give
impressively low T-scores, and by the time you have clinical rickets it
is off the chart.

Lactose intolerance may not be very important. Most humans on this
particular planet (#3 from the sun) are lactose intolerant, and most do
not have osteoporosis. Northern Europeans and their progeny are mutants.
Lactose intolerance is particularly important for the lactose intolerant
person who is trapped in a milk-drinking society. For that person, other
calcium sources may not be readily available in adequate quantities. One
of the best sources of calcium is salmon, and I hear that is popular in
Alaska.

If ionized calcium is low, if PTH is even a pinch elevated, if vitamin D
levels are low, diet change or supplementation is clearly indicated.
There are precious few Americans who would not benefit from an increase
in exercise. Osteoporosis and the Insulin Resistance Syndrome (IRS,
"Metabolic Syndrome") are key targets. IRS increases PCOS
(hypo-fertility, iron losses\...), diabetes, atherosclerosis,
hypertension and some cancer risks.

Have you run this by the IHS nutrition staff?

Tammy L. Brown, MPH, RD, BC-ADM, CDE

Nutrition Consultant, IHS National Diabetes Program

CAPTAIN, U.S.P.H.S.

5300 Homestead Rd. NE

Albuquerque, NM 87110-1293

Office Phone: (505) 248-4182

Fax: (505) 248-4188

Direct Line: (505) 248-4319

E-mail: <tammy.brown@mail.ihs.gov>

Jean Charles-Azure

Principal Nutrition Consultant, IHS (HQ)

The Reyes Building, #331

801 Thompson Avenue

Rockville, Maryland 20852-1627

Phone (301) 443-0576

Fax (301)594-6135

<jcharles@hqe.ihs.gov>

\...and our key person for adolescents in the diabetes program is

Kelly R. Moore, MD

Clinical Specialty Consultant

IHS National Diabetes Program

5300 Homestead Road NE

Albuquerque, NM 87110

Phone: 505/248-4811 or 4182

Fax: 505/248-4188

email: <kelly.moore@mail.ihs.gov>

I'll also cc this to the Phoenix Area MCH consultant, Dr. Roy Teramoto.

Chuck

**William Green \[greenfamil@yahoo.com\]**

**Tue 2/24/2004 6:22 AM**

Interesting discussion of a lot of the diet/diet change and exercise
issues around creation of more osteoporosis or osteopenia, somewhat
tangential to the original vitamin D/breast discussion, but certainly
one for adolescent "risk behaviors". Soft drinks are pernicious for many
reasons, soft bellies and soft bones. From my reading on obesity the
body doesn't "see" the caloric intake from the sodas, even though they
are not particularly calorically dense. The stimulation of PTH by hi
phosphate low Ca is interesting. He also points out we have only crude
tools to assess the real bone architecture. Good grist for future
adolescent discussion and your ongoing osteoporosis train.

**Holve, Steve (TCRHCC) \[steve.holve@TCIMC.IHS.GOV\]**

**Sun 2/29/2004 4:11 PM**

Since bone is so plastic, and not inert, I would think a brief period of
suboptimal nutrition (e.g. exclusive breastfeeding from 0- 12 months)
however undesirable, would be unlikely to have a significant long-term
risk of osteoporosis. There is vitamin D supplemented fresh milk from
one year on.

We probably should make it a moot point anyway. In Tuba we already put
infants of exclusively breastfeeding mothers on multivits with iron for
their iron needs at six months of age. We had found most of the infants
with iron deficiency anemia were exclusively breastfed. I think the iron
needs should drive the multivitamin prescription in breastfeeding
infants and that will supply vitamin D.

I can't think of anyone who has had vitamin D dependent rickets here in
the last 19 years. I assumed it was because of the sun exposure. Has
anyone in the southwest seen vitamin D dependent rickets in an otherwise
healthy Indian child?

**Avritt, Paul \[pavritt@ABQ.IHS.GOV\]**

**Mon 3/1/2004 11:00 AM**

Twenty years in the corps and only vitamin C resistant rickets so far.

**Nell and Nelson Branco \[nellandnelson@HOTMAIL.COM\]**

**Mon 3/1/2004 11:27 AM**

Ditto for me, only 3 years at Shiprock but the only case of rickets I
had was associated with polycystic kidneys, RTA, etc.

**Byron, Lori \[Lori.Byron@MAIL.IHS.GOV\]**

**Wed 3/3/2004 8:33 AM**

Ditto, after 16 years in Crow Agency, Montana! No rickets.