Rickets and osteomalacia: a call for action to protect immigrants and ethnic risk groups
Authors: Wolfgang Högler, Craig F Munns
Journal: The Lancet Global Health (2016)

The recent mass migration into Europe poses many challenges to society and public health. Prevention programmes within European countries are primarily designed for the risk profile and diversity of their residents, not those of refugees. Refugee children, many of whom arrive unaccompanied,1Ferrara P Amato M Hadjipanayis A del Torso S Stiris T The rights of children arriving in Europe.Lancet. 2015; 386: 1939-1940Summary Full Text Full Text PDF Scopus (5) Google Scholar are most vulnerable, especially since prevention programmes (vaccinations, vitamin and micronutrient provision, food fortification, routine infant health checks, and medical education) may not be in place in their country of origin, and their parents may be unfamiliar with the need for such programmes. Public health professionals in host nations need to prepare for a rapid increase in population as well as diseases and micronutrient deficiencies that are currently regarded as rare in the resident population. Two deficiencies particularly prevalent in refugees are vitamin D and dietary calcium deficiency, which in combination cause nutritional rickets in children and osteomalacia in adults (figure). The morbidity from prolonged vitamin D and dietary calcium deficiencies should not be underestimated. These deficiencies cause hypocalcaemic seizures, hypocalcaemic dilated cardiomyopathy with heart failure, muscle weakness, and growth failure, in addition to bone demineralisation (rickets and osteomalacia). Complications include pain, fractures, bone deformities and long-term disability, obstructed labour, increased risk of falls, and death.2Munns C Shaw N Kiely M et al.Global consensus recommendations on prevention and management of nutritional rickets.J Clin Endocrinol Metab. 2016; 101: 394-415Crossref Scopus (599) Google Scholar, 3Munns C Shaw N Kiely M et al.Global consensus recommendations on prevention and management of nutritional rickets.Horm Res Paediatr. 2016; 85: 83-106Crossref Scopus (115) Google Scholar, 4Högler W Complications of vitamin D deficiency from the foetus to the infant: One cause, one prevention, but who's responsibility?.Best Pract Res Clin Endocrinol Metab. 2015; 29: 385-398Summary Full Text Full Text PDF Scopus (45) Google Scholar Although rickets in children is diagnosed relatively easily by knee or wrist radiography, there are insufficient diagnostic criteria for osteomalacia in adults and chronically ill people. A post-mortem study in northern German residents found 25% of people affected by unrecognised osteomalacia.5Priemel M von Domarus C Klatte TO et al.Bone mineralization defects and vitamin D deficiency: histomorphometric analysis of iliac crest bone biopsies and circulating 25-hydroxyvitamin D in 675 patients.J Bone Miner Res. 2010; 25: 305-312Crossref PubMed Scopus (453) Google Scholar The prevalence in risk groups will be much higher. Risk groups include people with dark skin or those blocking sunlight with full-body clothing, and those with low intake of dairy products. Therefore, nutritional rickets is most prevalent in Africa, the Middle East, and southern Asia,2Munns C Shaw N Kiely M et al.Global consensus recommendations on prevention and management of nutritional rickets.J Clin Endocrinol Metab. 2016; 101: 394-415Crossref Scopus (599) Google Scholar, 3Munns C Shaw N Kiely M et al.Global consensus recommendations on prevention and management of nutritional rickets.Horm Res Paediatr. 2016; 85: 83-106Crossref Scopus (115) Google Scholar from which regions most current refugees originate. Leaving these regions, where plentiful sunshine allows normal cutaneous vitamin D production, towards northern Europe, which lacks the necessary ultraviolet spectrum of sunlight for about 6 months of the year (winter and spring), exponentially increases their risk of vitamin D deficiency. Vitamin D deficiency is also vertically transmitted from mother to child, making infants of at-risk women especially vulnerable to rickets and its complications. The recently published global consensus recommendations on prevention and management of rickets2Munns C Shaw N Kiely M et al.Global consensus recommendations on prevention and management of nutritional rickets.J Clin Endocrinol Metab. 2016; 101: 394-415Crossref Scopus (599) Google Scholar, 3Munns C Shaw N Kiely M et al.Global consensus recommendations on prevention and management of nutritional rickets.Horm Res Paediatr. 2016; 85: 83-106Crossref Scopus (115) Google Scholar advocate for the eradication of rickets and osteomalacia through implementation of national supplementation and food fortification programmes containing vitamin D, calcium, or both. On the basis of high-quality evidence, the consensus group issued a strong recommendation to provide vitamin D supplementation for: (1) all infants from birth to at least 12 months of age (minimum of 400 international units [IU] per day); (2) all pregnant women (minimum of 600 IU per day); and (3) all individuals from risk groups (minimum of 600 IU per day). Supplementation works best when integrated into public health programmes for infants alongside immunisation and antenatal care programmes.2Munns C Shaw N Kiely M et al.Global consensus recommendations on prevention and management of nutritional rickets.J Clin Endocrinol Metab. 2016; 101: 394-415Crossref Scopus (599) Google Scholar, 3Munns C Shaw N Kiely M et al.Global consensus recommendations on prevention and management of nutritional rickets.Horm Res Paediatr. 2016; 85: 83-106Crossref Scopus (115) Google Scholar Raising awareness among risk groups and health-care professionals for the need to supplement risk groups poses challenges, resulting in poor uptake rates and difficulties reaching remote populations. In addition, insufficient legislation, infrastructure, and knowledge of health-care professionals involved in primary care hinder success of supplementation programmes. Even in Europe, substantial differences exist in uptake of infant vitamin D supplementation.4Högler W Complications of vitamin D deficiency from the foetus to the infant: One cause, one prevention, but who's responsibility?.Best Pract Res Clin Endocrinol Metab. 2015; 29: 385-398Summary Full Text Full Text PDF Scopus (45) Google Scholar Instigating supplementation programmes may be even more difficult within the refugee population where other pressing health problems require addressing. Food fortification with vitamin D (or calcium) is an attractive alternative to increasing levels of 25-hydroxyvitamin D (the main serum marker of vitamin D sufficiency) in the whole population.6Spiro A Buttriss JL Vitamin D: an overview of vitamin D status and intake in Europe.Nutr Bull. 2014; 39: 322-350Crossref PubMed Scopus (449) Google Scholar, 7Braegger C Campoy C Colomb V et al.ESPGHAN Committee on Nutrition (2013). Vitamin D in the healthy European paediatric population.J Pediatr Gastroenterol Nutr. 2013; 56: 692-701Crossref PubMed Scopus (346) Google Scholar, 8Kiely M Black LJ Dietary strategies to maintain adequacy of circulating 25-hydroxyvitamin D concentrations.Scand J Clin Lab Invest Suppl. 2012; 243: 14-23PubMed Google Scholar Fortification is easily implemented since the distribution of the micronutrient relies on an effective distribution chain already established by the food industry. In addition, no additional burden is posed on the health system because fortification is not dependent on uptake rates and, if the vehicle selected is adequate (ideally a staple food consumed regularly by risk groups), it provides wide coverage. The consensus recommendations therefore promote fortification of habitually consumed foods such as milk, cooking oil, or other vehicles as appropriate in each country, but advise that fortification requires governmental leadership with supportive legislation, and needs to be policy-driven and adequately monitored.2Munns C Shaw N Kiely M et al.Global consensus recommendations on prevention and management of nutritional rickets.J Clin Endocrinol Metab. 2016; 101: 394-415Crossref Scopus (599) Google Scholar, 3Munns C Shaw N Kiely M et al.Global consensus recommendations on prevention and management of nutritional rickets.Horm Res Paediatr. 2016; 85: 83-106Crossref Scopus (115) Google Scholar Food fortification, as practised in Canada and the USA for decades, is safe, cost-effective, acceptable to manufacturers and the public, and has successfully prevented diseases, including rickets (calcium, vitamin D) and neural tube defects (folic acid).9Allen L de Benoist B Dary O Hurrel R Guidelines on food fortification with micronutrients. World Health Organization, Food and Agriculture Organization, Geneva2006Google Scholar, 10Tulchinsky T The key role of government in addressing the pandemic of micronutrient deficiency conditions in Southeast Asia.Nutrients. 2015; 7: 2518-2523Crossref Scopus (20) Google Scholar We call on national governments and international policy makers to recognise rickets and osteomalacia as fully preventable diseases with greatest risk in dark-skinned immigrant, refugee, and resident populations, and to provide appropriate legislation for implementation of effective supplementation and fortification programmes. Screening and prevention programmes for refugees from at-risk ethnic populations should include vitamin D supplementation on arrival, as well as during every winter and spring in all areas of northern or southern latitudes greater than 34 degrees. The consensus papers2Munns C Shaw N Kiely M et al.Global consensus recommendations on prevention and management of nutritional rickets.J Clin Endocrinol Metab. 2016; 101: 394-415Crossref Scopus (599) Google Scholar, 3Munns C Shaw N Kiely M et al.Global consensus recommendations on prevention and management of nutritional rickets.Horm Res Paediatr. 2016; 85: 83-106Crossref Scopus (115) Google Scholar provide the evidence and the framework for designing such prevention programmes. We declare no competing interests.