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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 214-218

Vitamin D status of children at a tertiary care hospital of Agartala, North-east India: A cross-sectional study


Department of Biochemistry, Tripura Medical College and Dr. B.R. Ambedkar Memorial Teaching Hospital, Agartala, Tripura, India

Date of Submission16-Feb-2022
Date of Acceptance23-Mar-2022
Date of Web Publication17-Sep-2022

Correspondence Address:
Dr. Elvia Jamatia
Department of Biochemistry, Tripura Medical College and Dr. B.R. Ambedkar Memorial Teaching Hospital, Agartala - 799 014, Tripura
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_135_22

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  Abstract 


CONTEXT: High prevalence of Vitamin D deficiency (VDD) has been reported in the pediatric population from the different parts of the country. However, there is a lacuna of data on the Vitamin D status of children from the north-eastern part of the country.
AIMS: The aim of this study is to assess the serum Vitamin D level and also to find out the prevalence of VDD among children and adolescents in Agartala, a major city in North-east India.
SETTINGS AND DESIGN: Cross-sectional descriptive study.
MATERIALS AND METHODS: The serum 25 (OH) D levels of 258 children from age 1 to below 18 years, attending the outpatient clinics of the hospital were analyzed from June 2020 to June 2021.
STATISTICAL ANALYSIS USED: Data being nonparametric was presented as median and inter quartile range. The group differences were computed by the Mann–Whitney U-test. P < 0.05 was considered statistically significant.
RESULTS: Sixty percentage of the study population had insufficient levels of Vitamin D, with girls having significantly lower levels of serum Vitamin D. Only 27% of adolescents had optimum level of serum Vitamin D.
CONCLUSION: A high prevalence of Vitamin D insufficiency and VDD was found among the children living in the urban and sub urban areas of Agartala city in North-east India.

Keywords: Children, North.east India, Vitamin D deficiency, Vitamin D insufficiency


How to cite this article:
Jamatia E, Roy S, Das A, Dewan P, Debnath T. Vitamin D status of children at a tertiary care hospital of Agartala, North-east India: A cross-sectional study. Indian J Health Sci Biomed Res 2022;15:214-8

How to cite this URL:
Jamatia E, Roy S, Das A, Dewan P, Debnath T. Vitamin D status of children at a tertiary care hospital of Agartala, North-east India: A cross-sectional study. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 Sep 29];15:214-8. Available from: https://www.ijournalhs.org/text.asp?2022/15/3/214/356267




  Introduction Top


Vitamin D plays a key role in calcium and phosphate metabolism and is an essential micronutrient for bone development in children. It has other noncalcemic functions as well, namely, immune, cardiovascular, endocrine, neuropsychological functions, neuromuscular performance, cellular differentiation, and anticancer actions. Hence, Vitamin D deficiency (VDD) is no longer confined to rickets or osteomalacia anymore, but it now comprises huger hidden problem which is unraveling by the day and making VDD an emerging global threat. VDD has been recognized as a pandemic, but even now, it is the most under-diagnosed and under-treated nutritional deficiency in the world.[1],[2]

Modern day lifestyle changes have been attributed as the catapult that is driving the VDD pandemic. The common risk factors reducing the skin exposure to sunlight being, more indoor time spent by children; cloud cover and pollution; usage of sunscreen; and the dietary factors like consumption of less calcium and high fiber diet. Other nonmodifiable factors appear to be the darker skin tone of the Indian population as compared to Caucasians and genetic factors such as several Vitamin D receptor polymorphisms.[3]

Pediatric participants are more susceptible to VDD, causing impaired bone mineral metabolism leading to growth retardation and bone deformities. Consequently, it is relevant to know the Vitamin D status in children and adolescence, as the bone accrual is taking place and the peak bone mass is achieved during this period.

Despite receiving abundant sunshine in our country, studies uniformly point to low vitamin D levels in the Indian population.[4] Studies conducted in the northern, western, and southern states of India have documented high prevalence (82%–98%) of VDD among school age children.[3],[5],[6],[7],[8] There are no data regarding the prevalence of VDD status in the pediatric population from the North-east part of India.

With this background, this study was conducted with the following aim and objectives: (a) to assess the serum Vitamin D level in children and adolescents in Agartala, a major city in northeast India; (b) to find out the prevalence of VDD in children and adolescents in Agartala.


  Materials and Methods Top


Study design

The present cross-sectional descriptive study was conducted in the Department of Biochemistry, Tripura Medical College and Dr. B. R. Ambedkar teaching hospital, Agartala. Ethical Clearance was obtained from Tripura Medical College and Dr. B. R. Ambedkar Memorial Teaching Hospital institutional ethical committee with Ref no IEC/SFTMC/2021/3/010 dated 08.07.2021. The serum 25 (OH) D levels of children from age 1 to below 18 years, attending the outpatient clinics of the hospital were retrospectively analyzed from June 2020 to June 2021.

Demographic data regarding the gender and age of the children and the clinics attended were collected from the department entry register. The exclusion criteria included children who were undergoing treatment for VDD; suffering from other systemic diseases (like nephrotic syndrome or chronic renal failure) or endocrine diseases (like rickets); having Vitamin D toxicity (serum 25 (OH) levels >100 ng/ml). Those cases that were undergoing repeat investigations, the first value of serum 25 (OH) D was taken for analysis.

Measurement of Vitamin D

Estimation of serum total 25 (OH) D levels was done by chemiluminescence immunoassay method using Beckmann Coulter Access 2 immunoassay system. This assay detects both 25 (OH) D2 and 25 (OH) D3 levels and has an assay range of 2.0 to approximately 167 ng/ml.

Diagnostic cutoff criteria according to the United States Endocrine Society Classification[9] was used for classifying Vitamin D status. The 25 (OH) D levels >30 ng/ml are considered “optimum;” between 20 and 30 ng/ml is considered as “insufficient;” levels <20 ng/ml is considered as “deficient,” whereas levels <10 ng/ml is considered “severely deficient.”

Sample size

The sample size of the study was calculated keeping in view the anticipated prevalence of Vitamin D as 85%, a confidence level of 95%, absolute precision of 5.0, and a design effect of 1.0. A total sample size of 196 was calculated.

Statistical analysis

IBM Statistical Package for the Social Sciences (SPSS) software version 20.0, Armonk, NY, USA: IBM Corp was used for the statistical analysis of the data. Quantitative data, i.e., serum (25 OH) D values were found to be nonparametric and hence presented as median and inter quartile range (IQR). The group differences were computed by the Mann–Whitney U-test. P < 0.05 was considered statistically significant.


  Results Top


General characteristics of study population

The serum 25 (OH) D levels of a total of 258 cases were analyzed. Out of this, 57% were male (n = 146) and 43% were female (n = 112). About 35% cases belonged to the preschool age group of 1–5 years (n = 90); 31% belonged to school age group of 6–11 years (n = 79); and 34% belonged to the adolescent age group of 12–18 years (n = 89).

Vitamin D status

The mean 25 (OH) D levels of the study population were 30.12 ± 13.37 ng/ml (median 28.12, IQR 16.14). Upon segregation, the girls had lower 25 (OH) D levels with mean levels 28.23 ± 12.61 ng/ml (median 26.86, IQR 16.39) as compared to boys with mean levels 31.38 ± 13.81 ng/ml (median 29.02, IQR 15.02), which is statistically significant (P = 0.03), as shown in [Table 1].
Table 1: Demographic characteristics of the study subjects

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[Table 2] shows the age wise distribution of the cases according to the Vitamin D status. The median 25 (OH) D levels of the severely deficient (<10 ng/ml) cases were 6.09 (IQR 3.23), 6.14 (IQR 1.73), 4.76 (IQR 6.04) in the age group 1–18, 1–5, and 6–11 years, respectively. The median 25 (OH) D levels of the deficient (10–19 ng/ml) cases were 16.58 (IQR 2.98), 18.53 (IQR 2.10), 16.01 (IQR 4.18), 16.58 (IQR 2.52) in the age group 1–18 years, 1to 5 years, 6–11 years and 12–18 years respectively. The median 25 (OH) D levels of the insufficient (20–29 ng/ml) cases were 25.75 (IQR 5.02), 27.26 (IQR 4.91), 25.54 (IQR 4.67), 25.83 (IQR 5.49) in the age group 1–18, 1–5, 6–11, and 12–18 years, respectively. The median 25 (OH) D levels of those cases who had optimum levels (>30 ng/ml) were 39.35 (IQR 11.49), 39 (IQR 8.49), 40.76 (IQR 15.69), and 38.24 (IQR 15.29) in the age group 1–18, 1–5, 6–11, and 12–18 years, respectively.
Table 2: Age wise distribution of participants as per Vitamin D status

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In the study population, about 6.97% of the participants were severely deficient; 12.4% were deficient; 40.69% were insufficient; and only 39.92% had optimum levels of 25 (OH) D. Among the various age groups, 14.44% of children in 1–5 years and 6.32% in 6–11 years were severely deficient. About 6.66% in the 1–5 years, 16.45% in 6–11 years and 14.6% in 12–18 years age groups were deficient. Around 24.44% in the 1–5 years, 39.24% in the 6–11 years and 58.42% in the age group of 12–18 years had insufficient levels. Only 26 96% of 12–18 years, 37.97% of 6–11 years and 54.44% of 1–5 years had optimum levels [Table 3].
Table 3: Prevalence of Vitamin D status when classified into different deficiency states

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When seen across the age groups, females had significantly lower 25 (OH) D levels as compared to their male counterparts in the 1–5 and 12–18 years age groups. The girls had median 25 (OH) D levels of 27.59 (IQR 20.48) in 1–5 years; 29.31 (IQR 20.47) in 6–11 years and 23.21 (IQR 7.65) in 12–18 years age group. The males had median 25 (OH) D levels of 37.04 (IQR 14.67) in 1–5 years; 26.04 (IQR 15.88) in 6–11 years, and 28.28 (IQR 14.21) in 12–18 years age group [Table 4].
Table 4: Values of serum Vitamin D (ng/ml) in boys and girls

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Serum calcium, phosphorus and alkaline phosphatase levels

The above parameters were all within the normal reference ranges for the population. No significant correlation was observed between 25 (OH) D levels and serum levels of the above metabolic bone parameters.


  Discussion Top


VDD is now universally acknowledged as a pandemic, still it is under investigated and least attended nutritional deficiency worldwide. But with increased awareness of the widespread prevalence of VDD in various populations of India, Vitamin D level is currently one of the most ordered investigation asked by an Indian clinician. This present study was conducted to provide a cross sectional view of the biochemical hypovitaminosis D among the pediatric inhabitants residing in and around the city of Agartala, in north east India.

The study data shows that 60% of children and adolescents had 25 (OH) VDD (VDD + Vitamin D insufficiency) of which 19% were nutritionally deficient in Vitamin D and 41% had insufficient circulating serum Vitamin D levels. Only 40% had optimum 25 (OH) Vitamin D levels. This is in accord with the findings of different studies across Indian population showing prevalence of VDD as 93% of children living at high altitude regions in Himachal Pradesh;[5] 53% in 1–16 years in Kolkata;[3] 96.9% in adolescents in Delhi;[6] 92.3% in 10–14 years healthy school children from northern India;[7] 81.5% in urban male children in the southern state of Andhra Pradesh.[8]

The main source of Vitamin D in our body is the exposure to sunlight, with diet contributing only 10%–15%. The common risk factors that have been recognized as associated with VDD are insufficient exposure to sun,[10] darker skin pigmentation,[11] atmospheric pollution,[12] low physical activity,[13] indoor confinement of children during the day and high rise buildings,[10] sunscreen usage.[14] Indians owing to the darker skin color have been said to have reduced cutaneous synthesis of Vitamin D due to increased melanin content in them. This is the Vitamin D paradox in our country that Indians despite of receiving plenty and abundant sunlight, require greater duration of sun exposure as compared to their light skinned counterparts to synthesize equivalent levels of Vitamin D.

Among the different pediatric age groups in this study, 73% of the adolescents had VDD (58% insufficient and 15% deficient), which is the highest among all other age groups. Only 27% of this population had optimum levels of Vitamin D. Similar findings were observed in some studies where the 94.4% adolescents from Shimla,[5] 88% of adolescents in eastern India,[3] 96.9% in adolescents in northern India,[6] and 97% adolescents in Delhi NCR,[14] and were the most deficient in Vitamin D levels. This is a perturbing finding as this age is the growth phase where most of the accrual of bone mass takes place and VDD at this stage can cause growth retardation and defect in skeletal mineralization.

This study also found girls to be more deficient in Vitamin D levels than boys across all the age groups studied. This might be attributed to less exposure to sun among girls due to more clothing as compared to their male counterparts. Also the wish to look fairer among girls make them use sunscreen and umbrella, furthermore reducing their sun exposure. Similar findings were seen in the studies conducted in the populations of other parts of the country.[5],[14],[15]

Nowadays it has been observed that most adolescents in the urban and sub urban areas are busy with indoor activities like playing with their mobile phones, watching TV or playing video games rather than playing outside in the porch or playgrounds. Due to the need wise lockdowns imposed due to the current COVID 19 pandemic, children have been more confined within their houses. Also due to the recent academic curriculum, students are rather busy in their tuitions and online classes and have very little time to go out of their homes. This has restricted their time of sun exposure all the more and might have contributed to the more prevalence of hypovitaminosis D among children, especially adolescents.

Parents should be made aware to use the safe sun period for adequate exposure of the children to sunlight without sunscreen before 10 am and after 3 pm at least 15 min a day. But due to the sun-protective action of epidermal melanin, which is abundant in pigmented skin types of Indian population, sun exposure alone may not be an adequate source of Vitamin D in Indian children.[16] Hence food fortification and Vitamin D supplementation should be encouraged and used judiciously.

The limitation of the present study is that the study population was the children attending the outpatient department of the hospital. Although the children with major known and recognizable causes of VDD have been excluded, still there may have been influences of other pathologies on the vitamin D levels. As it was conducted in a single centre, the results cannot be generalized. Information could not be collected regarding sun exposure, diet, physical activity, sunscreen use or intake of supplements.


  Conclusion Top


The present cross-sectional study reveals the high prevalence of Vitamin D insufficiency and VDD among the children living in the urban and sub urban areas of Agartala city in northeast India. The insufficiency was more in adolescents and girls. This adds to the robust reports of soaring deficiency states of Vitamin D in India. Action from the national authorities are solicited to create awareness regarding the prevalence of VDD and the importance of adequate sun exposure, dietary recommendations; to amp up food fortification and judicious Vitamin D supplementation.

Financial support and sponsorship

This study was financially supported by Department of Biochemistry, Tripura Medical College and Dr. B.R. Ambedkar Memorial Teaching Hospital, Agartala – 799014.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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van Schoor NM, Lips P. Worldwide vitamin D status. Best Pract Res Clin Endocrinol Metab 2011;25:671-80.  Back to cited text no. 1
    
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Mithal A, Wahl DA, Bonjour JP, Burckhardt P, Dawson-Hughes B, Eisman JA, et al. Global vitamin D status and determinants of hypovitaminosis D. Osteoporos Int 2009;20:1807-20.  Back to cited text no. 2
    
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Basu S, Gupta R, Mitra M, Ghosh A. Prevalence of vitamin d deficiency in a pediatric hospital of eastern India. Indian J Clin Biochem 2015;30:167-73.  Back to cited text no. 3
    
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van der Meer IM, Middelkoop BJ, Boeke AJ, Lips P. Prevalence of vitamin D deficiency among Turkish, Moroccan, Indian and sub-Sahara African populations in Europe and their countries of origin: An overview. Osteoporos Int 2011;22:1009-21.  Back to cited text no. 4
    
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Kapil U, Pandey RM, Goswami R, Sharma B, Sharma N, Ramakrishnan L, et al. Prevalence of Vitamin D deficiency and associated risk factors among children residing at high altitude in Shimla district, Himachal Pradesh, India. Indian J Endocrinol Metab 2017;21:178-83.  Back to cited text no. 5
    
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Garg MK, Marwaha RK, Khadgawat R, Ramot R, Obroi AK, Mehan N, et al. Efficacy of vitamin D loading doses on serum 25-hydroxy vitamin D levels in school going adolescents: An open label non-randomized prospective trial. J Pediatr Endocrinol Metab 2013;26:515-23.  Back to cited text no. 6
    
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Khadgawat R, Marwaha RK, Tandon N, Mehan N, Upadhyay AD, Sastry A, et al. Percentage body fat in apparently healthy school children from northern India. Indian Pediatr 2013;50:859-66.  Back to cited text no. 7
    
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Harinarayan CV, Ramalakshmi T, Prasad UV, Sudhakar D. Vitamin D status in Andhra Pradesh: A population based study. Indian J Med Res 2008;127:211-8.  Back to cited text no. 8
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Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al. Evaluation, treatment, and prevention of vitamin D deficiency: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011;96:1911-30.  Back to cited text no. 9
    
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Ekbote VH, Khadilkar AV, Mughal MZ, Hanumante N, Sanwalka N, Khadilkar VV, et al. Sunlight exposure and development of rickets in Indian toddlers. Indian J Pediatr 2010;77:61-5.  Back to cited text no. 10
    
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Misra M, Pacaud D, Petryk A, Collett-Solberg PF, Kappy M; Drug and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society. Vitamin D deficiency in children and its management: Review of current knowledge and recommendations. Pediatrics 2008;122:398-417.  Back to cited text no. 11
    
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Agarwal KS, Mughal MZ, Upadhyay P, Berry JL, Mawer EB, Puliyel JM. The impact of atmospheric pollution on vitamin D status of infants and toddlers in Delhi, India. Arch Dis Child 2002;87:111-3.  Back to cited text no. 12
    
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Hollis BW. Circulating 25-hydroxyvitamin D levels indicative of vitamin D sufficiency: Implications for establishing a new effective dietary intake recommendation for vitamin D. J Nutr 2005;135:317-22.  Back to cited text no. 13
    
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Shukla K, Sharma S, Gupta A, Raizada A, Vinayak K. Current scenario of prevalence of vitamin D deficiency in ostensibly healthy Indian population: A hospital based retrospective study. Indian J Clin Biochem 2016;31:452-7.  Back to cited text no. 14
    
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Marwaha RK, Tandon N, Agarwal N, Puri S, Agarwal R, Singh S, et al. Impact of two regimens of vitamin D supplementation on calcium – Vitamin D – PTH axis of schoolgirls of Delhi. Indian Pediatr 2010;47:761-9.  Back to cited text no. 15
    
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Jindal AK, Gupta A, Vinay K, Bishnoi A. Sun exposure in children: Balancing the benefits and harms. Indian Dermatol Online J 2020;11:94-8.  Back to cited text no. 16
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