Global Advanced Research Journal of Biochemistry and Bioinformatics Vol. 1(2) pp. 019-025, August, 2012 Available online http://garj.org/garjbb/index.htm Copyright © 2012 Global Advanced Research Journals

Review

Rickets in rift valley: A review of manifestation and links with flouride contents of drinking water supplies and

food

George Omolo Rombo1 and Margaret Muoki2

1Senior Lecturer, Food Biochemistry, Food Processing and Food Safety, Department of Foods, Nutrition and Dietetics,

Kenyatta University,P. O. Box 43844-00100, Nairobi, Kenya., 2Research Assistant Kenyatta University P.O Box 43844-00100 Nairobi, Kenya.

Accepted 09 August, 2012

The study is to determine the prevalence of rickets among children under five years and links with flouride contents in drinking water. Food sources and recommended adequate daily intake for vitamin D. Naivasha hospital Rift Valley Province, confounding correlations between the disease rickets in relation to flouride contents of water supplies and food. Case study design was used by comparing data from Yemen, Ethiopia, India, Ausralia and Kenya. Data in Kenya was extracted from Katolo in Kano, a part of the Great Rift Valley, showing bowlegged children and domestic animals from volcamic areas within and outside the Great Rift Valley showing evidence of rickets. Review of reports on incidences and distribution of rickets in East Africa, India, Ethiopia and Australia. Correlatons between rickets and fluoride contents of water supplies was reviewd in the report. The incidence of rickets is becoming worrisome in the Rift Valley, it is important to note that through empirical evidence flouride concentrates can enter public water systems from natural sources. The rise in cases of rickets observed in Rift Valley may be due to three causes ;- Decrease in the calcium content of water and increased concentration of fluoride in water due to global warming, decreased exposure to natural sunlight. They are ever dressed like Eskimos by mothers who leave for work very early in the morning while it is extremely cold in Naivasha and these children are kept indoors most of the time hence their bodies may never manufacture vitamin D from nutrients derived from food and water sources. It is recommended that urgent research is needed on links between drinking water and foods consumed in the Rift Valley basin to determine wheather their contents of flouride comply with the World Health Organisation’s recommendation of 0.5- 1.5 ppm. Keywords : Ricket, rift valley, drinking water, food.

INTRODUCTION It was reported that there is an increase in cases of rickets *Corresponding author E-Mail:gomolor@yahoo.com;Tel. 0723161865

in Naivasha Hospital especially among children of parents working in flower farms. Naivasha Town is right in the middle of Rift Valley where high fluoride contents have been reported before, in rivers, bore holes, soil and even dust of the air. (Oginni et al., 2003; Manji 1986).This paper aims to explain what rickets is, and to establish its

020 Glo. Adv. Res. J. Biochem. Bioinform.

prevalence and distribution in Kenya. Rickets is poor deposition of calcium in bones which leads to easy breakages or bow-leggedness. Calcium is normally deposited in bones as Calcium phosphate but high contents of fluoride intake in food or water may hinder its normal deposition in bones (Oginni et al., 2003). Uptake of calcium by bones is hampered by the high fluoride content of most natural water sources in the Rift Valley of Kenya. Naivasha Town is right in the middle of Rift Valley where high fluoride contents have been reported before, in rivers, bore holes, soil and even dust of the air.

The report above mentioned certain constraints in day care centres where services for child care are offered. However, after extensive review of literature, it was concluded that the rise in observed rickets could be due to contamination by fluoride in the water consumed around Lake Naivasha which might have been compounded by lack of adequate exposure to sunshine among the said children. The rise in fluoride concentrations could also be due to the lake drying up due to lack of replenishment from tributaries which have themselves dried due to deforestation in the catchment areas or even, from global warming. The level of fluoride in drinking water and foods consumed around Lake Naivasha are much higher than the 0.5-1.5 ppm recommended by the World Health Organisation.

What exactly is rickets and what are its manifestations? This is an important area that this discussion paper will address. Simply stated, rickets is a disease in which developing bones in infants and children become bent or misshapen has been known since antiquity. Since 1820s cod liver oil was shown to treat rickets. The vital factor which cured rickets was established by E. V. McCollum to be vitamin D (Oginni et al., 2003). The dependence on sunlight for manufacture of vitamin D under the skin was confirmed by Sir Edward Mellanby, between 1919 and 1920. Working with dogs raised exclusively indoors (in absence of sunlight or ultraviolet (UV) light), he devised a diet that allowed him to unequivocally establish that rickets was caused by deficiency of a trace component present in diet, and that the condition was treated by administering fish liver oil (Mellanby 1921).

Vitamin D is a hormone normally manufactured under the skin of mammals exposed to ultra-violet light or sunshine (Health Letter Associates (HLA) 1998). Most foods supply too little vitamin D to meet the needs of growing children- for instance, a five year old child would have to drink 35 pints of milk or eat 0.8 kg of butter or 11 eggs or 0.13 kg of margarine to fulfil the daily recommended intake (Bingham 1977).

Vitamin D is essential for normal mineralization (calcium deposition) in bones. Bone mineralization occurs when calcium and phosphorous crystals are deposited in the soft collagen matrix which forms the foundation of bones (Health Letter Associates (HLA) 1998). However, any

factor which interfere with either vitamin D development in the body or calcium deposition in bones causes rickets (Sandstead 1980). Recommended Adequate Daily Intake for Vitamin D Since vitamin D can be endogenously produced and is retained for very long periods by the human body, it is very difficult to determine the minimum daily requirements precisely (Teotia and Teotia 2008). This requirement depends on age, sex, degree of sun exposure, season (Harris and Dawson-Hughes 1998).

The current Adequate Intake(AI) of vitamin D, recommended in 1998, by the Food and Nutrition Board of the Institute of Medicine of United States of America is 200 International Units (IU) /day (5 µg/day) for infants, children,

and adults <51 (Food and Nutrition Board (FNB) 1998). This report recommends 400 IU/day (10 µg/day) for adults aged 51-70 and 600 IU (15 µg/day) for adults over 70. During pregnancy and lactation the Food and Nutrition Board suggests that 200 IU (5 ug/day) of vitamin D intake is adequate. Animal sources constitute the bulk sources of vitamin D that occur naturally in unfortified foods. Fish and fish liver oils are good sources (Wardlaw 2003). However, the best source is sunlight. Hence, the heavily dressed children of Naivasha (dressed like Inuit, Eskimos of Greenland) may have missed the advantage offered by natural sunlight.(Wardlaw 2003; Manji 1986). Data Selection Food and water samples obtained from Rift Valley region and analysed for fluoride contents ranged from 2-21 ppm in drinking water from rivers, milk samples from seven localities ranged from 0.05-0.22 ppm while vegetables ranged from 8.0-60 ppm, soil around Lake Elementaita had over 1000 ppm fluoride content while dust from the area had on average about 2300 ppm (Norman 2001). Lakes Elementaita and Naivasha are right in the middle of Rift Valley and have similar ecological characteristics (Jackson 1962). Similar results were reported for borehole and lake waters sampled around Lakes Nakuru and Baringo by Naslund (Pettifor et al., 1988) hence, confirming the shared ecological similarities for Lake basins in the Rift Valley. Distribution of rickets follows similar patterns, with higher prevalence in high fluoride content areas in Kenya (Teotia et al., 1998) and was reported for Yemen which is also part of the Greater Rift Valley (Williamson 1953).

Vitamin D is manufactured in human bodies exposed to adequate sunshine and ultraviolet light sources for 20 minutes daily for about three weeks. It is also relatively very stable in the human body once it has been manufactured

Rombo and Muoki 021

Figure 1a. Bow legged children from Katolo in Kano, a part of the Great Rift Valley, showing evidence of rickets (Picture taken in January, 2010 with permission from parents courtesy of New Nyanza General Hospital)

Figure 1b. The Bowed legs of a rickets patient suffering from vitamin D deficiency Source :( 15)

022 Glo. Adv. Res. J. Biochem. Bioinform.

Figure 3. Rickets may not be confined to humans. These Domestic animals from Rift Valley may have consumed high concentrations of Fluoride in their water or pastures. (Picture from The Standard, January 18

th,

2012, pg. 2).

Figure 4. Geographical areas with high natural fluoride level Source; Australian Government, National Health and Medical Research Council, 2007. A systematic review of the efficacy and safety of fluoridation

Rombo and Muoki 023

Figure 5. Source; Joy Wanja Muraya, Sunday Nation, March

(itonga and Nair 1982; National Institute of Health (NIH) 2009). This makes it very difficult to predict accurately the amount of vitamin D that should be consumed in foods on daily basis. The requirements for vitamin D also depend on age, sex, degree of exposure to the sun, season and amount of pigmentation (Teotia and Teotia 2008). This finding confirms that of Harris and Dawson Hughes (Harris and Dawson-Hughes 1998). Vitamin D is stored in the human body once it has been manufactured (Norman 2001).

Flouride- Calcium Interactions Fluoride levels in water or foods consumed by children under five have been shown to interfere with calcium uptake by bones in India, South Africa and Nigeria (Oginni et al., 2003; Jackson 1962; Pettifor et al., 1988; Novak 2007). This interaction has also been shown to cause rickets in experimental studies (Mellanby 1921; Norman 2001). Rift Valley area of Kenya consists mainly of volcanic soil with very high fluoride concentrations in soil, water and

024 Glo. Adv. Res. J. Biochem. Bioinform.

food sources (Manji 1986; Kahama et al., 1997; Naslund 2005). The World Health Organisation recommends 0.5-1.5 ppm fluoride content of drinking water as safe (Jansen et al., 1987). Levels above that range are considered to be dangerous to human health. The recent volcanic eruptions in Iceland were reported to deposit toxic ashes in pastures which cause long term bone damage that makes teeth fall out and bones break (Pettifor 2008; Pettifor et al., 2008). DISCUSSION While the incidence of rickets is becoming worrisome in the rift valley, it’s important to note that it has been established through empirical evidence that fluoride concentrates can enter public water systems from natural sources including run off from weathering of fluoride containing rocks and soils and leaching from soil into groundwater. Fluoride pollution from industrial waste can also contaminate drinking water supplies.

In this regard, it would be important through this literature review to establish whether diatomite and fluorspar wastes from industries Kerio Valley and Gilgil, have found way into surrounding domestic water supplies. Hence, policy to regulate fluoride in drinking water to acceptable levels and concentrations are required. Also establishment of guidelines to protect the public from exposure to harmful levels of fluoride is in dire need. This discussion paper will offer a debate that will inform appropriate practices minimising rickets prevalence. CONCLUSION Fluoride content of Lake Naivasha may have risen recently due to pollution and/ or global warming. The residents around Lake Naivasha may have switched from high calcium animal food products to cheaper cereal based complementary foods which are high in pytates, which inhibit uptake of calcium from food sources. The calcium concentration in Lake Naivasha has been reducing, possibly due to global warming.The relationship between fluoride content of Lake Naivasha and it’s relation to recent increase in cases of rickets need to be monitored closely to avoid further suffering by children.

It is recommended that urgent research is needed on links between drinking water and foods consumed in the Rift Valley basin to determine whether their contents of fluoride comply with the World Health Organisation’s recommendation of 0.5-1.5 ppm. Also, it is important to establish the magnitude of rickets deficiency in Rift valley so as to put in place appropriate and relevant strategies. In addition, as follow up to evidence based information, policy

frameworks and guidelines are needed on rickets manifestation. In addition, defluoridation systems should be designed and implemented to ensure health for all to meet the target set by the Millennium Development Goals. Rickets is a disease and it should not be allowed to increase. REFERENCES

Bingham S (1977). Dictionary of Nutrition: A Consumer’s Guide to the

Facts of Food. Barrie and Jenkins, London. Food and Nutrition Board (FNB) (1998). Dietary Reference Intakes: A

Risk Assessment Model for Establishing Upper Intake Levels for Nutrients, Washington, D C, National Academy Press.

Gitonga JN, Nair KR (1982). The Rural Water Fluoride Project: Technical Report. International Development Research Centre/University of

Nairobi. Harris SS, Dawson-Hughes B (1998). Seasonal changes in plasma 25-

hydroxyvitamin D concentration of young American black and white women.Ame. J. Clinical Nutrition 67: 1232-1236.

Health Letter Associates (HLA) (1998). The best D-fense. The University of California at Bekeley Wellness Letter, December 1998, pp 1-2.

http://www.fluoridealert.org/health/bone/fluorosis/rickets/html http://wwwarmiesofliberation.org/archives/2007/06/09/rickets Jackson WPU (1962). Further observation on the Kenhardt bone disease

and its relation to fluorosis. South Afric. Med. J. 36: 932-936. Jansen AAJ, Horelli HT, Quin VT (1987). Food intake studies. In: Food

and Nutrition in Kenya: A Historical Review. Department of Community Health, University of Nairobi, Kenya.

Kahama RW, Kariuki DN, Kariuki HN, Njenga LW (1997). Fluorosis in children and sources of fluoride around Lake Elementaita, Kenya. Fluoride 30(1): 19-25.

Manji F (1986). Dental Fluorosis in an area of Kenya with 2ppm fluoride in drinking

Mellanby E (1921). Experimental Rickets. Med. Res.in Great Britain,

special report series SRS-61, 1-78. His Majesty Stationery Office, London.

Naslund J (2005). GIS Mapping of fluoride contaminated groundwater in Nakuru and Baringo districts of Kenya. MSc Thesis, Lulea University of Technology, Sweden.

National Institute of Health (NIH) (2009). Fluoride and Rickets. Norman AW (2001). Vitamin D. In: Present Knowledge in Nutrition (8

th

ed). B. A. Bowman and R. M. Russell, (Eds). ILSI Press, Washington, DC, pp146-155.

Novak J (2007). Rickets on the rise in Yemen: Contaminated water to blame.

Oginni LM, Sharp CA, Bar OS, Risteli J, Davie MJW, Worsfold M (2003). Radiological and biochemical resolution of nutritional rickets with calcium. Archives of Diseases in Childhood 88: 812-817.

Pettifor JM (2008). Vitamin D and/ or calcium deficiency rickets in children: a global perspective. Indian J. Med. Res. 127: 245-249.

Pettifor JM, Fischer PR, Thacher TD, Arnaud J, Meissner CA (2008). Dietary calcium deficiency and rickets. Indian J. Med. Res. 128:673-

676 Pettifor JM, Moodley GP, Quirk M, Cavalerus M (1988). Skeletal

deformities, hyperosteoidosis and elevated 1, 25 dihydroxy vitamin D levels in children from an area of endemic fluorosis. In: Clinical Disorders of Bone and Mineral Metabolism M. Kleerekoper and S. Karne (Eds), Detroit, Michigan pg 31.

Sandstead HH (1980). Clinical manifestation of certain classical deficiencydiseases. in: Modern Nutrition in Health and Diseases. R. S. Goodhart and M. E. Shills, (eds), Lea and Febiger, Philadelphia.

Teotia SPS, Teotia M (2008). Nutritional bone disease in Indian

population. indian J. Med. Res. 127: 219-228. Teotia SPS, Teotia M, Singh KP (1998). Endemic chronic fluoride toxicity

and dietary calcium deficiency interaction syndromes of metabolic bone disease and deformities in India. Indian Journal of Pediatrics 65: 371-381.

Rombo and Muoki 025

Wardlaw GM (2003). Contemporary Nutrition: Issues and Insights (5

th

ed).McGraw Hill, London, pg. 243. water. J. Dental Res. 65(5):659-662.

Williamson MM (1953). Endemic dental fluorosis in Kenya: a preliminary report. East Afri. Med. J. 30: 217-233.