PRESENTATION OF OSTEOMALACIA IN KOHISTANI WOMEN
Ahmad Sohail Sahibzada, Muhammad Shoaib Khan, Mohammed Javed*
Department of Orthopaedics and *Medicine, Ayub Medical College,
Abbottabad
Background: Osteomalacia is a common
diagnosis in the Kohistani women presenting with aches and pains. This study
was conducted to assess calcium and Phosphate levels in Kohistani women with
osteomalacia. Methods: 50 diagnosed
cases of Osteomalacia selected from amongst the women presenting with body
aches were included in the study. History regarding age, marital status,
parity, dietary habits, socioeconomic status etc was taken. Results: The median age was 23 years.
74% were married. Most of the women had
5 children (mode). Nine (18%) patients had hypocalcaemia, 10 (20%) had
hypophoshatemia. Alkaline phosphatase was elevated in 13 patients (26%). Six
(12%) patients were pregnant at the time. 74 % of patients belonged to the poor
class. 70% of the patients drank less than 1 cup of milk per day. Body aches
(100%), waddling gait (14%), proximal myopathy (12%), bone tenderness (6%) and
carpopedal spasm (8%). Conclusions:
We therefore conclude that in comparison with other parts of the world where
individual risk factors cause osteomalacia, Kohistani population has a higher
frequency of osteomalacia due to aggregation of three major factors namely lack
of sunlight due to geographical location, excessive clothing blocking available
sunlight and nutritional deficiency.
Keywords: Osteomalacia, Body aches,
Serum Calcium, Serum Phosphate, Alkaline Phosphate
Introduction
Osteomalacia is a metabolic bone disease
caused by deficiency of vitamin D or its active metabolites. Reasons for the
deficiency are inadequate dietary intake of Calcium and Vitamin D1,
malabsorbtive conditions, inadequate exposure to sunlight2 and renal
disease. Low intake of available calcium and lack or inefficient supplements
are suggested to be the main factors in causing the low state of calcium.3
The
disorder is significantly worse in winter than in summer suggesting that
insufficient exposure to sunlight is a contributory factor.4 Because
poor sunlight exposure is one of the most common causes of osteomalacia, the
disease seems to be rare in countries with adequate sunlight.5
The disease is common in
females specially of the old age. An interesting study of Iliac bone biopsies
of 80 elderly white South African ladies with femoral neck fractures revealed
histological features of osteomalacia in 11.25% of cases.4
Osteomalacia is a condition
whose presentation may be subtle in adults. Symptoms include diffuse skeletal
pains. Signs are bone tenderness and proximal myopathy. Pain and weakness in the hips may produce
the typical waddling gait. The disease if not correctly diagnosed will lead to
unnecessary prescriptions of NSAIDs.
The minimum daily requirement for vitamin D is 2.5 mcg (100 IU) daily.
This study was undertaken to
assess the etiology, presenting signs and symptoms and laboratory findings of
Osteomalacia in Kohistani women so as to understand the magnitude of the
problem and increase awareness about this common and easily treatable disease
which is no more found in the developed world.
This study was carried out at Ayub Teaching
Hospital, Abbottabad with collaboration between medicine and orthopaedics
units. Fifty Kohistani women of reproductive age group reporting with body
aches as their primary symptom and diagnosed as osteomalacia were included in
this study.
A proforma was used to
collect data about each individual. Age, marital status, parity, pregnancy,
socioeconomic status, area of residence, dietary/milk consumption per day,
exposure to sunlight were the main variables of study.
Blood samples were collected
and tested for Calcium, Phosphate, Albumin and Alkaline Phosphatase. As serum
calcium is largely bound to albumin the corrected calcium levels were taken as
follows:
Corrected Ca = Serum Ca in mgs/dl + {0.8 x (4.0 –
Albumin gm/dl)}
Osteomalacia was diagnosed on the basis
of a history of bone aches or pains, muscle weakness, low or low normal serum
calcium and urinary calcium, decreased concentrations of serum inorganic
phosphorus and 25-hydroxyvitamin D and increased serum intact PTH and alkaline
phosphatase levels.
Results
The median age was 23 years. 74% were married. Most
of the women had 5 children (mode).
Nine (18%) patients had hypocalcaemia, 10 (20%) had hypophoshatemia. Alkaline
phosphatase was elevated in 13 patients (26%). Six (12%) patients were pregnant
at the time. 74 % of patients belonged to the poor class. 70% of the patients
drank less than 1 cup of milk per day.
Table-1: Clinical features of osteomalacia in the group studied (n=50)
Clinical feature |
Subjects (% ) |
Body
aches |
50 (100) |
Waddling
gait |
7 (14) |
Demonstrable
proximal myopathy |
6 (12) |
Bone
tenderness |
3 (6) |
History
of Carpopedal spasms |
4 (8) |
Table-2: Calcium and Phosphate levels in the group studied (n=50)
|
Subnormal (<8.5 mg/dl) |
Borderline (8.5-9 mg/dl) |
Normal (>9mg/dl) |
Calcium |
9 (18%) |
12
(24%) |
29
(58%) |
Phosphate |
10
(20%) |
13
(26%) |
27
(54%) |
Discussion
A study conducted in Karachi in 1976
surveyed 206 healthy Pakistani women and 252 pregnant Pakistani women near term
attending the antenatal clinic. This study reported 12-16% of healthy women and
33% of pregnant women to have biochemical abnormalities of serum calcium,
phosphorus, and alkaline phosphatase, that were corrected with subsequent
administration of vitamin D. This study suggested that absence of clinical
disease was due to adequate supplementation received through the ultraviolet irradiation
of the skin.6 This study was carried out in a port city at sea
level, where sunlight is no problem, and the women do not use excessive
clothing. Our study population belonged to an area where sunlight is scarce and
women are used to excessive clothing.
Kohistan
is a district of Hazara division of North West Frontier Province. It is a
mountain area where sunlight is available for a very short time everyday, if
there is no cloud cover. The ladies in this area use excessive clothing made up
of layers after layer of thick cloth. It is possible that excessive clothing
may be a risk factor for osteomalacia in young to middle-aged and otherwise
healthy women as was reported by Gulu et al from Turkey.5
Gulu et al reported nine Turkish female
patients with osteomalacia with ages between 21 and 50 years. Radiographically,
pseudo-fractures were present in seven of the patients. The patients' symptoms
and signs were relieved with the treatment with vitamin D analogues and
calcium. They reported that hypovitaminosis D may be caused by excessive
clothing in the outdoors due to sociocultural and religious reasons.5
A
study from Israel retrospectively surveyed hospital admissions over 10 years
period and reported nutritional osteomalacia in 20 patients all of whom were
Bedouin women. All of them suffered from bone pain, proximal muscle weakness
and fixed skeletal deformities. Mean serum alkaline phosphatase levels were
raised. Mean 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D levels in 60 %
cases were below normal.7
An
Egyptian study of 230 pregnant women of low socio-economic group suggested
association of a low nutritional status
with osteomalacia denoting an impaired calcium state and defective bone
mineralization.3 This can be true for this region also, where
majority of the population lives below poverty line. Women are most exposed to
nutritional deficiency as males are given priority, being a male dominated and
male centered society.8,9
It appears that in our
population malnutrition due to poverty is the predominant cause. Another
possibility that might be operative in Kohistani women is the traditional black
body covering (Chaddar) that they wear.
We therefore conclude that
in comparison with the above studies where individual possible risk factors
were causing osteomalacia, Kohistani population has a higher frequency of
osteomalacia due to aggregation of three major factors namely lack of sunlight
due to geographical location, excessive clothing and nutritional deficiency.
It is the need of the hour
to educate our medical students, the nurses and the paramedics about the
dietary aspects of disease, supplementation of essential nutrients in the
vulnerable population groups like the elderly, young children, pregnant women
and women of childbearing age. These simple measures will considerably reduce
morbidity and improve the quality of life to some extent in this impoverished
population.
1.
Binet
A; Kooh SW. Persistence of Vitamin D-deficiency rickets in Toronto in the
1990s. Can J Public Health. 1996 Jul-Aug; 87 (4): 227-30.
2.
Woitge
HW; Scheidt Nave C; Kissling C et al. Seasonal variation of biochemical indexes
of bone turnover. J Clin Endocrinol Metab. 1998 Jan; 83 (1): 68-75.
3.
Abd-el-Fattah
M, Gabrial GN, Shalaby SM, Morcos SR. An epidemiological and biochemical study
on osteomalacia among pregnant women in Egypt. Z Ernahrungswiss. 1978 Sep;17(3):140-4.
4.
Schnitzler
CM, Solomon L. Osteomalacia in elderly White South African women with fractures
of the femoral neck. S Afr Med J 1983;64(14):527-30.
5.
Gullu
S, Erdogan MF, Uysal AR, Baskal N, Kamel AN, Erdogan G.A potential risk for
osteomalacia due to sociocultural lifestyle in Turkish women. Endocr J 1998
Oct;45(5):675-8.
6.
Rab
SM. Occult osteomalacia amongst healthy and pregnant women in Pakistan.
Lancet. 1976 Dec 4;2(7997):1211-3.
7.
Lowenthal
MN, Shany S. Osteomalacia in Bedouin women of the Negev. Isr J Med Sci. 1994 Jul;30(7):520-3.
8.
Thomas
MK; Lloyd Jones DM; Thadani RI; Shaw AC. Hypovitaminosis D in medical
inpatients. N Engl J Med. 1998 Mar 19;
338 (12): 777-83.
9.
Hoshino
H; Kushida k; Takahashi M; Kawana K; Denda M; Yamazaki K; Inoue T.
Characteristics of Biochemical Markers in patients with metabolic bone
disorders. Endocr Res. 1998 Feb: 24 (1): 55-64.
_____________________________________________________________________________________________________________________
Address for Correspondence:
Dr.
Ahmad Sohail Sahibzada, Associate Professor, Department of Orthopedics, Ayub
Medical College, Abbottabad. Pakistan