BACKGROUND
1. Recognition of the Disease and Preliminary Studies
Rickets has emerged as a major source of disability in the Chakaria area of southeastern Bangladesh (Cox's Bazaar District). The disease does not appear to involve vitamin D deficiency. Preliminary studies by Cimma et al (1) and us (2) have found most affected children to have normal circulating levels of 25-hydroxycholecalciferol and up-regulated levels of 1,25-dihydroxycholecalciferol, supporting the exclusion of a problem in vitamin D biosynthesis and metabolism as a factor in the etiology of the disease. This is consistent with expectations based on plentiful exposure of children in this area to sunlight, which would afford ample production of vitamin D. In addition, our examination of radiographs of a rachitic child before and after treatment with pharmacologic doses of vitamin D3 (at the Memorial Christian Hospital, Chakaria) convinced us that such treatment was without effect. Thus, the disease in Chakaria resembles that described in South Africa (3) and Nigeria (4,5) as a calcium (Ca)-deficiency rickets. However, while available evidence suggests that low Ca intake is likely to be at least a pre-disposing factor to the disease in Chakaria, there would also appear to be other food/soil/water-borne factors in its etiology.
Children in Chakaria consume diets deficient in Ca as well as several other nutrients (e.g., iron, zinc, vitamins A and C, riboflavin, protein). Most of these children are stunted (height/age < 3rd percentile); 25-50% show signs of marasmus (protein-energy malnutrition) and/or riboflavin deficiency (cheilosis) and, in general, they have a significant morbidity burden (malaria, worms and episodic diarrhea). Cimma et al [1] estimated the Ca intakes of children in the affected area to be <135 mg/day; our recent analyses of local foods support that estimate. Thus, it is clear that many children in Chakaria do not consume adequate amounts of Ca(2), which is likely to be rendered even less useful to the extent that their diets are imbalanced with respect to phosphorus and also contain oxalates and phytates which can antagonize calcium. Calcium deficiency is likely to be fairly wide-spread in Bangladesh, affecting children directly as well as via their pregnant and lactating mothers.
2. Why Rickets in Chakaria?
That Chakaria is clearly not among the poorest areas of Bangladesh and its children are not among the most severely malnourished children in the country raises the question: Why is rickets prevalent in Chakaria when poor children throughout Bangladesh are consuming low-Ca diets apparently without the disease?
A clue to answering this question may be in the fact that Chakaria rickets appears to have increased dramatically within the last 12-15 yrs. This suggests one or more environmental factor(s) in its etiology. Possibilities include:
Cimma et al (1) have suggested the involvement of excess exposure to soluble aluminum, which is known to antagonize Ca utilization in Ca-deficient animals (6) and has been associated with impaired bone mineralization in premature infants (7). Our recent (Oct., 1997) analyses of blood, food and water sampled from Chakaria have not pointed to aluminum or other known mineral antagonists of Ca (8), though this warrants further study. Nevertheless, our findings show prevalent Ca-deficiency.
3. Working Hypothesis
Our working hypothesis is that Chakaria rickets is caused by two factors:
We believe that it is highly probable that increasing infant/child Ca intakes will reduce the prevalence of rachitic changes; however, this requires testing. Accordingly, we have devised a community-based, clinical intervention study (as part of a companion project) to evaluate the anti-rachitic efficacies of oral supplements of Ca and/or multi-vitamins and trace elements.
4. Impacts of Rickets
Rickets is a highly visible disease to which children are vulnerable by virtue of their rapid bone growth. In addition to causing rickets, chronic Ca deficiency can also result in other diseases of bone demineralization, such as osteomalacia, which may not be manifest clinically until late in life. Thus, it is likely that an underlying insufficiency and/or antagonism of Ca utilization that causes rickets can also affect the bone health of adults, particularly pregnant, lactating and post-menopausal women. Such problems would be expected to affect child health and survival in two ways: by crippling young children with rickets; and by increasing the morbidity of child care-givers.
Understanding and addressing the factors contributing to the Chakaria rickets will be important in order to find sustainable solutions to the problem (in Chakaria and, perhaps, elsewhere). Food system-based approaches will allow this to be done not only in ways that are sustainable (in local environmental, social and economic contexts), but that also enhance nutrition in multiple ways (i.e., by increasing availabilities of other limiting nutrients) to improve child health and survival.
Thus, there are several reasons for taking action to find means of preventing
the Chakaria rickets:
1. The disease is a major cause of disability in Chakaria, compromising the health, productivity and life quality of many people.
2. The disease may be widely under-diagnosed and underreported (4), as low Ca intakes are prevalent in many areas.
3. The disease may compromise child health directly as well as by affecting care-givers.
4. Other areas may be exposed to environmental factor(s) contributing to the disease.
5. The disease may be masked by growth stunting; interventions that reduce stunting may increase rickets prevalence.
5. Formation of the Chakaria Rickets Consortium
In October, 1997, we convened a workshop involving several national and international organizations and reported our views of the problem and possibilities for addressing it in an open meeting of local residents and thana officials. We formed the Consortium to Develop Sustainable Means of Preventing Rickets in Bangladesh and agreed to pursue a program comprised of three projects:
CHAKARIA FOOD SYSTEM PROJECT
GOAL:
The goal of the project will be to develop means of increasing the intake and utilization of Ca by children in sustainable, food-based ways that also improve their status with respect to other limiting micronutrients(5). Accordingly, the project will exploit multiple opportunities within the Chakarian food system to increase the Ca intake/utilization of children from the estimated present value of 130 mg/cap/day to at least 300 mg/cap/day. Emphasis will be placed on measures that also increase the supplies of vitamins and essential minerals, which the Chakaria food system presently does not provide in sufficient amounts to support child health and development.
APPROACH:
The project will undertake descriptive modeling of the Chakarian food system from which options will be identified for increasing the child-accessible supply of Ca and other limiting micronutrients. Using a multiple-values rubric, the most promising opportunities will be field-tested for feasibility, household acceptability and impact on child health.
MEASURABLE OBJECTIVES:
PROJECT DESIGN The project will consist of four semi-sequential component activities:
1. Characterization of the Chakarian Food System (year 01).
Plan. A nested series of studies will be conducted to generate descriptive data for use in modeling and, subsequently, analyzing the Chakaria food system. The purpose of this analysis will be to identify opportunities to improve yields and availability of Ca and other limiting nutrients:
Site Selection. This portion of the study will be implemented in two sites (6 villages total) in Chakaria Thana selected for having low (2 villages) or high (4 villages) rickets prevalence, respectively. We will select these sites after conducting an initial review of available information concerning the geographic distribution of rickets prevalence in the Thana as well as in the southern part of Cox's Bazaar District in general. Our review will be preliminary to the Ricket Consortium's formal prevalence study (a companion project). It will include interviews with Thana Health Center physicians and SARPV Village Organizations, as well as a detailed review of the medical records of all patients admitted (last 10 years records available) or cared for on an out-patient basis (30 yrs records available) by the Memorial Christian Hospital (MCH)(7), located in Chakaria(8). This review will consist of a patient-by-patient search of the paper files and the recording of diagnoses of or consistent with rickets and/or other metabolic bone diseases, patient characteristics (age, gender, postal address, etc.) and health outcome. These data will be used to map the geographic distribution of rickets in the MCH catchment area, which we will compare to the available information on soil and water chemistries, cropping systems, etc.
Implementation: In each site, the Field Data Team will collect the above-indicated village, household and individual-level data. To the extent possible, they will collaborate with the Community Project Teams who will be managing the intervention. The Field Data Team (Team Leader, 6 Enumerators and an Assistant) will be trained and directed by Dr. Hassan (who is thoroughly experienced in these methodologies), assisted by a Data Manager.
2. Food System Analysis (years 01-02)
Plan. The food system survey data will be used to construct a Chakaria Food System Model by the Cornell group (Combs, Duxbury and Welch)(9) working in collaboration with Dr. Hassan. The model will be analyzed to identify:
Implementation. We will seek a combination of measures that will be very likely to increase the Ca intakes of children (under 5 yrs) by at least 150 mg/cap/day. This target is based on the provisional assumption that most are presently consuming at least 130 mg Ca/cap/day and that an appropriate target level of consumption should be at least 280 mg Ca/cap/day (i.e., 70% of the American RDA). With this goal in mind, our analysis will be designed to identify opportunities to:
All possible options will be ranked using a multiple-value array of the following type.
| target value\system value | feasible | effective | acceptable | targeted | sustainable | enhances other nutrients |
| enhances Ca supply | ||||||
| enhances Ca utilization |
3. Agricultural Interventions in the Food System (years 01-05)
Plan. The most promising options identified by our food system analysis will be evaluated in the field for efficacy, feasibility, acceptability and sustainability. We can expect these to include several types of opportunities:
For some of these (e.g., liming studies, pulse production, low-oxalate amaranths, brassicas), available information is strong enough to warrant their implementation as part of the start-up of the SARPV Health Legs Demonstration Farm in the first year of the project.
Implementation. We will use a step-wise, expert/community-based approach to identify options for field-testing: first, we will consult with colleagues in the several appropriate agricultural disciplines (particularly agronomists, plant breeders, plant nutritionists and horticulturalists)(11); with that information, we will convene a series of village meetings at which the results of the Food System Model analysis will be discussed. These will be important to learn from local farmer experience and to engage farmers and households as partners in this process of discovery and evaluation.
We will field-test the most promising production-related food system options in three ways:
We will employ Community Project Teams composed of paid workers and part-time volunteers that will work with the existing SARPV village organizations at the village, para and household levels to provide seed stock, technical information, supporting education (using materials developed by Dhaka University) and some micro-loans to initiate and support these activities. We will augmented these activities by including the foods tested as part of the Thrasher-sponsored Ca-intervention study (in different villages), and through publicity and public education we will try to foster increased consumer demand for these "Healthy Legs" products. In addition, we will use micro-loans and/or cooperative ventures to incubate small business partner-ships with local businessmen and SARPV to market Ca-rich foods/supplements obtainable outside Chakaria (e.g., Chittagong). Such examples may include the marketing of processed (cooked/ground) fish racks from commercial filleting operations in Chittagong or animal bone from local slaughterers as weaning foods in Chakaria.
4. Impact Evaluation
The food-based strategies will be evaluated as follows:
| parameter | evaluation method | ||
| baseline (yr 01) | formative (yr. 03) | summative (yr. 05) | |
| process | village meetings household interviews |
village meetings household interviews | |
| adaptation of new cultivars, cropping practices, etc. | farmer survey | farmer meetings | farmer survey |
| access to Ca sources | household survey; village market survey | household inter-views: costs, accept-ability, use barriers | household survey: costs, acceptability, use; market survey: costs, availability |
| Ca intakes of infants, children, pregn./lact.women | household food frequency survey | household inter-views: food use | household food frequency survey |
| paraclinical signs of rickets | alk. phosphatase | alk. phosphatase | alk. phosphatase |
| clinical signs of rickets | physical exam, Xray | physical exam, Xray | physical exam, Xray |
| other signs of malnutrition | physical exam, anthro-pometry; albumin, retinol, Hb, transferrin sat'n | physical exam, anthropometry | physical exam, anthro-pometry; albumin, retinol, Hb, transferrin sat'n |
5. Project Staffing
Overall Direction
Scientific Direction
Project Management (full-time)
Community Health Teams (full-time)
6. Collaborative Arrangements
Rickets Consortium partners will collaborate in implementing specific aspects of the project.
SARPV (Mr. Shahidul Haque, Executive Director) will provide:
Dhaka University (Dr. Nazmul Hassan, Professor)
UNICEF-Bangladesh (Dr. Johnny Kyaw-Myint, Director, Health and Nutrition Branch) will:
AEM (Amis des Enfants du Monde) (Mr. Roland Crémades) will:
Cornell University (Drs. Combs and Duxbury, Professors) will:
CIMMYT-Bangladesh (Dr. Craig Meisner, Agronomist)
Helen Keller International (Ms. Lynnda Kies)
US Plant, Soil and Nutrition Laboratory, ARS/USDA (Dr. Ross Welch, Sr. Scientist)
REFERENCES
1. Cimma, J.P., R. Crémades, J.C. Gaudin and S. Idelman. 1994. Chakaria Area, Bangladesh: Medical, Nutritional, Agronomical Inquiry Results, unpublished trip report.
2. Fischer, P.R.et al, 1997. Nutritional rickets without vitamin d deficiency in the Chakaria region of Bangladesh. Proc. Ann. Mtg. Internat. Cent. Diarrheal Dis. Res., Bangladesh. Abstract (in press).
3. Pettifor, J.M., P. Ross, J. Wang, G. Moodley and J. Couper-Smith. 1978. Rickets in children of rural origin in South Africa: is low dietary calcium a factor? J. Pediatr. 92:320-324.
4. Okonofua, F., G.S. Gill, Z.O. Alabi, M. Thomas, J.L. Bell and P. Dandona. 1991. Rickets in Nigerian children: a consequence or calcium malnutrition. Metab. 40:209-213.
5. Thacher, T.D., S. I. Ighogboja and P.R. Fischer. 1997. Rickets without vitamin D deficiency in Nigerian children. Ambulatory Child Health 3:56-54.
6. Boudey, M., F. Bureau, C. Placé, D. Neuville, M. Drogsdowsky, P. Arhan and B. Bouglé. 1996. Effect of small variations of aluminum intake on calcium metabolism in young rats. J. Ped. Gastroenterol. Nutr.
7. Bouglé, D., F. Bureau, R. Moréllo, B. Guillow and J.P. Sabatier. 1997. Aluminum in the premature infant. Trace Elem. Electrolytes 14:24-26.
8. Welch, R.M. et al, 1997. Mineral status in relation to rickets in Chakaria, Bangladesh. Proc. Ann. Mtg. Internat. Cent. Diarrheal Dis. Res., Bangladesh. Abstract (in press).
1. Amis des Enfants du Monde, Paris; CIMMYT, Dhaka, Bangladesh; SARPV (Social Assistance and Rehabilitation for the Physically Vulnerable), Dhaka; Cornell University, Ithaca, NY, USA; Dhaka University, Dhaka; Institute for Mother and Child Health, Dhaka; International Center for Diarrheal Disease Research - Bangladesh, Dhaka; Memorial Christian Hospital, Chakaria; UNICEF-Bangladesh, Dhaka; US Plant, Soil and Nutrition Laboratory, USDA/ARS, Ithaca, NY, USA.
2. The RDAs for Ca for children are 400 mg: 0-0.5 yrs; 600 mg: 0.5-1 yr.; and 800 mg: 1-10 yrs.
3. It has been suggested that high levels of DDT can have anti-estrogenic effects that interfere with the action of 1,25-dihydroxycholecalciferol in effecting bone mineralization.4. In at least some thanas, rickets cases are recorded in the broad category of "malnutrition".5. These include micronutrients for which Chakarian children are known to be at high risk to deficiency (Fe, riboflavin, vit. A, and Zn) or which affect the utilization of Ca (P) or Fe (vit. C).
6. Because rickets is not normally fully correctable by dietary interventions for older children, who may require orthopedic and/or surgical procedures, this project will address the prevalence of clinical (radiographic) and para-clinical (serum alkaline phosphatase) indicators of rickets and will facilitate referral of florid cases to the Thana Health Office and/or Memorial Christian Hospital.
7. The MCH, widely regarded as a leading medical facility in Bangladesh, is located in Chakaria. Dr. Dave Staab and his MCH colleagues, partners in the Rickets Consortium, have agreed to grant us access to their patient medical records for this study. We are requesting support from UNICEF for this study.
8. Despite a potential ascertainment bias (involving differential access to MCH services) of a hospital record review, it will still be a useful and cost-effective way to identify sites within and/or near Chakaria Thana where rickets prevalence is notably high/low.
9. Dr. Howarth Bouis (IFPRI) has agreed to advise in this activity.
10. We hope to partner with Helen Keller International in these activities.
11. Cornell University, Bangladesh Agr. Res. Inst. (BARRI), Chittagong Agr. Ext. Service, Internat.Center for Res. in the Semi-Arid Tropics (ICRSAT), Asian Veg. Res. and Devel. Cent. (AVRDC)
12. SARPV recently acquired 3.5 ha. in Chakaria for this farm, which will be partially subsidized by AEM and SARPV; Cornell Univ. will provide agronomic expertise. The activities on the farm will be begin during project year 01 so that the unit can be fully operational during the subsequent years of the project.