Year : 2012 | Volume
: 1 | Issue : 1 | Page : 50--53
Vitamin D status in patients with musculoskeletal symptoms in Haryana, India
Sanjay Kalra1, Bharti Kalra2, Sachin Kumar Khandelwal3,
1 Department of Endocrinology, Bharti Hospital and B.R.I.D.E, Karnal, Haryana, India
2 Department of Gynaecology, Bharti Hospital and B.R.I.D.E, Karnal, Haryana, India
3 Research Fellow, Bharti Hospital and B.R.I.D.E, Karnal, Haryana, India
Department of Endocrinology, Bharti Hospital and B.R.I.D.E, Karnal, Haryana
Vitamin D deficiency often presents with musculoskeletal symptoms, such as pain and weakness. These symptoms are common, presenting complaints in patients across the country, across medical specialties. This work highlights the high incidence of low vitamin D levels among 234 female patients presenting with musculoskeletal symptoms in Haryana, North India. A single center cross-sectional study was performed in patients presenting with various musculoskeletal complaints, during winter months. Analysis of 25-hydroxy vitamin D levels revealed a prevalence of vitamin D deficiency of 55.55% and insufficiency of 38.46% (combined: 94.01%).
|How to cite this article:|
Kalra S, Kalra B, Khandelwal SK. Vitamin D status in patients with musculoskeletal symptoms in Haryana, India.J Med Nutr Nutraceut 2012;1:50-53
|How to cite this URL:|
Kalra S, Kalra B, Khandelwal SK. Vitamin D status in patients with musculoskeletal symptoms in Haryana, India. J Med Nutr Nutraceut [serial online] 2012 [cited 2019 Aug 18 ];1:50-53
Available from: http://www.jmnn.org/text.asp?2012/1/1/50/94631
Vitamin D deficiency has been known in North India for many years. , Reports of vitamin D deficiency have been published from various centers of India as well as in Asian immigrants settled in UK and USA. Recent reviews have noted the pan-Indian occurrence of this condition. ,
Studies from New Delhi and Lucknow have highlighted the prevalence of vitamin D deficiency in northern India. , However, all these studies have covered asymptomatic subjects. The clinical syndrome of osteomalacia has been identified and reported in elderly women and men in Haryana many decades ago. , Anecdotal reports of frequent occurrence of severe cases of rickets and osteomalacia in this state are also available. 
A very high incidence of low vitamin D levels in asymptomatic postmenopausal women  and in hypothyroid patients  has also been reported from Haryana in recent years. However, no systematic work has been done to assess the prevalence of vitamin D status in patients presenting with musculoskeletal complaints in metabolic and endocrine outpatient departments (OPDs) in Haryana. No work has been done to quantify vitamin D status in symptomatic patients. This cohort of patients is rather common in OPDs across the country, in different specialties, such as medicine, orthopedics, gynecology, neurology, rheumatology, and endocrinology. Hence, assessing vitamin D levels in such patients is justified as this can help improve treatment outcomes, in a cost-effective manner.
Materials and Methods
This cross-sectional single center study was performed at an endocrine center in northern India (latitude 2942ͲN and longitude 7702ͲE) to assess the prevalence of vitamin D deficiency in 234 symptomatic women presenting with musculoskeletal symptoms. The study was conducted during winter (Nov 2010 to Jan 2011).
Patients attending the OPD for various musculoskeletal symptoms were recruited. Inclusion criteria were symptomatic women, without known renal or hepatic disease or malignancy. Patients with history of surgery, hospitalization, or major medical illness within the past 1 year were excluded from the study. Patients on hormone replacement therapy, glucocorticoids, biophosphonates, teriparatide, and other drugs affecting bone metabolism were also excluded.
Intake of conventional calcium/vitamin D supplements was not considered an exclusion criterion. Only patients living at the same location, in Karnal district, for at least 1 year were included.
All subjects were enrolled after taking a written informed voluntary consent. They were subjected to a complete history and physical examination geared towards assessing bone and mineral status.
Investigations included a complete hemogram, renal and hepatic function tests as well as fasting and postprandial blood glucose. Serum, calcium, phosphorous, alkaline phosphate, protein, albumin and globulin levels were measured. Thyroid function tests and 25-hydroxy vitamin D were also assessed. Serum parathormone was not assessed due to resources limitations.
All tests were performed after 8-12 h of fasting. Samples were processed and the serum transported to a central laboratory for estimation within 24 h.
Serum, calcium measured by Arsenazo III method, phosphorous by phosphomolybdate method,
Aspartate aminotransferase and alanine aminotransferase by enzymatic method, and alkaline phosphatase by p-Nitrophenylphosphate (pNPP) method.
Serum creatinine by Jaffe method, protein (total), serum by Biuret method, albumin, serum by bromocresol purple method, and serum 25-hydroxy (OH) vitamin D was assessed by electrochemiluminescence immunoassay (ECLIA). The ECLIA kit, sourced from Roche, Mannheim, Germany, has range of measurement of 3.0-70.0 ng/mL, and suggests using health-based reference standards for diagnosis of vitamin D sufficiency.
Sunlight exposure and dietary intake of calcium or vitamin D were not measured in this pilot study, because of lack of manpower.
The presenting symptoms taken for inclusion were generalized aches and pains, bone tenderness, difficulty in squatting/getting up from squatting position/climbing stairs, difficulty in using Oriental toilet, difficulty in attending prayers in the temple/gurudwara/mosque, and altered gait. These symptoms represent the cardinal features of vitamin D deficiency: Musculoskeletal pain and weakness. This cohort of patient is rather common in OPDs across the country, in different specialties, such as medicine, orthopedics, gynecology, neurology, rheumatology, and endocrinology. For the same set of complaints, each patient will be investigated in different manners and treated in a manner completely different from the other. These 2 issues have huge implication in our country. Hence estimating vitamin D is justified as the pre-test probability of detecting a deficiency or insufficiency is quite high.
A total of 234 patients attending the OPD for musculoskeletal symptoms were screened. All the subjects volunteered symptoms suggestive of musculoskeletal disease on history taking.
The cohort comprised of 165 urban dwellers (70.51%) and 69 (29.48%) rural dwellers. 171 (73.07%) were of Hindu religion, with the rest 63 being Sikh (26.92%). All women were traditional Indian dress of sari or salwar-kameez. None of them observed purdah. All but 21 (8.97%) were vegetarian. All reported their occupation as housewife, all belonged to upper or middle socioeconomic class.
The average ageSD was 45.4311.72 years (range 18.0-65.0 years)
None of these subjects were detected to have hepatic or renal dysfunction, based on the biochemical investigations.
25 (10.68%) had hemoglobin below 10 gm/dL, while 99 (42.30%) had hemoglobin levels ranging from 10 gm/dL to 11.9 g%gm/dL.
Serum calcium levels were below 8.5 mg/dL in 24 subjects (10.25%), and were raised (above 10.5 mg/ dL) in one (0.427%). This patient was on oral calcium supplementation. No further investigations were done in this patient. Serum phosphorus was normal in all. Serum alkaline phosphatase was raised in 32 (13.67%) patients.
Vitamin D levels were less than 10 mg/mL in 130 subjects (55.55%) and between 10 and 30 mg/mL in 90 subjects (38.46%). Thus, the prevalence of vitamin D deficiency and insufficiency was 220/234 (94.01%) in this cohort of North Indian patients with musculoskeletal complaints.
Vitamin D deficiency is endemic in India. Numerous reports have highlighted the low levels of vitamin D noted in various spectrum of the population, including young adults, hospital personnel, and postmenopausal women. ,,,,,,,,,,
All the prospective studies, however, have analyzed "healthy," asymptomatic subjects. ,,,,,
Vitamin D deficiency has been noted to be an etiologic factor of rheumatologic symptoms by many authors. These reports originate not only from India and Pakistan, ,, but also from the western world. ,,,,,,,, Vitamin D supplementation has also been shown to improve morbidity in patients with rheumatologic disorders, although conflicting evidence is available. 
Recently, an attempt has been made to identify a symptomatic nonosteomalacic state as part of the clinical spectrum of vitamin D deficiency. The authors retrospectively studied records of patients with musculoskeletal or rheumatic symptoms, without evidence of osteomalacia, and found a high incidence of vitamin D deficiency. They have highlighted the correlation of vitamin D deficiency in patients with such symptoms. 
This cohort of patients is rather common in OPDs across the country, in different specialties, such as medicine, orthopedics, gynecology, neurology, rheumatology, and endocrinology. For the same set of complaints, each patient will be investigated in different manners and treated in a manner completely differing from the other. These two issues have a huge health impact in our country.
No prospective or cross-sectional study has been reported so far from South Asia, which focuses specifically on vitamin D status in symptomatic patients. This is surprising, as assessing vitamin D levels in such patients is justified as the pre-test probability of detecting a deficiency or insufficiency is quite high.
This is, to the best of our knowledge, the first such study with regard to vitamin D and health issues. The incidence of vitamin D deficiency/insufficiency is much higher in the symptomatic subjects (94.03%) than in healthy, asymptomatic postmenopausal women from the same region (66.67%).  Each work is more important from the South Asian point of view as this population is more prone to vitamin D deficiency. ,,,
This study highlights the high prevalence of vitamin D deficiency in patients with musculoskeletal symptoms (myalgia, bone tenderness, and myopathy) in an endocrine and metabolic center located in Karnal, Haryana, North India.
It sensitizes physicians to assess vitamin D levels in patients presenting with such symptoms. Further work is needed to assess the impact of vitamin D levels on severity of symptoms, and effect of vitamin D supplementation on these symptoms.
|1||Wilson DC. The incidence of osteomalacia and late rickets in northern India. Lancet 1931;218:10-2.|
|2||Vaishnava HP, Rizvi SN. Osteomalacia in northern India. Br Med J 1967;1:112.|
|3||Teotia SP, Teotia M. Nutritional bone disease in Indian population. Indian J Med Res 2008;127:219-28.|
|4||Harinarayan CV, Joshi SR. Vitamin D status in India- Its implication and remedial measures. J Assoc Physicians India 2009;57:40-8.|
|5||Goswami R, Gupta N, Kochupillai N. prevalence and significance of low 25-hydroxyvitamin D concentrations in healthy subjects in Delhi. Am J Clin Nutr 2000;72:472-5.|
|6||Arya V, Bhambri R, Godbole MM, Mithal A. Vitamin D status in primary hyperthyroidism with bone mineral density in healthy Asian Indians. Osteoporos lnt 2004;15:56-61.|
|7||Marya RK, Saini AS, Rathee S, Arora SR. Osteomalacia in Hindu population of Haryana. Indian J Med Res 1981;73:756-60.|
|8||Marya RK, Bhargava JS. Prevalence of hypocalcaemia and hypophosphataemia in the elderly males in Haryana. Indian J Physiol Pharmacol 1984;28:145-8.|
|9||Singh J, Marya RK, Sharma A. Screening of rickets in a Haryana town. Indian Pediatr 1992;29:226-8.|
|10||Kalra S, Kalra B, Khandelwal SK. Vitamin D deficiency in healthy postmenopausal women in Haryana. World J Life Sci Med Res 2011;1:11-5.|
|11||Kalra S, Kalra B, Khandelwal SK. Vitamin D status in well controlled hypothyroid patients in Haryana, India. Thyroid Res Pract 2011;8:12-6.|
|12||Harinarayan CV, Ramalakshmi T, Venkataprasad U. High prevalence of low dietary calcium and low vitamin D status in healthy south Indians. Asia Pac J Clin Nutr 2004;13:359-64.|
|13||Harinarayan CV. Prevalence of vitamin D insufficiency in postmenopausal south Indian women. Osteoporosis Int 2005;16:397-402.|
|14||Paul TV, Thomas N, Seshadri MS, Oommen R, Jose A, Mahendri NV. Prevalence of osteoporosis in ambulatory postmenopausal women from a semiurban region in Southern India: A relationship to calcium nutrition and vitamin D status. Endocr Pract 2008;14:565-71.|
|15||Kanekar A, Sharma M, Joshi VR. Vitamin D deficiency: A clinical spectrum: Is there a symptomatic nonosteomalacic state? Int J Endocrinol 2010;2010:521457.|
|16||Balakrishnan C, Kalke S, Mangat G, Joshi M, Joshi VR. Concomitant osteomalacia in rheumatological disorders: An important reversible cause of recent onset increase in morbidity. J Indian Rheum Assoc 1997;5:58-60.|
|17||Badsha H, Daher M, Ooi Kong K. Myalgias or non-specific muscle pain in Arab or Indo-Pakistani patients may indicate vitamin D deficiency. Clin Rheumatol 2009;28:971-3.|
|18||Holick MF. Vitamin D deficiency. N Engl J Med 2007;357:266-81.|
|19||Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc 2003;78:1463-70.|
|20||Holick MF. Vitamin D deficiency: What a pain it is. Mayo Clin Proc 2003;78:1457-9.|
|21||Chalmers J, Conacher WD, Gardner DL, Scott PJ. Osteomalacia: A common disease in elderly women. J Bone Joint Surg 1967;49:403-23.|
|22||Zittermann A. Vitamin D in preventive medicine: Are we ignoring the evidence? Br J Nutr 2003;89:552-72.|
|23||Armstrong DJ, Meenagh GK, Bickle I, Lee AS, Curran ES, Finch MB. Vitamin D deficiency is associated with anxiety and depression in fibromyalgia. Clin Rheumatol 2007;26:551-4.|
|24||Al-Allaf AW, Mole PA, Paterson CR, Pullar T. Bone health in patients with fibromyalgia. Rheumatology 2003;42:1202-6.|
|25||Huisman AM, White KP, Algra A, Harth M, Vieth R, Jacobs JW, et al. Vitamin D levels in women with systemic lupus erythematosus and fibromyalgia. Rheumatology 2001;28:2535-9.|
|26||Ford JA, Colhoun EM, McIntosh WB, Dunnigan MG. Rickets and osteomalacia in the Glasgow Pakistani community, 1961-1971. Br Med J 1972;2:677-80.|
|27||Warner AE, Arnspiger SA. Diffuse musculoskeletal pain is not associated with low vitamin D levels or improved by treatment with vitamin D. Clin Rheumatol 2008;14:12-6.|
|28||Alekel DL, Mortillaro E, Hussain EA, West B, Ahmed N, Peterson CT, et al. Lifestyle and biologic contributors to proximal femur bone mineral density and hip axis length in two distinct ethnic groups of premenopausal women. Osteoporos Int 1999;9:327-38.|
|29||Awumey EM, Mitra DA, Hollis BW, Kumar R, Bell NH. Vitamin D metabolism is altered in Asian Indians in the southern United States: A clinical research center study. J Clin Endocrinol Metab 1998;83:169-73.|
|30||Wills MR, Day RC, Phillips JB, Bateman EC. Phytic acid and nutritional rickets in immigrants. Lancet 1972;1:771-3.|
|31||Holick MF. Deficiency of sunlight and vitamin D. Br Med J 2008;336:1318-9.|