Strategies to build stronger bones in Indian children: Challenges for implementation

Background & objectives Globally, vitamin D deficiency has been incriminated in poor bone health and growth retardation in children, impaired adult musculoskeletal health (classically described), increased risk of cardiovascular events, immune dysfunction, neurologic disorders, insulin resistance and its multiple sequelae, polycystic ovary syndrome (PCOS) and certain cancers. This review intends to holistically highlight the burden of vitamin D deficiency among children in India, the public health importance, and potential therapeutic and preventive options, utilizing the concept of implementation research. Methods A systematic search was carried out on PubMed, Embase, China National Knowledge Infrastructure (CNKI) and Cochrane database, clinicaltrials.gov, Google Scholar, and ctri.nic.in with the keywords or MeSH terms namely 'vitamin D', 'cholecalciferol', 'ergocalciferol', 'children', connected with appropriate boolean operators. Results Vitamin D deficiency/insufficiency prevalence varies from 70-90 per cent in Indian children. Rickets, stunting, impaired bone mineral health, and dental health are common problems in these children. Serum 25-hydroxy vitamin D (25(OH)D) should be maintained >20 ng/ml in children. Oral vitamin D supplementation has a high therapeutic window (1200-10,000 IU/d well tolerated). Fortification of grains, cereal, milk, bread, fruit juice, yogurt, and cheese with vitamin D has been tried in different countries across the globe. From Indian perspective, fortification of food items which is virtually used by everyone would be ideal like fortified milk or cooking oil. Fortification of "laddus" made from "Bengal gram" with vitamin D as a part of a mid-day meal programme for children can be an option. Interpretation & conclusions There is enough evidence from India to suggest the importance and utility of food fortification with vitamin D to address the epidemic of vitamin D deficiency/insufficiency in children.