Understanding the Disease ofEndemic Skeletal Fluorosis and

Ways to Contain It

D. RAJA REDDY

Telangana Jagruti

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3Understanding The Disease Of EndemicSkeletal Fluorosis And Ways To Contain It

Endemic skeletal fluorosis is a disease caused by excessiveingestion of fluoride through water, food or both. The upper limit ofoptimum fluoride level in drinking water for a tropical country like Indiais 0.5 ppm. The upper limit of safe total intake of fluoride from foodand water per day for an adult is 5 milligrams (WHO-2002). The totaldaily intake through water and food determines the development offluorosis. First ever cases of endemic skeletal fluorosis and itsneurological manifestations in the world were recorded from Podili,Darsi and Kanigiri areas of Andhra Pradesh in 1937. Subsequentlycases of fluorosis were recorded from Nalgonda and other areas of theAndhra Pradesh state and other parts of India. It is now estimated that60 million people are living in these endemic areas and are at risk ofcontacting the disease and 2 million people are crippled because of it.The incidence of fluorosis affected districts in India are listedalphabetically: Assam=2; Andhra Pradesh= 17; Bihar=8; Delhi=4;Gujarat= All except Dang; Haryana= 12; Jammu & Kashmir=l;Karnataka= 14; Kerala=3; Maharashtra= 10; Madhya Pradesh= 10;Orissa= 3; Punjab=13; Rajasthan= All 32 districts; Tamil Nadu= 8;Uttar Pradesh= 7 and West Benga=4. Hence, skeletal fluorosiscontinues to be a major public health problem in India.

The factors, which govern the development of fluorosis, are thefollowing:1. High levels of fluoride in drinking water supplies and in the

foodstuffs grown in these endemic areas.2. Tropical weather and hard manual labor by affecting the intake of

water.

3. Poor nutrition and diets deficient in their content of calcium,magnesium and vitamin C aggravate fluoride toxicity. High intakeof calcium reduces the amount of absorbed into the bones.

4Magnesium has a peculiar relationship with fluoride and its optimumintake helps in elimination of fluoride from the body. Vitamin C isbeneficial in some way in reducing fluoride toxicity. Diets deficientin calories and calcium intake increase the incidence of fluorosis(WHO-2002).

4. Renal disease aggravates fluorosis by increased deposition offluoride in the bones. A diseased kidney cannot handle fluorideexcretion from the body and hence its increased deposition in thebones.

Father and daughter hailing from Marriguda village of NalgondaDistrict. Both are suffering from skeletal fluorosis. Daughter wascripted in her teens while the father got disabled in his forty's.This is a typical example of deterioration of nutrition in villagesduring the past two to three decades. This village has high levelsof fluoride in drinking water supplies as well as in the foodstuffsgrown locally and consumed by the villagers.

55. Presence of abnormal amounts of certain trace elements in thedrinking water supplies such as strontium, uranium etc. Strontiumlevels in drinking water supplies in some endemic areas are highand strontium is a bone-seeking element like fluoride and boththese aggravate the bony changes.

In a study of 94 drinking water samples from the endemic fluoroticvillages of Prakasam and Nalgonda districts the fluoride and strontiumlevels are as follows:

Fluoride levels ranged between 0.1 to 9.5 ppm for a mean of2.009 ppm and strontium levels ranged between 4.91 to 9931.74 ppbfor a mean of 1670.02 parts per billion. Any water strontium levels ofover 1000 ppb are suspect. Increased levels of fluoride and strontiumappear to playa role in the severe forms of fluorosis that is witnessed insome endemic areas of fluorosis in Andhra Pradesh especially inPrakasam where fluoride levels are not very high. Some elements likeuranium are nephrotoxic and may aggravate fluorosis problem. Levelsof trace elements such uranium, selenium, zinc, iron, lithium, lead, barium,

Another villager fromMarriguda ofNalgonda Districtsuffering fromendemic skeletalfluorosis. This villagewith highest levels offluoride in drinkingwater got supplies ofKrishna water onlyrecently. There is nowater provided forcultivation and thereis no provision forimproving thenutrition of villagersexcept for middaymeal scheme forstudents, which is notoptimum.

6aluminum etc were in abnormal concentrations in some of the drinkingwater supplies of villages in Prakasam and Nalgonda districts of AndhraPradesh. Aluminum is known to increase fluoride absorption from thegut and hence its abnormal concentration in water supplies is harmful.The role of these other elements except those of strontium, aluminumand uranium in fluoride metabolism are not known at present time.Defluoridation plants are based on adding aluminum compounds to thewater containing high levels of fluoride. It may be noted hundreds ofcrores of rupees were spent on erecting these plants in 1980s 1990sand not a single one of them are working now. So is the fate of householddefluoridation units. Besides there is the risk of increased intake ofaluminum which is being incriminated for the causation of Alzheimersdisease as well as motor neuron disease for which there is no therapylike AIDS disease. Tea contains exceptionally high content of fluorideand each cup may add upto 2milligrams of fluoride.

A native of Hanumanthapuram village in Prakasam districtsuffering from dental fluorosis and skeletal fluorosis as well.Fluoride levels are not very high in this village but strontiumlevels in drinking water supplies are exceptionally high rangingupto 9900 parts per billion. Strontium produces similar changes inbones like fluoride. Surface water provision or establishment ofdefluoridating plants based on reverse osmosis is the only answersfor this village Reverse osmosis is a very expensive proposition.

7Ideal solution for skeletal fluorosis is its prevention by providingsafe drinking water and providing such water for cultivation of crops inthese endemic areas. This appears to be only a very distant dream.Government of India envisaged health for all by 2000 in 1987 AD andplanned provision of safe drinking water to all villages by that date. Theplans failed miserably and now the authorities have become morepragmatic. One of the millennium development goals of 2002 is toprovide safe drinking water to half the rural population by 2015 .Henceprevention of fluorosis is not possible in the near future and at leastefforts must be made to lessen the suffering of the people by improvingtheir nutrition.

A lady of Neredupalli of Prakasm collecting drinking water fromriverbed. This water does not have high levels of fluoride butother elements such as strontium, uranium etc are high. Thisvillage has high incidence of kidney disease, which may be dueto high levels of some of these trace elements. Another bad habitof the villagers is consumption of analgesics all kinds of achesand pains which could damage kidneys in the long run. Adequatesupplies of surface water from Krishna for drinking, cooking andcultivation are the only solutions for the problems of this village.

8The situation in certain parts of Andhra such as Nalgonda is verygrim. When Daver first recorded cases of skeletal fluorosis from thisregion in 1945 AD and by Siddique in 1955 AD, there were no childrenwith deformed limbs. These cases with deformed limbs were recordedin 1970s. Rural nutrition in the past few decades has gotten worse inmany parts of state and in other parts of the country. National instituteof nutrition conducted surveys of status of rural nutrition in 715 villagesof seven states in 2002 and 2003. Eighty villages in AP were studiedand AP has the distinction of having highest incidence of dental fluorosisamong seven states. The results of nutrition study are contained inNational nutrition monitoring bureau reports 21 and 22, which revealthe appalling state of nutrition of rural population in the country. Sixtypercent of the children below 6 years of age are malnourished and athird of them suffer from severe under weight problem. Only a third ofthe children studied were getting an optimum diet. Calcium intake isexceptionally low in all states and calcium does playa big role in Nalgonda

This is a typical scene in the villages these days. Deeper the boresthe water content of fluorides and other harmful trace elementsgoes up. Surface water from perennial rivers like Krishna andGodavari are the only answers for these villages.

9having very high incidence of skeletal fluorosis in our country. Drinkingwater supplies of Nalgonda have a high content of fluoride because thecalcium content of Nalgonda soils and rocks is low. This allows morefluoride to seep in to the water supplies (Netherland study-1986).Siddiqui study revealed that average daily intake of calcium in Nalgondaindividuals was only 300 mg whereas it was 900 mg in Punjab. NNMBreport of 2002 reveals that calcium intake of rural population isappallingly low in Andhra and hardly averages around 300 milligramswhereas it should be around 800-1000 milligrams in growing children.Hence, there are no children with deformed limbs in Punjab villageswith similar levels of fluoride in drinking water supplies. Nutrition statusstudy of 50 children in Sharbanapuram village of Aler MandaI ofNalgonda revealed that only one boy was normal as per BMI andpercentile studies. Mid day meal scheme has not helped these childrenin Nalgonda in this regard. Children hardly get 300 calories of diet andmost of the times the food supplied is not even hygienically good.National family health survey-III by the government of lndia in 2006 in29 states revealed that 45 % of the children below are undernourishedand 57 % of women are anemic. All government policies to improvenutrition of rural folk have been a dismal failure so far.

What needs to be done? One has to pragmatic. Ideal way wouldbe to supplement the diet of children in the endemic areas with calcium,magnesium and vitamin C. This was also the basis of Chinese researchwork in early 1990s. The best way would be to give a glass of milkand a banana to every school-going child in these endemic areas. Milkis perishable and can be adulterated. A pouch containing 300 ml ofmilk becomes very expensive. A tablet containing 500 milligrams ofcalcium, 300 milligrams of magnesium and 40 milligrams of vitamin Cwith vitamin D to improve absorption of calcium would be cheap andpractical in addition to midday meal scheme, which needs to beimproved. Since anemia is widely prevalent in rural population it maybe advisable to add iron also to this tablet. The skeletal fluorosis wasdiscovered in our country in Prakasam district seventy years ago andthis continues to be major health problem even today. All efforts tocontain this disease have been a dismal failure so far. Unless pragmatic

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steps are taken this problem going to affect the lives of millions of peoplein our country for a long time to come.

SummaryThere are three factors for the causation of skeletal fluorosis, Water,

food and nutrition. Ask for Krishna water for drinking and cooking forevery fluorotic village. Try for Krishna water for cultivation in future.Improve the nutrition of the population especially those of growingchildren by whatever means practicable. A void drinks such as tea,which is very rich in fluoride and also sea foods. A void analgesics,which could damage the kidneys and aggravate the problem in theseareas where studies reveal a higher incidence of kidney disease.

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General name Telugu Calcium Magnesium Vitamin CEquivalent (in M/100m of the food source)

Name

Ragi Ragulu 344 Agathi Avisagu 1130 169Amaranth Thotakura 530-800 4.2 179Colacasia leaves Chama Aaku 1546 12.8 Curry leaves Karvepaku 836

Curry patthaPoppy feed Ghasalu 1584 9.9

khus khusJagary Gur / Bellum 1638 Gingelly seeds Nuuvulu / Til 1450 5.2 Jowar Jonalu 171 Cummin Jeera Jeelakara 1080 475 Amla Usirikaya 600Green chilly Hari Mirch 111

Annexure

PREFERRED FOODS IN FLUOROTIC REGION

A diet rich in calcium, magnesium and vitamin C would greatlybenefit the population living in areas where soil and water fluoride levelsare high while measures to provide safe drinking water could benefit byreducing fluoride intake, a diet enhancing calcium, magnesium andvitamin C intakes would considerably reduce the basic pathologyassociated with fluorosis. However these food sources should be grownin no fluoride areas and provided for consumption in region withfluorosis.

Though there are several food sources only those which arecommonly consumed in region of AP and which are affordable to thelower socio-economic groups are suggested. The resource for thiscompilation is the Nutritive value of Indian foods Published by theNational Institute of Nutrition, ICMR, Hyderabad.