Rickets describes a condition where bones are abnormally weak and the skeletal structure is thus compromised. It used to be visually observable in Victorian times, as children suffering from malnutrition would exhibit ‘bow legs’ – curved deformity in their limbs. Today’s cases more typically manifest themselves in bones breaking easily, rather than visual signs. Rickets is a sign of vitamin D deficiency. There are two minerals that are also vital for bone health – calcium and phosphorus. Phosphorus needs vitamin D for its absorption, so these three nutrients work together to determine bone health. They are usually found in the same foods (meat, eggs, dairy products), which is nature’s way of ensuring that we get the nutrients that we need to complement each other.
We know that vitamin D is one of our most vital nutrients – we are continually learning more about this particular vitamin. We know enough already to be sure that it plays a critical protective role in heart disease and cancer, as well as the more obvious osteoporosis and the less obvious mental health.
Just over two years ago, a Telegraph article raised the topic of rickets returning in children.
Rickets was back in the news last week. The Daily Mail headline was “Return of rickets: Cases up four-fold in the last 15 years as pregnant women and children fail to get enough Vitamin D“.
Barbara Ellen, writing in The Guardian, made a non-evidence based claim in her headline: “So rickets is back. Blame poverty, not a lack of sun“.
Cases of rickets have apparently risen fourfold since the mid-1990’s (from 183 to 762). Far more worryingly, the RCPCH reports that half of Britain’s white population, up to 90% of the ethnic population and a quarter of children are suffering from vitamin D deficiency.
Cholesterol and vitamin D
In our war on cholesterol we seem to have forgotten a critical route by which vitamin D is made – sunshine synthesises cholesterol in the skin and turns it into vitamin D. If we lack sunshine, or cholesterol, or both, we have impaired ability to make vitamin D. We can also obtain vitamin D from food, but we have demonised the foods most abundant in this vital nutrient: red meat, fatty fish, eggs and dairy products. Three ‘health’ dictats have thus contributed to the return of a disease that should have died with the Victorian era: 1) lower cholesterol 2) avoid dietary fat 3) don’t go out in the sun and/or cover up with clothing/factor cream if you do.
Ellen, in her Guardian article, wrote “No one seems to know why there is such a high incidence among certain ethnic groups.” If she had not been so quick to decide that rickets is about poverty, rather than lack of sunshine, the rationale for the ethnic dimension is obvious. Indigenously, darker skin people live nearer the equator and lighter skin people live further away from the equator. This is evolution. Those nearer the equator get more sunshine, but their darker skin lets less through to synthesise into vitamin D. Fair skinned Scandinavians get less sunshine, but their lighter skin allows more cholesterol to be synthesised into vitamin D.
The RCPCH position statement notes that “Sunshine (via skin photosynthesis) is the main natural source of vitamin D in humans. In the UK, vitamin D can only be made in our skin by the action of sunlight during the summer-time, and only during the middle of the day when the sun is high in the sky.”
Birmingham is the latitude, North of which we understand that sunshine is insufficient to provide any skin synthesis of cholesterol into vitamin D during the winter months. Hence any darker skinned people living in Birmingham, or further North anywhere in the world, are unable to make vitamin D during the winter time. They need to cover this with dietary intake in the winter months and get optimal sun exposure during the summer months. This doesn’t happen. Asian women particularly, cover themselves up all year round and deny themselves the gift that the sun is trying to give them.
Knowing the role that vitamin D plays in heart disease helps us to understand why Asians and black people, living outside their country of ethnic origin, suffer substantially higher heart disease. They literally have the wrong skin colour for their environment, reducing access to vitamin D. The ultimate irony is that the known higher incidence of heart disease in ethnic populations will have doctors place such people on cholesterol lowering medication and a low-fat diet and this will further reduce their chance of obtaining the very nutrient that they are missing. Our public health advice is bad enough for Anglo Saxons. For those of other ethnic origins, it is a death sentence.
The RCPCH call to action
We have brought this illness upon ourselves and the RCPCH should have pointed this out. Instead they listed nine points for action. You can see them for yourself in the position statement. They can be summarised as follows – my comments are below each recommendation.
1) We need more research.
No we don’t. We know how utterly vital vitamin D is not just for bone health, but for entire human health. The Department of Health[i], Dietary Reference Values for Food, Energy and Nutrients for the UK does not even have complete listings for the vitamin D Reference Nutrient Intake for adults. Where recommendations are made, the recommended daily intake is 10mcg. The USA recently revised their vitamin D Recommended Dietary Allowance (RDA) upwards from 10mcg to 15mcg.
The 2010 Family Food Survey[ii] reports that average UK vitamin D intake is 3.12mcg. We therefore have government evidence of substantial deficiency. (This survey is available annually and this deficiency has been observable for many years). Further research is not needed. We should revise the UK RDA upwards to 15mcg and take immediate steps to encourage sun exposure, cease all lowering of cholesterol and ensure that animal foods form the staple part of human diets.
2) Do surveillance to further understand the problem.
Research/surveillance – same difference. This is unnecessary procrastination. See the response to (1).
3) We should take supplements.
We don’t need supplements. We need to stop demonising fat, cholesterol and sunshine.
4) Paediatricians must work closely with other health professionals in ensuring optimal nutritional health of the foetus, infant and child.
Yes – by ceasing the demonisation of fat, cholesterol and sunshine.
5) Wait for the Scientific Advisory Committee on Nutrition, to report in relation to dosages and timing of supplements and wider food fortification.
No – this is the same as points (1) and (2). We have enough information. Don’t delay and act now.
6) Fortify fake foods.
This beggars belief. The position statement notes that margarine, infant formula milk and some breakfast cereals are fortified with vitamin D. Can we really be saying eat fortified, (hydrogenated), emulsified, bleached, deodorised and coloured margarine, with synthetic vitamin D added, instead of butter, which comes naturally with vitamin D? Can we really be saying that we should have sugary cereal, with synthetic vitamin D added, instead of eggs for breakfast, which come naturally with vitamin D? Can we really be saying that babies and toddlers should be having fake food (infant formula) during their most critical years, instead of breast milk and blended real food?
In my book The Obesity Epidemic: What caused it? How can we stop it? I analyse an infant formula. The composition of Similac Isomil Advance, Soy Formula is 50% corn syrup, 14.2% soy protein isolate, 10.4% high oleic safflower oil, 9.7% sucrose, 8.2% soy oil and 7.5% coconut oil.[iii] If a baby is unfortunate enough not to be breastfed, the infant can be started on a diet of 60% sugar from the first moment something is put in its mouth
7) Make single vitamin D supplements – because vitamin D/A combinations are bad for pregnant women.
Puh-lease! The same government data that shows serious deficiency in vitamin D also confirms that we are deficient in retinol – the form in which the body needs vitamin A. We should not lose any sleep thinking that anyone in the UK is getting too many nutrients, let alone pregnant women with even higher nutrient requirements than average.
This point is also the same as (3) – take supplements. The answer is thus the same – no – just stop demonising fat, cholesterol and sunshine.
8) Use the “Healthy Start” programme to get supplements into children.
No – just stop demonising fat, cholesterol and sunshine
9) Practical signposting should be made to paediatricians about best guidance on treatment and prevention to-date and learning opportunities, specifically the RCPCH e-learning and teaching sessions on nutrition.
The RCPCH advice can be summed up as 1) get more information and 2) get supplements into people. On this basis, the less well known the RCPCH advice is the better!
I reiterate. We need to stop demonising fat, cholesterol and sunshine and promote all three as healthful instead.
Dietary sources of vitamin D
For those winter months when we don’t have access to the sun and for optimal vitamin D intake at all times, we need to consume vitamin D in our diets. Dairy products are good sources of vitamin D. Oily fish is better. Sardines have approximately 7 times the vitamin D levels of whole milk and over 20 times the levels in hard cheese (and hard cheese is better than soft cheese for the bone nutrients generally).
200g of sardines (a medium sized tin) would give nearly 15mcg of vitamin D in one go. Other oily fish are excellent sources of vitamin D (herring, halibut, catfish, salmon, mackerel etc), but sardines are exceptional. Vegetarians would need to eat 26 medium eggs each day (1,634 calories) to get 10mcg of vitamin D. Mushrooms, which have been exposed to sunlight, are the only conceivable option for vegans. Over two kilograms of such mushrooms would need to be sourced and eaten daily to deliver 10mcg of vitamin D. Ideally, but not an option for vegans, these would need to be consumed with butter to make them ‘bio-available’ to the body.
The final important point to note about dietary vitamin D is that it comes in two forms – D2 and D3. D2 comes from plant sources (like the mushrooms mentioned above). D3 only comes from animal sources. This is the form that has been shown to have the most health benefits for humans.[iv] Supplements tend to be in the form of D2 and are therefore no substitute for the red meat, eggs and butter that we have shunned.
Vitamin A is the same – it comes in the form of carotene from plants and retinol from animal foods and retinol is the form needed by the body. Vitamin K has a plant form (K1) and an animal food form (K2). The latter is the one most needed. It was researching nutrition to this level that ended my 20 year period as a vegetarian.
If we want to be healthy we need to eat animals and we need to get out in the sunshine. It’s what we evolved to do and rickets is a terrible reminder of how far removed from our evolutionary roots we have come. RCPCH we do not need more information or supplements. We need to stop demonising the cholesterol that our body is trying to make and to stop demonising the dietary fat and the sunshine that has sustained us since time began.
[i] The Department of Health, Publication 41, Dietary Reference Values for Food, Energy and Nutrients for the UK, published by The Stationery Office
Table 2.1 – UK average energy and nutrient intakes from all food and drink for 2010
[iv] Robert P. Heaney, et al “Vitamin D3 Is More Potent Than Vitamin D2 in Humans”, The Journal of Clinical Endocrinology and Metabolism, March 2011 .