Ambrish Mithal MD, DM

Chairman, Endocrinology and Diabetes

MAX Healthcare- Pan Max

Member- Governing Body NHA

President, AIIMS, Gorakhpur

Fortification of milk for improving

Nutrition and immunity:

The Vitamin D Story

Association between Vitamin D deficiency and increased risk of

community acquired pneumonia

Vitamin D supplementation was safe and protected

against respiratory tract infections overall

Vitamin D status in adults

(>18 years)

Wahl et al, Arch Osteoporos. 2012 Dec;7(1-2):155-72.

Reasons for widespread deficiency

– Latitude, season, time of the day

– Cloud cover and atmospheric pollution

– Time spent outdoors

– Customary dress and sunscreen use

– Skin pigmentation and age

Nutrition Reviews® Vol. 66(Suppl. 2):S153–S164

Sunlight as a source in India(Marwah, Sethuraman et al, 2015, 2016)

• Regional and seasonal variations+

• Northeast- lowest UV Index with no seasonal

variation

• Very poor synthesis in cities

• Children- +4 ng/ml to -4 ng/ml with half an hour

exposure of 15-30% body surface area- depending

on season.

• Perhaps manual construction workers, security

forces may get adequate D through sunlight

Delhi 70-94%

Tirupati 45-82%

Lucknow75-90%

Hyderabad 34-52%

Punjab 50%

J & K 53-83%

Mumbai 88%

Kolkata 92%

States

Vitamin D deficiency at blood level (< 20 g/dL)

% population eating < 50% of required amount of Vit. A rich foods

Kerala 79.4 91.8

Tamil Nadu 48.8 81.9

Karnataka 52.1 90.4

AP /Telangana 61.5 92.9

Maharashtra 54.7 88.8

MP 88.0 87.4

Orissa 57.7 77.5

West Bengal 61.2 80.6

Pooled 61.8 86.3

India has a very high burden of vitamin A & D deficiencies, impacting all

Vitamin A and D Deficiency in India: NIN

Serum 25 (OH)D levels before and after

vitamin D fortified milk in Delhi children

Group (All

Subjects)

N S.25 (OH) D

level at

baseline

S.25 (OH) D

following

fortification

Group A 237 11.74±5.23 10.83±5.24

Group B 243 11.42±5.24 22.87±6.75*

Group C 233 11.94±5.62 27.67±8.47*

Total 713 11.69±5.36 20.44±9.88*

Group A—no fortification, group B—received milk fortified with 600 IU, group C—received milk fortified with 1,000 IU

R. Khadgawat ; Osteoporos Int; 2013

NFHS-4 for Year 2015-16 and CNNS-2016-17 Factsheet Data

Nutrition & Health Indicators (NFHS-4) in %

All India

Rajasthan Bihar AP Kerala

Underweight (< 5 years) (NFHS-4)

36 37 43.9 31.9 16.1

Stunted (<5 years) (NFHS-4)

38 39 48.3 31.4 19.7

Under 5 mortality (NFHS-4)

50.0 51 58 41 7

Prevalence of vitamin A deficiency in children 5-9 years (CNNS)

21.5 1.0 28.3 22.8 26.5

Prevalence of vitamin A deficiency in children 10-19 years (CNNS)

15.6 1.9 21.9 13.1 13.2

Fortification of edible oil and milk since 2012, MAY HAVE brought down the levels of vitamin A deficiency in children (CNNS 2016-17) in Rajasthan.

IOF – ANZBMS - 2011

Mass fortification

Target fortification

Market-driven fortification

IOF – ANZBMS - 2011

1. Milk and other dairy products:

including dried milk powder and

evaporated milk. Yogurt…

2. Margarine (in EU, 30% of the RDI for

vitamin D comes from margarine)

3. Orange juice, cereals; bread,

mushrooms also work! (AJCN-2010)

IOF – ANZBMS - 2011

Fortification studies in schoolgirls- Beijing

2 year :

Group 1: Ca fortified milk

(330 mg Ca)

Group 2: Ca fortified milk + 8 g VitD

Group 3: Control

Post supplementation 25(OH)D:

Group 1: 17.9 ± 9 nmol/L

Group 2: 47.6 ± 23.4 nmol/L

Group 3: 19.4 ± 10.2 nmol/L

Fraser, 2006

IOF – ANZBMS - 2011

Safety limit

Technological limit

Cost limit

IOF – ANZBMS - 2011

The way forward

• Awareness regarding sunlight

exposure

• Supplementation for vulnerable

groups

• Fortification: Fraught with

challenges- an idea whose time has

come