The role of dietary calcium in the etiology of childhood rickets in the past and the present

Abstract

For more than two centuries, lack of sunlight has been understood to cause vitamin D deficiency and documented as a primary cause of rickets. As such, evidence of rickets in the archeological record has been used as a proxy for vitamin D status in past individuals and populations. In the last decade, a clinical global consensus has emerged wherein it is recognized that dietary calcium deficiency also plays a role in the manifestation of rickets and classic skeletal deformities may not form if dietary calcium is normal even if vitamin D is deficient. This disease is now clinically called "nutritional rickets" to reflect the fact that rickets can take calcium deficiency-predominant or vitamin D deficiency-predominant forms. However, there are currently no paleopathological studies wherein dietary calcium deficiency is critically considered a primary etiology of the disease. We review here the interplay of calcium, vitamin D, and phosphorous in bone homeostasis, examine the role of dietary calcium in human health, and critically explore the clinical literature on calcium deficiency-predominant rickets. Finally, we report a case of rickets from the late Formative Period ($2500-1500 years ago) of the Atacama Desert and argue the disease in this infant is likely an example of calcium deficiencypredominant rickets. We conclude that most archeological cases of rickets are the result of multiple micronutrient deficiencies that compound to manifest in macroscopic skeletal lesions. For clinicians, these factors are important for implementing best treatment practice, and for paleopathologists they are necessary for appropriate interpretation of health in past communities.

Reply to Mays and Brickley, 2023 “Dietary calcium versus vitamin D in rickets: A response to Vlok et al.”

“…We thank Mays and Brickley (2023) for their engagement with our paper (Vlok et al, 2023) and acknowledge the important work they have done advancing the study of metabolic bone disease. Their engagement with epidemiological methods is commendable.…”

Growing up in the suburbs: Growth faltering and disease burden in the children from 16th to 18th century Tallinn, Estonia

“…Although recently there has been some debate about rickets reflecting dietary calcium deficiency, the disease is generally viewed as a reflection of severe vitamin D deficiency mainly arising from lack of sunlight (Brickley et al, 2020; Vlok et al, 2022). In contrast to high rates of scurvy, severe vitamin D deficiency was rare, affecting one child (1.1–2.5 years), although there were several more cases of unspecified metabolic disease in the sample that may have been mild examples (Brickley et al, 2020; Ives, 2018).…”

Molecular Mechanisms of Peptide–Calcium Complexes in Enhancing Calcium Absorption: A Transcriptome Analysis of Caco-2 Cells Treated with Whey Protein-Derived Peptides DAF and EAC

“…Calcium, an essential mineral for human health, plays a significant role in various physiological functions, such as nerve transmission, muscle contraction, and bone formation. , Therefore, calcium deficiency can lead to severe consequences, such as osteoporosis, rickets, tetany, and cardiovascular diseases. − It is important to ensure adequate intake and absorption of calcium from dietary sources or supplements. However, osteoporosis, a disease that makes a person’s bones weak and more likely to break, affects more than 200 million people worldwide .…”