Calcium, Iodine and

Fluorine
Calcium
 Calcium
• Major mineral element of the body
• Constitutes 1.5-2% of the body weight of an adult (About 1200
gms.)
• Of which over 98% is found in the bones
• Blood level – 10 mg/dl
• Dynamic equilibrium between the calcium in the blood and that in the
skeleton
• maintained by the interaction of vitamin D, parathyroid hormone,
and probably calcitonin
 Calcium
• Major mineral element of the body
• Constitutes 1.5-2% of the body weight of an adult (About 1200
gms.)
• Of which over 98% is found in the bones
• Blood level – 10 mg/dl
• Dynamic equilibrium between the calcium in the blood and that in the
skeleton
• maintained by the interaction of vitamin D, parathyroid hormone,
and probably calcitonin
 Calcium - Functions
• Controls many life processes ranging from muscle contraction to cell
division
• Ionized calcium in the plasma
• Formation of bones and teeth
• Coagulation of blood
• Contraction of muscles
• Cardiac action
• Milk production
• Relay of electrical and chemical messages
• Keeping the membranes of cells intact
• Metabolism of enzymes and hormones
 Calcium - Sources
• Best natural sources - Milk and milk products, eggs and fish
• Cheapest dietary sources - green leafy vegetables (limiting factor –
Oxalic acid), cereals (limiting factor – phytic acid) and millets
(Maximum – Ragi)
• Fruits – Custard apple (Sitaphal)
 Calcium - Sources
• Best natural sources - Milk and milk products, eggs and fish
• Cheapest dietary sources - green leafy vegetables (limiting factor –
Oxalic acid), cereals (limiting factor – phytic acid) and millets
(Maximum – Ragi)
• Fruits – Custard apple (Sitaphal)
 Calcium - Sources
• Best natural sources - Milk and milk products, eggs and fish
• Cheapest dietary sources - green leafy vegetables (limiting factor –
Oxalic acid), cereals (limiting factor – phytic acid) and millets
(Maximum – Ragi)
• Fruits – Custard apple (Sitaphal)
 Calcium - Sources
• Best natural sources - Milk and milk products, eggs and fish
• Cheapest dietary sources - green leafy vegetables (limiting factor –
Oxalic acid), cereals (limiting factor – phytic acid) and millets
(Maximum – Ragi)
• Fruits – Custard apple (Sitaphal)
 Calcium - Sources
• Best natural sources - Milk and milk products, eggs and fish
• Cheapest dietary sources - green leafy vegetables (limiting factor –
Oxalic acid), cereals (limiting factor – phytic acid) and millets
(Maximum – Ragi)
• Fruits – Custard apple (Sitaphal)
 Calcium - Sources
• Best natural sources - Milk and milk products, eggs and fish
• Cheapest dietary sources - green leafy vegetables (limiting factor –
Oxalic acid), cereals (limiting factor – phytic acid) and millets
(Maximum – Ragi)
• Fruits – Custard apple (Sitaphal)
 Calcium - Absorption
• About 20-30 per cent of dietary calcium is normally absorbed
• Enhanced by vitamin D and decreased by the presence of phytates,
oxalates and fatty acids in the diet
 Calcium - Deficiency
• No clear-cut disease due to calcium deficiency has ever been observed,
even under conditions of low intake
• If the intake of vitamin D is adequate, the problems of rickets and
osteomalacia do not arise even with low calcium intake
• No deleterious effects have been observed in man as a result of
prolonged intakes of large amounts of dietary calcium, neither have
any benefits been demonstrated
 Calcium - Requirement
• Adults – 600 mg/day
• Higher requirement in Children (10-17 years – 800 mg/day),
Expectant and nursing mothers (1200 mg/day)
Iodine
 Iodine
• Essential micronutrient
• Required for the synthesis of the thyroid hormones
• Essential in minute amounts for the normal growth and development
and well-being of all humans
• Adult human body contains about 50 mg of iodine
• Blood level - 8-12 micrograms/dl
 Sources
• Best sources - Sea foods (e.g., sea fish, sea salt) and cod liver oil
• Smaller amounts occur in milk, meat, vegetables, cereals, etc
• Iodine content of fresh water is small and very variable
• 1-50 micrograms/L
• About 90 per cent of iodine from foods eaten; remainder from
drinking water
• Iodine content of the soil determines its presence in both water and
locally grown foods. The deficiency is geochemical in nature.
 Goitrogens
• Chemical substances leading to the development of goiter
• Interfere with iodine utilization by the thyroid gland
• Brassica group of vegetables (e.g., cabbage, cauliflower) may contain
goitrogens
• Most important among the dietary goitrogens are cyanoglycosides and
thiocyanates
 Deficiency
• Most obvious consequence of iodine deficiency is goiter
• Much wider spectrum of disorders - Iodine Deficiency Disorders
(IDD)
 Iodine Deficiency Disorders - Problem
• Initially was identified in Himalayan belt in India – World’s biggest
goiter belt
• In later surveys
• Was also detected in other areas of the country
• Including sea-coasts
• No states can be termed free from IDDs
 Iodine Deficiency Disorders - Spectrum
Disorders Levels of severity
Goitre Grade I
Grade II
Grade III
Multi-nodular
Hypothyroidism Varying combinations of clinical
signs (depending on age of onset,
duration and severity)
Subnormal intelligence Variable severity
Delayed motor milestones
Mental deficiency
Hearing defects
Speech defects
 Iodine Deficiency Disorders - Spectrum
Disorders
Strabismus (squint)
Nystagmus
Spasticity (extrapyramidal)
Neuromuscular weakness
Endemic cretinism
Intrauterine death (spontaneous
abortion, miscarriage)
Levels of severity
Unilateral
Bilateral
Muscle weakness in legs, arms, trunk
Spastic diplegia
Spastic quadriplegia
Hypothyroid cretinism
Neurological cretinism
Goiter
Cretinism
 Iodine Deficiency Disorders - Control
1. Iodized salt
2. Monitoring and surveillance
3. Manpower training
4. Mass communication
 1. Iodized salt

2. Monitoring and surveillance

4. Mass communication
• Most widely used prophylactic measure for goiter

3. Manpower training
• Iodization level under Prevention of Food Adulteration (PFA)
act
• At production level – not less than 30 ppm
• At consumer level – not less than 15 ppm
• Most economical, convenient and effective
• Other methods – Injectable and oral iodized oil
• Rarely used
 2. Monitoring and surveillance
• Using laboratory investigation
1. Iodine excretion determination

4. Mass communication
3. Manpower training
2. determination of iodine in water, soil and food
1. Iodized salt

3. determination of iodine in salt for quality control

• Neonatal hypothyroidism is a sensitive pointer to
environmental iodine deficiency
 3. Manpower training
• Vital for implementing control measures
2. Monitoring and surveillance

• Trained for legal enforcement and public education

4. Mass communication
1. Iodized salt
 4. Mass communication
• For nutritional education
2. Monitoring and surveillance

• Public awareness for the nutritional lifestyle change is

3. Manpower training

central to the program

1. Iodized salt
 Nutritional Requirement
• Adults – 150 micrograms/day
• Pregnancy – 250 micrograms/day
 Assessment of Iodine deficiency
• Indicators
• Prevalence of goitre
• Prevalence of cretinism
• Urinary iodine excretion
• Measurement of thyroid function by determination of serum levels
of thyroxine (T4) and pituitary thyrotropic hormone (TSH)
• Prevalence of neonatal hypothyroidism
• Indices of urinary excretion are particularly recommended for use in
surveillance
• Neonatal hypothyroidism has been found to be a sensitive indicator of
environmental iodine deficiency
Fluorine
 Fluorine
• Essential micronutrient - required for the synthesis of the thyroid
hormones
• Essential in minute amounts for the normal growth and development
and well-being of all humans
• Adult human body contains about 50 mg of iodine
• Blood level is about 8-12 micrograms/dl
 Fluorine
• Most abundant element in nature
• About 96 per cent of the fluoride in the body is found in bones and
teeth
• Essential for the normal mineralization of bones and formation of
dental enamel
 Sources
• Drinking water
• In most parts of India, the fluoride content of drinking water is
about 0.5 mg/L
• In fluorosis-endemic areas, it may be as high as 3 to 12 mg/L
• Foods :
• In traces in many foods
• Some foods such as sea fish,, cheese and tea are reported to be rich
in fluorides
 Deficiency / Excess
• Two-edged sword
• Excess is associated with dental and skeletal fluorosis
• Inadequate intake with dental caries
• Use of fluoride is recognized as the most effective means available for
the prevention of dental caries
 Endemic fluorosis
• Where drinking water contains excessive amount of fluorine (3-5
mg/dl)
• In India,
• Andhra Pradesh (Nellore, Nalgonda and Prakasam districts),
Punjab, Haryana, Karnataka, Kerala and Tamil Nadu
• Manifestations

1. Dental fluorosis
2. Skeletal fluorosis
 1. Dental fluorosis
• Fluorosis of dental enamel
• When excess fluoride is ingested during the years of tooth
calcification - essentially during the first 7 years of life

2. Skeletal fluorosis
• Characterized by "mottling" of dental enamel
• Reported at levels above 1.5 mg/L
• Teeth lose their shiny appearance and chalk white patches develop
on them
• Later the white patches become yellow and sometimes brown or
black
• best seen on the incisors of the upper jaw.
• In severe cases, loss of enamel gives the teeth a corroded appearance
 2. Skeletal fluorosis
• Associated with lifetime daily intake of 3.0 to 6.0 mg/L or more
• When a concentration of 10 mg/L is exceeded, crippling fluorosis can
ensue
1. Dental fluorosis

• Leads to permanent disability

 Genu Valgum
• New form of fluorosis
• Characterized by genu valgum and osteoporosis of the lower limbs
• In some districts of Andhra Pradesh and Tamil Nadu
• Observed among people whose staple was sorghum (jowar)
• Diets based on sorghum promoted a higher retention of ingested
fluoride
 Intervention
a) Changing water source
• With a lower fluoride content (0.5 to 0.8 mg/L) if that is possible
• Running surface water contains lower quantities of fluorides than ground
water sources such as wells
b) Chemical treatment
• Chemically defluoridated in a water treatment plant
• Nalgonda technique
• Involves the addition of two chemicals (viz. lime and alum) in sequence
• Followed by flocculation, sedimentation and filtration
c) Fluoride supplements should not be prescribed for children who drink
fluoridated water
• Use of fluoride toothpaste in areas of endemic fluorosis is not recommended
for children upto 6 years of age
 Requirement
• In drinking water in India is accepted as 0.5 to 0.8 mg per litre
Thank you