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Vitamin D Deficiency in Three Nortiiern Manitoba

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Vitamin D Deficiency in Three Nortiiern Manitoba VITAMIN D DEFICIENCY IN THREE NORTIIERN MANITOBA COMMI.INITIES BY PAMELA JOY SMITH A Thesis Submitted to the Faculty of Graduate Studies in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF PHILOSOPHY Department of Community Health Sciences University of Manitoba 'Winnipeg, Manitoba @Copyright by Pamela Joy Smith,1999 ru¡fonat t-iurav nationare A*n SfBilåSå" Acquisitions and Acquisitions et Bibliographicservices servicesbibliographiques 395 Wellington Street 395, rue Wellington Ottawa ON K1A 0N4 Ottawa ON K1A 0N4 Canada Canada Your líle Volre rélérence Our l¡le Notrc rélérenc€ The author has ganted a non- L'auteur a accordé une licence non exclusive licence allowing the exclusive permettant à la National Library of Canada to Bibliothèque nationale du Canada de reproduce, loan, distribute or sell reproduire, prêter, distribuer ou copies of this thesis in microform, vendre des copies de cette thèse sous paper or electronic formats. la forme de microfiche/film, de reproduction sur papier ou sur format électronique. The author retains ownership of the L'auteur conserve la propriété du copynght in this thesis. Neither the droit d'auteur qui protège cette thèse. thesis nor substantial extracts from it Ni la thèse ni des extaits substantiels may be printed or otherwise de celle-ci ne doivent êhe imprimés reproduced without the author's ou autrement reproduits sans son permission. autorisation. 0-612-51667-9 Canadä THE IINTYERSITY OF MANITOBA FACULTY OF GRADUATE STI]DMS ***** COPYRIGHT PERMISSION PAGE Vitamin D Deficiency in Three Northern Manitoba Communitis5 BY Pamela Joy Smith A ThesislPracticum submitted to the Faculty of Graduate Studies of The University of Manitoba in partial fulfillment of the requirements of the degree of Doctor of Philosophy PAMELA JOY SMITH @1999 Permission has been granted to the Library of The University of Manitoba to lend or sell copies of this thesÍs/practicum, to the NatÍonal Library of Canada to microfilm this thesis and to lend or sell copies of the film, and to Dissertations Abstracts International to publish an abstract of this thesÍs/practicum. The author reserves other publication rights, and neither this thesis/pr¿cticum nor extensive extracts from it may be printed or otherwise reproduced without the author's wriffen permission. ABSTRACT' Background: The remote Aboriginal communities in the Island Lake area of Manitoba have high rates of rickets, unlike other seemingly-similar communities. Two Island Lake communities (Garden Hill and St. Theresa Point) and Norway House, a community without known rickets were chosen for this study. Clinical rickets in children, vitamin D deficiency in pregnant women, and risk factors for vitamin D deficiency and rickets were hypothesized to be greater in the Island Lake area than in Norway House. From a review of the literature from several disciplines, I hypothesized that vitamin D deficiency was prevalent in Norway House, despite the absence of known rickets. Methods: A historical prospective study of the incidence of clinical rickets in treaty- status Aboriginal children born in 1993 and 1994 (a retrospective chart review of birth cohorts) was conducted. A cross-sectional serum survey was conducted to determine the prevalence of vitamin D deficiency (Zí-hydroxyvitamin D < 35 nmol/L) among pregnant woman. A cross-sectional interview survey was also conducted among these women to investigate the presence, strength, and amenability to chanse of risk factors for vitamin D deficiencv. Results: The rickets incidence rate was 85/1000 for Garden Hill and 55/1000 for St. Theresa Point, and there were no cases from Norway House. The prevalence of vitamin D deficiency among pregnant women from all three communities was 84.6% (n:115), with84.4% in Garden Hill (n:32),91.4% in St. Theresa Point (n:35), and 78.4% (n:37) in Norway House. Significant differences were found between Norway House and Garden Hilt in vitamin D status. education. familv income source. and several risk factors for vitamin D deficiency and rickets. Conclusion: The interview data (n:95) provided insight into the possible reasons for vitamin D deficiency and factors to consider for prevention. Multiple logistic regression analyses were not possible due to the homogeneiry of results among pregnant women in all three communities. However, finding widespread vitamin D defîciency in Norway House may be important if vitamin D deficiency has a role in common conditions, such as Baby-bottle Tooth Decay, as I hypothesize from a review of the literahrre from several disciplines. 1l ACKNOWLEDGEMENTS I would like to thank the women of Garden Hill. St. Theresa Point and Norwav House who participated in this study, as well as the community leaders, health care workers, and community members who supported this research. I am grateful for the efforts of my research assistants Rene Knott, Charlotte Campbell and Dawn Wood, as well as Jenate Alcendor, Paula Monias, Paulette Keno, Hilary Samarson, Theresa Harper, Sandy Campbell, Marilyn Tanner-Spence, and many others too numerous to name. I am indebted to my supervisor, Dr. M.E.K. Moffatt and my committee members, Dr. G. Sevenhuysen and Dr. L. Poffenroth for their guidance. Dr. Bruce Martin, Dr. Sharon Macdonald and Dr. Sally Longstaffe also helped with this research. I wish to thank my family, friends and colleagues for their support, as well as my current employer, the Saskatchewan Cancer Agency. Specifically, I thank Peter Dickof, Konnie Malowany, Dr. Shauna Hudson and Maggie Pioro for their valuable assistance. This research was made possible in part by Health Canada through a National Health Research and Development training fellowship, a Manitoba Health Research Council 111 graduate studentship, and a University of Manitoba graduate fellowship. I gratefully acknowledge the support of the Children's Hospital Research Foundation of Manitoba Incorporated and the Northern Scientific Training Program. IV TABLE OF CONTET..{TS ABSTRACT ..... ............ i ACKNOWLEDGEMENTS.. ..... iii TABLE OF CONTENTS .......... v LIST OF FIGURES ....... x LIST OF TABLES ........ xi 1. INTRODUCTION ...... 1 2. LITERATURE REVIEW. ....,3 2.1 Literature pertaining to rickets ...........3 2.Il The role of vitamin D in rickets and osteomalacia ...........3 2.1.2 Vitamin D and the etiology of rickets ..... 4 2.I.2.1 Vitamin D is not a vitamin. .........4 2.I.2.2 Vitamin D is not commonly found in food .......5 2.I.2.3 Humans do not require a daily dose of vitamin D..... ..........5 2.L2.4 Pigmentation may not significantly reduce the skin's ability to make vitamin D. .... ........... 6 2.1.2.5 Breastmilk and sunlight are not the most important sources of vitamin D for infants. ......... 6 2.L2.6 Rickets does not necessarily begin as a pediatric disorder. ..... ...... 6 2.1.2.7 Rickets is not alwavs associated with a lack of sunshine. ......7 2.1.2.8 Vitamin D might not be the most important factor in rickets etiology ...........7 2.2 Literuture pertaining to the hypothesis that vitamin D deficiency is common in the comparison community despite the lack of an apparent rickets problem: a role for vitamin D deficiency in Baby-bottle Tooth Decay? ............ 8 2.2.I Vitamin D has a biological role beyond whole-body calcium homeostasis . .... ............ 8 2.2.2 Enamel hypoplasia and caries ............ 9 2.2.2.1 Prevalence of Baby-bottle Tooth Decay. .......... 10 2.2.2.2 Current model of causation in tooth decav ...... 11 2.2.2.3 Current model of causation in Baby-bottle Tooth Decay. .... 11 2.2.2.4 Critical appraisal of Baby-bottle Tooth Decay causal hypothesis... 12 2.2.2.5 Going beyond the current model: a role for host susceptibility..... 15 2.2.2.6 Evidence that ultraviolet light may have a role in caries ...... 19 2.2.2.7 Extent of caries in children in Island Lake, northern Aboriginal communities and rural Manitoba .. .........20 2.2.3 Relevance ....2I 2.3 Literature pertaining to prevalence of deficiency . ..........2I 2.3.I Vitamin D deficiencv and rickets in the Island Lake area. ........21 2.3.2 Vitamin D deficiency in other Aboriginal communities ... ........24 VI 2.3.3 Vitamin D deficiency in the general population .......27 3. OBJECTIVES .........30 4. HYPOTHESES .........30 5. THEORETICAL FRAMEWORK & METHODOLOGY .....31 5. 1 Social and cultural issues and health . ...... ..32 5.2 PRECEDE-PROCEED ........36 5.3 Methodology: PRECEDE-PROCEED applied to vitamin D deficiency . .....38 6. METHODS.. .........44 6.1 Ethics ......44 6.2 Rickets incidence..... ..........44 6.3 Prevalence of vitamin D deficiency among pregnant women. ..........48 6.4 Riskfactors...... .........52 6.5 Participatory approach...... ....57 7. RESULTS... ...........58 7 .I Rickets incidence .......58 7.2 Prcvalence of vitamin D deficiency among pregnant women. ..........69 7 .3 Risk factors ... ... .........77 7 .4 Prevention .......80 7 .5 Participatory approach... ... ....96 8. DISCUSSION .........98 vll 9. POTENTIAL SIGNIFICANCE OF SUBCLINICAL VITAMIN D DEFICIENCY. .... 1i6 9.I Relationship of vitamin D deficiency to conditions other than rickets and osteomalacia ..... ...... II7 9.1.1 Susceptibility to infections. ...1I7 9.1.2 Osteoporosis..... ........118 9.1,.3 Insulin secretion and diabetes . .. .. .... 120 9.I.4 Hypertension, Syndrome X and cardiovascular disease . ..... .. 124 9.1.5 Cancer .....I25 9.2 Relevance . ....... 125 10. FUTURE RESEARCH .... ....... 128 11. CONCLUSION ... 130 REFERENCES CITED .... .. 135 APPENDICES Appendix 1: Selection of Study Communities.... 159 Appendix 2: A Priori Sample Size Calculations & Power Analysis 161 Appendix 3: Laboratory Test Information and Normal Values r63 Appendix 4: Laboratory Research and Development Test Results for Vitamin D Kit. 168 Appendix 5: Laboratory Correlation Test Results for Vitamin D Analysis ......... 176 Appendix 6: Questions for Key Informants in Garden Hill .. 177 vlu Appendix 7: Information for Participants, Informed Consent Form and Interview Questionnaire ... ..... 178 Appendix 8: Blood Results ... 188 Appendix 9: Responses to Close-Ended Questions by Community.. .. 190 ix [.IST OF FTGURES Figure 1: Map of Canada Showing Location of Study Communities in Manitoba...
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