Understanding the Disease of

Endemic Skeletal Fluorosis and

Ways to Contain It

D. RAJA REDDY

Telangana Jagruti

Understanding The Disease Of Endemic

Skeletal Fluorosis And Ways To Contain It
Endemic skeletal fluorosis is a disease caused by excessive
ingestion of fluoride through water, food or both. The upper limit of
optimum fluoride level in drinking water for a tropical country like India
is 0.5 ppm. The upper limit of safe total intake of fluoride from food
and water per day for an adult is 5 milligrams (WHO-2002). The total
daily intake through water and food determines the development of
fluorosis. First ever cases of endemic skeletal fluorosis and its
neurological manifestations in the world were recorded from Podili,
Darsi and Kanigiri areas of Andhra Pradesh in 1937. Subsequently
cases of fluorosis were recorded from Nalgonda and other areas of the
Andhra Pradesh state and other parts of India. It is now estimated that
60 million people are living in these endemic areas and are at risk of
contacting the disease and 2 million people are crippled because of it.
The incidence of fluorosis affected districts in India are listed
alphabetically: Assam=2; Andhra Pradesh= 17; Bihar=8; Delhi=4;
Gujarat= All except Dang; Haryana= 12; Jammu & Kashmir=l;
Karnataka= 14; Kerala=3; Maharashtra= 10; Madhya Pradesh= 10;
Orissa= 3; Punjab=13; Rajasthan= All 32 districts; Tamil Nadu= 8;
Uttar Pradesh= 7 and West Benga=4. Hence, skeletal fluorosis
continues to be a major public health problem in India.
The factors, which govern the development of fluorosis, are the
following:
1.

High levels of fluoride in drinking water supplies and in the

foodstuffs grown in these endemic areas.

2.

Tropical weather and hard manual labor by affecting the intake of

water.

3.

Poor nutrition and diets deficient in their content of calcium,

magnesium and vitamin C aggravate fluoride toxicity. High intake
of calcium reduces the amount of absorbed into the bones.
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Magnesium has a peculiar relationship with fluoride and its optimum

intake helps in elimination of fluoride from the body. Vitamin C is
beneficial in some way in reducing fluoride toxicity. Diets deficient
in calories and calcium intake increase the incidence of fluorosis
(WHO-2002).
4.

Renal disease aggravates fluorosis by increased deposition of

fluoride in the bones. A diseased kidney cannot handle fluoride
excretion from the body and hence its increased deposition in the
bones.

Father and daughter hailing from Marriguda village of Nalgonda

District. Both are suffering from skeletal fluorosis. Daughter was
cripted in her teens while the father got disabled in his forty's.
This is a typical example of deterioration of nutrition in villages
during the past two to three decades. This village has high levels
of fluoride in drinking water supplies as well as in the foodstuffs
grown locally and consumed by the villagers.

5.

Presence of abnormal amounts of certain trace elements in the

drinking water supplies such as strontium, uranium etc. Strontium
levels in drinking water supplies in some endemic areas are high
and strontium is a bone-seeking element like fluoride and both
these aggravate the bony changes.

In a study of 94 drinking water samples from the endemic fluorotic

villages of Prakasam and Nalgonda districts the fluoride and strontium
levels are as follows:
Fluoride levels ranged between 0.1 to 9.5 ppm for a mean of
2.009 ppm and strontium levels ranged between 4.91 to 9931.74 ppb
for a mean of 1670.02 parts per billion. Any water strontium levels of
over 1000 ppb are suspect. Increased levels of fluoride and strontium
appear to playa role in the severe forms of fluorosis that is witnessed in
some endemic areas of fluorosis in Andhra Pradesh especially in
Prakasam where fluoride levels are not very high. Some elements like
uranium are nephrotoxic and may aggravate fluorosis problem. Levels
of trace elements such uranium, selenium, zinc, iron, lithium, lead, barium,
Another villager from
Marriguda of
Nalgonda District
suffering from
endemic skeletal
fluorosis. This village
with highest levels of
fluoride in drinking
water got supplies of
Krishna water only
recently. There is no
water provided for
cultivation and there
is no provision for
improving the
nutrition of villagers
except for midday
meal scheme for
students, which is not
optimum.

aluminum etc were in abnormal concentrations in some of the drinking

water supplies of villages in Prakasam and Nalgonda districts of Andhra
Pradesh. Aluminum is known to increase fluoride absorption from the
gut and hence its abnormal concentration in water supplies is harmful.
The role of these other elements except those of strontium, aluminum
and uranium in fluoride metabolism are not known at present time.
Defluoridation plants are based on adding aluminum compounds to the
water containing high levels of fluoride. It may be noted hundreds of
crores of rupees were spent on erecting these plants in 1980s 1990s
and not a single one of them are working now. So is the fate of household
defluoridation units. Besides there is the risk of increased intake of
aluminum which is being incriminated for the causation of Alzheimers
disease as well as motor neuron disease for which there is no therapy
like AIDS disease. Tea contains exceptionally high content of fluoride
and each cup may add upto 2milligrams of fluoride.

A native of Hanumanthapuram village in Prakasam district

suffering from dental fluorosis and skeletal fluorosis as well.
Fluoride levels are not very high in this village but strontium
levels in drinking water supplies are exceptionally high ranging
upto 9900 parts per billion. Strontium produces similar changes in
bones like fluoride. Surface water provision or establishment of
defluoridating plants based on reverse osmosis is the only answers
for this village Reverse osmosis is a very expensive proposition.

Ideal solution for skeletal fluorosis is its prevention by providing

safe drinking water and providing such water for cultivation of crops in
these endemic areas. This appears to be only a very distant dream.
Government of India envisaged health for all by 2000 in 1987 AD and
planned provision of safe drinking water to all villages by that date. The
plans failed miserably and now the authorities have become more
pragmatic. One of the millennium development goals of 2002 is to
provide safe drinking water to half the rural population by 2015 .Hence
prevention of fluorosis is not possible in the near future and at least
efforts must be made to lessen the suffering of the people by improving
their nutrition.

A lady of Neredupalli of Prakasm collecting drinking water from

riverbed. This water does not have high levels of fluoride but
other elements such as strontium, uranium etc are high. This
village has high incidence of kidney disease, which may be due
to high levels of some of these trace elements. Another bad habit
of the villagers is consumption of analgesics all kinds of aches
and pains which could damage kidneys in the long run. Adequate
supplies of surface water from Krishna for drinking, cooking and
cultivation are the only solutions for the problems of this village.

The situation in certain parts of Andhra such as Nalgonda is very

grim. When Daver first recorded cases of skeletal fluorosis from this
region in 1945 AD and by Siddique in 1955 AD, there were no children
with deformed limbs. These cases with deformed limbs were recorded
in 1970s. Rural nutrition in the past few decades has gotten worse in
many parts of state and in other parts of the country. National institute
of nutrition conducted surveys of status of rural nutrition in 715 villages
of seven states in 2002 and 2003. Eighty villages in AP were studied
and AP has the distinction of having highest incidence of dental fluorosis
among seven states. The results of nutrition study are contained in
National nutrition monitoring bureau reports 21 and 22, which reveal
the appalling state of nutrition of rural population in the country. Sixty
percent of the children below 6 years of age are malnourished and a
third of them suffer from severe under weight problem. Only a third of
the children studied were getting an optimum diet. Calcium intake is
exceptionally low in all states and calcium does playa big role in Nalgonda

This is a typical scene in the villages these days. Deeper the bores
the water content of fluorides and other harmful trace elements
goes up. Surface water from perennial rivers like Krishna and
Godavari are the only answers for these villages.

having very high incidence of skeletal fluorosis in our country. Drinking

water supplies of Nalgonda have a high content of fluoride because the
calcium content of Nalgonda soils and rocks is low. This allows more
fluoride to seep in to the water supplies (Netherland study-1986).
Siddiqui study revealed that average daily intake of calcium in Nalgonda
individuals was only 300 mg whereas it was 900 mg in Punjab. NNMB
report of 2002 reveals that calcium intake of rural population is
appallingly low in Andhra and hardly averages around 300 milligrams
whereas it should be around 800-1000 milligrams in growing children.
Hence, there are no children with deformed limbs in Punjab villages
with similar levels of fluoride in drinking water supplies. Nutrition status
study of 50 children in Sharbanapuram village of Aler MandaI of
Nalgonda revealed that only one boy was normal as per BMI and
percentile studies. Mid day meal scheme has not helped these children
in Nalgonda in this regard. Children hardly get 300 calories of diet and
most of the times the food supplied is not even hygienically good.
National family health survey-III by the government of lndia in 2006 in
29 states revealed that 45 % of the children below are undernourished
and 57 % of women are anemic. All government policies to improve
nutrition of rural folk have been a dismal failure so far.
What needs to be done? One has to pragmatic. Ideal way would
be to supplement the diet of children in the endemic areas with calcium,
magnesium and vitamin C. This was also the basis of Chinese research
work in early 1990s. The best way would be to give a glass of milk
and a banana to every school-going child in these endemic areas. Milk
is perishable and can be adulterated. A pouch containing 300 ml of
milk becomes very expensive. A tablet containing 500 milligrams of
calcium, 300 milligrams of magnesium and 40 milligrams of vitamin C
with vitamin D to improve absorption of calcium would be cheap and
practical in addition to midday meal scheme, which needs to be
improved. Since anemia is widely prevalent in rural population it may
be advisable to add iron also to this tablet. The skeletal fluorosis was
discovered in our country in Prakasam district seventy years ago and
this continues to be major health problem even today. All efforts to
contain this disease have been a dismal failure so far. Unless pragmatic
9

steps are taken this problem going to affect the lives of millions of people
in our country for a long time to come.

Summary
There are three factors for the causation of skeletal fluorosis, Water,
food and nutrition. Ask for Krishna water for drinking and cooking for
every fluorotic village. Try for Krishna water for cultivation in future.
Improve the nutrition of the population especially those of growing
children by whatever means practicable. A void drinks such as tea,
which is very rich in fluoride and also sea foods. A void analgesics,
which could damage the kidneys and aggravate the problem in these
areas where studies reveal a higher incidence of kidney disease.

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Annexure
PREFERRED FOODS IN FLUOROTIC REGION
A diet rich in calcium, magnesium and vitamin C would greatly
benefit the population living in areas where soil and water fluoride levels
are high while measures to provide safe drinking water could benefit by
reducing fluoride intake, a diet enhancing calcium, magnesium and
vitamin C intakes would considerably reduce the basic pathology
associated with fluorosis. However these food sources should be grown
in no fluoride areas and provided for consumption in region with
fluorosis.
Though there are several food sources only those which are
commonly consumed in region of AP and which are affordable to the
lower socio-economic groups are suggested. The resource for this
compilation is the Nutritive value of Indian foods Published by the
National Institute of Nutrition, ICMR, Hyderabad.
General name

Ragi
Agathi
Amaranth
Colacasia leaves
Curry leaves
Poppy feed
Jagary
Gingelly seeds
Jowar
Cummin
Amla
Green chilly

Telugu
Equivalent
Name
Ragulu
Avisagu
Thotakura
Chama Aaku
Karvepaku
Curry pattha
Ghasalu
khus khus
Gur / Bellum
Nuuvulu / Til
Jonalu
Jeera Jeelakara
Usirikaya
Hari Mirch

Calcium Magnesium
Vitamin C
(in M/100m of the food source)
344
1130
530-800
1546
836

4.2
12.8

169
179

1584

9.9

1638
1450
171
1080

5.2

475

12

600
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