Making it easier to deal with Fluorosis: Unwrapping the layers, simplifying some answers


Fluorosis has been a long standing problem with almost a century since its discovery in the 1930s in India. After several intense research of a few decades lasting till the 1970s, there has been a lull in any constructive research on this subject. More so, the findings become more complex, making it difficult for practitioners to grapple with it. Even though millions suffer from the disease, there is worldwide no existing programme for mitigation and no single institute that specializes on it, except for small institutions which do research and promote findings about fluorosis.

The purpose of this paper is to summarize learning from 1930s and bring them to a form in which it becomes possible to develop actionable programme. Growing evidence of many aspects of fluorosis and experiences in mitigation are making it clearer to deal with the problem. This paper synthesizes such experiences and presents a framework to approach mitigation. The sections of the paper are:

1. Understanding Fluorosis


1.1. Safe intake and body weight
1.2. Occupational and other linkages
1.3. Age of Onset of Dental fluorosis
1.4. Renal condition
1.5. Calcium and fluoride
1.6. Fluoride and Thyroid
1.7. Fluoride and Anemia
1.8. Fluoride and Osteoporosis
1.9. Vulnerability of pregnant and lactating mothers
1.10. Children and vulnerability to fluorosis
1.11. Entry of fluoride through food
1.12. Absence of doctor’s diagnosis

2. Solutions


2.1. Water treatment to remove fluoride
2.2. Role of Magnesium, Vitamin C and other nutrients
2.3. Possible detoxification and reversal
2.4. Food combination to tackle fluorosis

3. Approaches to action


3.1. Prioritizing action
3.2. A life-cycle approach to fluorosis mitigation
3.3. Programmatic directions
3.4. How to best communicate ideas
3.5. Systemic changes to be achieved

1. Understanding fluorosis
1.1 Safe intake and Body weight


The action of fluoride depends on amount consumed per unit weight of the body. Experiments determining such dosage were done in the 1930s by Kaj Roholm on fluoride affected patients of a factory in Europe (Roholm 1937). What he found was that fluoride in the range of 0.2-0.35 mg/kg of body weight per day after 2 years and 5 months can cause a initial degree of phase one of skeletal fluorosis (characterized by sporadic pain and stiffness of joints), after 4 years and 10 months can increase to a greater degree of phase 2 (arthritic symptoms and osteoporosis in long bones), and in 11 years and 2 months can aggravate to crippling skeletal fluorosis (crippling deformities of spine and major joints). He also noted that approximately 50% of fluoride ingested would be ejected out by the kidneys.

With this background, the dosage rate with body weight should be (as in Table 1):

Range of fluoride intake to cause skeletal fluorosisIt is clear from Table 1 that despite of drinking water standards being 1.5 mg/l (permissible limit) and 1 mg/l (required acceptable limit) for India, the chances of risk to debilitating skeletal fluorosis from long-time exposure is high even with low concentrations. Especially, if we take the case of children of weight 10 kgs or so, even smaller concentrations of 0..5-1 mg/l is very much harmful. If there is intake of Fluoride through food, these levels become even more significant.

As documented in several articles and research papers, however, this early finding by Kaj Roholm was incorrectly used later (due to a pound-kg confusion) and later on referred in many important international policy guidelines with an incorrect factor of 2.2 on the lower side (Editorial 1997). This mistake is only being corrected recently, however, the vestiges of the mistake remains still.

1.2 Occupational and other linkages


As early as in early 1930s and 1940s studies of fluorosis, it was observed and asked to why certain labourers where more affected (Shortt et al, 1937). One of the early responses, where that firstly in tropical environment there is greater water intake. Secondly, for people who labour in the sun, there is excess sweating and relatively more intake of water. If this all happens to contain high fluoride, then the chances of intake of fluoride becomes higher, with greater risk to fluorosis.

Extending this argument further, can mean that in places where there is greater need to walk longer distances in the sun, such as for collection of water, fuel and fodder, there would be greater risk to fluorosis, arising out of greater water consumption. As we later see, such burden also puts a burden of greater calorific need of food and introduces another dimension. Besides occupational burden, nutritional intake, calcium metabolism and genetic disposition may be the other factors that need to be considered.

1.3 Age of onset of Dental fluorosis


Dental fluorosis is a developmental disturbance of the dental enamel caused by successive exposures to high concentrations of fluoride during tooth development, leading to enamel with low mineral content and increased porosity. The critical period for risk to dental fluorosis is between 1 and 4 years of age. After the age of 8 when permanent teeth have established, there is no risk of dental fluorosis (Alvarez et al, 2009).

This simple aspect of dental fluorosis has several consequences. One, it gives an early sign of fluorosis, pointing to the obvious fact that there has been fluoride entry into the body. By observing a cross-section of children of ages 3-4 to around 10 in affected areas often gives an indication of increasing severity of dental fluorosis. This can be used for rapid surveys in large areas.

Lastly, we see many cases, especially of women, who are married into a high fluoride area and coming from a lower fluoride place. In such cases, these women would not be affected by dental fluorosis ever, but would get exposed to skeletal and other forms after marriage. Such possibility is lesser in case of men. For early detection therefore, one needs to keep mind and track whether the patient has stayed in an area with high fluoride in early age.

1.4 Renal condition


The relationship between fluorosis and renal diseases has been of interest since the early days of 1930s. One of the observations in the 1937 paper (Shortt et al, 1937) was that most of highly affected patients had a diseased kidney. This was further corroborated in the 1970s and later, due to onset of osteomalacia, a bone softening disease, in kidney patients, who were exposed to dialysis with fluoridated water.

A healthy kidney has the ability to eject a lot of fluoride from the body. However, fluoride has also been known to affect the kidneys with prolonged exposure to high concentrations. This cyclic nature of fluoride-renal disease leads to severe forms of skeletal fluorosis in some patients in the longer term.

Renal problems can also occur in children and young adults. Therefore, detection of Renal problems in early age can point us towards early corrective action for more vulnerable patients. Similarly, reducing fluoride in water can also be a way to improve Renal health in the long term (Schiffl, 2008).

1.5 Calcium and Fluoride


Fluoride increases the Osteoid content of bone. This basically means that fluoride induces a greater bone formation mechanism than what is sustainable by the body. However, in order to properly mineralize the Osteoids and form healthy bones, there is greater requirement for essential minerals such as Calcium and Vitamin D (Kragstrup 1989, Arnala 1985). One estimate is that the requirement for Calcium is 40 times that of ingested fluoride i.e 5 mg of ingested fluoride, requirement of Calcium becomes 200 mg (Jowsey, 1972).

At one point, fluoride was also being used in the treatment of osteoporosis since it was believed to lead to greater bone density. However, such treatment has been withdrawn over the years. Even if there is short term increase in bone density, there is lesser chance of healthy bone formation.

In adults, too much amount of unmineralized osteoids lead to softer bones and a condition called osteomalacia. The same condition developing during childhood leads to rickets, characterized mostly by bowed legs.

In summary, fluoride action in children or adults increases the need for other minerals such Calcium and Vitamin D. This increase in many cases is (unnatural) too large to be satisfied without causing other complications: especially for certain situations such as pregnant and lactating women and for growing children when the need for Calcium is already very high. This in effect creates other problems related to Calcium deficiencies.

1.6 Fluoride and Thyroid


Fluoride has a delicate link with Thyroidal health. It is not yet clear from research as to how exactly fluoride affects thyroidal behavior (NRC 2006, Burgi et al, 1984). But, both suppression of thyroidal action leading to hypothyroidism as well as over-activation leading to hyperthyroidism have been observed. Here, there is a link with Iodine (essential for thyroidal health) as well as Calcium (regulated by para-thyroidal and related hormones). The impact of fluoride inducing hypothyroidism is more among people already having Iodine deficiency. On the other hand, hyperthyroidism induced by fluoride can cause a cascading effect. In this case, it can lead in the long (term) run, to greater bone resorption (or bone degeneration) and causing problems such as osteoporosis. This is further increased by fluoride with its linkages to calcium, thereby causing a cyclic action accelerating the problem in some patients.

Detection of thyroidal health is essential in screening of fluorosis patients for future vulnerability. In case of possible Iodine deficiency, one direction is to make sure that there are no Iodine deficiencies with supplementation through iodized salt. On the other hand, early stages of hyperthyroidism can also be detected with, for example, by detection of para-thyroidal hormone (PTH) through a PTH test along with testing of serum calcium. Observation of serum calcitonin can also provide some early warnings. Such tests could be part of a fluorosis programme.

1.7 Fluoride and Anemia


Fluoride is known to increase (the effect of) Anemia: It causes serious damage to gastrointestinal (GI) mucosa by destroying microvilli resulting in non absorption of nurtients from diet. It also destroys erythrocytes, contributing to loss of haemoglobin resulting in anemia. Such exposure to fluoride over a longer period can cause chronic anemia and malnutrition (Susheela 2011).

However, some aspect of this problem can be reversed within a short period of time. Especially the GI mucosa can regenerate within a couple of weeks. This has been demonstrated in a trial of 205 pregnant women in New Delhi. The results show a demonstrably significant increase in Haemoglobin for women for whom fluoride was withdrawn from water and food (Susheela et al, 2010).

It is important to note that such destruction of GI mucosa causing loss of nutrients is also possible with smaller amount of fluoride consumption. Hence this phenomenon might be quite widespread across India. Since this destruction reduced absorption of nutrients, even supplementation efforts such as those with Iron supplements would not yield any desired results. Just stopping fluoride consumption will make such supplementation highly effective.

1.8 Fluoride and Osteoporosis


Perhaps the most devastating effect of fluoride on bones is osteoporosis. This is seen even in very young children leading to juvenile osteoporosis and rickets. Osteoporosis arising out of fluoride comes out of a combination of mechanisms – that of excess osteoblast formation induced by fluoride leading to poorly mineralized bones, thyroidal malfunction causing bone decay, and also renal problems exacerbating all of these. These factors might act in combination or isolation to. When there is prolonged exposure to intense fluoride loading and less capacity within the body to resist it, this kind of condition can result.

As is evident, such type of osteoporosis, if detected, means that fluorosis is in an advanced stage. According to Kaj Roholm’s 1937 definition, this means stage 2 of fluorosis. It also means that there has been fluoroapatite formation and possibly initial stages of bone deformation has started.

Addressing this type of fluoride-induced osteoporosis, especially in children, is very difficult. It first needs to start from a complete fluoride-eradication effort, along with intensive effort on calcium supplementation along with other minerals that aid bone formation – Magnesium, Vitamin D, Zinc. All these together do not guarantee any reversal of already existing osteoporosis, but can perhaps arrest further degeneration.

However, what is intriguing is that fluoride has been in use since several decades and is accepted in Europe towards treatment for osteoporosis (Jowsey et al, 1972). The ability of fluoride to stimulate osteoblast activity and almost reduce bone resorption, temporarily is being utilized here. However, studies have shown that even though there is initial increase in bone density, this unless accompanied by very high calcium and mineral supplementation, can result in poor unhealthy bones and higher susceptibility to fractures.

These seemingly diverse views on fluoride and osteoporosis point towards the same mechanisms. Fluoride induces the need for excessive mineral requirement, for bone formation, which if not available, can lead to soft bones or bones with high porosity leading to hypocalcemia or osteoporosis. The same fact could be utilized in very small amount of fluoride for treatment of the same. This aspect might not be of value to fluoride-induced osteoporosis.

1.9 Vulnerability of pregnant and lactating mothers


There are several factors why pregnant and lactating mothers can be affected by fluorosis. Firstly as already pointed out, the aspect of fluoride-induced Anemia can be very much harmful to pregnant mothers. Secondly, is the aspect of Calcium. During pregnancy as well in lactation period, the requirement for calcium is very high. When during this period, there is entry of fluoride into the body, this requirement increases even more, as pointed out earlier.

This massive sudden demand for calcium can cause devastating effects. Women have gone through entire stages of skeletal fluorosis leading to crippling in just a matter of 2-3 years in such cases. Such cases are hardly detected as caused by fluorosis since these linkages are often not clearly recognized and appreciated by field-level doctors analyzing them. Secondly, this overall calcium deficit can cause problems with quality of breast milk, compromising health of the child.

The combined effect of fluoride induced Anemia and Calcium deficit can together have highly negative impact on mother and child health. Therefore, fluorosis prevention programmes need to put specific emphasis on pregnant and lactating women.

1.10 Children and vulnerability to fluorosis


Children are more vulnerable to fluorosis in a variety of ways. Firstly, for infants, calcium and mineral absorption through breastmilk can be compromised due to comprised calcium deficit in mothers. Second, children generally are exposed to 5-10 times as much intensity of fluoride/body weight as compared with adults. Thirdly, since, there is already high calcium and minerals need in growing children, this increased requirement due to action of fluoride, causes further calcium deficit. Fourthly, teeth and especially bones, being soft and developing, cannot withstand certain aspects of fluoride eg. long bones of legs unable to bear body weight due to greater porosity and resulting in bowed and pointed legs as in Rickets.

These multiple reasons, along with others such as Anemia, etc. make fluoride highly harmful for children. What does this mean for fluorosis prevention programmes? In terms of priority, one needs to focus on children, since this is the age in which one can prevent harmful effects of fluorosis. Such prevention means full stoppage and entry of fluoride into the body along with mineral supplementation such as Calcium and related salts.

1.11 Entry of fluoride through food


Some natural substances such as certain forms of tea, black (pink) salt, rock salt contain high fluoride. Otherwise entry of high amount of fluoride through food can only be possible if crops are irrigated with high fluoride water. Often with years of irrigation with such water, soil also gets affected and such concentration in food increases in some places.

In some places, due to lack of availability and affordability of milk, there is habit even from quite lower ages to consume black tea with little to no milk or with tiny additions of milk powder. If there is existing entry of fluoride from water, this might just add to the overall loading.

Studies in villages of Nalgonda (Andhra Pradesh) showed that fluoride present in Rice, pulses and vegetables contribute as much as 75 mg/day, 54 mg/day and 62 mg/day respectively into the diet of an average adult. Looking at the daily intake figures from Table 1, these figures are sufficient by themselves to result in crippling skeletal fluorosis (Reddy 2011).

Studies by NEERI in villages of Dhar and Jhabua in Madhya Pradesh, show relatively lesser concentrations of fluoride in food (less than 1 mg/kg in Maize, wheat and Rice). These are confirmed by recent observations in Jhabua in which only Tuwar dal has relatively higher concentration of fluoride around 5 mg/kg for few samples (NEERI, 2007).

These observations are in agreement with the irrigation practices of the regions. Dhar and Jhabua are mostly rain-fed regions with irrigation mostly from shallow dug wells that contain relatively lesser amount of fluoride. However, over the years, as soil gets progressively more contaminated and borewell irrigation with deeper water spreads, we can expect greater fluoride entry from food here also.

The entry of fluoride from food that naturally has higher amounts of fluoride could be totally prevented by marking of such food and greater understanding. However, the problem of fluoride entry through irrigation is a more difficult one. Food production itself is a major priority and avoiding deeper groundwater having greater fluoride as a policy measure is not an easy option. Hence, some alternatives could be: shifting to non edible crops if possible, opting for crops that absorb lesser fluoride, reducing bioavailability of consumed fluoride with relevant nutrients.

1.12 Absence of Doctor’s Diagnosis


Unfortunately, most fluorosis cases go undetected by doctors. In fact, cases have been “discovered” mostly by targeted programmes by civil society, UNICEF, etc. There are several reasons to this, prime being that there is hardly any emphasis on fluorosis in medical teaching curriculum in India till now. In the text for Community Health by Park & Park, there is a small section and in some Dental college curriculum, fluorosis is taught. But, there is hardly any semblance of this in medicine practice.

Adding to this is the fact that national or state health programmes have not yet embarked on any significant programme for fluorosis. Most government programmes on fluorosis have been conducted by the water supply department, none from the public health side. For example, no health surveys, including those of school health, or under NRHM, etc., have any listing of fluorosis. As a consequence, neither is fluorosis being detected, nor enumerated.

Very often, many cases of dental fluorosis are confused with other dental problems. There is an incorrect perception that these yellow and red stains are tobacco related. Skeletal fluorosis problems are diagnosed as ‘Musculo-skeletal disorders’ (MSD) and administered general treatment, commonly with pain-killers. Fluorosis induced gastric problems and fluorosis induced Anemia or Thyroidal problems are never connected to the root cause and treatment is always for the symptom. Similar is the case for Osteoporosis that is induced by fluoride, as well as Rickets.

Consequently, most of the symptoms of fluorosis, even if detected by a doctor, is considered as a separate ailment, and very rarely, if ever, is it related to the root cause i.e. fluoride.

Proper diagnosis would also require good testing facilities, especially those for blood serum and urine. Apart from Dr A. K. Susheela’s laboratory in New Delhi, no other laboratory in the country does this testing accurately and at reasonable cost. Nowhere can patients get good radiological advice for skeletal problems.

A combination of all these factors have resulted into the current situation that fluorosis patients are incorrectly diagnosed and do not have any health facility to have proper consultation. It is thus clear that educating the medical personnel, particularly those working in fluorotic areas is essential.

2. Solutions


The best solutions in the order of preference for safe water are (a) supply of treated, surface water supply, (b) locating a well with no or least fluoride using the knowledge of hydrogeology and (c) rainwater harvesting and re-salting to required level.

In case none of the three could be implemented, water treatment has to be resorted to.

2.1 Water treatment to remove fluoride


Water treatment to remove fluoride has been tried for many decades now. The older technology that has been tried and failed is the Nalgonda technology promoted by NEERI. Various other techniques based on resins and electro-coagulation have also come up, but have not seen the light of practice yet.

In terms of fluoride removal alternate technologies such as removal by passing over certain types of bricks and immersing Tulsi (holy basil) in water has also been attempted. However, as of today, only two technologies stand up in terms of different desirable aspects. Yet, they too have not been able to reach and become practicable.

Activated Alumina (AA)


Affinity of alumunium with fluoride is exploited here, as in Nalgonda technology, the difference being that this is dehydroxylated Aluminium hydroxide producing a porous material. Finer the sizes of the beaded particles, greater is the surface area and better adsorbment of fluoride to form alumunium fluoride complexes. Generally particle size of around 0.4 mm – 1.2 diameter is a standard practice for AA which depending on quality of material and also other constituents of the water such as pH and alkalinity, can provide 3000 mg/kg to 5000 mg/kg of fluoride adsorption. A process of regeneration needs to be made, after which adsorbing capacity drops down by 10%-15%.

The benefit of AA is that if the high fluoride water can be in contact with AA for around 20 minutes passing through a layer of say 1 m height, then fluoride is reduced to well below 0.1 mg/l and lower. There is no requirement for any energy source. However, there are problems with the technology: one, adsorbing capacity reduces with high pH and alkanility and carbonate presence, secondly, regeneration can be a cumbersome process, thirdly, there can be an undesirable taste in water during initial days of use.

AA based fluoride removal filters have been in wide use in 1990s in India. They have tried in a large scale, but failed to succeed in the long term, except for few groups of people still using them after 10-15 years. There is renewed interest in AA filters now with some experiments ongoing in India currently.

Reverse Osmosis (RO)


Since the mid 1990s, RO technology has taken over the Indian water filter market. RO membranes can remove fluoride. However, the waste water ejected out contains high fluoride, so disposal of that water is a question. In rural areas, RO has been promoted as a community water treatment plant with sizes ranges from 100 litres per hour to 10,000 litres per hour. Gujarat and Andhra Pradesh are leaders in this field, with numerous partnerships between industry, community groups and government programmes, being promoted. Most of these efforts are run as water enterprises and sustain in terms of financial viability.

The benefit of RO is that there is no additional chemical being added to it. Also since it demineralizes, there is a better taste, especially in areas with hard water. However the problems with RO technology are that: it requires energy to apply pressure on the membranes, the waste water has higher concentration of fluoride, the demineralization can remove essential nutrients, and cost factor does not make it viable everywhere and for everybody, the membranes are imported and need replacement every 3-4 years.

2.2 Role of Magnesium, Vitamin C and other nutrients


Magnesium is helpful in two different ways for resisting fluoride. First, Magnesium is essential in calcium absorption in the bones. By reducing Para-thyroid hormone (PTH) and increasing Calcitonin levels in the blood, it increases the absorption of Calcium and arrests bone resorption.

Secondly, Magnesium is helpful in ejection of fluoride from the body. Though the mechanism of how Magnesium helps in such excretion through urine is not yet clear, experiments show that Magnesium supplementation helps in fluoride excretion from the body.

The role of Ascorbic acid has been observed with varied effects by many authors. In several studies it was seen that Ascorbic acid led to certain removal of fluorides from the body. But this was not successful in all trials concerning skeletal fluorosis. However, Vitamin C remains an important way to counter harmful effects of fluoride action within the body. Role of Iodine in preserving thyroidal health and in countering fluoride has also been seen. Apart from these, other such nutrients studies include Selenium, Vitamin D and Vitamin A.

In terms of practical programmatic direction to nutritional supplementation for countering fluorosis, the following could be followed:

- Calcium, Magnesium, Vitamin D3 and Zinc for better calcium absorption and other essential minerals for bone health

- Vitamin C and other nutrients such as Vitamin A and essential anti-oxidants

Apart from these, one can advocate:
- Iodine supplementation for better thyroidal health
- Iron supplementation to counter link of fluoride with Anemia

2.3 Possible detoxification and reversal


Many of the symptomatic observations of fluorosis are also consequences of other malfunctions within the body, for example, hypocalcemia, diseased kidney, thyroidal imbalance, osteoporosis, etc. However certain other symptoms such as bone deformities and crippling are consequences of fluorosis in higher stages which are unique to this disease.

One way to observe detoxification of fluoride and reversal of symptoms could be to observe these symptomatic consequences. A lot of fluorosis patients are actually treated for various other diseases, unknowingly to them and to doctors. In such case, unless there is stopping of further intake of fluoride, these symptoms would not cease in the longer term.

Some easier observations of fluoride directly are through blood serum fluoride and urinary fluoride. Though such decrease in blood serum fluoride does not directly indicate detoxification of fluoride from the body and reversal of fluorosis, it probably indicates of arrest of further progress of the disease. Such reduction in blood serum fluoride have been observed in many clinical cases. Field trials of fluorosis are few and far between. In most cases, there is observation of urinary fluoride.

On a very practical level, what one can observe is that pain in certain joints decreases temporarily. Also ability to bend, move arms over shoulders and walk longer distances are certain symptoms of fluoride detoxification. In patients for whom gastric problems have persisted due to fluoride, cessation of such symptoms could be an indicator. Another shorter term indicator could be rise in Haemeglobin levels, especially for patients who were suffering from iron deficiency Anemia. Absolute reversal of bone deformities have been observed in rare cases. Though in case of long term stoppage of fluoride entry in body, changes such as being able to bend fingers that were earlier difficult to bend, etc have been observed. These could also be due to pain-related factors that were earlier barriers to joint movement.

2.4 Food combination to tackle fluorosis


An overall food and nutrition based approach to address fluorosis needs to look at supplementing sources of calcium, aiding better calcium absorption with other nutrients, and helping detoxification with aiding internal processes.

Essential nutrients include Calcium, Magnesium, Vitamin D, Zinc, Vitamin C, Iodine, Iron. This can be achieved in many ways.

a) Calcium-Magnesium tablets


In order that a basic minimum amount of Calcium and Magnesium is consumed by patients, pharma-supplements canbe recommended with a combination of Calcium (210 mg elemental), Magnesium (100 mg elemental), Zinc (4 mg elemental), Vitamin D3 (200 I. U.). Currently we advise usage of this supplement for 2 years.

b) Dried Amla (Gooseberry) and Amla tablets


One of the highest sources of Vitamin C is Amla (Indian Gooseberry). It has 700 mg per 100 g of fruit pulp. However availability is only for 2-3 months a year from December to March. There are many traditional methods of storing Amla for year-around use. Drying in shade, pickles, Morabba are some common methods. It is possible to dry Amla in preserve it. However, looking at practicality of delivery, storage and acceptance by people, Amla tablets can also be used.

c) Til Chikki (Sesame and Jaggery)


Sesame (Til) and Jaggery (Gur) are very good sources of Calcium and Magnesium. Sesame has 1000 mg Calcium and 360 mg Magnesium per 100 g, whereas Jaggery has 1638 mg Calcium per 100 g. From our calculations, one Til-Chikki (Sesame and Jaggery) or a Laddu of weight 20 gms, provides 237 mg of Calcium and 32 mg of Magnesium and overall 282 Calories of energy. Especially in the winter season, this is easier to store and consume.

d) Greens abundantly available to supply the nutrients:


Seasonal green leaves are available throughout India. They can be dried and stored for use throughout the year.

Moringa oleifera is probably the best greens that is consumed not very frequently in several parts of India.

Some, especially like Cassia Tora are highly neglected, but contain very high nutritional content, suitable for the bones. These leave, when dried and powdered, provide around 4000 mg/100 g of calcium, 300 mg/100g of magnesium and 100 mg/100 g of Vitamin C, along with 25 g/100 g of protein. In combination, they are excellent to address fluorosis. To make such a combination taster, one can turn it into a Masala by adding other suitable contents such as Cumin (Jeera), etc. Such a Cassia Tora powder can be directly sprinkled on cooked food before consumption.

e) Ayurvedic sources


In terms of aiding detoxification through the liver, a combination of Yashtimadhu, Ushir, Rakta Punarnava, Gokhru, Prabal and Moti. The effectiveness of this combination to detoxify fluoride from the body is currently under observation.

Various other food items such as Soya based food, Milk based food, Eggs, all contain high calcium. They should be consumed where possible.

2.5 Increased excretion of fluoride


Making urine alkaline increases the excretion of fluoride. Till further studies are carried out, a fairly harmless path given below could be used. Use any one method for 5 days continuously, if no side effects are felt. Try as many of the methods given below as possible, without sticking to anyone. This should indicate which method is better and also avoid adverse effects if any. Do not try on children below 10 years without consulting your doctor:

1. Alkacitra (or Citralka) is a harmless, cheap medicine available in all medical shops –It could be prepared in bulk and made available.

2. Banana stem - 3cm long crushed well, mixed with 250mL water and taken twice daily on empty stomach

3. Ashgourd juice 30-50ml – twice daily

4. Coconutwater 100mL + very young coconut fibre juice 5-10mL

5. Barley water 20gm barley crushed and boiled with 100-150mL water, cooled and taken

3. Approaches to Action
3.1 Prioritizing Action


In order to put together all the above complexity, we need a strategy to counter fluorosis. This strategy can be thought about as a prioritized list with highest priority at the beginning and others following:

a. Minimize intake of fluoride through water and food; this can be done by opting for fluoride-free water source or by removing fluoride from unsafe sources. For this, best options that suit local conditions need to be adopted. Where possible, options such as rainwater harvesting and storage can be promoted. Treatment options such as Activated Alumina (not required energy), and Reverse Osmosis (requiring energy) are current technologies in use for treatment of high fluoride water. For one month, drink pure treated water. After one month, mix 10% raw water with treated water to provide some salts. Drinking saltless water for long may not be good. By experimentation we shall have to reach a balanced approach. People with low BP should not drink too much of salt free water.

b. Increase intake of Calcium and ways of absorbing Calcium: Here Magnesium, Vitamin D are important, apart from other ways to increase Calcium absorption and effectiveness. Some of the food items that can provide for this nutrition part are Milk, Green Leaves (including Palak, Methi, Moringa, Cassia Tora), Sesame (Til), Jaggery (Gur), etc.

c. Reduce Fluoride action within body and enable flushing from body with detoxifying mechanisms eg. improving body detox processes, Vitamin C, Iodine (through the thyroid and Calcitonin connection), Magnesium(decide the dose in consultation with your doctor), Antioxidants, Iron, etc. Sources of food such as Amla, Lemon, Tamarind, Tulsi are known to be good for enabling such processes within the body

d. Use indicators of fluorosis vulnerability to target interventions eg. dental fluorosis, early signs of skeletal fluorosis, Serum Fluoride, Serum Creatinin, etc. Or for special target groups such as pregnant and lactating women, growing children, any disease requiring excess Calcium, people using the same water source always, etc. could be special populations within affected community that are more vulnerable. This can broadly be referred to as a “lifecycle approach” towards targeting fluorosis interventions. Within such an approach, many affected patients whose symptoms cannot be reversed would need “rehabilitation” measures to withstand the impact of fluorosis.

e. Longer term action on social determinants of fluorosis such as access to better water facilities and better affordable nutrition; reducing drudgery (fuel/fodder/water) resulting in improved nutrition; water conservation to ensure supply of safe water; groundwater governance aimed at protecting safe water in aquifers, etc. Poverty is closely linked to vulnerability for fluorosis. Improved economy leading to better food habits, hygiene, lower labour activity, less children (with more years of spacing between them), and better status of women, can in the long run lead to sustained efforts at addressing fluorosis.

3.2 A life-cycle approach to fluorosis mitigation


Approaches to tackling fluorosis can be customized with age and gender, and also to particular stages of life. This approach will take care of certain vulnerabilities and address them. The barebones of such an approach is outlined here:

i) Pregnant and lactating women are not only highly vulnerable by themselves to fluorosis, but they also present a danger to their future children being affected with fluorosis at a very young age. These women need special attention in terms of safe fluoride-free water, as well as calcium and other mineral supplementation

ii) Anemia in pregnant women affected by fluorosis, can be addressed to some extent by fluoride-free water. This is especially important for both health of mother and infant.

iii) Since children are most vulnerable to fluorosis (due to their lower body weight and greater calcium activity), we need to have separate standards for fluoride intake for children. Having such a separate standard make it imperative that special-need food from Anganwadi and schools also are prepared with fluoride-free water and the drinking water in such centres are fluoride-free

iv) Dental fluorosis in children gives us an indication that fluoride has entered the body. This presents us an opportunity to prevent greater degree of fluorosis at higher age. Therefore, in places where there is greater concentration of dental fluorosis affected children, one must focus on preventive approaches for avoiding further problems

v) Renal health and thyroidal health are two factors closely related to fluorosis. This is important for both women and men. Both of these have a two-way relation with fluoride – they can be affected by fluorosis and in turn fluorosis can be aggravated by poor renal and thyroidal health. Therefore, assessing vulnerability to fluorosis should include both these aspects.

These above facts bring forward the need to factor in specific vulnerabilities posed by age, gender and other aspects into addressing fluorosis. Terming these together as a “life-cycle” approach, this also determines specific medicinal nutritional requirement needs for each other category. Currently, such customization of fluorosis mitigation paradigm has not been achieved, but doing this would fine-tune interventions and target better the more vulnerable patients.

3.3 Programmatic Directions


A variety of departments and government programmes can formulate policies to act on fluorosis. Here we list a few points of action which can be implemented.

- Identification and protection of safe fluoride–free water sources locally; their conservation, replenishment and equitable distribution

- Safe fluoride-free water in all food and nutrition programmes, eg. In Anganwadis, Schools, Mid-day meal programmes, etc (with technologies being advocated by the network such as filter, rainwater harvesting etc)

- Safe fluoride-free water in all health clinics – CHCs, PHCs, and local sub-clinics

- Additional supplementation in fluoride affected areas for Calcium and related minerals – through Public distribution System (PDS), Anganwadi, mid-day meal programmes, Women and child supplementation programmes

- Prevention programme for fluorosis targeting pregnant and lactating mothers and children under 5 – Ensuring safe fluoride –free water and better nutrition

- Preservation of nutrition-rich local food material useful for combating fluorosis – Amla, Til, Soya, Green Leaves such as Moringa, Cassia Tora, etc – and their distribution through local community-based groups or through the above mentioned food and nutrition programmes. Encouraging greater consumption of Calcium-rich Milk and Eggs, along with green leaves in daily diet.

- Referral system for fluorosis through ASHA/ANM and other health workers with patients referred upwards to PHCs, CHCs and dedicated regional referral centres having ‘fluorosis rehabilitation centres’ providing appropriate health-care for severely affected patients

3.4 How best to communicate the ideas


Communication is key to success of a fluorosis mitigation programme. Since behavior changes need to happen and sustain over many years, unless there is continuous reinforcement of positive habits, individual adherence dies down slowly. There is opportunity in fluorosis to follow many health communication procedures depending on the particular social context.

- Health belief model: Especially since the understanding of this disease is weak even among medical practitioners, people’s beliefs on fluorosis are quite varied and local. A field visit in Dharmapuri and Krishnagiri districts of Tamil Nadu would show that people here believe the yellow stains of dental fluorosis to be that coming from chewing coconut stem in early age. In other places, one would hear of reasons ranging from hereditary factors to mythical beliefs. One approach therefore could be work on this belief and in simple terms explain what this disease is all about. Countering such local beliefs require sustained communication from a variety of social anchors, ranging from local elders, teachers and medical practitioners. Over the longer term, such belief changes could lead to better appreciation of external interventions and adherence to mitigation procedures.

- Classical and operant conditioning: Depending on the type of symptoms involved, there is opportunity for conditioning techniques such as classical and operant conditioning. In some areas, gastric problems from fluoride are high. Such gastric problems are relieved in short term of a few days. There is also evidence that stopping fluoride entry recovers Iron deficiency Anemia in the medium term of few months. But this requires the additional requirement of testing and belief in such testing. Immediate symptoms such as gastric problems could be utilized for classical conditioning approaches and gradation of symptoms such as Anemia, joint pains and then bone deformation changes could be utilized for operant conditioning based communication.

- Self-control and self-reinforcement: Though more difficult, this approach could be emphasized for the subset of motivated patients who are more tuned to discipline and adherence. Such persons even though a minor proportion of population, could serve as models and early adopters for others to follow later by ‘Modeling’ based communication (i.e. vicarious or observational learning in which one witnesses such models of behavior change and learn from them). However, the effort which one needs to put on such individuals or families would be highly intense with a system of relapse management and some procedure of particular rewards or positive reinforcement to enhance the desired change in behavior.

- Social communication: In context of rural society into which we desire to operate fluorosis mitigation procedures, simultaneous reinforcement of ideas from various medium in society becomes important. Terming this as social communication, the strategy would focus less on the individual, and more on bringing change in social behavior and towards approaches that address the problem together. The above mentioned techniques could be tried also with such a societal approach, but alternative directions become open with social communication too.

3.5 Systemic changes to be achieved


The power of mitigation programmes would need widespread systemic changes to be achieved. Many such changes need to be aimed at in the future:

- Prime among that is for medical practitioners to start diagnosing fluorosis
- Testing facilities for fluorosis detection would need to be developed
- Fluorosis should be taught sufficiently well in college curriculum in medicine
- Fluoride removal filters need to be developed and available widely
- Widely available products with high fluoride (toothpaste, mouthwash, etc) need to carry a warning and should be available only on prescription
- Food products which naturally contain high fluoride should also carry a warning

These are changes which need a mix of government policy, medical councils, industry, academia and civil society. Such changes will help mitigation efforts at smaller levels and make them more effective in the longer run.

References


Alvarez J. A., Mayra P. K., Rezende C., Marocho S., Alves F., Celiberti P., Ciamponi A. L., 2009, Dental fluorosis: exposure, prevention and management, Med Oral Patol Oral Cir Bucal, Clinical and experimental dentistry, Feb 1; 14(2)

Arnala I, et al. (1985). Effects of fluoride on bone in Finland. Histomorphometry of cadaver bone from low and high fluoride areas. Acta Orthopaedica Scandinavica 56(2):161-6.

Burgi H, et al. (1984). Fluorine and the Thyroid Gland: A Review of the Literature. Klin Wochenschr. 1984 Jun 15;62(12):564-9

Editorial, 1997, Official “Safe” Fluoride Intakes Based on Arithmetic Error Fluoride 1997, 30:4 (Discussion Section)

Jowsey J, et al. (1972). Effect of combined therapy with sodium fluoride, vitamin D and calcium in osteoporosis. American Journal of Medicine 53: 43-49

Kragstrup J, et al. (1989). Effects of sodium fluoride, vitamin D, and calcium on cortical bone remodeling in osteoporotic patients. Calcified Tissue International 45:337-41

National Research Council. (2006). Fluoride in drinking water: a scientific review of EPA’s standards. National Academies Press, Washington D.C

NEERI, 2007, Integrated fluorosis mitigation: A Guidance manual, Nagpur, India

Reddy R., 2011, Endemic skeletal fluorosis, Lap Lambert Academic publishing

Roholm K., 1937, Fluorine Intoxication: A clinical hygiene study: with a review of literature and some experimental investigations, Copenhagen

Schiffl H., 2008, Fluoridation of drinking water and kidney disease: absence of evidence is not evidence of absence, Nephrological Dialysis Transport, 23(1): 411

Shortt H.E., Pandit C.G., Raghavachari T.N.S.., Endemic Fluorosis in the Nellore district of south India, Indian med. Gaz. 1937: 396

Susheela A K, 2011, A treatise on Fluorosis, Fluorosis Research and Rural Development Foundation, New Delhi

Susheela A. K., Mondal N. K., Gupta R., Ganesh K., Brahmankar S., Bhasin S.and G. Gupta, 2010, Effective interventional approach to control anaemia in pregnant women, Current Science, Vol. 98, No. 10

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