THE RELATIONSHIP BETWEEN THE LIFESTYLE OF THE RESIDENTS RESIDING IN FLUOROSIS ENDEMIC AREAS AND ADULT SKELETAL FLUOROSIS
- Authors: Ye Q.1, Liu G.2, Li Q.1
-
Affiliations:
- School of Nursing, Harbin Medical University, Harbin, Heilongjiang, China
- The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang
- Issue: Vol 10 (2021): Материалы XVII Международной Бурденковской научной конференции 22-24 апреля 2021 года
- Pages: 579-582
- Section: Medicine without frontiers
- URL: https://new.vestnik-surgery.com/index.php/2415-7805/article/view/6699
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Abstract
The relationship between fluorosis and the lifestyle of adult residents of areas in which fluoros is is endemic was evaluated. A cross-sectional and case-control analysis was performed to study 289 villagers living in fluorosis endemic areas who drank the local water. Subjects were divided into skeletal fluorosis and non-skeletal fluorosis groups according to whether they were afflicted with skeletal fluorosis. A semi-quantitative food frequency questionnaire, homemade lifestyle questionnaires, and general characteristics were analyzed. The factors that affected the occurrence of skeletal fluorosis were determined by generalized estimating equations. Our results showed that protective factors against skeletal fluorosis included drinking boiled water, storing water in a ceramic tank, and ingesting fruits, vitamin A,thiamine, and folic acid. Risk factors for skeletal fluorosis were overweight status and obesity, drinking tea, drinking water without storage, and ingestion of oils, fats, and phosphorus. Our results demonstrate that skeletal fluorosis has a close relationship with lifestyle.
Full Text
- Introduction
Endemic fluorosis is a whole-body chronic toxic disease caused by long-term excessive intake of fluoride by people living in a particular natural geological environment. Dental fluorosis and skeletal fluorosis are its two main symptoms. Many patients maimed, and even paralyzed[1] .Numerous studies indicated that the incidence of endemic fluorosis of different residents not only related to the fluoride exposure, but also related to the social demographic data , the altitude of residence, the use of fluorinated products, nutrition activity level, health status, their own individual conditions and other factors [2].At present, the epidemiological survey of fluorosis in and abroad showed that lifestyle can influence the occurrence and prevalence of fluorosis. However, the current study was restricted to studies of the relationship between several nutrients or overall nutritional status with fluoride [3]. Most of the studies were animal experiments, less population survey reports [4], and lack of the impact of the resident lifestyle on the endemic fluorosis. And there is poor guidance for resident daily life in fluorosis endemic areas.
Therefore, this study aimed to investigate lifestyle of resident, discuss the relationship between lifestyle and skeletal fluorosis and provide a scientific basis for the prevention and treatment of endemic fluorosis, thus improve the prevention and control of the disease.
- Methods
2.1The choose of investigation sites and investigation objects
According to years of monitoring data of Chinese Institute of Endemic Disease Center and Chinese health standards for drinking water [5], four villages of Zhaozhou County in Heilongjiang Province where fluoride concentration exceeding 1.2mg/L were chosen as our investigation sites, and they were Shuangjing, Yushu, Changshan and Nongan villages. The drinking water sources of villagers residing in these villages were their own small wells and pressure wells.
The basic characters such as age, sex and marital status of the residents living in these four villages were investigated. The age were between 40~60; live more than ten years in the investigation sites; drinking water from the same well more than a decade and the fluoride concentrations in their drinking water were more than 1.21mg/L were the inclusion criteria. Villagers with mental illness, serious cognitive impairment, vital organs (such as heart, liver, lung, kidney) function damaged and other serious chronic diseases were excluded.
2.2Questionnaire
Before the investigation, all staffs involved in the investigation were trained.The content included the purpose and procedure of this investigation, how to fill out questionnaires and so on. People who were qualified in the training can be involved in this investigation.
2.2.1General questionnaire
The general questionnaire was designed according to the objective and content of study. The content included age, sex, marital status, residence time, education level, income level, etc.
2.2.2Semi-quantitative food frequency questionnaire
Semi-quantitative food frequency questionnaire (SQFFQ) is a dietary assessment tool which is widely used in the international to study the relationship between nutrition and disease. It collected and studied the food consumption and consumption frequency in the past years. Questionnaire consists of three section, they were the list of foods, food intake frequency and weight of each intake.
2.2.3Lifestyle Questionnaire
The lifestyle questionnaire included smoking (to smoke at least one each day, six consecutive months or more, or a cumulative capacity reach this level in a short time ), drinking alcohol (to drink at least once a week, six consecutive months or more, or a cumulative capacity reach this level in a short time), drinking tea (to soak for at least 2 times or replace tea2 times a week, and more than three consecutive months), the type of water source, storage mode of water, drinking habits of water, daily intake of water, and so on.
2.3Physical examination
The height and weight meter was used to measure the height and weight of subjects and calculate the body mass index (BMI). According to People's Republic of China Health Industry Standard WS192-2008 (Health industry standard of the People's Republic of China, 2008), X-ray image were unified read by skeletal fluorosis experts in Harbin Medical University. The skeletal fluorosis was diagnosed by combined data of epidemiology and clinical manifestations.
2.4The collection and testing of the fluoride exposure situation
The drinking water of subjects from their well was collected by 25 mL centrifuge tubes and could not less than 20 mL per person. Then they were persevered in the refrigerator at 4°C. The content of fluorine was measured by national standard method. According to the different concentration of fluoride in drinking water, subjects were divided into three groups. They were the mild group (the fluoride concentration was in the range of 1.21~2.00mg/L), the moderate group (the fluoride concentration was in the range of 2.01~ 3.00mg/L) and the severe group (the fluoride concentration was higher than 3.01mg/L).
2.5 Ethical Issues
This study was accordance with the Helsinki Declaration and was approved by the Medical Ethics Committee of Harbin Medical University (HMUIRB2011001) and agreed by the village committee. All subjects had signed the informed consent form by himself (herself) or his (her) spouse.
2.6Statistical Analysis
All the data in the questionnaires was entry in Excel. The data was converted by the SAS statistical software and was entry in food nutrition calculator V1.6 (China CDC Nutrition and Food Safety Institute) to calculate the daily dietary intake of various nutrients. The SAS9.1.3 was used for statistical analysis. The measurement data and count data were expressed as mean ± standard deviation (s) and frequency (percentage). The continuous variable was segmented by quartile. The influence factors of skeletal fluorosis were analyzed by generalized estimating equations. All the tests were two-tailed, and P<0.05 was considered statistically significant.
3.Results
3.1The general characters of subjects
There were 428 villagers in total who met the inclusion criteria completed the questionnaire and physical examination. According to the physical examination results and the exclusion criteria, 289 villagers were eventually determined to be surveyed. There were 74 skeletal fluorosis residents, including 35 males (47.30%) and 39 females (52.70%). The mean age was 54.73 ±8.63 years old and the mean BMI was 24.77±3.90 kg/m2. There were 215 non-skeletal fluorosis residents which include 79 males (36.74%) and 136females (63.26%). The mean age was 53.03±8.52 years old and the mean BMI was 24.19±3.43 kg/m2.
3.2The effect of lifestyle on skeletal fluorosis (single factor analysis)
The results showed that the protective factors were drinking boiled water, storing water with ceramic cylinder, calcium supplements, cereal and potatoes, fruits, beans and nuts, protein, vitamin A, vitamin B2, vitamin C, folic acid, magnesium and selenium. And the risk factors were alcohol drinking, overweight and obesity, residence time, drinking water without storage, drinking tea, drinking un-boiled water, fluoride concentration, fluoride intake amount, fats and oil, phosphorus and iodine. The detailed was shown in Table 1.
Table 1 The relationship between lifestyle and skeletal fluorosis
Variable | LowerCL | UpperCL | Z | P-value | ||
Drinking | 0.5620 | 0.2149 | 0.1408 | 0.9831 | 2.62 | 0.0089 |
BMI | 0.4894 | 0.1142 | 0.2655 | 0.7133 | 4.28 | <.0001 |
Residence time | 0.0147 | 0.0064 | 0.0022 | 0.0271 | 2.30 | 0.0213 |
Drinking habits |
|
|
|
|
|
|
boiled water/tea | -4.1865 | 2.1577 | -8.4156 | 0.0425 | -1.94 | 0.0523 |
unboiled water /tea | -3.2040 | 2.1228 | -7.3647 | 0.9567 | -1.51 | 0.1312 |
unboiled water +boiled water /tea | -2.9209 | 2.3384 | -7.5040 | 1.6623 | -1.25 | 0.2116 |
Ways of storing water |
|
|
|
|
|
|
plastic drum /un-stored | -1.3712 | 0.2816 | -1.9231 | -0.8193 | -4.87 | <.0001 |
porcelain jar /un-stored | -1.5372 | 0.2590 | -2.0450 | -1.0295 | -5.93 | <.0001 |
Water fluorine | 0.8297 | 0.2284 | 0.3821 | 1.2773 | 3.63 | 0.0003 |
The intake of fluorine | 0.0739 | 0.0427 | 0.0097 | 0.1575 | 1.73 | 0.0833 |
Calciumsupplementation | -0.3960 | 0.1695 | -0.7282 | -0.0634 | -2.34 | 0.0195 |
Food |
|
|
|
|
|
|
cereal and potatos | -0.1494 | 0.0436 | -0.2349 | -0.0640 | -3.43 | 0.0006 |
fruits | -0.1316 | 0.0798 | -0.2879 | 0.0248 | -1.65 | 0.0991 |
fats and oils | 0.2199 | 0.0945 | 0.0346 | 0.4052 | 2.33 | 0.0200 |
soy and nuts | -0.1845 | 0.1118 | -0.4037 | 0.0347 | -1.65 | 0.0990 |
Nutrients |
|
|
|
|
|
|
protein | -0.3299 | 0.1075 | -0.5406 | -0.1192 | -3.07 | 0.0021 |
vitamin A | -0.1892 | 0.0630 | -0.3127 | -0.0657 | -3.00 | 0.0027 |
thiamine | -0.1804 | 0.0906 | -0.3580 | -0.0028 | -1.99 | 0.0465 |
viataminC | -0.1594 | 0.0665 | -0.2897 | -0.0291 | -2.40 | 0.0165 |
folic acid | -0.2249 | 0.0938 | -0.4088 | -0.0411 | -2.40 | 0.0165 |
magnesium | -0.3047 | 0.1095 | -0.5194 | -0.0901 | -2.78 | 0.0054 |
phosphorus | 0.2955 | 0.1204 | 0.5314 | 0.0595 | 2.45 | 0.0141 |
selenium | -0.1345 | 0.0654 | -0.2627 | -0.0063 | -2.06 | 0.0397 |
iodine | 0.1904 | 0.0732 | 0.0469 | 0.3338 | 2.60 | 0.0093 |
3.3The effect of lifestyle on skeletal fluorosis (multivariate analysis)
The results showed that the protective factors were drinking boiled water, storing water with ceramic cylinder, fruits, vitamin A, thiamine, folic acid. And the risk factors included residence time, overweight and obesity, drinking tea, drinking un-boiled water, drinking water without storage, fluoride concentration, fluoride intake amount, fats and oil, phosphorus. The detailed was shown in Table 2.
Table2 The relationship between lifestyle and skeletal fluorosis after adjusted different confounds
Variable |
| LowerCL | UpperCL | ||||
Intercept | -0.4751 | 0.6201 | -1.6904 | 0.7403 | -0.77 | 0.4436 | 0.62 (0.18~2.10) |
Residence time | 0.0092 | 0.0034 | 0.0025 | 0.0159 | 2.71 | 0.0068 | 1.01 (1.00~1.02) |
BMI | 0.2150 | 0.1058 | 0.0076 | 0.4223 | 2.03 | 0.0421 | 1.24 (1.01~1.53) |
Drinking habits |
|
|
|
|
|
|
|
boiled water/tea | -1.3209 | 0.3573 | -2.0211 | -0.6206 | -3.70 | 0.0002 | 0.27 (0.13~0.54) |
unboiled water /tea | -0.6112 | 0.3983 | -1.3919 | 0.1695 | -1.53 | 0.1249 | 0.54 (0.25~1.18) |
unboiled water +boiled water /tea | -1.2317 | 0.5220 | -2.2549 | -0.2085 | -2.36 | 0.0183 | 0.29 (0.10~0.81) |
Ways of storing water |
|
|
|
|
|
|
|
plastic drum /un-stored | -1.2144 | 0.2977 | -1.7978 | -0.6310 | -4.08 | <.0001 | 0.30 (0.17~0.53) |
porcelain jar /un-stored | -1.4717 | 0.2782 | -2.0169 | -0.9266 | -5.29 | <.0001 | 0.23 (0.13~0.40) |
Water fluorine | 1.0398 | 0.1373 | 0.7706 | 1.3090 | 7.57 | <.0001 | 2.83 (2.16~3.70) |
The intake of fluorine | 0.1462 | 0.0465 | 0.0550 | 0.2374 | 3.14 | 0.0017 | 1.16 (1.06~1.27) |
Fruits | -0.3030 | 0.1037 | -0.5062 | -0.0998 | -2.92 | 0.0035 | 0.74 (0.60~0.91) |
Fats and oils | 0.1850 | 0.0892 | 0.0102 | 0.3599 | 2.07 | 0.0381 | 1.20 (1.01~1.43) |
Vitamin A | -0.3445 | 0.1066 | -0.5534 | -0.1355 | -3.23 | 0.0012 | 0.71 (0.57~0.87) |
Thiamine | -0.4118 | 0.1206 | -0.6481 | -0.1754 | -3.41 | 0.0006 | 0.66 (0.52~0.84) |
Folic acid | -0.2705 | 0.1084 | -0.4830 | -0.0579 | -2.49 | 0.0126 | 0.76 (0.62~0.94) |
Phosphorus | 0.4208 | 0.1587 | 0.1097 | 0.7318 | 2.65 | 0.0080 | 1.52 (1.12~2.08) |
4.Discussion
As described in Table 2, the different daily drinking habits can influence the incidence of skeletal fluorosis. The habit of drinking boiled water was best. The study of Li[6]showed that boiled water was a simple method to remove fluoride. The fluorine content in the water would decrease because the solubility of salts decreased in the process of heating and generated electrostatic attraction with the heater, which caused the salt attached to the container wall. This study also found that drinking tea can increase the risk of skeletal fluorosis. Research[7] showed that regular consumption of tea will increase the excretion of urinary calcium, resulting in bone loss. At the same time, tea contained fluorine, and it easily released in the water .Therefore, residents in fluorosis endemic areas drink less or not to drink tea can reduce the incidence of fluorosis or mitigate the extent of the lesions .In addition, the stored way of water can affect the incidence of skeletal fluorosis. Compared to drinking un-stored water, drinking water stored with ceramic cylinder could decrease the risk of skeletal fluorosis.
The dietary risk factors of skeletal fluorosis included fats and oils, phosphorus (Table 2). There was few relevant literature to report that fats and oils were risk factors of skeletal fluorosis. Liu [8]had studied the impact of fat on the toxicity of fluoride which used rats,the results showed that high fat intake increased fluoride toxicity Liang's research showed that The heavier skeletal fluorosis patients, the higher the serum phosphorus levels. This study also demonstrated that the risk of skeletal fluorosis increased when increasing phosphorus in dietary.
The study found that the dietary protective factors of skeletal fluorosis included fruits, vitamin A, thiamine and folic acid (Table 2). Fruits were protective factors of skeletal fluorosis. It was probably because that the fruits were rich in vitamins A, C, E, folic acid and other antioxidants which can enhance the body's antioxidant capacity, thus blocked the occurrence of fluorosis. Therefore, the health education should be strengthen and initiate residents living in endemic areas increase the intake of antioxidant-rich fruits and food.
Conclusions
In summary, our findings suggested that skeletal fluorosis is closely related to drinking, diet, weight control and other lifestyle of the residents residing in fluorosis endemic areas. Therefore, the intervention of lifestyle of residents in fluorosis areas, such as to strengthen health education, develop healthy drinking habits and promote reasonable diet are critical. All these interventions would reduce the incidence of skeletal fluorosis or mitigate the extent of the lesion, then improve the life quality of residents.
About the authors
QingFang Ye
School of Nursing, Harbin Medical University, Harbin, Heilongjiang, China
Author for correspondence.
Email: yeqingfang810@163.com
ORCID iD: 0000-0003-2933-0444
doctor
Russian FederationGuoJie Liu
The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang
Email: 64754146@qq.com
ORCID iD: 0000-0003-2933-0444
QiuJie Li
School of Nursing, Harbin Medical University, Harbin, Heilongjiang, China
Email: liqiujie1949@163.com
ORCID iD: 0000-0003-2933-0444
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