Vitamin D is an essential prohormone that the body produces when the skin is exposed to UVB rays from the sun. It is required for the regulation of calcium and phosphorus metabolism and there is strong evidence that insufficient vitamin D affects musculoskeletal health, immunity, cardiovascular health, neurological conditions, respiratory infections, lung function and cancer.
Most recently, there has been interest in the potential role of vitamin D status in the susceptibility to COVID-19 and the overlap between risk factors for severe COVID-19 and vitamin D deficiency. Elderly residents in residential care homes are recognised in the UK as a group vulnerable to vitamin D deficiency and requiring routine supplementation without. The UK Government currently recommends members of the wider population take 400 IU daily of vitamin D but it is considering increasing its recommendation after months of campaigning from researchers and doctors.
Researchers from the University of Brighton note in the current report that care homes are required to assess resident’s nutritional needs and provide food to meet those needs, including “dietary supplements when prescribed by a healthcare professional”. However, guidance to NHS clinical commissioning groups expressly advises GPs against routine prescription of vitamins in primary care due to “limited evidence of clinical effectiveness” and because “vitamin D supplements can be bought cheaply and easily”. The guidance makes exceptions for medically diagnosed vitamin D deficiency or for osteoporosis but not for maintenance or preventative treatment.
In an aim to discover the perception and practices around this supplement, the researchers conducted semi-structured interviews with 13 people involved in elderly residential care in two different areas of South East England. Participants included 4 family doctors (GPs), 4 care home managers, a dietitian, a falls specialist, 2 public health practitioners/managers, and a senior doctor in elderly care.
Shifting responsibility
None of their respondents were aware of any care home routinely prescribing vitamin D supplements to its residents. Interviewees considered that GPs were responsible for the vitamin D status of elderly care home residents, with prescriptions only written in response to falls or a diagnosis of vitamin D deficiency or osteoporosis rather than as maintenance or preventive treatment, which reflects current NHS guidance.
Care home staff said they would feel vulnerable to malpractice allegations if they routinely provided over-the-counter vitamin D supplements to their residents: they felt this was beyond the scope of their role and expertise.
And there was considerable ambiguity about who should provide and bear the cost of these supplements, although most felt this was GPs' responsibility as prescribers, and that any change would have financial implications for care homes or the residents and their families.
Apart from the dietitian, none of the interviewees seemed familiar with the recommendation that all elderly care home residents should receive vitamin D supplements without the need for a confirmatory blood test, which itself costs more than a year's supply of supplements.
Social injustice
The report notes that recommendations for vitamin D rely on personal responsibility so community-dwelling elderly and independent care home residents can purchase their own vitamin D supplements for personal use. However, people often move into care homes because they no longer have mobility or the mental capacity to live independently, and accordingly have more limited control over lifestyle decisions.
The report states: "Most elderly care home residents have some form of dementia. This results in a two-tier system, discriminating against those with the least cognitive independence. Even if residents or their family purchase OTC vitamin D supplements and request that these are administered by care staff, the GP still needs to approve their use. They would not be covered by homely remedy policies since these are limited to OTC products for short term treatment of minor ailments.
"The regulatory environment would make it difficult for elderly care homes to unilaterally decide to offer all residents daily vitamin D supplements, not least because residents are frequently registered with different GPs."
The authors conclude: "Our investigation into how vitamin D nutrition supplementation is addressed in care homes reveals both a failure to implement evidence-based recommendations and a social injustice in urgent need of public health advocacy and resolution.
"Vitamin D in care homes needs further attention with mechanisms developed for the administration of low-risk dietary supplements or fortified foods by care staff. This will help us to progress from a situation where care staff feel constrained and vulnerable, to one where they are supported to improve the health of those in their care. For a universal, population-based approach, vitamin D supplementation at protective levels needs a professional separation from medicine and re-framing as a matter of public health nutrition."
Source: "BMJ Nutrition Prevention and Health"
Williams. J., and Williams. C.
"Responsibility for vitamin D supplementation of elderly care home residents in England: falling through the gap between medicine and food"
doi: 10.1136/bmjnph-2020-000129
