Glaring Gap Between Vit D Guidance and Practice in Care Homes

Becky McCall

October 21, 2020

Vitamin D supplementation in elderly care home residents is largely viewed as a "medicine" rather than a protective nutrient, risking vitamin D deficiency in this particularly vulnerable population, say British public health scientists.

Writing in BMJ Nutrition Prevention & Health, they stress an urgent review is needed of the nutritional guidelines and regulations in England on the use of the vitamin in elderly residential care homes.

Vitamin D supplementation "needs a professional separation from medicine and reframing as a matter of public health nutrition as well as a medical responsibility," emphasizes Joe Williams, MSc Public Health graduate, Brighton University, UK, and colleagues.

The findings reveal "both a failure to implement evidence-based recommendations and a social injustice in urgent need of public health advocacy and resolution," they emphasize.

For 30 years, vitamin D 10 µg as a daily supplement has been endorsed for care home residents. In 2016, the recommendations were extended to the entire population in the winter months and throughout the year for those living in care homes.

But this new study shows care home staff understood that they were only allowed to give residents vitamin supplements that have been prescribed and that physicians had been advised by the UK National Health Service not to prescribe preventative vitamins because they can be bought cheaply over the counter.

"This means that elderly care home residents often do not get the vitamin D they require, leaving them at increased risk of falls," Williams explained.

Vitamin D May Protect Against COVID-19

In the United States, the Institute of Medicine recommends 800 IU/day of vitamin D, and the American Association of Family Physicians/American Geriatric Society recommends 1000 IU/day.

"It is not a medicine to be taken only as needed," Catharine Ross, PhD, professor of nutrition and physiology at Penn State University, told Medscape Medical News.

"The diet of individuals who do not get much sunlight needs to include enough of the vitamin in foods or from a nutritional supplement," she stressed.

"The elderly living in long-term care facilities are a particular concern," she added. "They may not have much sun exposure, and it is known that the skin of older persons is not so efficient at making vitamin D. So for this group especially, attention does need to be paid to getting sufficient vitamin D from diet or a vitamin D-containing supplement," she said.

Martin Kohlmeier, MD, PhD, from the UNC Nutrition Research Institute at the University of North Carolina at Chapel Hill, wholeheartedly agreed.

Vitamin D deficiency increases not only the risk of bone fractures, but could also make people more susceptible to SARS-CoV-2 infection and worsen outcomes, he said. 

"Everybody should use a moderately dosed vitamin D supplement, and guiding patients and the public towards this is already established policy in many countries including the UK," he said.  

Dereliction of Duty: Whose Responsibility Is it to Give Vitamin D?

"Unfortunately," said Kohlmeier, "this message has not reached all health professionals and care providers." 

And he went so far as to say, "If residents of care homes, hospitals, prisons, and other accommodations with restricted autonomy are not provided with moderately dosed vitamin D supplements, then carers are failing in their duties." 

To understand current practice surrounding the implementation of public health guidance on vitamin D supplement use in elderly care homes in England, the new qualitative study included 13 interviews.

These took place with four members of care home staff, four general practitioners (GPs), a dietitian, a falls specialist, two public health practitioners/managers, and a senior clinician in elderly care.

Apart from one dietitian, none of the participants seemed familiar with the recommendation that all elderly care home residents should receive vitamin D supplements without the need for pre-assessment.

Nor did any of the stakeholders know of any care homes where vitamin D supplements were given routinely to residents as part of a protective public health measure.

Williams quoted an interviewee, saying, "There's no kind of protocol or carpet/universal plan to prescribe vitamin D supplements to patients of ours at care homes."

The interviews also revealed that care home staff would feel vulnerable to suggestions of malpractice in administering over-the-counter vitamin D supplements.

"If asked who is responsible for the health and well-being of care home residents, most people answered that the care home was, but upon thinking about this in a medical sense, the answers — including those of GPs — were 'the GP'," Williams noted.

One GP said: "How do we get over the concept of people wanting to take something that doesn't have to be prescribed?"

Williams pointed out that the primary care dietitian had also noted that "the practicalities of dispensing over-the-counter medications in care homes are very difficult."

But Williams stressed that routine vitamin D level testing or screening isn't needed, given that the cost of testing is approximately equivalent to the cost of a year's vitamin supplement supply.

"It would do no harm to provide vitamin D supplementation for this group of residents," he said.

A Gap Between Public Health Guidance and Practice in Care Homes

As residents in elderly care homes have limited ability to make lifestyle decisions, the study identified a glaring gap between public health guidance and practice around vitamin D supplementation.

The researchers hope that relevant national bodies will consider how these findings can be used to implement widespread vitamin D supplementation in care home residents. 

"Public Health England, the National Institute for Health and Care Excellence, and those working with local public health teams need to establish how this plays out and to rapidly address this problem that we have articulated," Williams asserted.

Vitamin D is recognized as a food category or dietary supplement by many regulatory bodies in a number of Western countries, including the European Food Safety Authority and US Food and Drug Administration, he said.

"Only New Zealand seems to have a good approach to this issue," Williams added, where "a publicly funded universal vitamin D supplementation program for care homes has been in operation since 2011. An evaluation [there] in 2014 found that 75% of care home residents took supplements, and almost all of those receiving the supplements had healthy serum levels of 25-hydroxyvitamin D, the marker for vitamin D status."

Vitamin D in Context of COVID-19

Williams notes data on the effect of vitamin D on the prevention or severity of COVID-19 is inconclusive, and in fact, researchers from Queen Mary University of London have, in the last week, launched a new clinical trial to investigate whether taking vitamin D could protect people from COVID-19, as reported by Medscape Medical News.

CORONAVIT will run for 6 months and involve more than 5000 people to find out whether a test-and-treat approach to correct vitamin D deficiency during winter will reduce the risk and/or severity of COVID-19 and other acute respiratory infections.

However, Amit Mandal, MD, of Wexham Park Hospital, UK, believes that vitamin D will turn out to be key. He was coauthor of a recently published study that found older patients with low concentrations of 25-hydroxyvitamin D (≤ 30 nmol/L) during acute infection with COVID-19 were more likely to develop cytokine storm and hypoxia requiring ventilatory support.

He told Medscape Medical News that institutionalized older adults are inherently vulnerable to vitamin D deficiency because of lack of sun exposure and dietary insufficiency. 

"It would seem reasonable to encourage efforts to achieve reference nutritional intakes of vitamin D in accordance with national guidelines. This cheap and safe intervention has multiple health benefits and should therefore be recommended for all older adults," he emphasized.

There has been increasing focus on the well-being of care home residents since the COVID-19 pandemic took hold and a large burden of severe morbidity and mortality has been experienced in these settings in multiple countries.

Williams stressed that UK government advice to all people — young and old — is that vitamin D supplements might be beneficial if they are inside more than usual due to lockdown measures.

Joseph Williams and Carol Williams have reported no relevant financial relationships. Professor Kohlmeier is editor-in-chief of BMJ Nutrition, Prevention & Health. Mandal and Ross have reported no relevant financial relationships.

BMJ Nutr Prev Health. Published online October 12, 2020. Full text

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