Vitamin D for the elderly: Experts call for “paradigm shift” from medication to supplements

13 Oct 2020 --- Health professionals perceiving vitamin D as a medicine, rather than as a key nutrient, are constraining practice and jeopardizing elderly care home residents’ health in the UK. This is according to a study published in BMJ Nutrition Prevention & Health.

“We suspected there were some problems, but we had not expected to uncover such a mismatch between the public health recommendations and what happens in practice,” Carol Williams from the School of Health Sciences, University of Brighton, and author of the study, tells NutritionInsight. 

She goes on to explain that the researchers were “astonished” to realize how much of this was due to vitamin D being seen as a medicine rather than a food supplement.

This means that people in care homes only supplement with vitamin D after they have been prescribed it by a health professional, instead of seeing it as an over-the-counter vitamin, such as vitamin C.

Vitamin D and COVID-19 link
At a time when the vulnerability of elderly care home residents is under the spotlight because of the impact of COVID-19, an urgent review is needed of the nutritional guidelines and regulations around the use of the vitamin, the researchers argue.

The main source of vitamin D is exposure to sunlight, levels of which plummet during the winter in countries in the northern hemisphere.The main source of vitamin D is exposure to sunlight, levels of which plummet during the winter in many countries in the northern hemisphere. With a few major food sources, it’s difficult to get enough vitamin D from diet alone, and vitamin D deficiency in care homes is widespread in many parts of the world, say the researchers.

Vitamin D is essential for good bone health and is thought to have a role in promoting immunity, cardiovascular health, lung function and proper neurological conditions, as well as preventing respiratory infections and cancer.

Most recently, it has been linked to susceptibility to, and severity of, COVID-19. Previously NutritionInsight reported on the perceived positive health outcomes that the vitamin has in connection to COVID-19.

“The evidence on vitamin D and its link to COVID-19 is still coming in. When we wrote our paper, our UK government committees had just done a rapid review of COVID-19 and vitamin D evidence concluding that there was no proof that vitamin D could protect against COVID-19,” Williams says.

“That is not the same as saying that it is okay for the most vulnerable to be allowed to continue becoming progressively more vitamin D-deficient. Since then, more research evidence is accumulating, which is quite suggestive that vitamin D status could have some impact on susceptibility or severity,” she adds.

Vitamin D deficiencies exacerbated
Vitamin D supplements have been recommended for care home residents for nearly 30 years. In 2016, recommendations for daily vitamin D supplements were extended to the entire population in the winter months and throughout the year for those living in care homes.

In a bid to better understand thinking and practice around the use of vitamin D, the researchers conducted semi-structured interviews with 13 people involved in elderly residential care in two different areas of South East England.

Participants included four family doctors (GPs), four care home managers, a dietician, a falls specialist, two public health practitioners/managers and a senior doctor in elderly care.

None were aware of any care homes routinely prescribing vitamin D supplements to its residents. Although vitamin D supplements are regulated as foods, they were nevertheless regarded as medicines.

Interviewees considered that GPs were responsible for the vitamin D status of elderly care home residents. This means that prescriptions were 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.

The researchers highlight, however, that NHS guidance advises against the routine prescription of vitamin D because supplements can be bought easily and cheaply over the counter.

A lack of understanding
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.

Carol Williams, University of Brighton.Additionally, not everyone was aware that diet and sunlight cannot provide adequate vitamin D levels for the general population in the UK during winter months. Current nutritional recommendations for supplementary vitamin D also heavily rely on personal responsibility, the researchers point out.

“It is questionable whether this is appropriate in populations with limited autonomy,” the study says. It argues that the recommendations effectively create “a two-tier system, discriminating against those with the least cognitive independence.”

The researchers acknowledge the small size of their study, but the fact that participants referred to national policy drivers as key determinants of current practice suggests the finding may be generalizable across England. 

“Much research is warranted, but the most pressing is how can we ensure the practical implementation of long-standing recommendations on vitamin D in care homes,” Williams concludes.

By Kristiana Lalou