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Vitamin D supplements for at-risk groups

The government has launched a scheme to provide vitamin D supplements to all those at risk of deficiency. Which patients are considered clinically vulnerable and therefore at risk?

Unplanned learning

Benjamin Lolo, a man in his 30s, regularly attends your pharmacy with his young daughter Adelaide. He asks to speak to someone about vitamin D supplements. Benjamin explains he had recently viewed a video clip online that stated, “People with darker skin should take vitamin D supplements”. Benjamin also asks about a new government scheme that provides free vitamin D. What advice can you give Benjamin and Adelaide?

Why vitamin D is important and mechanism of action in body?

Vitamin D is one of four fat-soluble vitamins (A, D, E and K) necessary for normal endocrine, metabolic, and immune function within the body. Vitamin D is involved in the absorption and regulation of calcium and phosphate required to maintain bone, teeth, and muscle health. A lack of vitamin D can therefore lead to a range of conditions including bone deformities (rickets), osteomalacia (soft bones) or osteoporosis (brittle bones).(1)

Most healthy individuals generate vitamin D in the skin following exposure to sunlight during summer months and will absorb vitamin D from food as part of their normal dietary intake throughout the year. Unfortunately, only a small number of foods contain vitamin D and not everyone is exposed to sufficient sunlight, so it can be very difficult to maintain the appropriate levels of vitamin D within the body.

See the CPD article on Vitamin deficiency: fat-soluble vitamins for more information on the importance and function of Vitamin D.

What groups are vulnerable to deficiency?

There are several physiological and sociological reasons why someone would be considered vulnerable to vitamin D deficiency. Vitamin D is converted to its active form in the kidneys and liver. Therefore, patients with renal and hepatic impairment are at a higher risk vitamin D deficiency. Additionally, individuals who have limited exposure to sunlight and people with darker skin tones may not be getting sufficient vitamin D through their skin production route.(2)

The following groups of people would be considered vulnerable to becoming vitamin D deficient:

  • People who are not often outdoors, for example: individuals who are housebound, frail, elderly or isolating for long periods of time
  • People who are in institutional style settings, for example residents in a care home
  • People that usually wear clothing that covers most of their skin
  • People who have darker skin tones, for example people of African, African-Caribbean or south Asian background
  • People with renal or hepatic impairment
  • Babies and young children
What dose is recommended?

The recommended dose of vitamin D is age dependant. Babies up to the age of one year require 8.5–10 µg of vitamin D each day whereas, children older than one year and adults require 10µg (400IU) of vitamin D each day.(3)

During the summer months (approximately late March to the end of September), most individuals will be able to get the required amount of Vitamin D from skin exposure to sunlight and by maintaining a healthy balanced diet.

However, for babies and young children, the Department of Health and Social Care (DH) recommends:

  • Babies breastfed from birth to one year should be given a vitamin D supplement containing 8.5–10µg of vitamin D each day.
  • Babies that are formula fed should not receive vitamin D supplements until they are routinely consuming less than 500ml of infant formula each day. This is because infant formula milk is fortified with vitamin D already.
  • Children aged 1-4 years should be given a daily supplement containing 10µg of vitamin D.

During the autumn and winter months, the DH recommend that for healthy adults (including women who are pregnant or breastfeeding) and children older than four years, to take a daily supplement of 10µg of vitamin D each day. Throughout the autumn and winter seasons, individuals are reliant on vitamin D from their dietary sources, due to reduced sun exposure and it can be difficult to get sufficient vitamin D from food sources alone.(2)  

Those who are vulnerable to vitamin D deficiency should consider daily supplementation throughout the year.(2)

As a result of the COVID-19 pandemic response, many people have faced disruption to their normal daily routines, including extended or repeated periods of isolation and often changes to their diet resulting from alternative working practices. Ultimately, this may have reduced their levels of vitamin D in the body. It is important that all people reflect on their current lifestyle and their individual need for vitamin D supplementation.

What is the new government scheme?

On November 28, the government announced a new scheme that that will provide a four-month supply of “one-a-day” vitamin D supplements containing 10µg of vitamin D to vulnerable adults in England. The scheme will automatically provide care homes with sufficient vitamin D supplements for their residents. People who are considered clinically extremely vulnerable to COVID-19 will receive a letter inviting them to opt in for a supply, which will be delivered for free to their homes.(4) The deliveries will begin in January 2020 and are designed to last individuals through the winter months.

All individuals are encouraged to consider taking part in the scheme except people:

  • already taking or already prescribed vitamin D supplements by a healthcare professional
  • under the age of 18 years
  • with high vitamin D levels
  • with kidney stones (past or present)
  • with hyperparathyroidism
  • with some cancers (resulting in high calcium levels)
  • with severe kidney disease
  • with sarcoidosis.

People who are not suitable for the scheme are advised to speak to their GP or another healthcare professional about vitamin D supplements at their next appointment.(5)

People who can purchase vitamin D supplements ahead of accessing the scheme, are advised to do so and to start taking them, even if they are eligible for delivery later in the year.(5)

Find out more about pharmacy's role in the distribution of the vitamin D supplements.

Is there any evidence that vitamin D can prevent COVID-19 or symptoms of COVID-19?

*On December 17, 2020, the National Institute for health and Care Excellence (Nice) updated it's guideline COVID-19 rapid guideline: vitamin D and concluded that vitamin D supplements should not be offered to people solely to prevent or treat COVID‑19, except as part of a clinical trial. However, all people should continue to follow UK government advice on taking a vitamin D supplement to maintain bone and muscle health.(6)

What advice can the pharmacy team give?

As a pharmacy team, it is important to identify suitable products that facilitate optimal dosing of vitamin D. Pharmacy teams are in an ideal position to identify people potentially vulnerable to vitamin D deficiency and to discuss vitamin D supplementation with them based on the latest government advice.

References
  1. Scientific Advisory Committee on Nutrition (SACN) (2016) Vitamin D and health
  2. NHS (2020) Vitamin D
  3. Public Health England (2016) Government dietary recommendations
  4. Gov.UK (2020)  Guidance on shielding and protecting extremely vulnerable persons from COVID-19
  5. Gov.UK (2020) At-risk groups to receive free winter supply of vitamin D
  6. National Institute for health and Care Excellence (2020) COVID-19 rapid guideline: vitamin D.

 

*This article has been updated on December 17 to reflect the updated Nice COVID-19 rapid guideline: vitamin D

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