Analysis

Why nurses need to talk about vitamin D with their patients

As the daylight hours get shorter, many people will need to top up their vitamin D levels to keep healthy
Picture shows a woman taking a vitamin D supplement. As autumn/winter approaches many people will need to top up their levels of vitamin D levels and nurses can play a key role in advising on this

As the daylight hours get shorter, many people will need to top up their vitamin D levels to keep healthy

  • Lack of vitamin D can lead to bone deformities such as rickets in children and osteomalacia in adults
  • With limited exposure to sunlight, a vitamin D supplement may be needed
  • People at higher risk of vitamin D deficiency should consider taking a daily supplement throughout the year

Picture: iStock

As the days shorten into autumn and the suns rays lose their summer strength, the need to consider vitamin D supplements comes to the fore.

Vitamin D is an essential nutrient needed to keep bones, teeth and muscles healthy.

...

As the daylight hours get shorter, many people will need to top up their vitamin D levels to keep healthy

  • Lack of vitamin D can lead to bone deformities such as rickets in children and osteomalacia in adults
  • With limited exposure to sunlight, a vitamin D supplement may be needed
  • People at higher risk of vitamin D deficiency should consider taking a daily supplement throughout the year

Picture shows a woman taking a vitamin D supplement. As autumn/winter approaches many people will need to top up their levels of vitamin D levels and nurses can play a key role in advising on this

Picture: iStock

As the days shorten into autumn and the sun’s rays lose their summer strength, the need to consider vitamin D supplements comes to the fore.

Vitamin D is an essential nutrient needed to keep bones, teeth and muscles healthy.

It is often known as the ‘sunshine vitamin’, and during the summer – early April to September – the UK population gets most of its vitamin D from sunlight.

In the winter months a different approach to getting enough vitamin D is needed

It is synthesised in the skin when exposed to sunlight containing sufficient ultraviolet B (UVB) radiation.

But during the winter months, and for those whose exposure to the sun in summer is restricted, a different approach is needed.

Advising patients on the amount they need is an important public health aspect of many nurses’ work, particularly those working with groups at higher risk of deficiency.

£3.10

of Healthy Start vouchers are available weekly to eligible pregnant women and children aged one to four to help buy some basic foods

This autumn it could be particularly important, after the population was told to stay at home throughout lockdown and, for those who were shielding, for even longer.

The current guidance is drawn from the Scientific Advisory Committee on Nutrition report, Vitamin D and Health.

Published in 2016, it states that everyone aged over one year, including pregnant and breastfeeding women, need 10 micrograms of vitamin D each day.

Effects of lockdown could include limited sun exposure

As it is difficult to get 10 micrograms of vitamin D from food alone in winter, a supplement should be considered containing that amount between September and March for everyone over four years of age.

Those at higher risk, including breast-fed babies up to one year, children aged one to four, people who do not spend much time outside in the summer, and people with darker skin tones that can affect the synthesis of vitamin D through the skin, should take or consider taking a daily supplement throughout the year.

And this year, due to the lockdown, the NHS has advised that the whole population consider a daily 10 microgram supplement, as this year’s circumstances could mean limited sun exposure.

Vitamin D: what the NHS advises

Four symbolEveryone over the age of four, including pregnant and breastfeeding women, should consider taking a daily supplement containing 10 micrograms of vitamin D during the autumn and winter


Breastfeeding image

Breastfed babies from birth to one year of age should be given a daily supplement containing 8.5-10 micrograms of vitamin D


Baby bottle image

Formula-fed babies should not be given a vitamin D supplement until they are having less than 500mL of infant formula a day, as it is fortified with vitamin D


Toddler image

Children aged one to four years should be given a daily supplement containing 10 micrograms



Senior person image

People at higher risk of deficiency should take 10 micrograms throughout the year, including those who are not often outdoors, who are living with frailty or are housebound, who live in a care home or usually wear clothes that cover up most of the skin when outdoors


Ethnicity imagePeople with dark skin, including those with African, African-Caribbean or south Asian backgrounds, may also not get enough vitamin D from sunlight, and should consider taking 10 micrograms daily

Source: NHS.UK. Pictures: Noun

Supplements are important because it is impossible to know how much vitamin D someone has made through their skin, and because there are relatively few naturally rich food sources of vitamin D, says the Scientific Advisory Committee on Nutrition.

Good food sources include egg yolk, meat, animal fat, liver, kidney, and oily fish such as salmon, mackerel, herring and sardines.

A lack of vitamin D can lead to bone deformities such as rickets in children, and bone pain caused by a similar condition called osteomalacia in adults.

Cases of rickets on the increase in the UK

April to September

are the months when people can get most vitamin D from sunlight

(Source: NHS)

Rickets, while still relatively rare, is on the increase in the UK, and many people have low levels of vitamin D, the NHS says. Symptoms include bone pain, a waddling walk, poor growth and development, dental problems, fractures and skeletal deformities including bowed legs.

The condition is more common in children with darker skin, as they need more sunlight to get enough vitamin D, as well as children born prematurely or taking medication that interferes with vitamin D.

Adults can experience similar symptoms in the condition called osteomalacia.

Staff need to be trained in health messages regarding vitamin D

Pauline Bigwood, professional lead for health visiting at Children and Family Health Surrey, an NHS community health service for children and young people, has run a campaign locally for the past five years to raise awareness of the importance of vitamin D among families.

‘We need to be telling families who are entitled to free vitamins how to access them’

Pauline Bigwood, professional lead for health visiting at Children and Family Health Surrey

A fundamental part of this has been ensuring that all staff who come into contact with children and families are trained in health messages regarding vitamin D and feel confident discussing it.

‘I wanted every professional to feel confident, to make every contact count and to have the knowledge to have an evidence-based conversation.

‘We had bespoke health review pages developed for every child’s personal child health record (the red book), to include a discussion on vitamin D and signpost parents to the vitamin D page on our website for more information. We have badges for professionals stating: “Ask me about vitamin D” to support initiating conversations.’

NHS Healthy Start programme could be viewed as a partnership

Some pregnant women and those on low incomes with children under four will be entitled to free NHS Healthy Start vitamins, which include vitamin D.

‘Raising awareness of Healthy Start vitamins is important to reduce health inequalities’

Research shows that women introduced to the scheme by a health professional who takes time to explain its public health context and health benefits are more likely to view it as a partnership with them to benefit the health of their child, rather than as a simple financial contribution. This means they may be more likely to make best use of the scheme, the NHS Healthy Start programme says.

Ms Bigwood says pregnant women and new parents are bombarded with public health messages, all of which are important, so she understands how the vitamin D information can sometimes be missed or lost.

‘But raising awareness of Healthy Start vitamins is so important to reduce health inequalities,’ she says. ‘We need to be telling families who are entitled to free vitamins how to access them, and how to exchange their vouchers.’

Picture shows a poached salmon fillet with vegetables. Oily fish are a rich source of vitamin D

Picture: iStock

Royal Osteoporosis Society specialist nurse and clinical adviser Sarah Leyland says vitamin D advice can be confusing.

When it comes to older people with frailty, including those with osteoporosis, the advice is that they may be able to get enough vitamin D in the summer months if they spend some time outside.

But if they can’t, and that includes those in care homes, it is worth considering a daily supplement.

After shielding and lockdown, vitamin D supplements could be vital

This year, with shielding and lockdown, some people may be going into the winter months with already low levels of vitamin D, making the need for a supplement particularly important, Ms Leyland says.

‘There will definitely be many frail older people who have not been out as much as normal and for whom there is still a fear around COVID-19, which means their normal activities are still restricted,’ Ms Leyland says.

‘We encourage people to spend time in the garden, on a balcony or even by an open window, but not by a closed one, as sufficient UV does not get through the glass. We normally say once or twice a day, getting ten minutes outside between 11am and 3pm in summer sun should be sufficient, but darker skin will often need longer, and any time spent outside needs to be balanced with the risk of skin cancer with too much sun.

‘Vitamin D supplements are affordable, easily available and, at recommended levels, very safe’

Sarah Leyland, specialist nurse and clinical adviser at the Royal Osteoporosis Society

‘It’s important not to get sunburnt. However, from the end of September through to April the sun’s rays aren’t going to produce vitamin D in the skin, so getting some extra will be important. Food sources don’t provide much vitamin D either, which is why a supplement in the winter will be a good option, especially for this group.’

While the evidence around increasing vitamin D intake and bone fracture is not completely clear-cut, it plays a definite role in bone and especially muscle strength.

‘Having sufficient levels is important when it comes to avoiding falls, and therefore fractures,’ Ms Leyland says. ‘Vitamin D supplements are affordable, easily available and, at recommended levels, very safe.’

Nurses need to emphasise the importance of vitamin D supplements this winter

Some people calling the Royal Osteoporosis Society phone line, which can also be contacted by healthcare professionals, report difficulties with combined calcium and vitamin D tablets causing constipation. But this is the calcium element, and patients can take tablets containing just vitamin D as long as they get enough calcium in their diet, Ms Leyland says.

Supplements are also available in vegetarian and vegan-friendly forms.

After six months of COVID-19 disruption, understanding and emphasising the role of vitamin D supplements could be particularly important for nurses this winter.

‘I am tenacious about keeping this on the agenda,’ says Ms Bigwood. ‘I have seen the impact for children with low vitamin D and, aware of the rise of rickets, this is a conversation that public health nurses should be having with all families.’

No evidence of vitamin D’s role in body’s immune response to COVID-19…

Suggestions were made early in the pandemic that vitamin D may have a role in the body's immune response to respiratory viruses, including COVID-19.

This prompted the Scientific Advisory Committee on Nutrition (SACN) to publish a report on vitamin D and acute respiratory tract infections, and the National Institute for Health and Care Excellence (NICE) to carry out a rapid review of the evidence.

… but it helps maintain muscle and bone health

The NICE review, published at the end of June, found there was no evidence to support taking vitamin D supplements to specifically prevent or treat COVID‑19.

But it stressed that people should continue to meet the current guidance to maintain their muscle and bone health.

The Scientific Advisory Committee on Nutrition did not find evidence to support supplementing vitamin D to prevent respiratory tract infections, but said it would keep emerging evidence under review.



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