Prevention of vitamin D deficiency improves population health, social inequalities and health care budgets

Around the world, populations struggle to achieve healthy levels of vitamin D1 and even in Europe, an estimated 13% of the population is deficient, defined as serum 25OH vitamin D levels below 30 nmol/L.1 Geographical, cultural and ethnic risk factors such as living in high-latitude countries with limited UVB light, sun-avoidance behaviour and specifically dark-skin pigmentation predispose to vitamin D deficiency and its complications.2 Hypocalcaemic seizures, tetany, cardiomyopathy, rickets and osteomalacia with associated muscular hypotonia and pain occur specifically in ethnic groups that are vitamin D deficient and/or consume little dietary calcium.2 A combination of socioeconomic factors puts migrant and ethnic populations in high latitude, western countries at a disproportionally high risk for severe vitamin D deficiency, with growing children being at greatest risk of complications.2 In these settings, vitamin D deficiency can be seen as an indicator of health care inequalities between ethnic groups. In Australia, Sweden, Norway and the UK, rickets is almost exclusively reported in dark-skinned children, which signposts public health strategies that continually miss the target.3 In Britain during the industrial revolution, rickets became known as the English disease before food fortification eradicated it. Once this approach was abandoned, the disease made a rapid comeback. In the last decades, millions of dark-skinned migrants from mainly Commonwealth countries have shifted the UK population’s demographics. However, instead of re-designing its public health measures to ensure that rickets was once again eradicated, the UK government continues in policy apathy and stigmatized the disease as ‘Asian rickets’.3 Protecting entire populations, or just specific high-risk groups, from micronutrient deficiencies is a challenge, and supplementation and fortification are the options. There is evidence that supplementation programmes are inefficient in tackling vitamin D deficiency in some European countries such as the UK, mainly due to poor policy implementation, access, monitoring and adherence. For supplements to be effective, people need to somehow become aware that they need them, find where to get them, purchase them and finally take them religiously according to the appropriate schedule. Often those who need supplements the most likely fall through. In contrast, food fortification overcomes many of these obstacles by reaching all individuals, with the only requirement that they regularly consume the fortified food. Staple foods such as bread, oil and flour are therefore good candidate vehicles to reach entire populations. A recent economic evaluation found that fortifying wheat flour with vitamin D in England and Wales would prevent 10 million new cases and save the National Health Services’ budget £65 million.4 Adding flour fortification to the current policy was found to be cheaper than doing nothing since savings would be generated through the prevention of hospital admissions caused by vitamin D deficiency. Another important aspect that makes food fortification an economically attractive alternative to the public sector’s eyes is that most of the costs fall on the private sector and are diluted as they are passed-on to the consumers. In the case of the UK, some nutrients are already added to wheat flour, which means the structure is already in place and minimal investments need to be made. The benefits, on the other hand would be felt in population health and public sector budgets. Finland’s approach has been highlighted as the example to follow. The country implemented mandatory fortification of a variety of foods, mainly milk and spreadable fats but also yogurt, bread, orange juice and breakfast cereals, and data from its national nutrition survey—the National FINDIET Survey—show that the policy has successfully raised population 25OH vitamin D levels.5 Despite this great success, concerns persist that policies might not be reaching ethnic minority groups in Finland, specifically due to their low intake of selected vehicle staple foods. Demographics are ever changing and as more ethnically dark-skinned or culturally full-body covered migrants settle in Europe, the number of people at highest risk of deficiency under the current policies increases. National diet and nutrition surveys tend to report results stratified by age and sex but ignore important ethnic differences. Data on ethnic minority and immigrant populations are urgently needed. Without such national data, it is not possible to evaluate whether policies are reaching these vulnerable ethnic groups. Adequate vitamin D levels are vital as they maintain a healthy calcium supply to the bones and prevent rickets, osteomalacia and hypocalcaemia, and associated morbidity and deaths, in the population. We call on governments to introduce food fortification with vitamin D to bring about better health, improved children’s developmental outcomes and wider societal benefits that include reducing socioeconomic and ethnic disparities and alleviating the financial burden of vitamin D deficiency on the health sector. Conflicts of interest: None declared.

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