Vitamin D deficiency

I read the report on Vitamin D deficiency¹ with interest. In my practice in Hounslow we have a list size of 3700 with a large Somali population. We have been testing for Vitamin D deficiency for 2 years in any patient in an at-risk group who presents with bone or joint pain or non-specific malaise. We started to do this because we picked up several cases of young Somali women presenting with symptoms who were discovered to have frank osteomalacia and two children with rickets.

In the 2-year period we have identified 138 cases of low Vitamin D (70% frank deficiency; serum level <25 nmol/l) and 30% insufficient (serum levels 25–50 nmol/l). Of the individuals found to have low Vitamin D, 93% are non-white patients, and the majority come from the Somali, African, Asian, and Afghan communities.

We have been treating these people with oral vitamin D according to our locally developed protocol, but often find that levels do not respond. Although is has not always been possible to ascertain whether this is due to compliance issues or absorption, we have adopted a pragmatic approach and started to give IM treatment if re-testing shows little or no improvement at 6 months. There are several pregnant women, and although we have not been formally testing their babies' levels, we have started to advise supplementation from birth with appropriate vitamin drops.

We are offering blood testing to screen asymptomatic family members of affected individuals, but this does have resource implications for smaller practices such as ours. To date, of the blood tests carried out 88% have been abnormal, so we are confident that we are reaching some of the vulnerable population.

We have also identified some Read Coding issues, and hope that addressing these will assist in the process of auditing and recall of patients.

I agree with the authors that vitamin D deficiency is a significant and sizeable public heath issue in primary care.

There are likely to be a high proportion of cases that are unrecognised and untreated. The current lack of coherent guidelines about screening and treatment is a major problem.