Public health is the responsibility of all nurses (Royal College of Nursing, 2016; Nursing and Midwifery Council, 2018). Traditionally, nurses have focused on the prevention of disease and challenged the behaviour and attitudes of individuals in order to promote health (Yousefi et al, 2019). However, Edelman et al (2017) argue that the nurse's role has become much more complex due to the increasing number of health policies guiding health promotion practice; trends influencing population health such as new technologies and ecological changes; and organisational cultures that are supportive or unsupportive of health promoting activities (Kemppainen et al, 2013). Nevertheless, nurses consider the art of health promotion to be invaluable, with Kemppainen et al (2013) arguing that they require sound knowledge and competent communication skills to become effective health promotors and to facilitate effective health promotion (Roden et al, 2016). This article will outline why nurses might consider vitamin D as an appropriate health promotion topic when engaging with post-menopausal women.
Vitamin D deficiency
Vitamin D deficiency is one of the most common medical conditions in the world (Sizar et al, 2020). It is highly prevalent in older adults in Northern Europe (McCarroll et al, 2015). One in eight over the age of fifty in Ireland are lacking in vitamin D (Laird et al, 2014). People living in Northern Ireland and the North and West of Ireland are found to be lacking in vitamin D (Laird and Kenny, 2020) due to the latitude of these areas (Webb et al, 2018). Research has shown vitamin D deficiency occurs in women of all ages; however, risk increases with advancing age (Khadilkar, 2013). Studies have observed a strong link between declining oestrogen levels and vitamin D deficiency (LeBlanc et al, 2014).
Northern Ireland has an aging population, with women making up the greatest proportion of the population, as men tend to die younger (McGill, 2010). According to NISRA (2019) the population of over 65 year olds has increased by 1.7% between 2017 and 2018. The UK has projected that there will be an additional 8.2 million in the 65 and older category by 2041 (Government Office for Science, 2016). As people age, their risk of developing vitamin D deficiency increases considerably (Meehan and Penckofer, 2014). Older adults are more at risk due to a number of factors including reduced dietary intake, impaired intestinal absorption, decreased sunlight exposure and reduced skin thickness (Kweder and Eidi, 2018).
Vitamin D intake
Vitamin D is a fat soluble vitamin produced by the body in response to sunlight. The primary function of vitamin D is to promote the uptake of calcium and phosphates in the stomach and intestines and it also increases bone health and strength (Blann, 2015). A common myth among elderly people is that dietary intake of vitamin D-rich foods, such as salmon, dairy products and eggs, is enough; however, this does not meet the daily intake recommendation (Scientific Advisory Committee on Nutrition, 2016). Studies have shown that low levels of vitamin D can increase the risk of cardiovascular disease, some cancers, diabetes, autoimmune diseases and depression in older women (Melamed and Manson, 2011). Increased levels of vitamin D have been shown to lower the risk of bone disorders such as osteoporosis and osteopenia (Yoon et al, 2016).
Vitamin D is an important nutrient in women's health (Khadilkar, 2013). Women endure immense illness and death related to osteoporosis and fractures, which may be reduced by the inclusion of vitamin D in the diet (Bohon and Goolsby, 2013). An estimated three million people have osteoporosis in the UK and women aged 50 years and older are four times more likely to suffer from osteoporosis (NHS, 2017). Prevalence increases with age, and over a quarter of women over the age of 80 living in the UK will suffer from osteoporosis (Alswat, 2017). Women tend to lose bone at a quicker rate and therefore have a younger onset of bone loss; in particular, vitamin D-deficient women can lose as much as 3–4% of skeletal mass per year (Gunton and Girgis, 2018).
A study carried out in Asia on women aged 60–97 years discovered that a third of women in Bangkok suffered from vitamin D insufficiency. Sufficient vitamin D intake by elderly women in Thailand had proven to improve their bone health. The study concluded that education on osteoporosis early in the women's lives could improve their dietary intake of vitamin D. It also alluded that vitamin D3 supplements and a Mediterranean style diet could potentially decrease the level of bone loss in women with osteoporosis (Jennings et al, 2018).
Supplementation
Vitamin D supplementation is recommended for most of the population. The different doses are listed in the Public Health Agency's publication (2017) with most of the population recommended a supplement of 10 mcg daily. Women over 50 are advised to have a daily intake of 800 international units or 20 mcg of vitamin D (Aggarwal and Nityanand, 2013). Women who have dark skin, who are confined indoors and those who cover their skin for cultural reasons need a daily supplement of vitamin D because their skin is not exposed to enough sunlight. Nursing home residents are in the at-risk category as they are limited to an indoor setting for long periods and tend to have reduced mobility. Although the recommendations are readily available, research has highlighted that a mere 8.5% of the over 50s population take vitamin D supplements, 13% of these being women (Laird and Kenny, 2020).
A study was carried out by Weaver et al (2019) to evaluate the cost-effectiveness of the use of vitamin D supplements to prevent fractures related to osteoporosis in women aged over 50 years. The results alluded that there would be 544 687 fewer fractures in the EU if people with osteoporosis took calcium and vitamin D supplements. They also highlighted an estimated saving of around 6.9 million euro to the economy. This research emphasised the cost effectiveness of vitamin D supplements and how increased use among women suffering from osteoporosis across the EU could significantly decrease fractures and related costs (Weaver et al, 2019).
Conclusion
Nurses have a role in creating greater awareness of vitamin D as being important for all ages, but especially for women over 55 and post-menopausal women. Vitamin D deficiency is prevalent across the world and it is the responsibility of all health professionals to educate the population on the importance of vitamin D as a nutrient and to promote vitamin D intake. Post-menopausal women are at an increased risk of vitamin D deficiency due to the hormonal changes that occur during this time, their reduced skin thickness and decreased intestinal absorption. The daily intake of a vitamin D supplement is a cost effective beneficial method for these women to ensure the amount of vitamin D in their bodies is sufficient.