Mystery pain was confusing the doctors of Somali patients in Liverpool. One GP recognised that vitamin D deficiency was the likely culprit, and set about getting the evidence and support she needed to change practice in Liverpool, and eventually across the UK.
Vitamin D is an essential nutritional component, the lack of which can lead to musculo-skeletal issues such as; rickets, osteoporosis, and muscle and bone weakness causing general aches and pains which can be difficult to diagnose (for a comprehensive review see Holick 2007). Deficiency in pregnant and breast-feeding women can lead to especially acute symptoms for both mother and child. While a small amount of vitamin D can be absorbed from foods such as oily fish, eggs, dairy products and fortified foods like cereal and margarine, most comes from exposure to sunlight. When skin is exposed to ultra-violet (UV) radiation from sunlight, vitamin D is synthesised. However, during the winter in Northern climates, there are rarely enough hours of daylight, and since glass blocks UV light, people must be outdoors to get any benefit. In winter months deficiency affects up to half of UK preschool children (Davies et al. 1999).
People with dark skin require three times more exposure to sunlight to get the same amount of vitamin D as people with lighter skins (Webb and Engelsen 2006). Theoretically, the problem is easily solved by vitamin D supplements and access to direct sunshine, but first the problem must be diagnosed, and people with dark skin, especially when pregnant, need to be recommended high enough doses from their doctors.
Katy Gardner worked as a GP at Princes Park Health Centre, an inner city practice in Liverpool for 28 years, and during that time saw the local population change as the black British moved to more affluent areas, and Somali and Yemini communities moved in. By partnering with Bennett Lee at John Moores University, they managed to get a grant from the Department of Health to do a detailed ethnicity profile of the practice population. This gave them evidence of the diverse communities, and got PCT funding to run a Social Inclusion team including Yemeni, Somali and Bengali speaking health workers.
As part of this project, the practice realised lots of patients had aches and pains, and after talking to a Professor of Clinical Chemistry, confirmed that mild deficiency in vitamin D could produce these symptoms. Katy was now diagnosing vitamin D deficiency in many of her Somali patients, but needed more data to prove this was a big issue. The team sampled 292 Somalis in Liverpool, and found that 82% were deficient, 59% severely. Crucially they also realised by talking to patients that they disliked like the taste of the supplements, and uptake was low. Funding from the Liverpool Children’s Fund provided a detailed investigation into the diet of Liverpool Somalis, and suggested that people were not eating foods high in vitamin D. For example, people expressed preference for imported Somali brands of margarine, which unlike UK brands were not fortified. Now the group had critical evidence; not just of the extent of the problem, but the reasons behind it, and culturally specific interventions developed by in-depth community research.
The last hurdle was the practitioners. Katy was worried that other GPs in Liverpool might not be aware of the higher risk in non-white patients, and so be misdiagnosing the vague symptoms of aches and malaise. Sure enough, an audit done with a colleague in public health showed that GP practices in the same building, covering the same diverse population, as shown by practice patient profiling data, had huge differences in the number of tests for vitamin D deficiency (a cheap and simple blood test). Awareness training, word of mouth and a booklet for GPs narrowed this gap, and made sure more correct diagnoses were being made, and more appropriate treatment.
This work has been an impetus for much more local work on vitamin D deficiency, including the Healthy Start scheme. This is a national programme to encourage good nutrition, and supplement uptake including a vitamin programme for pregnant women. This is being locally commissioned by Michelle Cox at the PCT, now armed with the knowledge to target the local Somali population.
Project Journey and Challenges:
The key challenge in this example is convincing others – clinicians and commissioners at the PCT in this case, about the importance of a health issue which was observed in practice. However, to make a convincing case, the team have had to use partnerships to provide evidence through research. The resources to do this research, both in terms of time, expertise and funding were difficult to obtain, and instigating research is not ordinarily considered the role of a GP practice. Partnering with academics in Liverpool was a key step in getting research projects started, especially in finding sources of funding.
Getting grant money for research is often a lengthy and complicated process, and although there are some pots of money available directly to clinicians and NHS staff, most research grants must involve academic institutions. However, building networks with researchers in academia, and convincing them of the importance (and viability) of a research issue can be challenging.
For more information, contact Katy Gardner