Impact case study database

Vitamin D is an essential vitamin, helping to regulate the amount of calcium and phosphate in the body, and therefore important to healthy bones and muscles. A lack of vitamin D can lead to bone deformities and pain, and recent research suggests vitamin D reduces infection and modulates the severe complications of Covid-19. For most people, exposure to sunlight is the primary source of vitamin D. Yet the dominant message in health advice has focussed solely on the risk of sun exposure, such as sunburn and skin cancer, rather than these important benefits. In 2019, a YouGov poll for the University of Manchester showed that while many people know about the benefits of sun exposure their behaviour is still very often driven by risk aversion.

This research [1-6] has produced impact in two key areas relating to vitamin D acquisition: UK public health policy and communications relating to sunlight exposure, and sales of vitamin D supplementation.

i) Changing guidance and informing UK public health policy

Impact through changing guidance and informing public health policy has been achieved as a result of the research being used in policy development by relevant public bodies and charities. By virtue of their research [1-6], Webb and Rhodes have acted as scientific experts to these bodies. Much of this policy change has resulted through the Scientific Advisory Committee on Nutrition (SACN). SACN’s recommendations directly inform those of Public Health England (PHE) and the National Institute for Health and Care Excellence (NICE).

In 2013, SACN undertook a review of their sun exposure assumptions in providing for the nation’s vitamin D needs. Webb was a special advisor on the photobiology of vitamin D to the SACN ‘Vitamin D and Health’ committee and report ([A], p. v), delivering a position paper in October 2013 and following up with further evidence in November and December 2013. This drew upon the research into safe summer sun exposure providing adequate vitamin D [1, 3, 4] as well as how this is simply conveyed for lighter and darker skin tones [2].

Subsequently, SACN published recommendations based on the University of Manchester research [1-4] that – for the first time – recommended a Reference Nutrient Intake for vitamin D of 10 µg (400 IU) per day for everyone over age 4 years [B]. Prior to the 2016 report and based on the assumption that needs were met through sunlight exposure, there was no recommended dietary intake of vitamin D for most of the UK population. Whilst SACN Recommendation S.37 ([A], p. xv) acknowledges that sunlight is a major source of vitamin D, it notes that numerous complex factors associated with exposure preclude offering specific advice on sun exposure. [Text removed from publication].

In July 2016, based on the SACN report and UoM research, PHE updated their advice on vitamin D. PHE now recommend that everyone take a vitamin D supplement in autumn/winter or all year round in particular cases e.g. those with little sun exposure, or pigmented skin [C]. PHE (to be replaced with the National Institute for Health Protection in 2021) has responsibility for advising the UK governments and agencies on standards of protection for exposure to non-ionising radiation. To support this, they set up the PHE Advisory Group on Non-ionising Radiation (AGNIR) in 1990, which is specifically a scientific review body advising Government. AGNIR last published a review of the health effects of ultraviolet radiation (UVR) in 2002. In 2013, AGNIR appointed Rhodes as a Board member, and to co-author the 2017 ‘UVR and Vitamin D Report’ [D]. PHE commissioned the report in response to the difficulties faced by SACN in handling sun exposure recommendations and specifically the nuanced messaging required to address the entire population [4, 5]. The report contributed to PHE’s recognition of the importance of sunlight in vitamin D supply. This underpinned a change in PHE advice on supplementation during Covid-19 lockdown (April 2020) [C]: the limits on outdoor activity for the whole population during this time, led to advice for the whole population to supplement through summer.

NICE Public Health Advisory Committee on sunlight and vitamin D have also changed guidance and recommendations following the UoM research [E]. Rhodes was invited onto the Committee as an Expert Member (2014-2016) and NICE confirm that the UoM work [3-5] “ *directly contributed to the new NICE guidance (NG34)*” on Sunlight and Vitamin D [F]. NG34 now acknowledges that, despite the recommendations in the 2016 SACN report, some people will choose to get their vitamin D from sunlight. The guidelines directly reflect the findings of the UoM research of population sub-groups [4, 5], and recommend developing tailored messages for sun exposure for different skin types. NICE guidelines for Vitamin D (PH56) [G] were updated in 2017, in accordance with the updated SACN recommendations from the UoM research to define specific at-risk groups, and to update reference nutrient intake details [F].

Further public health messages have since been revised, based on the UoM research. Rhodes’ advice [3-5] on sunlight exposure was reflected in adjustments to NHS Choices public advice website post-2010 to include the vitamin D benefit of sunlight exposure [H]. Webb’s advice was further reflected in new guidance regarding supplementation [H: 2016], while PHE advice to NHS on Vitamin D during the 2020 Covid-19 pandemic was informed by the work of Webb and Rhodes [C]. Cancer Research UK (CRUK) have also used the research, specifically using the findings of [2] to update their policy and online advice to include specific advice in terms of recommended minutes of safe sunlight exposure for different skin types [I]. In 2018, Rhodes and CRUK collaborated on a CRUK blog including this advice, which has been accessed more than 20,000 times [I]. In 2018, this research also led the British Association of Dermatologists (BAD) to develop two new areas of the BAD public-facing information website: ‘Sun advice for skin of colour’ and ‘Vitamin D Information’ [Text removed for publication].

ii) Changing behaviour of the UK population

The UoM research can be seen to be changing public behaviour in relation to Vitamin D in-take and sun exposure. In late 2018 Boots plc (a major pharmaceutical retailer in the UK), through advertisers Ogilvy, approached Professor Webb to develop a UK UVR and vitamin D availability map [6]. Between February and April 2019, Boots Plc used this research [6] to undertake a UK-wide press campaign promoting vitamin D supplementation and other bone health products [K]. The UoM research specifically identified Stirling as the UK city with greatest risk of vitamin D deficiency [6], and targeted marketing activity by Boots in the city led to a [text removed for publication] increase in sales there. Nationally, Boots experienced an increase in like-for-like sales of vitamin D products of [text removed for publication], compared to 2018 [K]. This increase demonstrates that this public health advice has now reached a significant proportion of the UK population, and altered their vitamin D intake behaviour.