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Vitamin D
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2. This course should take approximately 20 minutes to complete…
you will get an update to let you know when you are half way through!
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Why do I need to know about Vitamin D?
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Quick Quiz
Vitamin D deficiency is present in what percentage of the population in Britain today? 1% 3% 7%
15%
>25%
YES- >25%!!!
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5. What do you know about Vitamin D?
Before starting this package, think about the following questions:
Do you think you need to know about vitamin D for your role?
Do you know everything you need to about Vitamin D?
What could you gain from completing this package?
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6. Whatever your level of knowledge about or interest in Vitamin D…
This course is for you! It covers the basic information that we all need to know And contains more detailed information for those who are interested in knowing a bit more…
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Some pages will have a treasure chest symbol
Click on this to access more detailed information about that subject and references
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Background
Vitamin D deficiency is re-emerging in Britain
More than 25% of the population are thought to be Vitamin D deficient
For Salford children this has meant:
Much higher rates of rickets
More fractures
Some cases requiring safeguarding investigations*
*the role of vitamin D deficiency in safeguarding investigations is controversial. See treasure chest.
Treasure chest- needs to have hyperlink inserted to PDF file 1 (containing Birmingham paper plus more safeguarding info)
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9. Re-emergence of rickets
This is the reason you are doing this training on vitamin D
There is an emerging problem in Salford
We need to make sure frontline staff are fully aware of the issues…
…and what to do about them!
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Learning Objectives
By the end of this e-learning package you should:
Know how Vitamin D deficiency can affect health
Understand that natural sources of Vitamin D are unlikely provide us with enough Vitamin D
Know which groups are recommended to have vitamin supplementation
Be able to give accurate information to clients about obtaining vitamins in Salford
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What does Vitamin D do?
Vitamin D has several important functions for health and growth.
It helps to regulate the amount of calcium and phosphate in the body.
Treasure chest needs to have hyperlink to PDF file 2 (containing ranges for vitamin D deficiency)
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Vitamin D deficiency
Can cause rickets in babies and children
Severe deficiency affecting the bones in babies and children is called rickets and may lead to
soft skull
bowing of the legs
Bones can break more easily
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Vitamin D deficiency
Can cause osteomalacia in adults and older children
This can cause bone pain and tenderness
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Vitamin D deficiency
May cause poor growth
Height is usually affected more than weight
Children might be reluctant to start walking
Children may be late teething as the development of milk teeth can be affected
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Vitamin D deficiency
Severe vitamin D deficiency can cause low calcium
This can cause
muscle pain
spasms (cramps)
muscle weakness
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Vitamin D deficiency
Can cause low calcium which can
lead to seizures
be life threatening
1 child per week has a seizure due to vitamin D deficiency in the UK
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Vitamin D deficiency
Can cause irritability
Those taking anti epileptic medication can be more at risk of vitamin D deficiency
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Vitamin D deficiency
Rarely, an extremely low vitamin D level can cause weakness of the heart muscle
(cardiomyopathy)
This is life threatening
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Quick Quiz
The following can be symptoms of Vitamin D deficiency:
Muscle aches
Yes- Muscle aches are a common symptom
Bowed legs
Yes- While a child is still growing, this a classical sign of rickets
Seizures
Yes- This is a risk with a low calcium level, which can happen in Vitamin D deficiency
Tiredness
Yes- A common symptom
Broken bones
Yes- Bones can be weakened by Vitamin D deficiency which means that they can break more easily
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20. Importance of Vitamin D
There is on-going research into other effects of vitamin D deficiency. It is possible that Vitamin D may be much more important for long term health than is currently recognised
The treasure chest below contains more information about the effects of vitamin D deficiency and why we become vitamin D deficient
Treasure chest- needs hyperlink to PDF file 3 (containing effects of vit D and why we become vit D deficient)
Treasure chest re other effects
Ref NHS choices website/SACN
(cardiovascular risk and vit d)
(immune system and vitamin D) TB
Cancer/autoimmune/cardiovascular
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21. Where does vitamin D come from?
It is :
made in the body when the skin is directly exposed to the sun
present naturally in some foods, such as oily fish, eggs, liver and cheese
present in some fortified foods, such as breakfast cereals, yoghurt, margarine, powdered milk
unlikely that you can get enough Vitamin D from sunlight and diet alone if you live in the North of England
therefore available as a supplements
such as vitamin tablets or drops
By Sbrools (Own work) [GFDL (
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By Sbrools (Own work)
[GFDL (

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Sunlight- advice
To make enough Vitamin D:
A fair-skinned person needs minutes of sunlight on the face and forearms around the middle of the day 2-3 times a week in summer months in the UK
Some groups need much more than this: ie people with darker skin and the elderly
The sunlight has to fall directly on to bare skin (through a window is not enough)
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Sunlight- advice
However:
Too much exposure to the strong sun can be damaging.
Sunburn should be avoided (mainly because it increases the risk of skin cancer)
Children should wear sun screen to prevent sun burn
Further North than 52 degrees latitude (Gloucester), there is not enough UVB rays in sunlight necessary to make vitamin D between October and April
Many people in the UK are therefore at risk of not getting enough vitamin D unless they get it in their diet and supplements
Treasure chest- needs hyperlink to PDF file 4 (containing extra sunlight advice)
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24. Well done for getting this far…
you are about half way through!
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25. Do you know which of these contain Vitamin D?
No- Green beans do not contain vitamin D Yes- breakfast cereals are fortified with vitamin D No- Red meat does not contain vitamin D
Yes- egg yolk does contain vitamin D Yes- dairy products do contain vitamin D Yes- mushrooms do contain vitamin D
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Diet and Vitamin D
Did you know…?
Other aspects of your diet are important too:
High calcium intake can lessen the bone effects of vitamin D deficiency
High fibre diet can worsen the effects of vitamin D deficiency
Meat eaters seem to have some protection against the effects of vitamin D deficiency
Treasure chest needs hyperlink to PDF file 5 (contains info re some protective factors ie ca and red meat/genetic predisp)
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27. Who is at risk of Vitamin D deficiency?
ALL OF US!
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28. Who is most at risk of Vitamin D deficiency?
All pregnant and breastfeeding women, especially teenagers and young women.
Women who have had lots of children, particularly close together (not enough time to build up stores)
Infants and young children under 5 years of age.
Older people aged 65 years and over.
People who have low or no exposure to the sun
For religious regions (skin covered up ie wearing a burqua or the orthodox Jewish community)
Elderly housebound
Children with special needs
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29. Who is most at risk of Vitamin D deficiency?
People who are obese
People who live with lots of cloud cover or atmospheric pollution
People who have darker skin
People can be genetically more likely to be Vitamin D deficient
People with low calcium and high fibre diets
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Quick Quiz
The following groups are at risk of Vitamin D deficiency:
People whose skin is fully covered for religious reasons
Yes- being fully covered greatly reduces the production of vitamin D
People who are housebound
Yes- lack of sun exposure is a risk for vitamin D deficiency
Those who use sunscreen when outside
Yes- sunscreen drastically reduces the amount of vitamin D produced
People with darker skin
Yes- the more pigmented the skin, the more more sun is needed to make vitamin D
Those who live north of Gloucester
Yes- the angle of the sun and amount of sun mean you cannot make enough vitamin D in winter months
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31. Who recommends Vitamin D supplements?
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32. The most senior doctors!
In February 2012 the chief medical officers for England, Wales, Scotland and Northern Ireland wrote to:
GPs
Practice Nurses
Health Visitors
Community pharmacists
To highlight the importance of vitamin D supplements
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Department of Health
The chief medical officers recommend that:
All pregnant and breastfeeding women should take a daily supplement containing 10μg of vitamin D
All infants and young children aged 6 months to 5 years should take a daily supplement of vitamin D
Infants who are formula fed will not need vitamin drops until they are receiving less than 500ml of formula a day
Breastfed infants may need to receive drops containing vitamin D from one month of age if their mother has not taken vitamin D supplements throughout pregnancy.
People aged 65 years and over and people who are not exposed to much sun should also take a daily supplement containing 10 micrograms of vitamin D.
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34. Who else recommends Vitamin D supplements?
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35. NICE (National Institute of Clinical Excellence)
NICE guidance (published in 2008 and updated in 2011), supports the UK Health Department’s recommendations on vitamin D supplements
It recommends:
during the pregnancy booking appointment, midwives should offer every woman information and advice on the benefits of taking a vitamin D supplement during pregnancy and while breastfeeding
health professionals check that women at greatest risk of deficiency* are following the advice during pregnancy and while breastfeeding
*This includes women from ethnic minority groups (particularly of African, South Asian or African-Caribbean origin) and women who do not get much sun (for example, women who cover their skin when outside or who spend large amounts of time indoors).
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36. Which supplements are available?
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Supplements
Vitamin drops and tablets can be bought in shops such as pharmacies and supermarkets
Different supplements are available for
Babies
Children
Pregnant and breastfeeding women
The government provide free vitamins for low income groups via the healthy start scheme
BUT this is not available to asylum seekers
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38. Healthy Start Programme
The government’s Healthy Start scheme provides free vouchers each week to spend on milk, fresh and frozen fruit and vegetables, and infant formula milk
It also provides free vitamins
The following people qualify for the scheme:
Pregnant women
Women with a baby under 1 year
Children from 6 months- 4 years
WHO RECEIVE ANY OF:
Income Support
Income-based Jobseeker’s Allowance
Income-related Employment and Support Allowance
Child Tax Credit (but not Working Tax Credit unless the family is receiving Working Tax Credit run-on only*) and has a total annual income of £16,190 or less (2012/13)
All pregnant women 18 and under qualify for the scheme, whatever their income
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39. Healthy Start Vitamins
Healthy Start women’s vitamin tablets contain:
Folic acid
reduces the chance of spina bifida
Vitamin C
helps maintain healthy tissue in the body
Vitamin D (10mcg/400 IU)
Contains no Vitamin A as this can be harmful in pregnancy
Healthy Start children’s vitamin drops contain:
Vitamin A
for growth, vision in dim light and healthy skin
Vitamin D (7.5mcg/300 IU)
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40. When should I recommend vitamin supplements?
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41. Supplements should be recommended to…
Pregnant women
Breastfeeding women
Babies and children under 5 taking less than 500ml/day infant formula
From 1 month if mother has had no supplements
From 6 months if mother has taken supplements
This is illustrated by the ‘Healthy Start decision tree’ on the next slide
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43. Recommending supplements
If babies, children, pregnant or breastfeeding women are not eligible for the healthy start programme…
…we need to recommend that they buy the appropriate product from their local supermarket or pharmacy.
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Quick Quiz
A 17 year old girl is pregnant with her first child. She has bought folic acid tablets and is taking them. What advice would you give her about vitamins in pregnancy?
She should take a supplement containing vitamin D designed for pregnant women
She would be eligible for free Healthy Start vitamins as she is under 18
They contain both vitamin D and folic acid
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Quick Quiz
A mother of a 2 month old baby is exclusively breast feeding. She took no vitamins in pregnancy. What advice would you give them both about vitamins?
Both mum and baby are at risk of vitamin D deficiency and should take appropriate preparations containing vitamin D (either through Healthy Start or bought over the counter)
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46. Where can I get Healthy Start Vitamins?
People who already receive Healthy Start food vouchers will receive a vitamin voucher every 8 weeks
To apply for the scheme a form can be filled in and then signed by the health visitor or GP
The vouchers are exchanged for vitamins
Healthy start vitamins cannot be prescribed
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47. Where can I get Healthy Start Vitamins?
Vitamins can be exchanged for vouchers in the following places:
Health Centres
Children’s centres
Gateways
Eccles
Pendleton
Walkden
Treasure chest needs hyperlink to PDF file 6 (contains details on availability of vitamins in Salford)
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Quick Quiz
Healthy Start Vitamins:
Can be prescribed by the GP
No- HS vitamins cannot be prescribed
Are available from GP surgeries
No- they are not currently available at GP surgeries
Can be bought in the supermarket
No- they cannot, but other vitamin supplements containing vitamin D can be bought in the supermarket
Can be bought from a pharmacy
No- they cannot, but other vitamin supplements containing vitamin D can be bought in pharmacies
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Vitamin Supplements
Multivitamin supplements which contain Vitamin D can be bought from pharmacies and supermarkets and are separate from the healthy start scheme.
Treasure chest needs hyperlink to PDF file 7
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50. Are people taking these supplements?
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51. Healthy Start voucher uptake Dec 2012
In Salford voucher uptake was 80.3%
Nottingham achieved the highest uptake at 86%.
In Salford children’s and women’s uptake were 1.7% and 9.4%
This is compared to 19.1% and 37.2% for the highest achievers in England
The highest uptake in the North West was in Blackpool where uptake was 13.7% and 23.9% for children’s and women’s vitamins
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Healthy Start data
Things may not be quite that bad…
The healthy start data relies upon vouchers being collected and returned to London
This information therefore may not reflect the whole picture in Salford
PDF file 8 needs to be healthy start return info
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Barriers to uptake
Lack of health professionals awareness of:
The problem of Vitamin D deficiency
Current national guidelines on supplementation
Local availability of supplements
This is the case for health professionals across all disciplines
reference and link- cleghorn 2006, lockyear 2011, whiting 2010
Treasure chest needs hyperlink to PDF file 9 (containing HS return data)
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54. You have finished! Just 1 last thing…
Congratulations!
You have finished!
Just 1 last thing…
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Personal action plan
We want you to take what you have learnt into your practice
Please take the time to write down 3 actions you will take as a result of this course
Examples might be:
Looking in local shops to see if they sell vitamin supplements with the recommended amount of vitamin D
Speaking to specific families about vitamin D deficiency and supplements
If you have any clinical questions about vitamin D deficiency or supplementation, then local paediatricians will be happy to answer them
To register your compliance please click here for the course inputting form
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