1. 1 Healthy Start and Early Years Anna Kitt Anna.Kitt@dh.gsi.gov.uk

2. 2 What is Healthy Start? Replaced Welfare Food Scheme in 2006 A statutory scheme A nutritional safety net A public health tool

3. 3 Healthy Start Introducing Solid Food Start4Life Active play Baby Life check Breastfeeding Inter related infant health initiatives

4. 44 What does it provide? Vouchers:Vitamins: Liquid milkFor women Fresh fruit and vegetablesFor children Infant formula milk Eligible families are able to get these from 10wks pregnant to their child’s 4 th birthday AND: Information on breastfeeding and healthy eating through the Healthy Start magazine sent with the vouchers

5. 5 Who is it for? Pregnant women and families with children under four getting: Income Support, or Income Based Jobseekers’ Allowance, or Income related Employment and Support Allowance, or Child Tax Credit (but not Working Tax Credit) with an annual family income of £16,190 or less. And ALL pregnant under 18 year olds NOTE: There are no back payments for missed time periods

6. 66 The Voucher £3.10 each week Issued 4 weekly to beneficiaries Double vouchers for under 1’s (£6.20/week) Voucher value reviewed annually Over the course of a pregnancy this equates to £93 food vouchers

7. 7 Health professionals can make a huge difference! The way the parents find out about the scheme effects their relationship with the scheme. Role of Health Care Professionals

8. 8 Healthy Start is a Statutory Scheme Health Professionals are given the key tasks of: Signposting to the scheme Supporting applications Signing application forms PCTs have a duty to make Healthy Start vitamin supplements available

9. 9 Potential beneficiary hears about Healthy Start Tax credits helpline Jobcentre Plus Internet Invitation from HSIU Midwife/Health Visitor Application form in GP surgery Pregnancy or Birth to Five Book Poster in children’s centre Get application leaflet/Form Website HSIU Helpline GP Surgery Health Visitor Complete Form Get signature from midwife or health visitor Submit to HSIU Family becomes eligible Healthy Start application process

10. 10 HSIU receives application form Fully completed Wrongly completed Returned to applicant Clearly do not qualify Applicant informed Application for pregnant Vouchers Issued Validation checks later Application includes children Validate against HMRC and JCP data Match found Repeat validation checks every 2 wks (HMRC) or 4 wks (JCP) Vouchers Issued Match not found Inform applicant and invite to give additional information. Repeat 2/4 weekly checks for 3 months Match found Voucher Issued No match found Vouchers not issued Letter confirming match not found

11. 11 Why give Vitamins? Sufficient evidence to convince COMA and SACN to recommend supplementation NICE report on Maternal and child nutrition (March 2008) places the onus on PCTs to ensure supplementation happens Source: COMA – Committee on Medical Aspects of Food and Nutrition Policy SACN – Scientific Advisory Committee on Nutrition NICE – National Institute for Clinical Excellence

12. 12 Children’s Drops Code:ABX 072 Cost to PCT:£1.61 Cost when selling: £1.77 Available to:Children; 6 months – 3 years Contains:233mcg Vitamin A 20mg Vitamin C 7.5mcg Vitamin D One bottle:10 mls (8 week supply) Daily Dose:5 drops Classification:General Sales List Medicine Manufacturer:SSL International Women’s Tablets Code:ABX 073 Cost to PCT:82p Cost when selling: 90p Available to:Women; pregnant and until child is 1 yr old Contains:70 mg Vitamin C 10 mcg Vitamin D 400 mcg Folic Acid One bottle:56 tablets (8 week supply) Daily Dose:1 tablet Classification:Multivitamin Food Supplement Manufacturer:Bayer Vitamin Facts

13. 13 Vitamin Collection Points Local Vitamin Collection Points (marketing) Collection of vitamin coupons (administration)

14. 14 Arrow points towards either the women’s or children’s vitamins depending on which product they should be picking up.

15. 15 Synthesis of Vitamin D Our main source of vitamin D is that made by our own bodies. 90% of our vitamin D is made in the skin with the help of sunlight

16. 16 Dietary Sources of vitamin D Oily fish including trout, salmon, mackerel, herring, sardines, anchovies, pilchards, and fresh tuna Amount will depend on preparation, with smoked herring containing approximately 4μg per 100 g and raw herring 40μg per 100g Cod liver oil and other fish oils

17. 17 90% of the UK lies above the latitude that permits exposure to the ultraviolet B wavelengths necessary for vitamin D synthesis

18. 18Univ WestminsterCarol Williams, 2009 Vitamin D deficiency is Sunlight Deficiency UK :13-28% of women of childbearing age have low plasma vitamin D levels 2 hours/week sunlight exposure if face only, 30 minutes face, arms and hands is sufficient for Vitamin D synthesis. (SPF 8+prevents) Darker skin blocks some of the UV rays, so need more exposure to make Vit D In UK the wavelength of sunlight received in winter (November to March) is not effective at making vitamin D.

19. 19 Who gets vitamin D deficiency? Pregnant or breast-feeding women. Vitamin D deficiency is even more likely to develop in women who have had several full-term pregnancies with short gaps between them. In the last three months of pregnancy, babies are growing at their fastest and mothers often become short of vitamin D especially if these months occur during winter or early spring.

20. 20 Who gets Vit D Deficiency? Breast-fed babies whose mothers are lacking in vitamin D, or with prolonged breast-feeding Bottle-fed babies do not need vitamin D supplements as formula milk is fortified with vitamin D

21. 21 Explanations provided for low sun exposure and low vitamin D intake by mothers (Outpatient survey, West London) Little time outside: busy indoors or at work Going “out” often includes shopping in malls Use of sun block Dislike or fear of sunlight for themselves and their infants Use of skin lightening creams regularly No Healthy Start vitamins No mention of vitamin D in antenatal care No knowledge of vitamin D How to improve knowledge and healthy behaviour relating to vitamin D (Michie C. London Journal of Primary Care, 2010)

22. 22 Rickets Vitamin D insufficiency is common in the UK population Vitamin D deficiency typically presents with bony deformity (rickets) or hypocalcaemia in infancy and childhood, and with musculoskeletal pain and weakness in adults Currently there is a lack of coding of vitamin D deficiency in primary care and secondary care

23. 23 Vitamin D Supplement Recommendation People at risk of vitamin D deficiencyDaily vitamin D supplement All pregnant and breastfeeding women10µg/day All infants and children from 6 months to 5years, unless they are drinking 500mls (a pint) of infant formula a day at any time during this age range (If there is any doubt about the mother’s use of vitamin supplements during pregnancy and/or breastfeeding, breastfed infants will benefit from vitamin D supplements from 1 month) 6 months to 5 years - 7µg/day People whom lack exposure to the sun e.g. people confined indoors for long periods and those who cover their skin for cultural reasons 10µg/day People from ethnic minorities who have darker skin, because their bodies are not able to produce as much vitamin D. Clinical deficiency has been most reported among children of African-Caribbean and South Asian origin. 10µg/day

24. 24 Vitamin D Supplements Prices correct Nov 2010 Boots 12.5mcg (90 tablets) £2.79 ASDA 10mcg (60 tablets) £2.23 Holland & Barrett 10mcg (100 tablets) £3.19 Healthy Start (56 tablets) 10mcg 90p

25. 25 Vitamin D in the Headlines