for internal use only. copyright protected vitamin d

For internal use only. Copyright Protected

Vitamin D


This course should take approximately 20 minutes to complete…

you will get an update to let you know when you are half way through!


Why do I need to know about Vitamin D?


Quick Quiz

• Vitamin D deficiency is present in what percentage of the population in Britain today?– 1%– 3%– 7%– 15%– >25%YES- >25%!!!


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?


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…


• Some pages will have a treasure chest symbol

• Click on this to access more detailed information about that subject and references

https://sites.google.com/site/vitamindextraresources/why-does-vitamin-d-deficiency-occur


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.

http://elearning.hope-academic.org.uk/vitd/treasurechest1.pdf


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!


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


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.



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



• Can cause osteomalacia in adults and older children

• This can cause bone pain and tenderness



• 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



• Severe vitamin D deficiency can cause low calcium

• This can cause– muscle pain– spasms (cramps)– muscle weakness



• 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



• Can cause irritability

• Those taking anti epileptic medication can be more at risk of vitamin D deficiency



• Rarely, an extremely low vitamin D level can cause weakness of the heart muscle– (cardiomyopathy)

• This is life threatening


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


– Tiredness• Yes- A common symptom

– Broken bones• Yes- Bones can be weakened by Vitamin D deficiency which means

that they can break more easily


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



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 (http://www.gnu.org/copyleft/fdl.html)


Sunlight- adviceTo make enough Vitamin D:• A fair-skinned person needs 20-30

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)


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



Well done for getting this far…you are about half way through!


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


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



Who is at risk of Vitamin D deficiency?

ALL OF US!


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


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


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


Who recommends Vitamin D supplements?


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


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.


Who else recommends Vitamin D supplements?


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).


Which supplements are available?


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


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


Healthy Start VitaminsHealthy 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 C

– helps maintain healthy tissue in the body • Vitamin D (7.5mcg/300 IU)


When should I recommend vitamin supplements?


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


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.


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


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)


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


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


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


Vitamin Supplements

• Multivitamin supplements which contain Vitamin D can be bought from pharmacies and supermarkets and are separate from the healthy start scheme.



Are people taking these supplements?


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


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


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



Congratulations!

You have finished!Just 1 last thing…


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

http://elearning.hope-academic.org.uk/srht_eportal/input_course.asp

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