Am rather concerned by the stipulation that all over 65s should have a vitamin D supplement

when the evidence is rather less clear: see Cochrane, who are also clear about risk of harms.

Ironic, given how few commercial skin products are SPF- free.

Our reference: CEM/CMO/2012/04
Gateway reference: 17193
To:
General Practitioners
Practice Nurses
Health Visitors
Community Pharmacists
2 February 2012
Dear Colleague
~~~
The Scottish
Government
,DH)Department
of Health
VITAMIN D - ADVICE ON SUPPLEMENTS FOR AT RISK GROUPS
We are aware that some of the UK population may be at risk of vitamin D deficiency. This is a
concern, particularly for at-risk groups such as pregnant women and infants and young
children, which is why we, the Chief Medical Officers for the United Kingdom, are writing to
health professionals to increase awareness of this important issue.
Last year the Chief Medical Officer for Scotland, Sir Harry Burns, wrote to health professionals
in Scotland on this topic.
http://www .scotland.gov. uk/Topics/Health/health/Health/EatingHealth/vitamind/CMOletter
This letter is a restatement of this advice and contains important information about prescribing
and recommending vitamin D supplements to those groups of the population at risk of vitamin
D deficiency.
The National Diet and Nutrition Survey, demonstrates that up to a quarter of people in the UK
have low levels of vitamin D in their blood, which means they are at risk of the clinical
consequences of vitamin D deficiency!. Although we do not have clear data on the
implementation of the current advice on the use of dietary supplements containing vitamin D by
1 Data from years 1 & 2 of the National Diet and Nutrition Survey (NDNS) rolling programme. Low status is defined
by the Department of Health as a plasma concentration of 25-hydroxyvitamin D (25(OH)D, the main circulating form
of the vitamin) of below 25nmol/l (equal to 10 ng/ml).
the at-risk groups listed below, information from the 2005 Infant Feeding Surve/ suggests that
the majority of women do not take vitamin D supplements during pregnancy.
Vitamin D deficiency impairs the absorption of dietary calcium and phosphorus, which can give
rise to bone problems such as rickets in children, and bone pain and tenderness as a result of
osteomalacia in adults.
The following groups of people are at risk of vitamin D deficiency:
• All pregnant and breastfeeding women, especially teenagers and young women.
• 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 example those who cover their skin
for cultural reasons, who are housebound or confined indoors for long periods.
• People who have darker skin, for example people of African, African-Caribbean and
South Asian origin, because their bodies are not able to make as much vitamin D.
Recommendations
All UK Health Departments recommend:
• All pregnant and breastfeeding women should take a daily supplement containing
10 micrograms of vitamin D, to ensure the mother'srequirements for vitamin D are met
and to build adequate fetal stores for early infancy.
• All infants and young children aged 6 months to 5 years should take a daily supplement
containing vitamin D in the form of vitamin drops, to help them meet the requirement
set for this age group of 7-8.5 micrograms of vitamin D per day. However, those infants
who are fed infant formula will not need vitamin drops until they are receiving less than
500ml of infant formula a day, as these products are fortified with vitamin D. 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.
Are free vitamin D supplements available?
Women and children from families who are eligible for the Government's Healthy Start scheme3
can get free vitamin supplements which include vitamin D, in the form of tablets for women and
drops for children.
It is the statutory responsibility of PCTs, the local trust or Health Board4 to make Healthy Start
vitamins available locally to women and children on the scheme. Health
2 Bolling K, Grant C, Hamlyn B, Thornton A (2007). Infant Feeding Survey 2005. The Information Centre
3 Healthy Start is a UK-wide statutory scheme providing a means-tested nutritional safety net to pregnant women
and families with children under four years old in very low income and disadvantaged families. It provides vouchers
for basic healthy foods and coupons for Healthy Start vitamin supplements to women and children in around
460,000 UK families.
professionals should fa milia rise themselves with local distribution arrangements for Healthy
Start vitamins.
Uptake of the Healthy Start vitamins among families qualifying for the scheme is currently low.
However, the UK Health Departments are committed to continuing to support NHS staff
involved in maintaining local distribution arrangements, and those in a position to champion
Healthy Start, to share and encourage good practice.
It is important that women and families who may be eligible for Healthy Start know how they
can apply for the scheme, and are made aware of how they can obtain vitamins locally.
Women qualify for Healthy Start from the 10th week of pregnancy or if they have a child under
four years old, and if she or her family receive:
• Income Support, or
• Income-based Jobseeker's Allowance, or
• Income-related Employment and Support Allowance, or
• Child Tax Credit (but not Working Tax Credit unless the family is receiving Working Tax
Credit run-on only) and has an annual family income of £16,190 or less.
Women who are under 18 and pregnant also qualify, even if they do not get any of the above
benefits or tax credits. Further information can be found on the Healthy Start website at
www.healthystart.nhs.uk
NHS organisations can choose to sell the vitamins or supply them free of charge to those who
are not eligible for Healthy Start, and we encourage thiss. Alternatively, vitamin D supplements
are available for purchase or can be prescribed for those who are not eligible for the scheme.
The National Institute for Health and Clinical Excellence (NICE) publiC health guidance on
maternal and child nutrition6 (publiShed in 2008 and updated in 2011), supports the UK Health
Departments' recommendations on vitamin D supplements. NICE recommend that during the
booking appointment at the beginning of pregnancy, midwives should offer every woman
information and advice on the benefits of taking a vitamin D supplement during pregnancy and
while breastfeeding. NICE also recommend health professionals take particular care to 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).
4 The Healthy Start Scheme and Welfare Food (amendment No.2) Regulations 2006 (2818). Section 7 and The
Healthy Start Scheme and Day Care Food Scheme Regulations (Northern Ireland) 2006 (S.R. 2006 No. 478)
Regulation 11 'Provision of Healthy Start vitamins'
5 For more information about Healthy Start vitamins including distribution case studies visit
www.healthvstart.nhs. uklfor -health-professionals/vitam ins
6 NICE public health guidance (2008). PH 11 Improving the nutrition of pregnant and breastfeeding mothers and
children in low-income households.
It is important for public health that low levels of vitamin D are avoided. As health
professionals, you can make a significant difference to people's health by making those at risk
aware of how important it is to make sure they get enough vitamin D, and how they can get
access to these important daily supplements.
We, the Chief Medical Officers, thank you for your continued help and support with raising
awareness of this issue, which in turn should raise the levels of vitamin D in those at risk, and
vulnerable groups.
PROFESSOR DAME SALLY C DAVIES
CHIEF MEDICAL OFFICER ENGLAND
CHIEF SCIENTIFIC ADVISER
DR TONY JEWELL
CHIEF MEDICAL OFFICER WALES
DR MICHAEL McBRIDE
CHIEF MEDICAL OFFICER NORTHERN IRELAND ~C~b~q~
Sir HARRY BURNS
CHIEF MEDICAL OFFICER SCOTLAND