Recommendations

Recommendation 1 Increase access to vitamin D supplements

The Department of Health should:

Work with manufacturers to ensure vitamin D supplements providing the reference nutrient intake (RNI) as recommended by the Scientific Advisory Committee on Nutrition, are widely available for the following specific population groups:
- infants and children aged under 4
- pregnant and breastfeeding women, particularly teenagers and young women
- people over 65
- 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 with dark skin, for example, people of African, African-Caribbean or South Asian family origin.
  
  Suitable supplements should also be available for people with particular dietary needs (for example, people who avoid nuts, are vegan or have a halal or kosher diet). Supplements should undergo quality control checks to ensure they contain the correct dose of vitamin D.
Work with manufacturers to ensure licensed products containing the recommended reference nutrient intake for specific population groups are available on prescription and are listed in the British National Formulary.
Amend existing legislation to allow Healthy Start vitamins to be more widely distributed and sold. This includes encouraging manufacturers to sell them direct to pharmacies.
Encourage manufacturers of multivitamin food supplements to include the recommended reference nutrient intake for vitamin D in their preparations.

Recommendation 2 Clarify existing guidance

Public Health England and the Department of Health should:

Consider whether there are any risks to infants from taking a supplement containing the RNI when they are consuming more than 500 ml of infant formula per day. Be aware that the complexity of existing advice (based on feeding type and maternal supplementation) may hinder uptake.
Make it clear which type of supplement most people would benefit from. Be aware that people may be more likely to take a vitamin D-only supplement than one that is combined with calcium. Supplements containing vitamin D and calcium may be harder to swallow and cause side effects such as constipation.

Recommendation 3 Develop national activities to increase awareness about vitamin D

Public Health England should:

Lead development of national action to raise the population's awareness of the importance of vitamin D. This should start as soon as existing recommendations on vitamin D have been clarified and made consistent (see recommendation 2). Awareness-raising activities should:
- Emphasise the importance of vitamin D for good health.
- Emphasise the limitations of other UK sources of vitamin D (it is only contained in a few foods and sunlight is only effective from the beginning of April to October).
- Emphasise the importance of a daily supplement providing the reference nutrient intake.
- Explain existing advice as clearly as possible, particularly if it may be misinterpreted. This includes making clear: what a term such as 'low sun exposure' means; who is covered by 'dark skin'; which women and children are at risk (note that children aged 4 to 5 years are not usually eligible for Healthy Start supplements).
Let people know where they can get vitamin D supplements free or as cheaply as possible.
Develop resources that are accessible and easy to adapt for local use by a range of agencies, to ensure a consistent message and to minimise duplication of effort.

Recommendation 4 Ensure a consistent multiagency approach

Directors of public health should:

Ensure a consistent, multiagency approach is adopted to improve the vitamin D status of the local population. This should include commissioners and senior managers in local authorities and the NHS, council leaders, elected members, public health teams and voluntary and community organisations. They should:
- address local needs, as identified by the joint strategic needs assessment and other local data
- target specific population groups
- target health, social care and other practitioners in contact with specific population groups
- work with relevant community and voluntary groups
- ensure mechanisms are in place to increase the availability and uptake of supplements
- ensure mechanisms are in place to increase awareness of vitamin D
- ensure action is culturally appropriate (for example, involve community organisations and develop messages that resonate with the community or take account of any cultural barriers to taking supplements).

Recommendation 5 Increase local availability of vitamin D supplements for specific population groups

Local authorities should ensure vitamin D supplements containing the recommended reference nutrient intake are widely available by:

Establishing arrangements with a range of settings to promote and distribute them. This could include local pharmacies, children's centres, midwifery and health visiting services and GP reception areas.
Considering providing free supplements for specific population groups.
Encouraging pharmacies and other outlets selling food supplements (such as supermarkets) to stock the lowest cost vitamin D supplements and promote them to specific population groups.
Ensure improvements in the availability of vitamin D supplements are supported by local awareness-raising activities (see recommendations 9 and 10).

Recommendation 6 Improve access to Healthy Start supplements

Local authorities should:

Review current accessibility, availability and uptake of Healthy Start supplements.
Consider how accessibility, availability and uptake could be improved. For example:
- Encourage a range of outlets where pregnant and breastfeeding women and families and carers of under-4s may go to stock and promote Healthy Start supplements. This includes high street and supermarket pharmacies, children's centres, schools and clinics with a range of opening times. Many of them should also be accessible by public transport.
- Consider offering free Healthy Start supplements to all pregnant and breastfeeding women and children aged under 4 years.
- Encourage pharmacies to sell the Healthy Start supplement to:
  - pregnant and breastfeeding women and children under 4 years
  - children aged over 3 who are in 1 of the other specific population groups
  - women planning a pregnancy and women of child bearing age (see recommendation 1).
- Set up a central point for ordering, storing and distributing Healthy Start supplements across the local authority area. Individual distribution sites should be encouraged to order supplements from the central distribution point, rather than managing their own stock.
- Consider using an electronic card system to distribute supplements and use the data collected to improve the supply chain and for system monitoring.

Recommendation 7 Only test vitamin D status if someone has symptoms of deficiency or is at very high risk

Health professionals should not routinely test people's vitamin D status unless:

they have symptoms of deficiency
they are considered to be at particularly high risk of deficiency (for example, they have very low exposure to sunlight)
there is a clinical reason to do so (for example, they have osteomalacia or have had a fall).

Local authorities, primary care, and clinical commissioning groups should:

Ensure computerised prompts on vitamin D are integrated into health and social care systems.
Ensure health professionals recommend and record vitamin D supplement use among specific population groups (and other family members, as appropriate) whenever possible. This could take place during registration appointments with new patients in general practice, flu, other vaccine and screening appointments. It could also take place during routine appointments and health checks including, for example:
- NHS Health Check
- diabetes check-ups
- falls appointments and check-ups
- health assessments for looked-after children
- the first contact with someone who is pregnant
- antenatal and postnatal appointments
- medicine use and prescription reviews
- health visitor appointments
- developmental checks for infants and children.
Developers of standardised electronic and handheld maternity notes and developers of personal child health records (the 'red book') should:
- add specific questions about the use of vitamin D supplements.

Health Education England, Public Health England, clinical commissioning groups, health and wellbeing boards and local authorities should:

Ensure health and social care practitioners receive information on the following as part of their registration and post-registration training and continuing professional development:
- the importance of vitamin D for good health
- sources of vitamin D in the UK (from safe sun exposure, supplements and limited dietary sources)
- groups at risk of low vitamin D status
- supplement recommendations for different groups (this should address any confusion about, for example, age groups or the type of supplement to recommend)
- how to encourage people to start and continue taking supplements (see medicines adherence NICE guideline CG76).
Ensure health, social care and other relevant practitioners in contact with specific population groups are made aware of the following:
- local policies and procedures in relation to vitamin D
- local sources of vitamin D supplements (including Healthy Start)
- eligibility for Healthy Start vitamin supplements.

Recommendation 10 Raise awareness of the importance of vitamin D supplements among the local population

Local public health teams, health and social care practitioners and voluntary and community groups working with specific population groups (see who should take action?) should:

Increase people's awareness of:
- the importance of vitamin D for good health
- sources of vitamin D in the UK (from safe sun exposure, supplements and limited dietary sources)
- specific population groups and the importance of a daily vitamin D supplement for some of those groups
- local sources of vitamin D supplements (including Healthy Start)
- eligibility for Healthy Start vitamin supplements
- sources of further information.
Adapt any national resources for local use to minimise the risk of inconsistent advice (see recommendation 3).
Ensure awareness-raising activities meet the needs of all specific population groups. This includes:
- addressing any misconceptions specific groups may have about their risk
- working with local practitioners, role models and peers to tailor national messages for local communities to ensure information about vitamin D is culturally appropriate.
Share vitamin D messages and information with specific population groups using:
- local newspapers, social media and local radio channels targeted at these groups
- local shops and businesses
- community workers, groups and events
- social establishments
- nurseries and educational institutions
- workplaces
- places of worship
- local health care establishments, for example, community health facilities, hospitals and urgent care centres.

Recommendation 11 Monitor and evaluate the provision and uptake of vitamin D supplements

The Department of Health, Public Health England and local authority commissioners should:

Monitor national and local awareness of, access to, and uptake of, vitamin D supplements among specific population groups (including those covered by Healthy Start).
Use a range of sources to assess local uptake, for example, orders for supplements and information collected in personal child health records, maternal antenatal notes and computerised prompts (see recommendation 8).
Use monitoring data to improve activities related to the awareness of, access to and uptake of vitamin D supplements.

Vitamin D: supplement use in specific population groups

Guidance