Vitamin D supplementation in the United Kingdom: time for change

by Dr Wolfgang Högler, Institute of Metabolism and Systems Research

by Dr Suma Uday, Institute of Metabolism and Systems Research

The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of the University of Birmingham

“The UK currently has vitamin D supplementation policies for risk groups including infants, pregnant women and the dark skinned population. However, these are out-dated and poorly implemented.”  

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In the UK, the number of children hospitalised due to complications of vitamin D deficiency is on the rise and almost exclusive to the BAME groups (Uday et al 2018). However, these patients only represent the tip of the iceberg of widespread deficiency in the community and the true disease burden remains unidentified. Given the increasing proportion of the BAME groups in the UK through birth and immigration (Uday and Högler 2018) there is an urgent need to update the current policies and adopt evidence based implementation strategies. 

Active vitamin D helps absorb calcium from the gut which is required to maintain optimal bone health. Hence vitamin D deficiency can result in rickets in children and osteomalacia (soft bones) in children and adults, but also hypocalcaemic complications. Low calcium can cause life threatening seizures and heart failure in babies. Since there is very little vitamin D in diet, we rely on its synthesis in the skin triggered by exposure to ultra violet B (UVB) rays in sunlight. 

However, the UK’s geographic location renders it UVB deficient for most of the year. Unsurprisingly, nearly half of the UK population were vitamin D deficient in the National Diet and Nutritional Survey. Amongst the UK residents, the Black, Asian and Minority Ethnic (BAME) groups are most at risk, as darker skin produces far less vitamin D than lighter skin. 

The UK currently has vitamin D supplementation policies for risk groups including infants, pregnant women and the dark skinned population. However, these are out-dated and poorly implemented (Uday and Hogler 2018). Adherence to supplementation in UK infants is the lowest in Europe at 5-20%. 

We have compared supplementation policies and implementation strategies across 29 European countries to determine factors influencing adherence (Uday et al 2017). We identified the following factors to be significantly associated with increased adherence: universal supplementation of breast and formula fed infants, giving parents information at discharge from the hospital after child birth, providing financial support to families and monitoring adherence at child health surveillance visits. 

The UK currently does not adopt any of the above factors: 

  1. Whilst 85% of European countries supplement all infants irrespective of the mode of feeding; Public Health England recommends supplementing breast fed babies and those babies who consume less than 500ml of formula milk. Moreover the infant doses recommended by the UK policy are not in line with the global consensus recommendations (Munns et al 2016). Vitamin D in formula milk is not sufficient to protect infants from rickets. 
  2. Nearly 85% of parents are unaware of the need for supplementation. Parents are not given information on supplementation at discharge from hospitals after child birth. 
  3. Only low income families receive financial support through the ‘Healthy Start’ scheme. However, the scheme is overly complex thereby resulting in poor uptake. To confuse matters even more, the amount of vitamin D in the ‘Healthy Start’ vitamins is lower than that recommended by Public Health England.  
  4. Adherence to supplementation is currently not monitored at child health surveillance visits.  

We recommend the following policy changes to improve adherence and prevent serious health complications:

  1. Universal supplementation of breast and formula fed babies will make the policy simpler and more effective. 
  2. At each health care contact such as antenatal visits, routine child health checks and immunisations adherence to supplementation should be monitored and documented. 
  3. At discharge from neonatal units, parents should be informed about supplementation and provided with the first bottle of vitamins. 
  4. A dedicated group of healthcare professionals should be made responsible and held accountable for delivering the policy. 
  5. General practitioners should be given financial support and/or incentives to implement a vitamin D supplementation programme similar to immunisation programmes. 

If you would like a briefing on this topic then please email Jeremy Swan, Public Affairs Officer (Policy Impact).