Vitamin D: Action needed on the 'sunshine' vitamin

From The Guardian
London, UK
2 April, 2014

Action needed on the 'sunshine' vitamin

An estimated 40% of young children are vitamin D deficient and the bone disease rickets is up four-fold. So how can we get the right message to parents – and the population at large? Joanna Moorhead reports

Vitamin deficiency in children is a problem many of us associate with other parts of the world, or other times in history in Britain. But the reality is that vitamin D deficiency is a serious and growing issue in this country and, a Guardian roundtable was told, it's something that needs to be tackled properly, and quickly.

The roundtable heard that, despite a call to action on vitamin D by the chief medical officer Prof Dame Sally Davies last October, no headway has yet been made in issuing proper guidelines on how to deal with a problem that has led to a four-fold increase in the number of cases of the bone disease rickets in recent years. However, the roundtable – sponsored by Danone Baby Nutrition and held under the Chatham House rule under which contributions are reported without attribution to encourage a frank discussion – heard that the strategy that needs to be adopted is clear, and in many ways relatively simple. But the process for change at government level has currently stalled – while the problem is continuing to increase.

The extent of vitamin D deficiency, the roundtable was told, is hard to measure – but several participants had statistics to share. Around 40% of young children in Britain now have below the threshold of vitamin D recommended as optimal ("deficiency"); as many as 80% in the population have low levels ("insufficiency"). Most teenagers are below the optimal level. "What that all means is – a large proportion, even the majority, of the population have vitamin D insufficiency. That's a very big problem," said one of the doctors present. Another participant spoke about recently published data. "A group in Oxford have reviewed 50 years' worth of figures, and the graph is going straight up," he said. "There are problems of definition with this issue, but across the spectrum there's a big problem and it's growing."

One clinician described the reality of rickets, the sharp end of vitamin D deficiency. "I saw a two-year-old child with rickets in my clinic last week," he said. "The family were immigrants from West Africa. Their child was very small for his age; he'd been solely breastfed for two years. He was a profound case." Rickets causes bone tenderness, skeletal deformity including the classic "bow-leg" effect; in extreme cases, it can lead to convulsions or heart failure. The irony, said the doctor, was that it was not difficult to treat. "In this case, the child was given vitamin D and the parents were given nutritional advice. He will do really well; quite quickly, within two or three weeks, he'll be a different child," he said.

Current advice

But another clinician spoke of the difficulty of getting the right messages across to some parents. "What's really upsetting is when I see a child cured, and the mother comes along breastfeeding the next baby and no one has ever told her how important it is for her child to be taking vitamins," he said. Current advice is for all pregnant and breastfeeding women to take vitamin D supplements, as well as babies and children aged six months to five years. Breastfed babies, however, may need supplements from one month of age if their mother did not take vitamin D during pregnancy.

Getting the right messages across to mothers is crucial, the roundtable was told; and it was particularly important to target mothers in some ethnic minority communities. One of the main ways the body makes vitamin D is through exposure to sunshine; but in some Muslim communities mothers traditionally cover themselves up to the extent that – especially in a frequently sun-starved country like the UK – they don't get enough sunshine to make any vitamin D. If they are also breastfeeding, especially long-term, this has serious implications, and the messages on supplementation have to be put across effectively. Worries were also voiced about the recommendation that babies should receive supplements from six months, since families are not routinely seen at that stage; a better approach, some speakers believed, would be universal supplementation from two weeks of age, since that's a time when babies are seen by a health professional.

Another issue is the safe sun campaign, which some roundtable participants held strong views about. Sunshine has a vitamin D health upside but also a skin cancer downside. Getting the balance right in public health messages was seen as crucial – and, for some participants, that had not been the case in recent years. "The cancer societies have been telling us the wrong thing for a long time," said one of those round the table. "But we've not had a lead from the government on it. We've all heard the slogan 'there's no such thing as a healthy tan'. We were told to stay out of the sun. We all believed that message. So people put on sunscreen, stayed out of the sun, and vitamin D deficiency levels went up.

"Of course we need to avoid sunburn, but we do need to go out as much as we can when the sun is shining. We need to change the messages we're giving out on sunshine."

However, another participant pointed out that exposure to sun alone will not entirely solve the problem. "Our geographical position means that, particularly in the autumn and winter, we just don't have enough sunshine in the UK to enable us to make vitamin D," he said. What's more, people with different amounts of pigment in their skin need different amounts of sunshine to make the vitamin: one piece of research found light-skinned people could make enough vitamin D if they were exposed to 30 minutes of UV light three times a week but dark-skinned people would need two hours three times a week for the same effect.

Supplementation (vitamin drops or pills) and fortification of staple foods (for example, adding vitamin D to milk and bread) were the answer to this, the roundtable heard. One participant pointed out that many other countries did have mandatory fortification of staple foods, and that Britain was unusual in that it did not – the only legal requirement here is for infant formula, and margarine, to be fortified with vitamin D.

What, then, is the way forward? "We've got all the scientific evidence we need," said one participant. "We know what to do: fortification, sunshine and supplements." Another contributor described the success of an initiative begun in Birmingham a decade ago, and since taken up in some other areas of the country. "It was started after one of the primary care trusts with a high ethnic minority population noticed a resurgence in rickets and decided to do something about it. They convened a group that included public health specialists, GPs, health visitors and pharmacists. They had a major advertising campaign and put across the message, and they made supplements available for children from two weeks of age up to five. Uptake was 20% and that led to a 59% reduction in the incidence of vitamin D deficiency cases presenting at hospital in that area." Mention was also made of the Vitamin D Mission, which tackles the issues online for both parents and healthcare professionals.

The general consensus was that the current messages were too complicated, and that a clearer, and multi-pronged, approach needed to be taken. Several participants mentioned that the government is currently awaiting a report on the vitamin D issue from the Scientific Advisory Committee on Nutrition. But there was a general sense of frustration that the wait was holding up getting the right information out to the public.

"We shouldn't be waiting for this report," said one of those round the table. "We do need to have the issues defined, but the general message is clear and we need to get it out to the public."

Key discussion points

• Vitamin D deficiency, and insufficiency, is a large and growing problem in Britain.

• Sunshine is a source of vitamin D, and safe sun messages have reduced people's exposure to the sun, which has impacted on deficiency levels.

• There are particular risks in some ethnic communities: dark-skinned people need more sunshine to make vitamin D, and some groups cover up more and so get less sunshine.

• There are difficulties over getting the right messages out to mothers of infants: baby formula is fortified with vitamin D by law, but breastfed babies need supplements.

• A multi-pronged approach is needed to address the issues in a public health campaign, but the government is dragging its feet and failing to act quickly.

The Vitamin D Mission aims to raise the awareness of children's vitamin D needs. Visit vitamindmission.co.uk for details.

At the table

Paul Arundel
Secretary, British Paediatric and Adolescent Bone Group

Andrew Thomas
Founder and managing director, Better You

Brian Dow
Director of communications, Royal College of Paediatrics

Leanne Olivier
Senior medical affairs manager, Danone Baby Nutrition

Claire Bowring
Medical policy manager, National Osteoporosis Society

Dr Mitch Blair
Reader in paediatrics and child public health, Imperial College London

Barbara Evans
Community nursery nurse, Leicestershire Partnership NHS Trust

Prof Euan Ross
Emeritus Professor of community paediatrics, King's College London

Dr Benjamin Jacobs
Clinical consultant for the vitamin D mission, Royal National Ortho- paedic hospital

Oliver Gillie
Director, Health Research Forum

Dr Nick Shaw
Consultant paediatric endocrinologist, Birmingham Children's hospital

Credits
Seminar report commissioned and controlled by the Guardian. Discussion hosted to a brief agreed with Danone. Funded by Danone.

http://www.theguardian.com/

Just a caveat regarding the Vitamin D Mission  their partners include Kelloggs 

http://www.vitamindmission.co.uk/

Graham