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1 For internal use only. Copyright Protected
Vitamin D For internal use only. Copyright Protected

2 This course should take approximately 20 minutes to complete…
you will get an update to let you know when you are half way through! For internal use only. Copyright Protected

3 For internal use only. Copyright Protected
Why do I need to know about Vitamin D? For internal use only. Copyright Protected

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Quick Quiz Vitamin D deficiency is present in what percentage of the population in Britain today? 1% 3% 7% 15% >25% YES- >25%!!! For internal use only. Copyright Protected

5 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? For internal use only. Copyright Protected

6 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… For internal use only. Copyright Protected

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Some pages will have a treasure chest symbol Click on this to access more detailed information about that subject and references For internal use only. Copyright Protected

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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. Treasure chest- needs to have hyperlink inserted to PDF file 1 (containing Birmingham paper plus more safeguarding info) For internal use only. Copyright Protected

9 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! For internal use only. Copyright Protected

10 For internal use only. Copyright Protected
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 For internal use only. Copyright Protected

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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. Treasure chest needs to have hyperlink to PDF file 2 (containing ranges for vitamin D deficiency) For internal use only. Copyright Protected

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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 For internal use only. Copyright Protected

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Vitamin D deficiency Can cause osteomalacia in adults and older children This can cause bone pain and tenderness For internal use only. Copyright Protected

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Vitamin D deficiency 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 For internal use only. Copyright Protected

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Vitamin D deficiency Severe vitamin D deficiency can cause low calcium This can cause muscle pain spasms (cramps) muscle weakness For internal use only. Copyright Protected

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Vitamin D deficiency 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 For internal use only. Copyright Protected

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Vitamin D deficiency Can cause irritability Those taking anti epileptic medication can be more at risk of vitamin D deficiency For internal use only. Copyright Protected

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Vitamin D deficiency Rarely, an extremely low vitamin D level can cause weakness of the heart muscle (cardiomyopathy) This is life threatening For internal use only. Copyright Protected

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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 Vitamin D deficiency Tiredness Yes- A common symptom Broken bones Yes- Bones can be weakened by Vitamin D deficiency which means that they can break more easily For internal use only. Copyright Protected

20 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 Treasure chest- needs hyperlink to PDF file 3 (containing effects of vit D and why we become vit D deficient) Treasure chest re other effects Ref NHS choices website/SACN (cardiovascular risk and vit d) (immune system and vitamin D) TB Cancer/autoimmune/cardiovascular For internal use only. Copyright Protected

21 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) For internal use only. Copyright Protected By Sbrools (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html)

22 For internal use only. Copyright Protected
Sunlight- advice To make enough Vitamin D: A fair-skinned person needs 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) For internal use only. Copyright Protected

23 For internal use only. Copyright Protected
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 Treasure chest- needs hyperlink to PDF file 4 (containing extra sunlight advice) For internal use only. Copyright Protected

24 Well done for getting this far…
you are about half way through! For internal use only. Copyright Protected

25 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 For internal use only. Copyright Protected

26 For internal use only. Copyright Protected
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 Treasure chest needs hyperlink to PDF file 5 (contains info re some protective factors ie ca and red meat/genetic predisp) For internal use only. Copyright Protected

27 Who is at risk of Vitamin D deficiency?
ALL OF US! For internal use only. Copyright Protected

28 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 For internal use only. Copyright Protected

29 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 For internal use only. Copyright Protected

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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 For internal use only. Copyright Protected

31 Who recommends Vitamin D supplements?
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32 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 For internal use only. Copyright Protected

33 For internal use only. Copyright Protected
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. For internal use only. Copyright Protected

34 Who else recommends Vitamin D supplements?
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35 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). For internal use only. Copyright Protected

36 Which supplements are available?
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37 For internal use only. Copyright Protected
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 For internal use only. Copyright Protected

38 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 For internal use only. Copyright Protected

39 Healthy Start Vitamins
Healthy 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 D (7.5mcg/300 IU) For internal use only. Copyright Protected

40 When should I recommend vitamin supplements?
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41 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 For internal use only. Copyright Protected

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43 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. For internal use only. Copyright Protected

44 For internal use only. Copyright Protected
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 For internal use only. Copyright Protected

45 For internal use only. Copyright Protected
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) For internal use only. Copyright Protected

46 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 For internal use only. Copyright Protected

47 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 Treasure chest needs hyperlink to PDF file 6 (contains details on availability of vitamins in Salford) For internal use only. Copyright Protected

48 For internal use only. Copyright Protected
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 For internal use only. Copyright Protected

49 For internal use only. Copyright Protected
Vitamin Supplements Multivitamin supplements which contain Vitamin D can be bought from pharmacies and supermarkets and are separate from the healthy start scheme. Treasure chest needs hyperlink to PDF file 7 For internal use only. Copyright Protected

50 Are people taking these supplements?
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51 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 For internal use only. Copyright Protected

52 For internal use only. Copyright Protected
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 PDF file 8 needs to be healthy start return info For internal use only. Copyright Protected

53 For internal use only. Copyright Protected
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 reference and link- cleghorn 2006, lockyear 2011, whiting 2010 Treasure chest needs hyperlink to PDF file 9 (containing HS return data) For internal use only. Copyright Protected

54 You have finished! Just 1 last thing…
Congratulations! You have finished! Just 1 last thing… For internal use only. Copyright Protected

55 For internal use only. Copyright Protected
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 For internal use only. Copyright Protected


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