Vitamin D and Sunshine in Bradford Ann Hobbiss : Public Health Manager for Every Baby Matters Zak Ansari : Public Health Dietitian

Incidence of vitamin D deficiency in women of childbearing age and children remains high in Bradford Between 2008 and 2010 : nearly 2,000 new diagnoses in women aged of 16 – 44 from primary care Between 2007-2010 there were 67 cases of rickets diagnosed in children, 46 of which were under nine years old Over 1,100 children were identified with vitamin D deficiency 2007-2010 It is likely many women and children remain undiagnosed

Incidence of Vitamin D deficiency in women of childbearing age 2008 -2010. Incidence per 1,000 women 2009 2010 Total number Age range number 15 - 44 538 5.3 610 5.5 751 6.9 1958 Source: NHS Bradford & Airedale Intelligence SystmOne July 2011

What it is and why we need it Substance that is formed from the action of sunlight falling on the skin Fat soluble substance Stored and activated in the liver Key Action: to enable the body to absorb and utilise calcium for bone growth and muscle function Possible additional health benefits: prevention of multiple sclerosis and other long-term conditions Come back to these statements – angle of sunlight appears crucial Fat soluble – hence fatty foods contain vit D – only obtain about 10% of what we need in food Stored and activated in liver – healthy live

Obtaining Vitamin D Sunlight Supplements Diet – ‘top up’

What are the factors that contribute to a deficiency in Bradford? Reduced exposure to the sun through: Latitude – angle of UVB rays Weather Clothing Sun-cream (above factor 8) – above 52 degrees N only effective in summer months – our hours of annual sunshine are similar to that of northern Scotland – covering the skin will inhibit vitamin D formation – reduced exposure through being housebound

Who is at risk? Those with someone else in the family with vitamin D deficiency People from South Asian, African, African Caribbean and Middle Eastern backgrounds Those that have a low exposure to sunlight due to wearing concealing clothing or spending time indoors Teenagers Strict sunscreen users People who are obese Pregnant or breastfeeding women Breastfed and some formula fed babies Children during periods of rapid growth such as in infancy Children with chronic conditions (malabsorption, juvenile idiopathic arthritis, rheumatic conditions, chronic steroid use, diabetes, disability and reduced mobility) People on medications interfering with Vit D metabolism: phenytoin, carbamazepine, steroids, rifampicin

Exposure to sunlight - Angle of the sun’s UVB rays is important Around noon – 11-3pm without sun protection cream Summer time – April to September In and out of the sun - care not to redden Up to 15-20 minutes total Vitamin D is manufactured during the summer months and stored for the winter

Supplements for standard dose Advise a preventative dose of 10 mcg or 400 IU a day For infants 7.5mcg or 300 IU For people unable or unwilling to expose skin to sunlight - Healthy Start tablets and drops provide these amounts Also: Pro D-3 and other OTC supplements (see children’s pathway)

Dietary sources Important in winter for topping up stores BUT only ever supplies 10% of required amount Oily fish Fortified breakfast cereals – check label Fats and margarines (fortified) Evaporated milk Egg yolks

Achieving 10mcg(400IU) Vitamin D through diet Daily intake of : 120g of pilchards and 1 egg OR 14 bowls of fortified breakfast cereal OR 130g (13 pats) of margarine OR 1 large tin (250ml) of evaporated milk OR 12 eggs

Who in Bradford should be receiving free Healthy Start vitamins? All mothers and children qualifying for Healthy Start vouchers (up to age four) All pregnant women who book-in with a midwife from the BRI or AGH All infants from first Health Visitor visit to six months old All infants up to age 2 considered ‘at risk’ by the HV

Summary of key concepts Diet is not an adequate source of vitamin D – the average intake is 10% of requirements Vitamin D status is dependent on exposure to sunlight NOT diet To manufacture vitamin D at northern latitudes, regular exposure of some skin between 11-3pm during summer is needed. Darker skins need more time to produce vitamin D, fairer skins need more care not to redden. ALL skin types need to take care not to burn.

Key concepts cont…. Breast-milk will not necessarily provide sufficient vitamin D for the infant (dependent on mother’s vitamin D status) All babies, including breastfed babies will be offered vitamin D drops from first HV visit at 14 days. There will be some people for whom sunlight and/or standard dose supplements is not enough, eg people with liver or renal disease, or on particular medications and will need to see their GP (see adult and children’s pathways for Vitamin D insufficiency and deficiency). HV and MW are key professionals to ensure distribution for mothers and young children. Early Years are in a key position to support families to understand their needs and assist vulnerable families to access vitamins.