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Vitamin D: increasing supplement use among at-risk groups

About

What is covered

This interactive flowchart aims to increase supplement use to prevent vitamin D deficiency among at-risk groups as identified in 2012 by the UK Health Departments Vitamin D – advice on supplements for at risk groups – letter from UK Chief Medical Officers, and in 2007 by the Scientific Advisory Committee on Nutrition Update on vitamin D.
Vitamin D is essential for skeletal growth and bone health. Severe deficiency can result in rickets (among children) and osteomalacia (among children and adults).
Dietary sources of vitamin D are limited. The main natural source is from the action of sunlight on skin. However, from mid-October to the beginning of April in the UK there is no ambient ultraviolet sunlight of the appropriate wavelength for skin synthesis of vitamin D. National surveys suggest that around a fifth of adults and 8 to 24% of children (depending on age and gender) may have low vitamin D status.
The risks and benefits of sunlight exposure (including exposure to prevent vitamin D deficiency) are covered in NICE's recommendations on sunlight exposure: risks and benefits.

Updates

Updates to this interactive flowchart

30 May 2017 Increase access to supplements and improve access to healthy start supplements updated after publication of The SACN vitamin D and health report 2016. At-risk age ranges amended and reference nutrient intake details updated.

Supplements

For the purpose of this guidance, a supplement refers to supplements of vitamin D, either alone or contained in multi-vitamin products (including Healthy Start supplements). It includes licensed products available only on prescription or through pharmacies and (unlicensed) food supplements available from a range of pharmacies and retail outlets.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on preventing vitamin D deficiency among at-risk groups in an interactive flowchart

What is covered

This interactive flowchart aims to increase supplement use to prevent vitamin D deficiency among at-risk groups as identified in 2012 by the UK Health Departments Vitamin D – advice on supplements for at risk groups – letter from UK Chief Medical Officers, and in 2007 by the Scientific Advisory Committee on Nutrition Update on vitamin D.
Vitamin D is essential for skeletal growth and bone health. Severe deficiency can result in rickets (among children) and osteomalacia (among children and adults).
Dietary sources of vitamin D are limited. The main natural source is from the action of sunlight on skin. However, from mid-October to the beginning of April in the UK there is no ambient ultraviolet sunlight of the appropriate wavelength for skin synthesis of vitamin D. National surveys suggest that around a fifth of adults and 8 to 24% of children (depending on age and gender) may have low vitamin D status.
The risks and benefits of sunlight exposure (including exposure to prevent vitamin D deficiency) are covered in NICE's recommendations on sunlight exposure: risks and benefits.

Updates

Updates to this interactive flowchart

30 May 2017 Increase access to supplements and improve access to healthy start supplements updated after publication of The SACN vitamin D and health report 2016. At-risk age ranges amended and reference nutrient intake details updated.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Vitamin D: increasing supplement use among at-risk groups (2014 updated 2017) NICE guideline PH56

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Pathway information

Supplements

For the purpose of this guidance, a supplement refers to supplements of vitamin D, either alone or contained in multi-vitamin products (including Healthy Start supplements). It includes licensed products available only on prescription or through pharmacies and (unlicensed) food supplements available from a range of pharmacies and retail outlets.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Culturally appropriate interventions take account of the community's cultural or religious beliefs and language and literacy skills by:
  • Using community resources to improve awareness of, and increase access to, interventions. For example, they involve community organisations and leaders early in the development stage, use media, plan events or make use of community-specific festivals.
  • Understanding the target community and the messages that resonate with them.
  • Identifying and addressing barriers to access and participation, for example, keeping costs low to ensure affordability and taking account of working patterns and education levels.
  • Developing communication strategies that are sensitive to language use and information needs. For example, involve staff who can speak the languages used by the community, and provide information in different languages and for varying levels of literacy (for example, using colour-coded visual aids and spoken rather than written information).
  • Taking account of cultural or religious values, for example, in relation to body image, separate physical activity sessions for men and women, beliefs and practices about hospitality and food, or dates, days, settings, or timings considered unsuitable for community events or interventions.
  • Providing opportunities to discuss how interventions would work in the context of people's lives.
  • Considering how closely aligned people are to their ethnic group or religion and whether they are exposed to influences from both the mainstream and their community in relation to diet and physical activity.
Population groups at higher risk of having a low vitamin D status include:
  • All pregnant and breastfeeding women, particularly teenagers and young women
  • Children under 3 years
  • 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 who have darker skin, for example, people of African, African-Caribbean and South Asian origin.
Reference nutrient intake is the amount of a nutrient needed to meet the needs of 97.5% of individuals in a group. Reference nutrient intake for a given nutrient may vary by gender, age and physiological status (for example during pregnancy and lactation). The reference nutrient intake is not a minimum target that all people need to achieve, but the risk of deficiency is minimised if the average population intake exceeds it.
The current reference nutrient intakes (µg/day) for vitamin D are:
  • 10 micrograms of vitamin D per day, throughout the year, for everyone in the general population aged 4 years and older
  • an RNI of 10 micrograms of vitamin D per day for pregnant and lactating women and population groups at increased risk of vitamin D deficiency
  • a 'safe intake' of 8.5 to 10 micrograms per day for all infants from birth to 1 year of age
  • a 'safe intake' of 10 micrograms per day for children aged 1 to 4 years)
Currently there is no reference nutrient intake for people aged between 4 and 65 years. It is assumed that the action of sunlight on skin will provide adequate vitamin D, except for specific at-risk groups, such as women whose clothing conceals them fully or those confined indoors. ('Dietary reference values for food energy and nutrients for the United Kingdom. Report of the panel on dietary reference values of the Committee on Medical Aspects of food policy' Department of Health.)
At risk groups are currently advised to take a supplement that meets 100% of the reference nutrient intake for their age group (as above). The reference nutrient intake for at risk groups is 10 micrograms/day (1 microgram=40 international units, so 10 micrograms=400 IU).
The Scientific Advisory Committee on Nutrition is currently considering whether to amend the reference nutrient intake.

Glossary

foods or non-food items such as cosmetics or pharmaceuticals permitted by and prepared according to Islamic law
a UK-wide government scheme that provides a 'nutritional safety net' for pregnant women and families on benefits and tax credits. Every 8 weeks, beneficiaries get vitamin coupons to swap for Healthy Start vitamins. The vitamin tablets for mothers contain folic acid and vitamins C and D. Healthy Start vitamin drops for children contain vitamins A, C and D
food (or premises where food is sold, cooked or eaten), cosmetics and pharmaceuticals that comply with Jewish law
(sometimes called vitamin D deficiency) is defined by the Department of Health as a plasma concentration of 25-hydroxyvitamin D (the main circulating form of the vitamin) of below 25 nmol/litre (equal to 10 ng/ml)
people who follow a vegan diet consume only plant products. They avoid all food, drink and non-food items, such as pharmaceuticals that contain any animal products

Paths in this pathway

Pathway created: December 2014 Last updated: July 2017

© NICE 2017

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