Summary

Subject of this call for evidence

Vitamin D helps keep bones and muscles healthy. This call for evidence seeks views on how to improve the vitamin D status of the population in England, in line with existing recommendations, as well as addressing associated health disparities and improving health outcomes through maximising the benefits of vitamin D. This includes seeking views on improving vitamin D intake and status through diet and dietary supplements, particularly among at risk groups.

Scope of this call for evidence

This call for evidence invites respondents’ views on the following specific areas:

• addressing health disparities related to accessing and consuming vitamin D

• improving population awareness of vitamin D

• improving awareness among health and care professionals of vitamin D

• improving vitamin D status through diet, including fortified foods and biofortification

• improving vitamin D status through dietary supplements, and increasing access to and availability of dietary supplements

Who should read this

The government welcomes engagement from any individual, organisation or business with views on improving the vitamin D status of the population in England, reducing associated health disparities and improving health outcomes.

Duration

This call for evidence will run for 6 weeks, starting from 3 April and ending on 15 May 2022.

Lead official

This call for evidence is led by the Office for Health Improvement and Disparities (OHID), Department of Health and Social Care (DHSC).

How to respond or enquire about this call for evidence

The easiest way to participate in this call for evidence as an individual is by completing this survey.

Written submissions can be submitted in Word or PDF format and emailed to [email protected]

The address to post written responses is:

Written responses will be destroyed after they have been scanned to create a digital copy.

If you have any problems using this survey, send your queries to [email protected]. Please do not send any personal information to this email address.

Respondents may choose to respond to some or all of the questions in this document. OHID welcomes partial responses, focused on the aspects that are most relevant to the respondent.

When responding to questions in the call for evidence, please do not include any information that could identify you or somebody else. For example, do not include anyone’s name, age, job title or email address where it is not asked for.

To help ensure our policy making is representative and to understand how views and experiences may affect certain population groups, we would like to ask some additional questions about your personal characteristics. Results will be grouped with responses from individuals who share the same characteristics. Individuals will not be personally identifiable in our analysis or any results we publish.

Do not identify anyone else in your answers to any questions during this call for evidence.

Data protection

Please see the privacy note for further information.

After the call for evidence

The government will publish a summary of responses shortly after the call for evidence closes on 15 May 2022. Evidence submitted will be considered as part of a policy to improve the vitamin D status of the population, and this may lead to further consultation in the future.

Ministerial Foreword

Vitamin D is needed to keep muscles and bones healthy (musculoskeletal health). However, we know that dietary sources of vitamin D are limited and that we obtain the majority of our vitamin D from exposure of our skin to the sun during the spring and summer.

Existing advice is for everyone to consider taking a daily dietary supplement of vitamin D between October and March, and for some at risk groups, including people who are not often outdoors such as the frail or housebound, and those with dark skin, to consider taking a dietary supplement throughout the year. However, we know that uptake of dietary supplements is poor and intakes of vitamin D fail to meet recommendations in all age groups. This is backed up by data showing around 13% to 16% of all adults have low vitamin D status and mean vitamin D status is higher in white adults compared with people from black African, black Caribbean, black ethnic groups or south Asian adults.

These figures expose health risks and health disparities across the population that we must address if we are to meet our commitments to improve the diet of the nation and to empower people to make healthier choices. OHID was established to lead our work on improving the nation’s health so that everyone can expect to live more years of life in good health, and levelling up health disparities to break the link between background and prospects for a healthy life.

During the coronavirus (COVID-19) pandemic, these health challenges and disparities were brought to the fore as our lifestyles changed and social restrictions were put in place. During the pandemic, the government provided over 900,000 vitamin D supplements to people who were clinically extremely vulnerable and people in care homes who had to spend less time outdoors.

As social restrictions are lifted and we manage living with COVID-19, it’s timely to consider how we improve the population’s vitamin D status, particularly within at risk groups.

This call for evidence will kick-start a national campaign to raise awareness of the importance of maintaining a healthy vitamin D status and a period of engagement with key stakeholders to identify ambitious and innovative ways to improve population vitamin D status. I have also asked the Scientific Advisory Committee on Nutrition (SACN) to consider this issue. I welcome your views on how we can achieve this together.

Introduction

The government’s dietary advice is that individuals should generally be able to meet nutritional requirements, including for fibre, vitamin, and minerals from a healthy, balanced diet. This is based on the advice of SACN and encapsulated in the UK’s national food model, the Eatwell Guide. However, most people do not meet the dietary recommendations.

The most recent National Diet and Nutrition Survey (NDNS) data shows that population intakes of saturated fat, sugar, and salt are above government recommendations, whereas intakes of fibre, fruit and vegetables, and oily fish are below government recommendations. It is estimated that on average, adults’ diets contain 200 to 300 more calories per day than are required for a healthy body weight.

While people in lower income groups have slightly less healthy diets than those in higher income groups (for example lower consumption of fruit and vegetables, fibre and some vitamins and minerals), all income groups generally fail to meet government recommendations.

Vitamin D

Vitamin D helps regulate the amount of calcium and phosphate in the body. These nutrients are needed to keep bones and muscles healthy. Vitamin D deficiency can lead to bone problems such as rickets in children, and bone pain and muscle weakness in adults, which may also increase the risk of falls in older people.

Vitamin D is only found in a small number of foods. Sources include oily fish (such as salmon, sardines, herring and mackerel), red meat, liver and egg yolks. In addition, some foods are fortified such as fat spreads and breakfast cereals. Fortification of foods and drinks with vitamin D is voluntary, but must meet legislative requirements regarding safe levels.

The main source of vitamin D is from direct sunlight exposure on the skin. Between late March and early April to the end of September, most people can make (synthesise) all the vitamin D they need through sunlight exposure on their skin and from a balanced diet. However, during the autumn and winter months, the sun is not strong enough to enable this synthesis to take place. Therefore, current government advice is that everyone should consider taking a daily vitamin D supplement during the autumn and winter months. Current vitamin D recommendations are based on musculoskeletal (muscle and bone) health.

During the summer months, some people have very little or no sunshine exposure and will not make enough vitamin D from sunlight. This may include the elderly, people who are housebound, confined to the indoors for longer periods, or those in care homes or confined indoors in other institutions, and those who usually wear clothes that cover up most of their skin when outdoors.

Recommendations

DHSC recommends that adults and children aged over 4 years take a daily supplement containing 10 micrograms (400 units) of vitamin D throughout the year if they:

• are not often outdoors – for example, if they are frail or housebound

• are in an institution like a care home

• usually wear clothes that cover up most of their skin when outdoors

People with dark skin from a black African, black Caribbean, black ethnic group or south Asian background may also not make enough vitamin D from sunlight. These people are advised to consider taking a daily dietary supplement containing 10 micrograms of vitamin D throughout the year.

Children aged 1 year to 4 years should also have a daily supplement containing 10 micrograms (400 units) of vitamin D, this is to be taken throughout the year. Babies from birth to 1 year should have a daily supplement containing 8.5 micrograms (340 units) to 10 micrograms (400 units) of vitamin D throughout the year if they are breastfed or formula-fed and are having less than 500 millilitres of infant formula per day (because infant formula is already fortified with vitamin D).

Government advice on vitamin D is based on advice from the SACN vitamin D and health report 2016.

Dietary intakes of vitamin D in the UK are below the recommended levels in all age groups, and this is backed up by data showing low blood levels of vitamin D. NDNS data (2014 to 2016) indicates that around 13% to 16% of UK adults have poor vitamin D status. Mean vitamin D status is higher in white adults compared to Asian and black adults.

The National Institute for Health and Care Excellence (NICE) has published guidelines on vitamin D dietary supplement use which aim to prevent vitamin D deficiency among specific populations.

Evidence are we looking for

We welcome your views on the following specific areas:

• addressing health disparities related to accessing and consuming vitamin D

• increasing population awareness of vitamin D

• raising awareness among health and care professionals of vitamin D

• improving vitamin D status through diet, including fortified foods and biofortification

• improving vitamin D status through dietary supplements, and increasing access to and availability of dietary supplements

Call for evidence questions

Addressing health disparities related to accessing and consuming vitamin D

Certain groups of the population are particularly at risk of low vitamin D status including those with dark skin (such as people from a black African, black Caribbean, black ethnic group or south Asian background) and those with limited exposure to sunlight in the spring and summer, such as the elderly, people who are housebound, confined to the indoors for longer periods, or those in care homes or confined indoors in other institutions , and those who usually wear clothes that cover up most of their skin when outdoors. These groups are advised to consider taking a daily dietary supplement throughout the year.

Increasing population awareness of vitamin D

DHSC provided guidance in 2012 to health and care professionals on vitamin D supplements for at risk groups and further guidance to the population in 2020 on taking vitamin D supplements during autumn and winter. The NHS website also provides information on vitamins and minerals, including vitamin D, its sources and benefits, the risks of vitamin D deficiency and consuming too much vitamin D. Regional or local areas may also implement awareness raising activities on vitamin D dietary recommendations.

As free vitamin D supplements were provided in England to at risk groups during the COVID-19 pandemic, DHSC provided further guidance on safe vitamin D supplement use.

This call for evidence kick starts a national campaign to increase awareness of national guidance and dietary advice on vitamin D and associated health disparities, which will include engagement with various stakeholders and industry.

Leading up to autumn, when most people begin to be at risk of low vitamin D status, we will increase awareness of our advice and guidance for maintaining sufficient vitamin D status during the winter.

Raising awareness among health and care professionals of vitamin D

We know that people who have less access to the outdoors are at higher risk of vitamin D deficiency, including the elderly, people who are housebound, confined to the indoors for longer periods, or those in care homes or confined indoors in other institutions, and those who usually wear clothes that cover up most of their skin when outdoors.

Health and care professionals in clinical and community settings care for a diverse range of people and make valuable connections in delivering that care and support. They are in unique positions to provide advice and guidance to people they care for.

For most people, their first point of contact with health services will be in primary care settings, and usually their GP. Primary care settings are increasingly becoming local health hubs providing a wider range of advice and support to the communities to promote good health. Alongside this, regional and local public health services may deliver interventions to promote good health and wellbeing within their communities.

Improving vitamin D status through diet, including fortified foods and biofortification

The main sources of vitamin D are sunlight exposure, a limited number of foods and dietary supplements. It is difficult to get enough vitamin D from food alone as it is only found in a small number of foods. Sources include oily fish (such as salmon, sardines, herring and mackerel), red meat, liver, egg yolks, and fortified foods – such as some fat spreads and breakfast cereals.

Some foods in the UK are voluntarily fortified with vitamin D including some fat spreads, plant-based drinks (for example, soya or almond milk), dried and evaporated milks and breakfast cereals. In the UK, all margarine sold for domestic use was previously subject to mandatory fortification with vitamin D (and vitamin A) from 1940, until the mandatory requirement was removed in 2013. This requirement was removed as very few products remained on the UK market that would legally qualify as ‘margarine’. However, many fat spreads now sold are fortified with vitamin D on a voluntary basis.

In accordance with former European legislation, retained by the UK following exit from the EU, infant formula is mandatorily fortified with vitamin D to promote the development of strong teeth and bones at the earliest stages in life. Current government guidelines advise that if you are breastfeeding, you should consider taking a vitamin D supplement (containing 10 micrograms (400 units)). If your baby is only having breast milk or formula-fed and having less than 500 millilitres of infant formula per day, (infant formula is already fortified with vitamin D), you should also give them a daily vitamin D supplement of 8.5 micrograms to 10 micrograms (340 to 400 units).

Fortifying a staple food may provide a method of improving the vitamin D status of the population, and particularly for groups at higher risk of vitamin D deficiency who may not have the same access to sources of vitamin D through their usual diet, sunlight or dietary supplements.

In the US, almost all milk is fortified with vitamin D on a voluntary basis. Other foods fortified on a voluntary basis include breakfast cereals (about 75%), milk substitutes (slightly more than 50%), yoghurts (about 25%) and cheeses, juices, and spreads. The addition of vitamin D to infant formula in the US is mandatory.

In Canada, fortification of milk and margarine with vitamin D is mandatory and fortified plant-based drinks (for example, soya milk) must contain an amount equivalent to that in cow’s milk. Infant formula is also fortified on a mandatory basis.

Biofortification of foods is the modifying of a food source rather than adding nutrients to a food source (fortification). Biofortification of eggs or UV-exposed mushrooms with vitamin D may improve the population’s vitamin D status.

We are interested in innovative programmes and interventions to highlight or promote vitamin D in food and drinks in retail and other settings.

Improving vitamin D status through dietary supplements and increasing access to availability of dietary supplements

As of November 2020, data shows around 7 million units of vitamin D supplements were purchased in Great Britain (England, Scotland and Wales) in 2020 (Nielsen, 2020). People typically purchase vitamin D supplements over the counter from retail outlets such as supermarkets, chemists, pharmacists or health food shops

A prescription only medicinal form of vitamin D may be provided for those with a clinical need.

Provision of free vitamin D supplements during the pandemic in England

During the COVID-19 pandemic, the government provided over 900,000 vitamin D supplements to people in England who were clinically extremely vulnerable and people in care homes who were most at risk of vitamin D deficiency through greatly reduced access to the outdoors. Now that COVID-19 social restrictions have been lifted and as we manage living with COVID-19, we want to consider how we improve the population’s vitamin D status, particularly amongst these at risk groups.

Healthy Start Vitamins

Healthy Start is a statutory scheme which provides £4.25 per week for pregnant woman and children aged under 4 and over one year, and £8.50 for children under one year, to be spent on fruit, vegetables, pulses, milk and infant formula. Healthy Start beneficiaries are also able to access free vitamins.

Eligibility for Healthy Start is linked to pregnancy and/or having children under the age of 4 years and to the receipt of prescribed benefits and tax credits. All pregnant women aged under 18 years are also eligible for Healthy Start, regardless of income.

Healthy Start Vitamins are available for women and children. Pregnant women and new mothers can receive a free dietary supplement which contains folic acid, vitamin C and vitamin D. Children under the age of 4 years can receive a supplement which contains vitamin A, vitamin C and vitamin D. Local authorities and NHS organisations are responsible for distributing vitamins at local level, through outlets such as ante-natal appointments, health visitors and health clinics.

As the Healthy Start Vitamins is run at local level there are no centralized figures on uptake. However, anecdotally, we understand that uptake is low.

We are interested in access and availability to vitamin D supplements.