Lynne Garton reports on your views and concludes that the Government needs to give clearer guidance on vitamin D supplements for mothers and the under-fives

Lynne Garton BSc(Hons) PostgradDipDietetics
Registered Dietitian Director, Alimenta Ltd, Buckinghamshire

ABSTRACT Two focus groups of health visitors, practice nurses and community nursery nurses were held to find out how much health visitors and nurses know about children's bone nutrition, and whether they are able to identify dietary sources of these nutrients. Results showed that these professionals spend a significant part of their time giving nutritional advice about children and young people and answering questions on a range of dietary matters. They were well informed about the importance for bone health of calcium, vitamin D, exercise and a healthy, balanced diet. The biggest misconception was that dairy products in the UK contain vitamin D. Most of the professionals knew that bone strength develops quickly during childhood, and some that it does so in adolescence, but few were aware that 90% of the full genetic potential for bone strength is achieved before adulthood. The groups reported confusion over the Government's initiatives for vitamin D supplements, and lack of guidance from Primary Care Trusts on making Healthy Start vitamins available at clinics for mothers and babies.Overall, health visitors and nurses have a good knowledge of bone health but there are gaps and more educational resources are needed, including on dietary sources of vitamin D. The Government needs to give clear guidelines about its initiatives for vitamin D supplements for mothers and children aged under five years. It is disappointing that the Dairy Council's 3-a-Day message on meeting essential calcium needs through three daily servings of dairy foods has not got through. Journal of Family Health Care 2008; 18(5): 175-17 

Key points 
_ At recent focus groups, nurses and health visitors showed a good understanding of bone health but there were some gaps in their knowledge and a lack of practical educational resources  
_ A common misconception was that dairy foods contain vitamin D. This is not so in the UK
_ The nurses and health visitors reported spending a significant amount of their time - 20-50% - on giving dietary advice on a range of topics. All gave advice to mothers of children under five years, and most gave general dietary advice for all age groups
_ The Government stipulates that all children under five years and all expectant and breastfeeding mothers should be taking a supplement containing vitamin D, such as that included in Healthy Start. The health visitors reported huge confusion over the practicalities of supplying the supplements at mother and baby clinics and a lack of direction from Primary Care Trusts
_ Few had heard of the Dairy Council's 3-a-Day campaign and its resources for encouraging the population to eat three portions of dairy foods every day to ensure essential calcium needs are met
_ The Government needs to give clear guidelines about its initiatives for vitamin D supplements for mothers and the under-fives

Two focus groups were held recently to find out how much health visitors and nurses know about children's bone nutrition, and whether they are able to identify the types of nutritional resources that are needed. Overall, health visitors and nurses have a good understanding of bone health nutrition, but there are some gaps in their knowledge and practical resources are desperately needed. Most surprising is the lack of clear advice from the Government on its new initiative on vitamin D-containing drops for all children under the age of five years and the availability of the Healthy Start vitamins. In regard to bone health, some common misconceptions still exist about the sources of vitamin D.

The focus groups

Two separate focus groups were run in February and July this year. In total, 22 nurses and health visitors were asked for detailed feedback on a number of issues relating to child and infant feeding, bone health, dairy products, calcium and vitamin D, as well as their needs for resources on these topics. The composition of the groups is shown in the FigureChild bone health figure

How much nutritional advice do participants give?

A significant proportion of the groups' working day is dedicated to providing nutritional advice - from 20 to 50% of their time. 

All 22 professionals gave advice to mothers with children aged under five years, and most gave general dietary advice for all age groups.

The main dietary queries they dealt with were:
_ Weaning
_ Children's milks and formula vs. breast milk
_ Fussy eaters
_ Failure to thrive
_ Weight matters
_ Questions about specific conditions such as  coeliac disease, diabetes, food intolerances, eczema

Bone health  

All health care professionals were fully aware that children's bone quality would influence their bone health in later life. While most were aware that bone strength develops quickly during childhood, and some were aware that it does so in adolescence, few were aware that 90% of our full genetic potential for bone strength is achieved before adulthood -18 years for girls and 20 years for boys1,2. 

Diet and lifestyle for strong bones  

There was a high degree of awareness of the importance of calcium, vitamin D, exercise and a healthy, balanced diet.

Vitamin D - is sunshine a sufficient source for everyone?

All members of the groups cited sunshine as a major source of vitamin D. There is general consensus about this, although recent science is demonstrating that sunshine is not enough and that a significant proportion of the UK population has low and sub-optimal vitamin D status, especially the very young3-6.Child Bone Health Table
Why is sunshine not enough1,7?  

_ Seasonality. The sun's rays are only strong during April to September and during the hours of 10am to 3pm. This is also the time when the public, and especially young children, are advised to keep away from direct sunlight
_ Pollution and clouds absorb a large proportion of the sun's UVB rays (the rays responsible for converting the vitamin D precursor under the skin into vitamin D)
_ Melanin is the skin's natural sun-block, hence individuals with dark skin will be less efficient at producing vitamin D
_ Sunscreen creams - SPF 8 and above. Sunscreen creams are designed to block out both UVB and UVA sun rays. A study has shown how effective they are at doing this - an SPF 8 cream will block out at least 95% of UVB rays
_ Clothing will block the majority of UVB rays, so those who cover themselves up between the months of April and September are more likely to be deficient in vitamin D
_ Obesity - preliminary studies are showing a correlation between obesity and a lower vitamin D status. 

Vitamin D - there are very few food sources  

Very few foods contain vitamin D and food fortification with this vitamin is minimal8. The biggest misconception is that dairy products in the UK contain vitamin D. Unlike the USA, in this country milk or dairy products are not fortified as standard and therefore these foods do not provide any vitamin D in the diet.  

What foods provide vitamin D8?  

The focus groups were asked to name foods, which they felt were sources of vitamin D. Although some incorrect suggestions were made, it was encouraging to see that the nurses and health visitors knew the majority of food sources for vitamin D (see Table).

Government vitamin D initiatives9-11 - are they getting through?  

The Government has stipulated that all children under five years and all expectant and breastfeeding mothers should be taking a vitamin D containing supplement. Additionally, it relaunched its Healthy Start vitamin D-containing supplements for children and mothers, with the advice that these should be available free of charge to all those who qualify for the Healthy Start scheme.
The focus groups were mixed in their response to this. Most health visitors were aware of this initiative. However, the groups reported huge confusion on the practicality of supplying the supplements and how to get hold of them. They reported that there were no clear guidelines on how each local Primary Care Trust went about ensuring that adequate stores were available at all clinics for mothers and babies. 

The 3-a-Day campaign: is this gettingthrough?

Few in the groups were aware of the Dairy Council's 3-a-Day campaign12,13, yet when it comes to bone health this is an excellent tool to help people meet their calcium needs in a simple way. Three portions of dairy produce - for example, milk, cheese and yoghurt - will meet the calcium needs for most individuals. Different portion sizes will be needed depending on the individual's age and size. The 3-a-Day message is extremely important for teenagers, and especially teenage girls - many of whom fail to meet the minimum requirements - in order to sustain bone health and prevent osteoporosis in later life4.

Conclusion  

Dietary advice to parents with children aged under five years to teenagers takes up a significant part of health visitors', practice nurses' and community nursery nurses' time.
These health professionals give advice on many nutritional topics, from weaning to intolerances and allergies. Although bone health has not generally been on their agenda, health care professionals have kept up to date with key requirements for bone nutrients. For bone health, more education is needed on dietary sources of vitamin D. The Government needs to give clear guidelines about its initiatives for vitamin D supplements for mothers and children aged under five years. As dairy foods are a major source of calcium, they make up one of the four major food groups encouraged by the Government for a balanced diet. It is therefore disappointing that the Dairy Council's 3-a-Day message has not got through.

ResourcesUseful websites for further information on children's nutrition and bone matters  

National Osteoporosis Society. www.nos.org.uk Food Standards Agency. www.eatwell.gov.uk British Nutrition Foundation. www.nutrition.org.uk Healthy Start. www.healthystart.nhs.uk The Dairy Council. www.milk.co.uk Yoplait. www.calciumeveryday.com; yoplaitnutrition.co.uk  

References   
1. Lanham-New S, Thompson RL, More J, Brooke-Wavell K, Hunking P, Medici E. Importance of vitamin D, calcium and exercise to bone health with specific reference to children and adolescents. Nutrition Bulletin 2007; 32(4):364-377
2. Heaney RP, Abrams S, Dawson-Hughes B et al. Peak bone mass. Osteoporosis International 2000; 11(12): 985-1009. Review
3. Hyppönen E, Power C. Hypovitaminosis D in British adults at age 45y: nationwide cohort study of dietary and lifestyle predictors. American Journal of Clinical Nutrition 2007: 85(3): 860-868
4. Gregory J, Lowe S, Bates CJ et al. National Diet and Nutrition Survey: Young People Aged 4 to 18 years. Volumes 1 and 2. Report of the Diet and Nutrition Survey. London: The Stationery Office, 2000
5. Heaney RP. The case for improving vitamin D status. Journal of Steroid Biochemistry and Molecular Biology 2007; 103(3-5): 635-641. Epub 2007 Jan 10
6. Cashman KD. Vitamin D in childhood and adolescence. Postgraduate Medical Journal 2007; 83(978): 230-235
7. Holick MF. Vitamin D deficiency. New England Journal of Medicine 2007; 357(3): 266-281. Review
8. Food Standards Agency. McCance and Widdowson's The Composition of Foods. 6th summary edition. Cambridge: Royal Society of Chemistry, 1991
9. Department of Health. Nutrition and Bone Health with particular reference to calcium and vitamin D. Report of the Subgroup on Bone Health. (Working Group on the Nutritional Status of the Population of the Committee on Medical Aspects of Food and Nutrition Policy.) Report on Health and Social Subjects No.49. London: The Stationery Office, 1998
10. Department of Health. Weaning and the Weaning Diet. Report of the Committee on Medical Aspects of Food Policy (COMA). Report on Health and Social Subjects No. 45. London: HMSO, 1994
11. NHS Healthy Start. www.healthystart.nhs.uk
12. McKinley M. A new health promotion message for dairy - the 3-A-Day campaign. Nutrition Bulletin 2003; 28(4): 369-372
13. The Dairy Council. www.milk.co.uk