Below is a full transcript of the recent JFHC-chaired debate on vitamin D and the under-fives:
Penny Hosie - Chair of the debate and editor of Journal of Family Healthcare (JFHC)
Dr Robert Moy - Feeding for Life Foundation
Patricia Mucavele - School Food Trust
Jacqui Lowden - Chief paediatric dietitian, Birmingham Children's Hospital, chair of BDA paediatric group
Barbara Evans - Community nursery nurse, NHS Leicestershire and Rutland and Board member of JFHC.
Professor Euan Ross - Co-director, Child Studies Department, King's College Hospital Medical School and Board member of JFHC
Dr Oliver Gillie - Director, Health Research Forum
Alison Wall - Health Visitor and Board member of JFHC. Declared interest as a member of the Feeding for Life Foundation
Penny Hosie:In essence the debate is like painting a picture, except it's not finished. So I'm hoping we can discuss vitamin supplementation for the under 5s… we know children are short of vitamins and we want to discuss today how to address this and you've all bee invited along for your ideas and discussion.
Dr Robert Moy: So, The Feeding For Life Foundation, which is a non-promotional foundation that is supported by Cow & Gate took, as its first hot topic after its foundation in the summer to look at vitamin supplementation and I was the lead director and author of this report, which I should emphasise is still in a draft format and there's still some work to be done on it.
The report looks at the policy around vitamin supplementation and how it is meeting the needs of children and notes that, to give the title of the report, a gap in what children require and what they actually get.
I think perhaps that there may be a bit of a misconception that vitamin D is a nutritional vitamin, which it isn't. Vitamin D sources come from exposure to sunlight but because of this nation's northerly latitude - it was pointed out to me that it is the same as the more northerly districts of Canada, so we are actually very northerly - means we don't, particularly at this time of year, get much sunlight exposure, therefore, by virtue of that, are at risk of vitamin D deficiency.
And, in fact, I do need to report that I am, in fact, vitamin D deficient, having recently had my vitamin D levels tested, which was rather a surprise to me, seen as though I thought I had a fairly outdoors lifestyle.
But that does bring up the issue about what is deficiency, and there are current debates about what should be the blood level of 25 hydroxin vitamin D and some people feel quite strongly advocating that the cut off should be much higher, and thereby the amounts that is set as the daily requirements should be much, much greater. That is another major issue, which does need to be addressed.
We are recognising in this country a resurgence of vitamin D deficiency diseases - that is, hypocalcaemic seizures in newborn babies, rickets in toddlers and also in adolescents as well; aches and pains and also in young children, muscle weakness presenting as developmental delay and muscle weakness presenting as potentially fatal cardiac diseases.
So it is a big clinical issue there. But it is, from all of the surveys that have been done and from case reports written, an ethnic issue, and that brings another dimension too, to what we're talking about. The case reports are, pretty much entirely, in Asian families, particularly those of the Islamic religion who may well modest dress and therefore don't get any sun at all.
Another related issue is the vitamin D status of mothers and how that is a determining factor of the vitamin D status of their children. So when we're thinking of supplementation it's not just about children, it's also about mothers as well.
Now, this country does provide vitamin D supplementation, and as you said, it is DH and Nice recommendations that all pregnant women, all lactating women and all children under 5 should receive vitamin supplementations but they're not getting them. The government scheme called Healthy Start is purely directed at those who are in receipt of benefits and can thereby access the free Healthy Start scheme, but for the vast majority of the population they are excluded from that, and that might include many of the families who are at risk by virtue of being Asian, but are actually working and in receipt of an income. So there's another problem.
Even though now, this programme has been in existence for some years, the uptake on it is pretty minimal - actually, it's quite disgraceful - that such low proportions of those eligible for the scheme actually up take the vitamins.
Penny Hosie: Alison, why do you think the public aren't getting the message?
Alison Wall: I think there are various issues involved. I think one thing is capacity, that health visitors, school nurses - the health visiting team - are terribly stretched. I think the main priority on the agenda is safeguarding…The healthy child Programme I think, generally I think children are seen at the 2 year review, but there's so many topics to cover it's a tickbox exercise…they're not looking in detail at the type of vitamins and the types of food that children are having. So it's the pressing concerns that are taking their time up.
Also, the access to healthy start and vitamins is very poor. We know the shelf-life is short, isn't it? Also, if you're not entitled to Healthy Start, they're quite expensive. I think they're something like £12 for a month's supply for some of the brands…
I think some of it is quite hidden - like you think 'what difference would it make if I tick a box on that?' and I know a lot of health visitors don't actually discuss vitamin supplementation; their knowledge is quite poor about it.
I think that maybe supplements should be given out, like with Healthy Start, to a wider number ... maybe all children, or all children identified by health visitors, should be entitled to supplementation or [at least] better knowledge.
Jacqui Lowden: I think a lot of what you're saying is true. We see children all of the time, and even children who are referred to us with other reasons, not necessarily for a lack of vitamin D, but we ask them all about vitamin drops and the parents look blank at you and say 'I don't know anything about them, what are they?' so I think it's a lack of education for health visitors not understanding why they're important and what they're for, so it's not really part of their priority in a tickbox list because they don't understand the importance of it, and I think targeting…
I think the messaging needs to be simple about who we're targeting and who needs them, because at the moment I think there's also mixed messages out there, it's not just health visitors, it's also GPs…
Penny: I was going to ask you about GPs, they seem to have poor knowledge…
Jacqui Lowden: I've had several conversations with GPs. I see children for different reasons but I always think about the children's vitamin drops, and I've written to several GPs saying that the children's not on vitamin drops and they should be. And that's children who are Asian and from that particular sector and children who have particular needs. And they write back to me and say they refuse to do it and say why are we doing this?
I had one conversation this week with a GP who phoned me up and said 'this mum has come to my clinic, she's an Asian child and her mum is worried about vitamin D - why is she worried about vitamin D, isn't it in formula milk?' There is just a lack of education there.
Dr Oliver Gillie: I don't think the professionals can blame themselves at all over this; not the doctors or the midwives or the health professionals. There have been mixed messages from the authorities, from NICE. They said it wasn't necessary for pregnant women and then they disagreed with themselves and then said it was.
They didn't do their research properly. SACAN was asked to look into this by the health minister and they didn't do their job properly. They say in their own report that they didn't read all of the literature so they gave it a complacent reply.
So the politicians were being misled by the people that produced these learned reports, but the politicians and civil servants had also failed to give it leadership. You used the word disgraceful and I think it is disgraceful; we haven't had leadership with this.
When they've produced these supplements, and they are modest supplements - as Robert says they should produce larger ones - they didn't give publicity to promote them…Danone - my friend here is from Danone…Danone wouldn't release a product and give it no publicity….it was a totally pathetic performance by our leaders really.
Fortunately, more people know about vitamin D now and people are asking about better solutions.
Penny: some foods have vitamins added - fortified cereals and stuff, so should we consider adding vitamins to more foods?
Dr Robert Moy: The thing for me is that, though evidence worldwide and in particular in Finland (a very Northern place) does show that the response to adding it to the population's food is not enormous. They do need to eat a lot of margarine to actually get much in the way of vitamins. Or munch their way through mackerel.
Certainly milk is something that could be fortified as it is in the United States and France. That's the normal shop bought milk, so that would require some additional dietary source. But overall, the answer has to be for us, at this stage of attitudes, supplementation.
Penny: Dr Ross, you must have seen many vitamin campaigns, so is this problem something new or something that we've seen for a few years?
Prof Euan Ross: Well, I sort of grew up with this…I didn't have much choice as my father was a GP, and I think there was a tremendous effort between and after the wars to eliminate unnecessary diseases…and health of children in Britain improved in those years.
But there was far more information available at all levels; there were food facts, cartoons in the newspapers, there was of course orange juice with vitamin C…
…But I felt, and it is a distant memory, that there was a tremendous effort on food. There were people who were identifiable leaders. There was Sir [David] Jack Golun [sic] who was so influential and I think Churchill understood the importance of children having proper nutrition right across the board, and rickets was a major problem in the country at the time and that was being managed by the end of the war.
And I think complacency set in after this. I don't think paediatric profession did any help when they started to diagnose hypocalcemia and getting scared with the amount of vitamin D children were getting.
Then I think the whole problem slumped off the radar…
Now if you look at research from then ... we didn't know about sub-clinical rickets or sub clinical vitamin D levels, and that is one of the more interesting things in paediatrics nowadays…there was a wonderful paediatrician in Luton of Indian origin, and he realised in Luton he was finding a resurgence of rickets, and he did a great deal about it, because he involved the Asian community, which I don't think we're hearing about…there is a problem that people need to be helped to see that they own the problem and get involved in it.
Although a higher percentage of British professionals are Asian, the people we're talking about here are of Asian origin, so everything we do sounds like a ticking off. So it has to be the other way round - they have to own the problem, and similarly they've got to be encouraged to take part in the discussion about what clothes people should wear.
I know a flat in Edinburgh that overlooks a school, and at play time, the Asian girls all sit in the corner in the shade - and its dark anyway…but they're not running around… and it is a new ethos that needs to be encouraged.
Penny: So how so we get these messages out?
Professor Euan Ross: Well, it's for themselves to decide. They need to have the information, but they need to own the problem. In Pakistan I saw more children in hospital with rickets than I have here in the UK in my career; I think maybe half a dozen children in the UK in my entire career where we've actually made a diagnosis of rickets. What we have no way of knowing is how many we have sub-clinical walking around.
It would be quite funny if we all had a blood test…and what we would all see for ourselves and what I don't know is a) how much it costs to ascertain someone's vitamin D levels - could it be the case that for mothers who we do blood tests on for this and that, could it be possible to test that?
Dr Robert Moy: Now that is clearly out of the question. The vitamin D test is £10 usually.
Professor Euan Ross: Could that be brought down?
Dr Robert Moy: It is, I'm told, an expensive test to do; it takes a long time and manpower to do it, so a strategy of actually testing everyone would actually bankrupt the NHS.
Professor Euan Ross: I think the organisers, or somebody, needs to bring the price down to 10p. It wasn't so long ago that to test your genes cost several million, and that's about 10p now … so these things can be done
Dr Oliver Gillie: So many people - almost everybody in the UK or British Isles is short of vitamin D. Very few people, maybe 5 per cent, come into the optimum category, but very few people know it so the simple thing to do is to remedy that everybody takes it. And you could say at the same time if you want that the people who have a great deal of sun exposure and who actively sunbathe and who go on sunshine holidays in the winter might not need it - but everybody else really does.
Professor Euan Ross: In the past I remember there's been all this issue with fluoride in water and [inaudible]. So if we're going to have a strategy we're going to have to work through all of these pitfalls very early in the design.
Alison Wall: I think one of the other problems is the confliction between the conflicting public health messages, because we have all of this advice about keeping in the shade and not being out in the sun, and I think that message has definitely won above getting enough sunlight to produce vitamin D.
I think people know what cancer is like and they know how terrifying it is and what skin cancer is like, but they don't really know what vitamin D deficiency is; we're not clear about how it affects the person and what the implications are.
And I think there's a lot of conflict like this in public health, so breastfeeding and diets as well…. But it is particularly stark with vitamin D and sunshine.
Dr Oliver Gillie: I can say something about that, because I've been campaigning on this for 8 years, and the people who have been holding us back more than anybody is Cancer Research UK, because they've been late to acknowledge that their message has been wrong - very, very badly wrong.
They said that you shouldn't go out in the sun in the middle of the day. They said that you should cover up with a shirt and clothing with sleeves and so forth. You should wear sunscreen. If you do all that, you're going to make yourself ill sooner or later with vitamin D deficiency. I mean, you would become severely deficient.
A lot of people don't pay attention to health messages, thank God. But a lot of people do pay attention. We want them to listen, and people have been listening to Cancer Research UK; we all know them and we've all met them, and they don't go out in the sun, they're terrified of burning and all of the rest of it, and they've taken this message to heart, and Cancer Research UK are too proud to do corrective advertising and tell people that their message is wrong and that they should be getting a certain amount of sun.
So I blame Cancer Research UK for a great deal, and I would just like to add to what Euan said, because he mentioned what we did during the war…and one of the things they did then was to have clinics, where children were irradiated with mercury vapour lamp solution by ultra violet light, and all children, as far as I know where irradiated in this way regularly in order to give them vitamin D.
I know Cancer Research UK will say that is terrible and that they'll get skin cancer, but as far as I'm aware no child got skin cancer. There's not a blip on the chart that anybody has ever mentioned that this cohort of children got more skin cancer so if it is done properly without risk of burning, there's no reason why they should increase their risk of getting skin cancer.
And that is the natural way to get vitamin D, through irradiation ... I would like to bring back these clinics. But I don't know whether the time is right for that yet. I think a lot of people would scream and shout and talk about skin cancer, because we haven't yet, unfortunately, got a proper grip on this thing yet. A lot of people are still scared about the original Cancer Research UK message which is wrong.
Barbara Evans: Can I just jump back a few steps, right back to how people access the vitamins and the Healthy Start and what have you.
There's a couple of issues. First of all, initially, the vitamins are very hard to get hold of, and they become stigmatised in a lot of ways. The whole SureStart programme has moved from being all-encompassing/all inclusive to more targeted - and that includes things like the vitamin drops and Healthy Start.
And I completely agree with what you said about professionals time to discuss it and go through it as a lot of people don't know that they are available; in some places they're still not available or still quite difficult to get hold of and, as you said, the population that needs them are the ones least likely to have access to them. And I think that is a massive issue and…anything where it seems like you're doing it to them…I've been a community nursery nurse for 18 years and in that time I've seen such mixed messages coming that the response to messages from average, every day people is 'Oh, they'll change their minds in a few weeks, we'll just stick to what we know because they don't know what they're talking about, they keep changing their minds'.
So I think you need some consistent messages, you need to be saying what it is preventing and as Euan said, encouraging people to take ownership of it themselves and not telling them what to do.
Penny: What's the most effective vehicle for getting the message out do you think?
Barbara Evans: I think we're reaching the hard to reach in what we think are the context of the hard to reach. What we're not reaching is the families that need vitamins but wouldn't come into a health drop in department. Hard to reach in terms of health are those children who experience very poor parenting, whose parents are perhaps quite scared of authority, don't work, perhaps poor educational achievement, those sort of hard to reach families.
Jacqui Lowden: In Manchester as well, English isn't always the first language that is spoken, so the mums don't access healthcare at all. [Reaching those families] is very difficult. It's linking up with link workers, people that maybe speak the language…there's a large number of asylum seekers in Manchester as well, as in any major inner city - London, Birmingham are the same - and they're hard to reach as well, so it's linking in to those that have links to these other families.
Dr Robert Moy: I think this really does go back to the important point Euan made about ownership of the issue; that it's not to be forced upon people, but one which they should own.
Prof Euan Ross: There are all sorts of ways we as professionals don't think about….that's why we need to get inside society and help society to own the problem [passes book round].
Barbara Evans: We've been talking about it earlier, the different age of youngsters…and there's youngsters now with 'Text Thumb' because they spend so long texting. And the whole internet, it seems like netmums, netbuddys all do a lot of blogging or tweeting…it seems like a drip-drip thing to me. The more often the message is heard, the more likely it is to be acted upon.
As long as what you agree to do is easy to set up and make available and affordable. And I think you've got to give the message in different formats as well.
Dr Oliver Gillie: One of the interesting things about vitamin D is that it is incredibly cheap. Vitamin D is put into hen food because hens are kept in the dark and they are also tropical creatures. Even if they weren't in the dark, in cages, they would still probably need vitamin D to help them along. But they certainly need vitamin D in their cages. It only costs 3p a day to give somebody 2,000 units of vitamin D. And the major costs of vitamin D comes with packaging and distribution. And if the government were doing this properly, distribution could be free through the professional channels that we've got, that includes health visitors. They'd have to be trained of course, so there would have to be some input there, but the financial cost isn't enormous and I was at the DH talking to a woman there who was responsible for the Healthy Start programme and she said she wanted to give the Healthy Start vitamins to everybody. She put forward a proposal to the department; she found that she had £3million left over at the end of the year and she said that is what it would cost to give it to every pregnant woman in the country.
And it had gone to some other department in the DH who did a cost/benefit analysis and they said that the benefit wouldn't be worth the cost. She was very disappointed and I don't think they did that cost benefit analysis properly.
I don't think anyone wanted her to do it as obviously it would then set the precedent for one year and they would have to start doing it for another year.
It's not expensive to do these programmes. You could target pregnant women and babies in the first year of life and maybe give free supplements. There's no reason why people shouldn't buy them themselves. I think there would be tremendous benefit from doing pregnant women and babies in the first year of life, because on the back of that you could sell the message that people need to take vitamin D and people can afford to spend 3p a day.
Barbara Evans: My oldest son is 24 and we went along to what was then the drop-in centre and they sold [inaudible] and there was some debate about that, at the same time they also sold vitamins, so those on benefits just got them, and those who weren't on benefits could buy them and were encouraged to do so. They were in tiny little bottles and cost 37p. You just didn't think about it, everybody was doing it. They were easy to get, they were very cheap…and I believe the factory burned down!
Dr Oliver Gillie: there's some excuse about the bottles leaking. Why the bottles should suddenly have started leaking after 20 years…you see, this was a government project, the private sector wasn't actually involved in this. And the Healthy Start is government as well, and it is very…I think the government is ideologically against it so they used excuses. I don't really see why they stopped it.
Barbara Evans: Also, you lost the baby milk. Because it was volunteers that sold it…and it was deemed not suitable. And once you lost the storage facilities for it, you also lost the storage facilities for everything else as well.
Dr Oliver Gillie: I don't think they want receptions in clinics to take money now either.
Alison Wall: I've got a question about vitamin D. When you read the articles you read about vitamin D2 and vitamin D3, with the D3 being more effective and taken and absorbed better - and the drops seem to be using D2 more than D3. Is there anything we should be doing to ensure it is D3 instead of D2.
Dr Oliver Gillie: It's an old formula basically so that's why it is D2 and not D3. That's another way in which the department has failed basically. They just produced the stuff that had been produced before.
But what they did actually was they took the vitamin A out of the product for pregnant women - they said there would be too much vitamin A it (and that was another of the reasons why they changed it all) and they didn't do anything else. So the shelf-life was wrong and the chemists wouldn't stock it. It was a whole bungled operation by the department from beginning to end.
Patricia Mucavale: Well, I suppose from the School Food Trust perspective, we would not advocate fortification unless there was a public health problem. Obviously, we acknowledge that there is a public health problem.
But I think we need to live in the real world. We've got a short amount of resources, we don't have access to a bottomless pit, and in some respects we need to take an opportunity that we're in this change of policies with public health England and change within the NHS, and with Public Health England being set up, maybe you could look for opportunities in relation to addressing this growing concern and in terms of where you can get consistent messages.
So, for example, at the moment, there was an official statement that was made in July by the DH and Department for Education, only as teams in the local authority, the health visiting teams and other health experts in PCTs [inaudible] so they could be physically in the same building, and they were definitely in the same team as part of the clusters of the health and wellbeing boards there is an opportunity that we can catch them with those consistent messages.
My understanding is, in relation to some of the issues, could be around both the supply side and the demand side in relation to getting supplementation right and in perfect balance.
I just want to let you know in terms of the School Food Trust and what we've done recently, we've been commissioned after we set up and managed the advisory panel on food and nutrition in early years. We were commissioned by the Department for Education to draft the food and nutrition guidelines for early years settings.
Scotland, Wales and Northern Ireland have set in place food and drink guidelines. The thing about it is some children are in these settings from 7 o clock until 7 o clock. So they get 90% of their calories and 90% of their nutrients in these settings. England does not have this. So we've drafted these guidelines with the evidence base represented in the original table [?] report and we've pilot tested this guidance with the early years sector. So all of them are strategic partners - there are 6 major strategic partners and we have finalised that guidance - it has been submitted to the government and it will be published next month.
I have a copy of the guidance. I can't leave it with you because it is not in the public domain, but we will obviously share that with you.
In that guidance - in the first chapter - we do talk about the Healthy Start programme and we have to acknowledge that early years settings are not considered the right place to be promoting the Healthy Start access to…but it has got a paragraph in there which signposts them to where they can go to get that information if a parent asks them for that.
Also, in acknowledgement that the dietary sources are not necessarily the main component of vitamin D in terms of the dietary side, but we do, in those guidelines, highlight the importance of oily fish, eggs are also in there.
…[inaudible questions and noise]
Well, we put it on the guidelines and we pilot tested it with child minders, who make up 2/3 of the providers - so you've got 86,000 early years providers in this country according to the 2010 Providers Survey, of which 56,000 of them are child minders. And the childminders we pilot tested with, pre schools, children's centres, nurseries - local, private, voluntary and independent. And oily fish was one of the things that wasn't on the menu often, and they were challenged.
So basically, those settings had to follow those guidelines for a week and report back what amends they had made to their menus to reflect it. And what actual impact that had in relation to food was that the children liked it - which was the main thing. And also making sure that they didn't have increased organising and child care costs and also making sure it was easy to access as well.
And they came back with a lot of recipes - and I've brought the recipe document along with me as well. We've done 2 recipe documents, 1 is autumn winter and all of the recipes in there are done to serve across 5 days.
So I'll pass those around for you to see. In terms of the description there are a couple of things in relation to this document. The first thing is…I've had this thing with the Feeding for life Foundation already and it is whether it is a passive thing in that it is making sure that they're not just getting fed, but that you are encouraging them to eat well and we do it in a community way.
And the actual title of this is asking whether the current vitamin recommendations are meeting the needs. And the whole document is about 1 vitamin
Dr Robert Moy: Because the other vitamins are irrelevant.
Patricia Mucavale: But maybe you should say "Are The Current vitamin D guidelines meeting the needs of the population" or not..
So childminders have a large responsibility, and in terms of opportunities, there are a lot of opportunities at the moment, because Professor Katy Brown [sic] is going through the workforce review in relationship to the foundation years and looking at what education, and levels of education are influencing those services. And the actual opportunities there are to get information into people's training. So that's not going to necessarily impact upon those who already train, but they'll be handing over the role to children's centres as a hub of information.
So part of the work that the trust has been commissioned to do, it's not just around the guidelines, we're also pilot testing local authorities between November and March next year.
We're doing 2 lots of training programmes. One is at local authority and PCT level and that training is a 1 day/1.5 day course depending on how long the local authority would like it to be. But if the local authority is part of that course they have to provide 50% of the workforce from health and 50% of the workforce from early years, because one of the main recommendations in the [Taylor?] report was the lack of consistency in terms of health messages so one of the things we're aiming to do is to provide a consistent health message. So half of the course is around the guidelines themselves and the other half of the course is around measuring impact and we're giving them the tools to go out and measure the impact of the change of using those guidelines on the food in the childrens and nursery centres. So there's a tool for them to go out and audit.
And the second part of the training is being delivered at setting level, and those settings are invited to a three day course; two days initially and a 1 day follow up. The two day course is looking at food, nutrition and vitamin guidelines, but it is also giving them the skills, knowledge and confidence to cook with hard to reach families and to be then able to give them the confidence to go out and 1) know what to purchase on budget and 2) how to cater for the family, within the family without having to cook separate meals. It also ensures the salt and sugar side is addressed as well as the micronutrient side.
The overall aim of the programme is not just to influence the food that is in the settings but also the food that is in the households and improving that.
Barbara Evans: That sounds really wonderful. Where I'm coming from, and I'm basing it on wider work, but the majority of our children aren't in settings where they learn about this. It comes back to the same thing about the targeting of the population, because I think it depends on what wave of SureStart that you've got.
The first wave of SureStart tends to be a lot more inclusive than later waves. [inaudible] You have to have particular ratios of children to staff…[inaudible]
Patricia Mucavale: Reaching particular childminders is our hardest bit, nurseries too. The nurseries have been managing to attend, but in terms of the childminders we are looking at disseminating this as a training…so we're going to provide them with all of the information that they require and all of the training facilities that they require. So they'll then be trained to disseminate that information out.
And it is done in a very interactive way, all of the sessions and activities, to make it as active as possible….
To get results we've got 4 to do. It was only announced on 6th of August that we were going to be monitoring the whole impact of the programme. We've got some tools that we're putting in to look at the impact at a setting level of the change in food that is based on a follow up and whether they've been on the course or not using the guidance. And then at a family level we're doing a questionnaire on the day that they actually come to the session and then after looking at the changes in their shopping habits and their food preparation habits and their consumption.
I can tell you the local authority where we did the training, that is in the public domain, and there was an article in the trade press recently - that was Hertfordshire. I can't tell you who the other 4 local authorities are because we're in the process of signing the MOUs [Memorandum of Understanding?] but as soon as they are signed we'll put them on the website. But they've been identified. Each of the 35 local authorities over the 2 year programme have been identified based on free school eligibility in 2010 - primary schools - as an indicator of deprivation - and 2010 NPC data at reception as a base for health inequalities.
In terms of coverage it is not a national programme, but there are opportunities for other local authorities if they want to.
And my observation, having shadowed a very small group of child minders and nurseries and children's centres and spoken to a few - well, 15, local authorities, professionals (health and early years) and talking to parents - everybody wants to protect under 5s. That's a commendable thing. Even in the middle of a disaster, under 5s and, in this country, their red book, would go with them to look after their health and well being. So I don't think it is a matter of not wanting to do something, it's a matter of supply and demand and I think you need to look at both sides of the equation.
Barbara Evans: My concern is that, again, over the years, lots of things have been produced and implemented, and they're short term, so you only ever solve the problem for one particular year. It's seems there needs to be a fundamental thing about educating people how to cook.
There are many children who leave school without that skill, and it's something that authorities could help with and put together health programmes.
Patricia Mucavale: There is also an opportunity for GPs. We know that GPs will be our commissioners…
GPs will be commissioners of public health services so we would need - and health and well being boards would need - to know how to get your actual issues onto health and well being boards, and you would obviously need to look at who was going to chair those and my understanding is that it is probably going to be the electoral member. And you need to think about how you're going to get those issues onto the agenda.
Penny Hosie: not a lot of children are getting breakfasts, so could fortified foods be the best way, in dietary form, to give them the vitamins they need.
Patricia Mucavale: We did say in this document that the fortification of breakfast cereals is a useful public health measure, but we do also acknowledge that quite a few fortified breakfast cereals have confectionary in them, and we'd like to make sure that when they are choosing their fortified breakfast cereal which are either low or medium - I wouldn't recommend that you use too many brands you can actually use lower…If you use low sugar breakfast cereal, you're actually limiting yourself to 4 [varieties] so there's not that many varieties. So we've also acknowledged that you can have medium sugar levels as well.
But again, it's that fortification angle and balancing it.
Jacqui Lowden: That's right, because a lot of low fat spreads are not fortified, so it's exactly the same with breakfast cereals - it's all about balance.
Patricia Mucavale: A lot of the practical activities that we do; we've made up a shopping card so you can look at the label, and on the back of that label you can discern how to convert and see what salt is there and list all of the food additives based on the Southampton University study.
And that is just a simple thing that you can go around and actually look in the supermarket. I did have a call, I thought it was a security guard from Tesco, but in the trial, one of the women, a childminder, was there for 3 hours working out what she could go and purchase, and I think supermarkets could help the consumer out a bit more.
Penny Hosie:Would it help to get the message across if we just went back to basics again? We're bombarded with all these different messages - do you think if we just kept it very simple, that would really help?
Prof Euan Ross: I think it is very important, because a lot of people do read health notices and there is…just like there is a food chain, there is an information chain. If you get the more articulate people interested, it sort of permeates through society, and sometimes these things become quite fashionable.
Now, I've taken to the supermarket recently because my wife's vision near vision is not as good as mine. I've got shortsighted, so I take my glasses off and I can see the tins, so I'm reading how much salt and calcium and carbohydrates and everything else that is in the tins. And it is terribly slow work, so there could be an obligation on food producers to tell us much more precisely about what is there.
The reality is, the current system - the wheel or whatever it is, the yellow or red or whatever, none of it is right, because it is all too difficult, so let's improve our recommendations. We need somebody in the government who can take these food issues much more pro-actively than is occurring at the moment, continue with our campaigns.
There is another point too. Let's think about it as an expanded vitamin D need; I mean, in the GP surgery, the number of people who come in with aches and pains or are a bit run down. Are they suffering with a lack of vitamin D, do they have depression, do they have heart trouble associated with a lack of vitamin D and so on?
I think, as a doctor, I haven't got an antenna that would rapidly diagnose the need for a vitamin D-containing boost. It does all need looking at very seriously.
I did send round the book with all of the horrible pictures - and they are very rare. I've seen very few as bad as that, even in recent years - but the low level of vitamin D problems do need to be worked out and properly presented to our professions so we can then have an understanding across society.
Also, of course, we're going to be very confused in the next few months because there is a rapid rise in interest about vitamin D and multiple sclerosis and the origin of other problems and Alzheimer's disease and all sorts of other things and we do need, I think, a much better communication system, which may be put out as extremely excitable headlines in the newspapers and television, but actually getting the underlying science into our health professions so that they know what it is really going on - but of course we're all bamboozled by…you know, whether coffee is good for us or bad for us, and we need to start with simplification and genuine knowledge. And it can be done.
This is clearly an area which needs emphasis, and just at a time when all of the money is going into DNA and genetic research, it's those that shout most can get rational research proposals and the people that get the money. Otherwise it goes to other people to develop bombs or whatever.
Allison Wall: On another issue, having worked for the NMC for a while, they're definitely reviewing the third-party register, which is the specialist community health nursing and they are looking at the standards and competencies. So I'm just wondering if there is an opportunity there to look at what should be in the training of health visitors and how that's working with health visitors. I just think that might be an opportunity to.
Patricia Mucavale: It's an opportunity for new people entering the profession, but in terms of people that are already in the profession the Royal College course on-line, healthy child CPD course, you have to have an NHS number for and their individual use.
Now, I don't have an NHS number.
Allison Wall: Can I just say from experience that that is terribly difficult to access. I don't know if I'm the only one who has problems with it.
Patricia Mucavale: It's quite a good tool in terms of lots of ideas…
Jacqui Lowden: I went to a meeting back in September for the…I don't think they did a very good launch for it; it sort of got launched but wasn't given a widespread marketing. I think they're going to try and launch it again, and they did say that the actual use of it and trying to get access to it is very difficult.
Allison Wall: I think the idea is good.
Patricia Mucavale: But that might be another area where we lack a consistent message in that.
Jacqui Lowden: The child health module, there is also a safeguarding and one for adolescence and transition. And there is a bit about vitamins in that.
Patricia Mucavale: But in terms of consistent messaging, there is a lot of opportunity with the fact that it's all in one area.
Penny Hosie: Given then that there is very little money in the pot, as we know…what do you think we can take from this discussion? And what do you suggest we do to take the message forward?
Patricia Mucavale: I think you have to decide whether you're going to target or blanket. If you're going to target, you're going to need to target successfully [inaudible].
Dr Robert Moy: I'm going to have to disagree with that, based on our experiences in Birmingham. Specifically, we felt that the targeting by ethnic group raised enormous issues, and if you were going to go for vitamin supplementation programmes it should be universal rather than targetted … The Heart of Birmingham Primary Care Trust has a programme, which is documented, which gives free Healthy Start vitamins to ALL mothers and children, with a certain measure of success I think, in terms of documented reduction of cases of vitamin D deficiency seen in hospitals.
I feel that vitamin D is something that everybody should partake in - young and old.
Prof Euan Ross: I've been involved in endless discussions for instance - should all children under 4 be looked at for sickle cell…[inaudible]…so it cuts at a stroke talk about dividing up the population or people deciding they don't want something. Give it to everybody is the only way around it. It's so much cheaper; I mean, even people like me, who has a general pension and is getting my winter fuel money, I'm pretty sure it would be much cheaper to actually give us £200…rather than to pick out who should have it. And I think it is exactly the same problem here.
Penny Hosie: Do you think, in order to help health professionals who are already stretched in terms of the information they have and the limited time they have to spend with every mother or young child, do you the chemists could help with the message.
Patricia Mucavale: In supermarkets they might. …does everybody shop in supermarkets?
Penny Hosie: I think so.
Dr Oliver Gillie: I think there are mothers who are trapped with children on sink estates where there aren't supermarkets and they have to buy expensive stuff in their local shops. That's well recognised.
Prof Euan Ross: Well, we need some research on this then. It'd be a quite interesting project. Am I too out of date or are any clinics providing welfare goods now, or is that all gone?
Dr Oliver Gillie: That's all gone
Dr Robert Moy: The Healthy Start scheme is purely based on vouchers which you can exchange for goods.
Dr Oliver Gillie: There is no excuse for not reaching mothers and children under 5 - especially children under 1 - because the mothers are going to clinics, they're dealing with lots of professionals, and I don't think actually - although the professionals may have a big workload - that it doesn't take a lot of time to say 'this is vitamin D, it comes from sunshine, we don't get a lot of sunshine (they should all know we don't get a lot of sunshine). We're all talking about the weather all of the time. We know we don't get a lot of sun in the winter time. These are things we all talk about. So you could talk about it quickly and go onto the next thing.
It is not expensive to do a programme like this, it doesn't have to be expensive, because the government has a lot of public relations people; 100, or more - 200, public relations people, they can do public relations in the different parts of the country and they can access the health professionals. They can do all that out of their existing staff. They just have to decide that they want to do it, ministers will have to make statements, the press will report it, people will talk about it and people will start doing it. What's the problem.
Patricia Mucavale: In terms of hard to reach families, I've not seen any data, but do they visit a health visitor?
Barbara Evans: It's not necessarily what they want, it's what they're allowed. Because that has changed - that has been quite a sea change in the last few years that the more open access to health visiting teams, and Sure Start has gradually diminished and become more targeted, what there is still, and my understanding is that it is national…and it is alluded to in this document…and that is a return to universal services, with health visitors and health teams and later on school nurses.
So I was sitting there thinking was pregnant mothers, mothers with young children, who do they all see? And the only person I could categorically say they all saw - unless they opted out of it - are health visitors. But the amount of time they see them has become less.
Alison Wall: Yes. There are levels of intervention, and universal is the basic one, which as Barbara says, is basically in that first visit, there may be a follow up visit, and then an 8 month visit or a visit after a year. And that might be all of the contact that they have with the health visitor. And when you go to a clinic, there is generally 1 health visitor in a team for the skill mix - so you can't just rely on the health visitors, it's got to be the whole team. And I think we need to think about practice nurses as well, because they are involved too.
Jacqui Lowden: There are another couple of initiatives that are going on around the UK. I don't know if anybody is aware of the one that is going on in Cardiff over the last year? There, they've been giving out free vitamin drops to every child under 5 in Cardiff over the last year. That was a pilot scheme run by the Welsh Assembly, free of charge. The results will be taken to the Welsh Assembly at the end of the year. I've tried to get the results back, but because they haven't been taken to the Welsh Assembly, they didn't want to release them (the dietitian that was involved with that, obviously), so I haven't heard any more on that - but that might be worth investigating - what they found, what the uptake was like, was it worth their while doing it? Because depending on the results of that they were going to roll it out to the rest of Wales. …
So it does show what you can do if you've got the resources there. I think the same sort of thing was going on in certain parts of Scotland, looking at rural parts of Scotland and how they could distribute them easier, using things like local pharmacists, so it might be worth trying to gather information from pockets around the UK about what is happening.
Dr Oliver Gillie: They're doing a similar thing in the North West. They involved the local authority because pharmacists don't get paid anything for distributing this, so they had to do it on goodwill. So that is a major flaw in the schemes as far as I can see, and they found that they had to train everybody who was involved - all of the health professionals, they had to train receptionists in the clinic, because the receptionist was often the person who handed the stuff out and they found that if they didn't train them, the receptionist would do stuff. Like a woman came in and said she'd lost it, could she have some more and the receptionist was saying 'no, no, you can't, you have to wait for the next batch.' But if you want people to take the vitamins, you give them extra. But receptionists have to be trained to do that.
Anyway, they found after a lot of training that they managed to get through to 10% of children. So it is a major major effort. It involves the existing health professionals, and it is doing the sort of thing they know how to do, just they had to be trained to do it.
Alison Wall: We've talked about Wales and Scotland, but I wouldn't be surprised if Northern Ireland weren't doing similar things, because they've got the public health agency there.
Jacqui Lowden: You've got a recent document on vitamin D supplementation in children…
Alison Wall: What we're talking about is a public health initiative, and I think England is behind other countries in the UK and a friend of mine who works in public health in Camden, the whole department is disintegrating because people are losing their jobs, because public health isn't high profile. Public health workers aren't used to promoting messages…
It needs to be health department who promote these [messages]
Dr Oliver Gillie: But these initiatives are coming from other areas, not central government. It is a failure of central government.
Dr Robert Moy: Perhaps another direction…we usually consider this as something like everybody takes something every day, but that is actually totally unnecessary. You could just take a big dose once a month - 10,000 international units roughly. Because this vitamin is fat soluable, it gets stored in muscles and fat, rather than say vitamin C, which is peed out in the urine. So you could have a programme like that.
I understand there is a trial going on in New Zealand which examining the efficacy of a monthly dosing, which might be much more convenient for people to take, rather than something every day.
Dr Oliver Gillie: Well, an obstetrician could say to a woman when she's pregnant 'have you taken any vitamin D?' and if she says 'yes', say 'OK, please continue taking it, it is important'. If she says 'no' they could give her a whopping dose. You might think that is an odd thing to do during pregnancy - give a woman a whopping dose of anything, but the French have been doing this apparently and it has been successful, so there is a precedent for it, and if anybody is interested I can send them the paper on it - it is in French though…
Dr Robert Moy: This is perhaps where the Birmingham programme has also gone out on a limb, which is to provide the healthy start vitamins from the age of 2 weeks onwards instead of six months…this is purely an operational thing, so the health visitors take out with them a kind of a starter pack of vitamin D drops during their primary visit, so it gets into the home at an early stage. And the idea of getting a vitamin drop.
Dr Oliver Gillie: This six month thing Robert is a complete nonsense. They don't do it in any other country in the world. How it got into recommendations, I've not found anybody who knows, in other countries they all start with vitamin D.
Dr Robert Moy: The healthy start programme does have a rider about if there is a medical reason drops can be started sooner from a younger age - not that it actually defines what that concern might be - there is perhaps a slight theoretical risk of exceeding the safe upper limit of vitamin A dosage if you give certain formula milks and vitamin drops together; but that is only a theoretical risk which is not related to any adverse clinical outcomes.
Dr Oliver Gillie: See Robert, that six month thing, they didn't have that qualification when they first brought it out, they started at 6 months. They then brought in a qualification because of the campaigning that had been going on, saying they should have it from the beginning. The people in the department of health just want to cover themselves. They just want to say 'yes, we thought about that, so they put it back to the doctor to decide whether they should have it at 1 or 2 weeks, and again it's a complete nonsense and again it's bureaucrats I think being irresponsible.
Penny: Do you think it would help if the Journal did a campaign on this issue? To try and educate health professionals in some way - as well as articles?
Prof Euan Ross: It has to be beneficial. I think the more that can be got into professionals the better.
Two other small suggestions. Pharmacies and supermarkets. In West Rothshire, it's half a day here to there - 90 miles round trip. And our method in getting to these folk is through the post office, which I'm sure they wouldn't mind a bit of extra work to do…. Say the once a month dose?
Also, are we being too pompous calling the stuff vitamin D? I think people understand what folic acid is about, so could we just call it the sunshine vitamin, rather than call it…
Penny: So rebranding it so the message gets across better?
Prof Euan Ross: Yes. I think we agree that the one thing that really matters….
Dr Robert Moy: That's what they called it in Birmingham.
Alison Wall: I think a campaign is a good idea, but joining forces with the Feeding for Life Foundation, RCN, CPHVA, trying to get a broader front and doing something with the pharmacists and dietitians.
Jacqui Lowden: We did do a survey of dietitiains in the summer, a simple survey that went out and we had a good response rate - 120 responses - which was pretty good for dietitians asking paediatric dietiatians how many cases of rickets they'd seen, is it a problem, what are the issues, why aren't we addressing them, what could we do. And that's something I could look to release, to put in the journal. That is partly owned by us and partly by an other company.
But we had a really good response and they said it was the best response the BDA had ever had on a survey they'd sent out to its members and that just backs up the strength of feeling paediatric dietitians have on this issue. It was a very, very good response and I think paediatric dietiatians do feel quite strongly about the lack of support and guidance for the Healthy Start children's vitamin drops.
Patricia Mucavale: The only issue I can see about doing this is, is the supply sorted? Because you can send out as many messages as you like, but if the supply is not there, they will give up….you need to map your issues and your barriers…
Jacqui Lowden: I had a meeting with a pharmaceutical company the other week and they were interested and will be looking at that, and they would be helping to improve the distribution of it. It's a national pharmaceutical company who could help with the distribution of child vitamin drops.
I think - although I might be wrong - that it is a small company that makes the drops.
Dr Oliver Gillie: It's something like TSL or YSL that used to make, they're manufacturors.
Jacqui Lowden: yes, they're quite small. But I've spoken to pharmaceutical companies about the problem and they didn't realise …it was part of something else with dietitians and I said it was a nightmare, and they said what's the problem and they were looking at other avenues.
Dr Oliver Gillie: They would have to charge more because distribution is in effect done free through the health service.
Penny: Well, thank you for coming, I hope you enjoyed it and thanks again!