Guidance

Vitamin D and clinically extremely vulnerable (CEV) guidance

Updated 24 February 2021

Applies to England

Introduction

During the autumn and winter months everyone in the UK is advised to take a supplement of vitamin D every day to support general health and in particular for bone and muscle health. Many of us have been indoors more than usual this year and so might not have been making enough vitamin D from sunlight. The NHS provides general advice on vitamin D.

This advice is particularly important for people who have been shielding this year due to coronavirus (COVID-19), or who are living in care homes, because they are more likely to have been indoors over the spring and summer and so may not have been able to obtain enough vitamin D from sunlight.

Vitamin D supplement announcement

The service for applying for free vitamin D supplements closed on 21 February 2021.

2.7 million vulnerable people in England have been offered free daily 10 microgram (400 international unit) vitamin D supplements for the winter by the government. The vitamin D supplements have been offered to those on the clinically extremely vulnerable (CEV) list and those in residential and nursing care homes in England.

The existing government advice is for everyone to take a vitamin D supplement during the winter months, so we would recommend that those who did not opt in should be doing this. If people have any specific requirements outside of this opt-in offer, they remain free to choose from a wide range of vitamin D products on sale in a wide range of retail outlets.

The 2 permitted forms of vitamin D allowed under the food supplements legislation are:

• cholecalciferol (vitamin D3)
• ergocalciferol (vitamin D2)

The products offered do not contain any allergens, nor were they offered in combination with any other vitamin or mineral (for example, ‘multi vitamins’). They do not contain gelatine from animal sources and any ingredient from an animal source must be clearly identified in the list of ingredients.

Clinically extremely vulnerable

People who are defined as clinically extremely vulnerable (CEV) are at very high risk of severe illness from COVID-19. There are 3 ways you may be identified as CEV:

• you have one or more specified conditions that automatically mean you have been added to the clinically extremely vulnerable list
• your hospital clinician or GP or healthcare professional has added you to the clinically extremely vulnerable list because, based on their clinical judgement, they deem you to be at higher risk of serious illness if you catch the virus
• you’ve been identified through the COVID-19 Population Risk Assessment as potentially being at high risk of serious illness if you catch the virus.

For the full list of the conditions that qualify for automatic inclusion on the clinically extremely vulnerable list, see the guidance on shielding and protecting people who are clinically extremely vulnerable from COVID-19.

Importance of vitamin D supplements for those that are CEV

In the UK everyone is advised to take a daily vitamin D supplement in autumn and winter to protect their general health, in particular bone and muscle health. This is because during the autumn and winter we cannot make vitamin D from sunlight. CEV people are likely to have been indoors more than usual this spring and summer, so might not have been able to obtain enough vitamin D from sunlight.

The government has prioritised groups that were asked to stay indoors more than usual over the spring and summer due to national restrictions, such as those who are considered to be CEV and those living in care homes, to receive vitamin D supplements for this reason.

Vitamin D

Vitamin D helps regulate the amount of calcium and phosphate in the body. These nutrients are needed for healthy bones, teeth and muscles. Too little vitamin D 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.

Sources of vitamin D

Vitamin D is a nutrient that forms part of a healthy balanced diet. The body makes vitamin D from direct sunlight on the skin when outdoors during spring and summer. From about late March/early April to the end of September, most people should be able to get all the vitamin D they need from sunlight. During the autumn and winter we cannot make vitamin D from sunlight.

Vitamin D can be found in a small number of foods, but it is difficult to get enough vitamin D from food alone. Food sources include:

• oily fish – such as salmon, sardines, herring and mackerel
• red meat
• liver
• egg yolks
• fortified foods – such as some fat spreads and breakfast cereals

Read further information on vitamin D from the NHS.

Current advice on vitamin D

In the UK during autumn and winter everyone is advised to take a supplement containing 10 micrograms (400 international units) of vitamin D a day to support general health and in particular bone and muscle health. This is because we cannot make vitamin D from sunlight at this time of year.

This advice is particularly important for those who have limited exposure to sunlight during the spring and summer, such as those in residential and nursing care homes and those in prisons; and those who usually wear clothes that cover up most of their skin when outdoors. These groups are more at risk of not having enough vitamin D. Those with dark skin (such as people who have an African, African-Caribbean or South Asian background) may also not get enough vitamin D from sunlight. All of these groups are advised to take a vitamin D supplement all year round in line with usual government dietary advice.

Opt-in system

If you opted in to receive vitamin D supplements

If you applied for free supplements before the service closed on 21 February 2021, the service will check whether you’re on the shielded patients list of people at high risk from coronavirus.

If you’re on the list, the partner provider will send out supplements directly to your home. If you gave an email address, you will also get an email to let you know your application was successful. The email will include contact details for any questions.

If you have applied, but are not on the shielded patients list, you will not receive the supplements. If you gave an email address, you will get an email to let you know that your application was not successful.

CEV people are advised to read the guidance on how to take vitamin D supplements safely in full before they start taking the vitamin D supplements that have been provided.

When to avoid opting in

Those on the CEV list should not haved opted in to receive the vitamin D supplement if:

• they are already taking, or are prescribed, a vitamin D supplement by their GP or healthcare professional
• they are already taking, or are prescribed, a medication that contains vitamin D by their GP or healthcare professional
• they are under the age of 18
• they have a medical condition or treatment that means they may not be able to safely take as much vitamin D as the general population

If they are one of the following groups or have any of the following medical conditions, they should not have opted in through this process and they should speak to their GP or healthcare professional at their next appointment.

There are some groups who need to be particularly careful including people:

• under the care of a renal, endocrinology or cancer specialist
• with high vitamin D levels
• with kidney stones, now or in the past
• with too much parathyroid hormone (hyperparathyroidism)
• with cancer (some cancers can lead to high calcium levels)
• with severe kidney disease
• with a rare illness called sarcoidosis

Vitamin D and medication interactions

While some medications may interact with high doses of vitamin D, there are no issues associated with the 10 microgram (400 IU) vitamin D supplement. They are intended to supplement the diet and should not be substituted for a varied diet.

Your choice to opt in

We want everyone to understand the benefits to general health of taking vitamin D and to give people on the CEV list the choice to access it more easily where they need to.

Everyone on the CEV list has been advised to read the guidance on how to take vitamin D supplements safely in full before deciding whether to opt in and before they start taking the vitamin D supplements that have been provided.

How to take vitamin D supplements

Each ‘1-a-day’ vitamin D supplement contains 10 micrograms of vitamin D. This is equivalent to 400 IU of vitamin D. This is the daily amount recommended for the general population by government for general health and in particular to protect bone and muscle health.

Advice on the recommended dose

If your GP or healthcare professional has recommended that you take a different amount of vitamin D, you should follow their advice.

10 micrograms of vitamin D is a safe level of intake, designed to meet your nutritional needs. Taking more is not currently recommended.

For most people taking up to 100 micrograms equivalent to 4,000 IU) per day is considered safe. In a few people, taking too many vitamin D supplements over a long period of time can cause too much calcium to build up in the body (hypercalcaemia). This can weaken the bones and damage the kidneys and the heart. The NHS website has information about vitamin D, including advice on safe intakes for children.

Storing vitamin D supplements

The supplements should be stored out of the reach of young children. The supplements should be kept away from pets. Consult with a vet if you are concerned that your pet has consumed any of the vitamin D supplements provided.

Those receiving the supplements should check that the product seal is still in place on delivery and should not take the supplements if the seal has been broken.

Vitamin D and COVID-19

Vitamin D is needed to keep bones and muscles healthy. It has also been suggested that vitamin D could reduce the risk of and COVID-19. As yet, there is insufficient evidence to prove that it helps people respond to COVID-19, but as more evidence is accumulated, our understanding may change. There are currently trials underway which we are keeping a close eye on. In the meantime, people should follow the current UK government advice on vitamin D supplementation to support general health, in particular bone and muscle health.

In collaboration with PHE and the Scientific Advisory Committee on Nutrition (SACN), NICE conducted a rapid evidence review evaluating evidence from recent studies on vitamin D in relation to COVID-19. The expert panel supported current government advice for everyone to take the supplement throughout the autumn and winter, however the panel concluded that there is currently not enough evidence to support taking vitamin D solely to prevent or treat COVID-19.The COVID-19 rapid guidance on vitamin D was published on 17 December.

Due to the lack of reliable evidence on the effects of the supplement on COVID-19, this guidance recommends that more research be conducted on the subject, stressing the use of high-quality randomised controlled trials in future studies.

SACN have carried out a rapid review which assesses the evidence on vitamin D and acute respiratory tract infections (ARTI) that has been published since the SACN report on Vitamin D and Health (2016). An updated SACN rapid review on vitamin D and ARTI on vitamin D and was published in December 2020, following publication of the first rapid review in June 2020.

Healthcare professionals

You should seek GP or healthcare professional advice where you have a medical condition that is listed in the when to avoid opting in section of this guidance. If you have one of the listed medical conditions, you should not haved opted in to receive the vitamin D supplements and should speak to your GP or healthcare professional at your next appointment.

If your GP or healthcare professional has recommended that you take a different amount of vitamin D, you should follow their advice.

The vitamin D supplements being provided are not a medication and are equivalent to those that are readily available in retail outlets such as supermarkets, chemists and health food shops.

Care homes

Vitamin D supplements are being supplied to those in residential and nursing care homes in England to support general health and in particular bone and muscle health.

Those in residential and nursing care homes do not need to opt in to receive vitamin D supplements. The supplements will be delivered directly to residential and nursing care homes free of charge from January 2021.

See guidance for care homes about vitamin D.