4 Context


Healthy Start is a UK‑wide, government scheme that provides 'a nutritional safety net' for pregnant women and families on qualifying benefits and tax credits. Women who are at least 10 weeks pregnant and families with children under 4 years old qualify if the family receives the relevant benefits.

Pregnant women under 18 are also eligible, regardless of whether they receive benefits. The scheme includes food vouchers and vitamin supplements.

Healthy Start was introduced in 2006 to replace the previous Welfare Food Scheme. The Healthy Start supplements for women contain vitamins C and D and folic acid.

Vitamin C is included because of the strong social class gradient in intake. Vitamin D is included because of the increased need for it in pregnancy and while breastfeeding. Women from minority ethnic groups may be at greater risk of deficiency ('Scientific review of the Welfare Food Scheme').

The Healthy Start children's supplement contains vitamins A, C and D. The aim is to provide a safety net for children who may have a low intake of these vitamins linked to a 'failure to thrive'[8]. Or they may have increased needs (for example, during infections), or be vulnerable to low vitamin D status because of their ethnic origin ('Scientific review of the Welfare Food Scheme').

Vitamin D

Rickets may be re‑emerging among children in the UK ('Diagnosis and management of vitamin D deficiency'). Concerns have also been raised about hypocalcaemic fits due to vitamin D deficiency, particularly in children under 2 years.

However, these remain relatively rare ('Incidence of hypocalcemic seizures due to vitamin D deficiency in children in the United Kingdom and Ireland'). National survey data show that there is evidence of low vitamin D status among all ages and genders, especially in the winter months[9] (National Diet and Nutrition Survey: results from years 1 to 4 (combined) of the rolling programme for 2008 and 2009 to 2011 and 2012 Public Health England and Food Standards Agency).

In 2007[10], the Scientific Advisory Committee on Nutrition (SACN) recommended that the following should be offered vitamin D supplements:

  • all pregnant and breastfeeding women

  • breastfed babies from the age of 6 months (or earlier if the mother's vitamin D status in pregnancy was not adequate)

  • formula‑fed babies receiving less than 500 ml formula a day

  • all children aged 1–4 years.

('SACN update on vitamin D – 2007').

In 2012, the UK Chief Medical Officers recommended that all pregnant and breastfeeding women and infants and young children aged from 6 months to 5 years take a daily supplement of vitamin D ('Vitamin D – advice on supplements for at risk groups').

Folic acid

Since 1992, all women have been advised to take 400 micrograms of folic acid daily from when they start planning a pregnancy until the end of week 12 of the pregnancy. The aim is to reduce the risk of their baby being born with a neural tube defect such as spina bifida ('Folic acid and the prevention of neural tube defects. Report of an expert advisory committee' Department of Health 1992 [not available online])[11].

A recent study suggests the number of women taking folic acid supplements when they are planning a pregnancy may be in decline ('Prevention of neural tube defects: a cross‑sectional study of the uptake of folic acid supplementation in nearly half a million women').

The women least likely to take folic acid supplements are those most likely to have an unplanned pregnancy – and around 50% of all pregnancies are unplanned ('Scientific review of the Welfare Food Scheme'). In addition, uptake of folic acid advice is not always timely (Barbour et al. 2012; Factors affecting the use of folic acid supplements in pregnant women in Glasgow McGovern et al. 2012) The direct medical costs and the indirect costs for the lifelong care of those born with spina bifida have been estimated to be substantial (Yunni et al. 2011). Peri‑conceptual supplementation with folic acid is estimated to be cost effective (Postma et al. 2002; Yunni et al. 2011).

Uptake of Healthy Start vitamins

Many (72–86%) of those eligible for the Healthy Start scheme redeem their food vouchers. But 2 studies suggest that less than 10% redeem their vitamin coupons ('Understanding the use of vouchers and vitamins'; Jessimen et al. 2013). Another study puts the number redeeming vitamin coupons at less than 3% (Which is more effective, a universal or targeted approach, to implementing the National Healthy Start Programme? A mixed methods study Moonan et al. 2012).

Suggested reasons include:

  • lack of awareness of the importance of the vitamins among women and some practitioners

  • difficulties for practitioners in obtaining supplies

  • the complicated assessment process

  • confusion surrounding use of the vitamin coupons

  • difficulties finding an accessible location for distribution.

The time health professionals devote to overcoming such difficulties is often at the expense of promoting other aspects of the scheme and other public health work ('Healthy Start vouchers study: the views and experiences of parents, professionals and small retailers in England'; 'Healthy Start: understanding the use of vouchers and vitamins').

Health professionals suggest that making the Healthy Start vitamins freely available to all pregnant women, mothers and young children would be a way to overcome this ('Healthy Start vouchers study: the views and experiences of parents, professionals and small retailers in England'; 'Healthy Start: understanding the use of vouchers and vitamins'; Jessimen et al. 2013).

This approach may also be more cost effective ('Healthy Start: understanding the use of vouchers and vitamins').

See the scope for further details on the background to this work.

[8] 'Failure to thrive' in infants and young children is characterised by failure to gain weight at an appropriate rate. It is associated with being undernourished. It is also referred to as 'growth faltering'.

[9] Low vitamin D status is defined by the Department of Health as a plasma concentration of 25 hydroxyvitamin D (25[OH]D, the main circulating form of the vitamin) of below 25 nmol/litre (equal to 10 ng/ml).

[10] SACN is currently reviewing the dietary reference values for vitamin D.

[11] Women are advised to take a 5 mg/day supplement of folic acid if: they have previously had a baby with a neural tube defect; if they or their partner have a neural tube defect or a family history of neural tube defects; or if the woman has diabetes.