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Interventions and public health nutrition

The economic case for prevention of population vitamin D deficiency: a modelling study using data from England and Wales



Vitamin D deficiency (VDD) affects the health and wellbeing of millions worldwide. In high latitude countries such as the United Kingdom (UK), severe complications disproportionally affect ethnic minority groups.


To develop a decision-analytic model to estimate the cost effectiveness of population strategies to prevent VDD.


An individual-level simulation model was used to compare: (I) wheat flour fortification; (II) supplementation of at-risk groups; and (III) combined flour fortification and supplementation; with (IV) a ‘no additional intervention’ scenario, reflecting the current Vitamin D policy in the UK. We simulated the whole population over 90 years. Data from national nutrition surveys were used to estimate the risk of deficiency under the alternative scenarios. Costs incurred by the health care sector, the government, local authorities, and the general public were considered. Results were expressed as total cost and effect of each strategy, and as the cost per ‘prevented case of VDD’ and the ‘cost per Quality Adjusted Life Year (QALY)’.


Wheat flour fortification was cost saving as its costs were more than offset by the cost savings from preventing VDD. The combination of supplementation and fortification was cost effective (£9.5 per QALY gained). The model estimated that wheat flour fortification alone would result in 25% fewer cases of VDD, while the combined strategy would reduce the number of cases by a further 8%.


There is a strong economic case for fortifying wheat flour with Vitamin D, alone or in combination with targeted vitamin D3 supplementation.

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Dr. Sue Horton, School of Public Health and Health Systems, University of Waterloo, for initial advice on the economics of food fortification. Dr. Helena Pachón, Rollins School of Public Health, Emory University, for the insights on the practicalities of wheat flour fortification. The team at the Center for Health Economics Research and Evaluation, University Technology Sydney, particularly Dr. Phillip Haywood, as well as Dr. Kim Dalziel, Center for Health Policy, University of Melbourne, for the methodological advice. Smita Hanciles and Gwenda Scott from Lewisham Local Authority, UK, as well as Eleanor McGee from Birmingham Local Authority, UK, for the insights on supplementation alternatives and data access.


This research was funded by the College of Medical and Dental Sciences of the University of Birmingham, through an internal PhD studentship grant.

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All authors contributed to designing the research. MA conducted the research and analysed data supervised by LA, MP, WH and EF. All authors contributed substantially to writing the paper, while MA and EF had primary responsibility for final content. All authors have read and approved the final paper.

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Correspondence to E. Frew.

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Aguiar, M., Andronis, L., Pallan, M. et al. The economic case for prevention of population vitamin D deficiency: a modelling study using data from England and Wales. Eur J Clin Nutr 74, 825–833 (2020).

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