The winter months mean more people suffering from colds, flu and other viruses and infections. This is partly because more of these are circulating in the colder months, but also because our immune systems are not functioning as well as at other times of the year. “More indoor living together, the stress of exposure to low outdoor temperatures and low vitamin D status all combine to make us more susceptible to winter illness,” says Dr Carrie Ruxton, dietician at the Health & Food Supplements Information Service.
In winter, our immune response can become weakened by repeated infections, poor diet, stress, lack of sleep and not enough exercise. Fighting off infection uses up lots of energy, which is why customers often complain of feeling exhausted at the end of the winter months.
The first line of defence is our skin, which is a waterproof barrier to prevent pathogens entering the body and gastric juice produced by the stomach helps kill off any harmful bacteria in food. “Many customers will be unaware that 70 per cent of our immune cells are located in the gut, and are supported by strong microflora,” says Natalie Lamb, nutritional therapist at Protexin. “It’s important to keep this balanced. The immune system is responsible for the speed and effectiveness of the body’s defence response to an infection such as the common cold, so it’s important to keep it working well.”
“A daily multivitamin and mineral A to Z supplement is a good way of making sure customers are getting the nutrients they need over winter,” says Dr Ruxton. “Vitamins A, C and D and zinc are the best proven, while iron, selenium and folate are important, too. There is also consistent evidence for echinacea. If a customer feels a cold or flu is starting, high-dose vitamin C and zinc can reduce the period of symptoms. Aim for at least 500mg vitamin C and 10mg zinc.”
Sarah Coe, nutrition scientist at the British Nutrition Foundation, says: “A number of nutrients contribute to the normal function of the immune system, and have health claims approved by the European Food Safety Authority. These include copper, folate, iron, selenium, vitamins A, B12, B6, C and D and zinc. If you have a deficiency of these nutrients, then your immune system may be affected.”
It’s important to eat a wide range of foods. “No one food or food group can supply all the nutrients our bodies need,” says Kirsty Bamping, a registered dietician and spokesperson for the British Dietetic Association. “Enjoying a healthy, balanced diet means choosing a variety of foods from each food group in the right proportions.”
The BDA advises:
A recent study at the University of Colorado found that prebiotics may help to improve sleep quality, which in turn may protect us from the negative impacts of stress. They can also support the gut’s microflora, which is important for a healthy immune system. “The main benefit of prebiotics is boosting levels of good bacteria in the gut, which can positively influence immune health,” says Dr Ruxton.
It may not be possible for some probiotics, however, to reach the gut because they are killed by acid in the stomach. “One way of boosting your own natural good gut bacteria is through eating prebiotics,” says Ms Bamping. “These are types of carbohydrate that only our gut bacteria can feed upon and cause more good gut bacteria to grow. We can get prebiotics by eating onions, garlic, asparagus, artichoke, chicory and banana. However, in the UK we don’t eat large quantities of these foods, so you could take a prebiotic supplement such as fructo-oligosaccharide.”
Ms Lamb recommends a daily probiotic supplement during winter. “The rationale for the use of probiotics to improve the function of the immune system is supported by their potential to influence and stabilise the composition of the gut microflora, enhance resistance to potential pathogens and modulate immune function parameters,” she says. “Probiotics are increasingly studied for their ability to enhance resistance to, and recovery from, infection.”
A lack of vitamin D is linked with low energy levels and is also important for a healthy immune system. “The only way to ensure a healthy vitamin D status is to take a supplement,” says dietician Kirsty Bamping.
“All adults and children over the age of one should consider a daily supplement containing 10mcg vitamin D, especially during autumn and winter. In the UK, ultraviolet light is only strong enough to make vitamin D on exposed skin from April to September.”
“When your body is under stress, it releases the hormone cortisol as part of the fight-orflight response,” says nutrition scientist Sarah Coe. “Chronic stress leads to a build-up of this hormone, which has been shown to suppress the immune system. This may lead to increased susceptibility to colds and other illnesses.” She advises to recommend customers who are under stress to eat a healthy, balanced diet, eat regularly and stay well hydrated.
“A healthy, balanced diet provides a rich supply of antioxidants (beta-carotene, vitamins A, C and E, flavonoids and selenium), which are thought to help protect and repair our body cells,” adds dietician Kirsty Bamping.
“First, I would advise customers eat a balanced diet,” says Alphega Pharmacy member Surjit Pawar from Tower Hill pharmacy. “I would also recommend taking a multivitamin to ensure the customer has the recommended daily intake of vitamin D, zinc and selenium, which contribute to normal immune functioning. If a patient is recovering from a round of winter viruses, I would recommend a tonic supplement, such as Metatone or Floradix. These help to restore health and vitality.”
Customers often think about their immune health as winter approaches. “Around the time of the flu jab campaign, our customers start to think about how they can boost their immune system,” says Well pharmacist Sadik Al Hassan. “There are a range of products available to improve immunity in the pharmacy, but it is also important to offer our patients advice to enhance their winter health.” He says that supplements containing vitamin C and zinc are popular with customers.
Take the opportunity to talk to your customers about immune support products. “Help them understand what solutions are available,” suggests Redoxon brand manager Claire Montgomery. “The body can’t store vitamin C or always make enough vitamin D, so they need to take measures to ensure they are not missing out. Draw attention to high strength products and reassure customers about the taste and how easy it is to incorporate into their lifestyles.”
Regular exercise can help boost immunity and improve energy levels. Studies have shown it can increase the range of bacteria in the gut, which improves immune function. Exercise may help to flush harmful bacteria from our respiratory system and cause changes to white blood cells to improve their circulation and ability to fight infection fast. It also slows the release of cortisol. “Regular, moderate-intensity exercise (eg, brisk walking, cycling) can reduce the risk of infections, compared with a sedentary lifestyle. It can also help boost your mood and energy levels and reduce your risk of stress,” says nutrition scientist Sarah Coe.
About 21 per cent of us are affected by seasonal and light changes in winter, according to the Seasonal Affective Disorder Association, with a further eight per cent experiencing a more serious version of SAD and becoming moderately to severely depressed. The lack of light in winter can create an imbalance in our brain, causing symptoms such as sleep problems, lack of energy, overeating, depression, anxiety, loss of libido and mood changes. “A common symptom of SAD is craving carbohydrates and sugary foods,” says Ms Coe. “It is important to eat a healthy, balanced diet that includes plenty of fresh fruit and vegetables. A low level of vitamin D has been associated with depression.”
A lack of vitamins B6 and B12 in the diet can make us feel tired and depressed, too. “Folate deficiency can also result in an increased chance of feeling depressed,” says Ms Bamping. “Having low iron in the blood can result in anaemia, with the main symptom being fatigue. A lack of selenium (Brazil nuts, meat, fish, bread, seeds) is also linked with depression. Drinking more fluid can help to improve our mood, as dehydration can make us feel tired and lack concentration.”
“Immunity and vitality displays can often offer too much choice,” says Mr Al Hassan. “A more focused section based on a value and premium offering makes it easier for customers to find a product to meet their needs. It’s also a good idea to offer a value product display and small offering by the till to encourage impulse buys.”
“I would recommend holding staff training on immunity and vitality over the winter months,” says Mr Pawar. “This will ensure everyone is talking to patients about boosting their immune system. We had a manufacturer come in to do this and now our entire team is confident about speaking to patients on the subject. We also moved our immune support supplements and vitality range to eye level within the category to drive extra sales.”
“There is a real opportunity to grow the immunity category by proactively engaging multivitamin and energy vitamin shoppers,” says Ms Montgomery. “Younger shoppers show the greatest propensity to buy immune supports. They will be reactive users, looking for a pick-me-up when feeling run down. Highlight your pharmacy offering and encourage use of immune support as part of their daily routine at this time of year.”
“In the past few years we’ve seen a large rise in sales of multivitamins and vitamin D,” says Mr Pawar. “I encourage my team to recommend these as an add-on to patients shopping for cold and flu remedies.”
“It helps to add in a variety of link-sell opportunities, such as cold/flu remedies, lip balm and tissue packs,” says Mr Al Hassan.
“Soluble supplement products reach their peak sales at this time of year when presented properly, with value products at impulse till areas selling well,” he comments.
“Before visiting a pharmacy, many consumers will have done online research for information,” says Ms Montgomery. “Ensuring your category is clearly signposted will help customers to find a solution when they come in store.”
“It’s phenomenal the number of customers who come in wanting something to boost their immune system. In winter we bring in a huge planogram for our vitamins and healthy living sections and place as many products as we possibly can. One of our best sellers is a vitamin C 1000mg dissolvable tablet. After that, another big seller in winter is Metatone. When we’re talking to customers we give them lots of healthy living tips, such as getting enough sleep and keeping stress levels under control. We’ve run a couple of small vitamin D campaigns and this has been great for helping people recognise the problem. This is a hugely important category for us. We’ve extended the range we keep in store, and promote it through our work as a healthy living pharmacy.”
“We’re a healthy living pharmacy level 2. We have a healthy living area that we update every month, and for February we are looking at getting the balance right with healthy eating. What we generally recommend is taking vitamins alongside a healthy diet; on their own, they’re not a cure-all. This is actually quite an important area for us commercially, because queries often do lead to sales. We tend to sell more generic multivitamins than branded ones, and overall there have recently been a lot of queries around immunity nutrients, such as vitamins B and C and zinc. I’m getting more queries from women: perhaps they’re more health conscious, or perhaps men are still reluctant to ask for advice from the pharmacist.”
Sadik Al Hassan
“We find this category sees a spike from late October to February – probably two to three times what you would see in June. People can feel a bit run down with less sunlight, and I did actually see a spike in interest in vitamin D as a result of the updated PHE guidelines, because we were working with the surgery and had a range of supplements in stock to recommend to people. I’m still waiting for a combination product to emerge, maybe with a little bit of everything – vitamin B, vitamin C, caffeine, echinacea – an all-in-one, once a day product, ideally in a soluble preparation. I think that could be a real game changer, but I’ve already been waiting for quite a few years!”