Sports Medicine

, Volume 45, Issue 3, pp 365–378

Prevalence of Vitamin D Inadequacy in Athletes: A Systematic-Review and Meta-Analysis

  • Forough Farrokhyar
  • Rasam Tabasinejad
  • Dyda Dao
  • Devin Peterson
  • Olufemi R. Ayeni
  • Reza Hadioonzadeh
  • Mohit Bhandari
Systematic Review

Abstract

Background

Vitamin D is essential for maintaining optimal bone health. The prevalence of vitamin D inadequacy in athletes is currently unclear.

Objective

The objective of this study is to determine the prevalence of vitamin D inadequacy in athletes.

Methods

We conducted a systematic review and meta-analysis. Multiple databases were searched and studies assessing serum 25-hydroxyvitamin D [25(OH)D] status in athletes were identified. Serum 25(OH)D is measured to clinically determine vitamin D status. Reviewers independently selected the eligible articles, assessed the methodological quality, and extracted data. Disagreements were resolved by consensus. Weighted proportions of vitamin D inadequacy [serum 25(OH)D <32 ng/mL] were calculated (DerSimonian–Laird random-effects model) and compared using Chi-squared (χ2) test. Subgroup analyses were conducted and risk ratios (RRs) with 95 % confidence intervals (CIs) were reported.

Results

Twenty-three studies with 2,313 athletes [mean (standard deviation) age 22.5 (5.0) years, 76 % male] were included. Of 2,313 athletes, 56 % (44–67 %) had vitamin D inadequacy that significantly varied by geographical location (p < 0.001). It was significantly higher in the UK and in the Middle East. The risk significantly increased for winter and spring seasons (RR 1.85; 95 % CI 1.27–2.70), indoor sport activities (RR 1.19; 95 % CI 1.09–1.30), and mixed sport activities (RR 2.54; 95 % CI 1.03–6.26). The risk was slightly higher for >40°N latitude [RR 1.14 (95 % CI 0.91–1.44)] but it increased significantly [RR 1.85 (1.35–2.53)] after excluding the Middle East as an outlier. Seven studies with 359 athletes reported injuries. The prevalence of injuries in athletes was 43 % (95 % CI 20–68) [bone related = 19 % (95 % CI 7–36); muscle and soft-tissue = 37.5 % (95 % CI 11.5–68.5)].

Conclusion

Despite the limitations of the current evidence, the prevalence of vitamin D inadequacy in athletes is prominent. The risk significantly increases in higher latitudes, in winter and early spring seasons, and for indoor sport activities. Regular investigation of vitamin D status using reliable assays and supplementation is essential to ensure healthy athletes. The prevalence of injuries in athletes is notable but its association with vitamin D status is unclear. A well-designed longitudinal study is needed to answer this possible association.

References

  1. 1.
    Angeline ME, Gee AO, Shindle M, et al. The effects of vitamin D deficiency in athletes. Am J Sports Med. 2013;41(2):461–4.CrossRefPubMedGoogle Scholar
  2. 2.
    Ogan D, Pritchett K. Vitamin D and the athlete: risks, recommendations, and benefits. Nutrients. 2013;5(6):1856–68.CrossRefPubMedCentralPubMedGoogle Scholar
  3. 3.
    Allison RJ, Close GL, Farooq A, et al. Severely vitamin D-deficient athletes present smaller hearts than sufficient athletes. Eur J Prev Cardiol. Epub 2014 Jan 7.Google Scholar
  4. 4.
    DeLuca HF. Overview of general physiologic features and functions of vitamin D. Am J Clin Nutr. 2004;80(6 Suppl):1689S–96S.PubMedGoogle Scholar
  5. 5.
    Holick MF. Vitamin D status: measurement, interpretation, and clinical application. Ann Epidemiol. 2009;19(2):73–8.CrossRefPubMedCentralPubMedGoogle Scholar
  6. 6.
    Heaney RP. Functional indices of vitamin D status and ramifications of vitamin D deficiency. Am J Clin Nutr. 2004;80(6 Suppl):1706S–9S.PubMedGoogle Scholar
  7. 7.
    Calvo MS, Whiting SJ, Barton CN. Vitamin D fortification in the United States and Canada: current status and data needs. Am J Clin Nutr. 2004;80(6 Suppl):1710S–6S.PubMedGoogle Scholar
  8. 8.
    Whiting SJ, Langlois KA, Tanparast H, et al. The vitamin D status of Canadians relative to the 2011 dietary reference intakes: an examination in children and adults with and without supplement use. Am J Clin Nutr. 2011;94(1):128–35.CrossRefPubMedGoogle Scholar
  9. 9.
    Holick MF. The vitamin D epidemic and its health consequences. J Nutr. 2005;135(11):2739S–48S.PubMedGoogle Scholar
  10. 10.
    Holick MF. The D-lightful vitamin D for child health. JPEN J Parenter Enteral Nutr. 2012;36(1 Suppl):9S–19S.CrossRefPubMedGoogle Scholar
  11. 11.
    Holick MF. Vitamin D: a d-lightful solution for health. J Investig Med. 2011;59(6):872–80.PubMedCentralPubMedGoogle Scholar
  12. 12.
    Shuler FD, Wingate MK, Moore GH, et al. Sports health benefits of vitamin D. Sports Health. 2012;4(6):496–501.CrossRefPubMedCentralPubMedGoogle Scholar
  13. 13.
    Redzic M, Lewis RM, Thomas DT. Relationship between 25-hydoxyvitamin D, muscle strength, and incidence of injury in healthy adults: a systematic review. Nutr Res. 2013;33(4):251–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Slim K, Nini E, Forestier D, et al. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712–6.CrossRefPubMedGoogle Scholar
  15. 15.
    Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17(1):1–12.CrossRefPubMedGoogle Scholar
  16. 16.
    Marcus R, Feldman D, Nelson D, et al. Fundamentals of osteoporosis. 4th ed. London: Academic Press; 2010.Google Scholar
  17. 17.
    Viera AJ. Odds ratios and risk ratios: what’s the difference and why does it matter? South Med J. 2008;101(7):730–4.CrossRefPubMedGoogle Scholar
  18. 18.
    Badawi A, Arora P, Sadoun E, et al. Prevalence of vitamin D insufficiency in Qatar: a systematic review. J Public Health Res. 2012;1(3):229–35.CrossRefPubMedCentralPubMedGoogle Scholar
  19. 19.
    Racinais S, Hamilton B, Li CK, et al. Vitamin D and physical fitness in Qatari girls. Arch Dis Child. 2010;95(10):854–5.CrossRefPubMedGoogle Scholar
  20. 20.
    Bescos Garcia R, Rodriguez Guisado FA. Low levels of vitamin D in professional basketball players after wintertime: relationship with dietary intake of vitamin D and calcium. Nutr Hosp. 2011;26(5):945–51.PubMedGoogle Scholar
  21. 21.
    Close GL, Leckey J, Patterson M, et al. The effects of vitamin D(3) supplementation on serum total 25(OH)D concentration and physical performance: a randomised dose-response study. Br J Sports Med. 2013;47(11):692–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Close GL, Russell J, Cobley JN, et al. Assessment of vitamin D concentration in non-supplemented professional athletes and healthy adults during the winter months in the UK: implications for skeletal muscle function. J Sports Sci. 2013;31(4):344–53.CrossRefPubMedGoogle Scholar
  23. 23.
    Constantini NW, Arieli R, Chodick G, et al. High prevalence of vitamin D insufficiency in athletes and dancers. Clin J Sport Med. 2010;20(5):368–71.CrossRefPubMedGoogle Scholar
  24. 24.
    Ducher G, Kukuljan S, Hill B, et al. Vitamin D status and musculoskeletal health in adolescent male ballet dancers a pilot study. J Dance Med Sci. 2011;15(3):99–107.PubMedGoogle Scholar
  25. 25.
    Galan F, Ribas J, Sanchez-Martinez PM, et al. Serum 25-hydroxyvitamin D in early autumn to ensure vitamin D sufficiency in mid-winter in professional football players. Clin Nutr. 2012;31(1):132–6.CrossRefPubMedGoogle Scholar
  26. 26.
    Guillaume G, Chappard D, Audran M. Evaluation of the bone status in high-level cyclists. J Clin Densitom. 2012;15(1):103–7.CrossRefPubMedGoogle Scholar
  27. 27.
    Halliday TM, Peterson NJ, Thomas JJ, et al. Vitamin D status relative to diet, lifestyle, injury, and illness in college athletes. Med Sci Sports Exerc. 2011;43(2):335–43.CrossRefPubMedGoogle Scholar
  28. 28.
    Hamilton B, Grantham J, Racinais S, et al. Vitamin D deficiency is endemic in Middle Eastern sportsmen. Public Health Nutr. 2010;13(10):1528–34.CrossRefPubMedGoogle Scholar
  29. 29.
    Hamilton B, Whiteley R, Farooq A, et al. Vitamin D concentration in 342 professional football players and association with lower limb isokinetic function. J Sci Med Sport. 2014;17(1):139–43.CrossRefPubMedGoogle Scholar
  30. 30.
    He CS, Handzlik M, Fraser WD, et al. Influence of vitamin D status on respiratory infection incidence and immune function during 4 months of winter training in endurance sport athletes. Exerc Immunol Rev. 2013;19:86–101.PubMedGoogle Scholar
  31. 31.
    Lewis RM, Redzic M, Thomas DT. The effects of season-long vitamin d supplementation on collegiate swimmers and divers. Int J Sport Nutr Exerc Metab. 2013;23(5):431–40.Google Scholar
  32. 32.
    Lovell G. Vitamin D status of females in an elite gymnastics program. Clin J Sport Med. 2008;18(2):159–61.CrossRefPubMedGoogle Scholar
  33. 33.
    Magee PJ, Pourshahidi LK, Wallace JM, et al. Vitamin D status and supplementation in elite irish athletes. Int J Sport Nutr Exerc Metab. 2013;23(5):441–8.Google Scholar
  34. 34.
    Peeling P, Fulton SK, Binnie M, et al. Training environment and Vitamin D status in athletes. Int J Sports Med. 2013;34(3):248–52.PubMedGoogle Scholar
  35. 35.
    Pollock N, Dijkstra P, Chakraverty R, et al. Low 25(OH) vitamin D concentrations in international UK track and field athletes. S Afr J Sports Med. 2012;24(2):55–9.Google Scholar
  36. 36.
    Shanely RA, Nieman DC, Knab AM, et al. Influence of vitamin D mushroom powder supplementation on exercise-induced muscle damage in vitamin D insufficient high school athletes. J Sports Sci. 2013;32(7):676–9.Google Scholar
  37. 37.
    Shindle MK, Voos J, Gulotta L, et al. Vitamin D status in a professional American Football team [abstract no. 46-9849]. AOSSM Annual Meeting; 7–10 Jul 2011; San Diego.Google Scholar
  38. 38.
    Storlie DM, Pritchett K, Pritchett R, et al. 12-Week vitamin D supplementation trial does not significantly influence seasonal 25(OH)D status in male collegiate athletes. Int J Health Nutr. 2011;2(2):8–13.Google Scholar
  39. 39.
    Willis KS, Smith DT, Broughton KS, et al. Vitamin D status and biomarkers of inflammation in runners. Open Access J Sports Med. 2012;3:35–42.PubMedCentralPubMedGoogle Scholar
  40. 40.
    Wilson G, Fraser WD, Sharma A, et al. Markers of bone health, renal function, liver function, anthropometry and perception of mood: a comparison between flat and national hunt jockeys. Int J Sports Med. 2013;34(5):453–9.PubMedGoogle Scholar
  41. 41.
    Wolman R, Wyon MA, Koutedakis Y, et al. Vitamin D status in professional ballet dancers: winter vs. summer. J Sci Med Sport. 2013;16(5):388–91.CrossRefPubMedGoogle Scholar
  42. 42.
    Wahl DA, Cooper C, Ebeling PR, et al. A global representation of vitamin D status in healthy populations. Arch Osteoporos. 2012;7(1–2):155–72.CrossRefPubMedGoogle Scholar
  43. 43.
    Ceroni D, Anderson de la Llana R, Martin X, et al. Prevalence of vitamin D insufficiency in Swiss teenagers with appendicular fractures: a prospective study of 100 cases. J Child Orthop. 2012;6(6):497–503.CrossRefPubMedCentralPubMedGoogle Scholar
  44. 44.
    Zhang W, Stoecklin E, Eggersdorfer M. A glimpse of vitamin D status in Mainland China. Nutrition. 2013;29(7–8):953–7.CrossRefPubMedGoogle Scholar
  45. 45.
    Palacios C, Gonzalez L. Is vitamin D deficiency a major global public health problem? J Steroid Biochem Mol Biol. 2014;144PA:138–45.Google Scholar
  46. 46.
    Brito A, Cori H, Olivares M, et al. Less than adequate vitamin D status and intake in Latin America and the Caribbean: a problem of unknown magnitude. Food Nutr Bull. 2013;34(1):52–64.PubMedGoogle Scholar
  47. 47.
    Lee YA, Kim HY, Hong H, et al. Risk factors for low vitamin D status in Korean adolescents: the Korea National Health and Nutrition Examination Survey (KNHANES) 2008–2009. Public Health Nutr. 2014;17(4):764–71.CrossRefPubMedGoogle Scholar
  48. 48.
    Hirschler V, Maccallini G, Molinari C, et al. Low vitamin D concentrations among indigenous Argentinean children living at high altitudes. Pediatr Diabetes. 2013;14(3):203–10.PubMedGoogle Scholar
  49. 49.
    Lanteri P, Lombardi G, Colombini A, et al. Vitamin D in exercise: physiologic and analytical concerns. Clin Chim Acta. 2013;415:45–53.CrossRefPubMedGoogle Scholar
  50. 50.
    Kumar J, Muntner P, Kaskel FJ, et al. Prevalence and associations of 25-hydroxyvitamin D deficiency in US children: NHANES 2001-2004. Pediatrics. 2009;124(3):e362–70.CrossRefPubMedCentralPubMedGoogle Scholar
  51. 51.
    Turer CB, Lin H, Flores G. Prevalence of vitamin D deficiency among overweight and obese US children. Pediatrics. 2013;131(1):e152–61.CrossRefPubMedGoogle Scholar
  52. 52.
    Lehtonen-Veromaa M, Mottonen T, Irjala K, et al. Vitamin D intake is low and hypovitaminosis D common in healthy 9- to 15-year-old Finnish girls. Eur J Clin Nutr. 1999;53(9):746–51.CrossRefPubMedGoogle Scholar
  53. 53.
    Korchia G, Amitai Y, Moshe G, et al. Vitamin D deficiency in children in Jerusalem: the need for updating the recommendation for supplementation. Isr Med Assoc J. 2013;15(7):333–8.PubMedGoogle Scholar
  54. 54.
    Hamilton B. Vitamin D and athletic performance: the potential role of muscle. Asian J Sports Med. 2011;2(4):211–9.PubMedCentralPubMedGoogle Scholar
  55. 55.
    Holick MF. Vitamin D: a D-lightful health perspective. Nutr Rev. 2008;66(10 Suppl 2):S182–94.CrossRefPubMedGoogle Scholar
  56. 56.
    Prentice A. Vitamin D deficiency: a global perspective. Nutr Rev. 2008;66(10 Suppl 2):S153–64.CrossRefPubMedGoogle Scholar
  57. 57.
    Godar DE. Worldwide increasing incidences of cutaneous malignant melanoma. J Skin Cancer. 2011;2011:858425.CrossRefPubMedCentralPubMedGoogle Scholar
  58. 58.
    Burgi AA, Gorham ED, Garland CF, et al. High serum 25-hydroxyvitamin D is associated with a low incidence of stress fractures. J Bone Miner Res. 2011;26(10):2371–7.CrossRefPubMedGoogle Scholar
  59. 59.
    Ruohola JP, Laaksi I, Ylikomi T, et al. Association between serum 25(OH)D concentrations and bone stress fractures in Finnish young men. J Bone Miner Res. 2006;21(9):1483–8.CrossRefPubMedGoogle Scholar
  60. 60.
    Ju SY, Lee YJ, Jeong SN. Serum 25-hydroxyvitamin D levels and the risk of depression: a systematic review and meta-analysis. J Nutr Health Aging. 2013;17(5):447–55.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2014

Authors and Affiliations

  • Forough Farrokhyar
    • 1
    • 2
    • 4
  • Rasam Tabasinejad
    • 3
  • Dyda Dao
    • 1
  • Devin Peterson
    • 4
  • Olufemi R. Ayeni
    • 4
  • Reza Hadioonzadeh
    • 3
  • Mohit Bhandari
    • 1
    • 2
    • 4
  1. 1.Department of SurgeryMcMaster UniversityHamiltonCanada
  2. 2.Department of Clinical Epidemiology and BiostatisticsMcMaster UniversityHamiltonCanada
  3. 3.School of Kinesiology and Health ScienceYork UniversityTorontoCanada
  4. 4.Division of Orthopedic Surgery, Department of SurgeryMcMaster UniversityHamiltonCanada

Personalised recommendations