Vitamin D Status Relative to Diet, Lifestyle,

Injury, and Illness in College Athletes

TANYA M. HALLIDAY1, NIKKI J. PETERSON1, JOI J. THOMAS2, KENT KLEPPINGER2,3,
BRUCE W. HOLLIS4, and D. ENETTE LARSON-MEYER1
1
Department of Family and Consumer Sciences, University of Wyoming, Laramie, WY; 2Department of Athletics, University of
Wyoming, Laramie, WY; 3Laramie Pediatrics, Laramie, WY; and 4Medical University of South Carolina, Charleston, SC

ABSTRACT
HALLIDAY, T. M., N. J. PETERSON, J. J. THOMAS, K. KLEPPINGER, B. W. HOLLIS, and D. E. LARSON-MEYER. Vitamin D
Status Relative to Diet, Lifestyle, Injury, and Illness in College Athletes. Med. Sci. Sports Exerc., Vol. 43, No. 2, pp. 335343, 2011.
Vitamin D deficiency is endemic in the general population; however, there is much to be learned about the vitamin D status of athletes.
Purpose: The purposes of this study were to assess the prevalence of vitamin D insufficiency in collegiate athletes and to determine
whether 25(OH)D concentrations are related to vitamin D intake, sun exposure, body composition, and risk for illness or athletic injury.
Methods: 25(OH) vitamin D concentrations were measured in 41 athletes (18 men/23 women, 12 indoor/29 outdoor athletes) throughout
the academic year. Dietary intake and lifestyle habits were assessed via questionnaire, bone density was measured by dual energy x-ray
absorptiometry, and injury and illness were documented as part of routine care. Results: The 25(OH)D concentrations changed across
time (P = 0.001) and averaged 49.0 T 16.6, 30.5 T 9.4, and 41.9 T 14.6 ngImLj1 (mean T SD) in the fall, winter, and spring, respectively,
and were higher in outdoor versus indoor athletes in the fall (P G 0.05). Using 40 ngImLj1 as the cutoff for optimal status, 75.6%, 15.2%,
and 36.0% of athletes had optimal status in the fall, winter, and spring, respectively. 25(OH)D concentrations were significantly
(P G 0.05) correlated with multivitamin intake in the winter (r = 0.39) and tanning bed use in the spring (r = 0.48); however, status was
otherwise not related to intake, lifestyle factors, or body composition. 25(OH)D concentrations in the spring (r = j0.40, P = 0.048) was
correlated with frequency of illness. Conclusions: Our results suggest that collegiate athletes can maintain sufficient status during the fall
and spring but would benefit from supplementation during the winter to prevent seasonal decreases in 25(OH)D concentrations. Results
further suggest that insufficient vitamin D status may increase risk for frequent illness. Future research is needed to identify whether
vitamin D status influences injury risk during athletic training or competition. Key Words: BONE DENSITY, BODY COMPOSITION,
PARATHYROID HORMONE, SUN EXPOSURE, 25(OH)D

N
umerous studies have recently reported a high
prevalence of vitamin D deficiency (25(OH)D G
20 ngImLj1) and insufficiency (25(OH)D G
32 ngImLj1) for all age groups worldwide (15,16,23,38). It
is widely accepted that vitamin D is necessary for adequate
bone health through up-regulation of the expression of
genes that enhance calcium absorption and bone deposition
(15). However, recent evidence has also linked low vitamin
D status to various nonskeletal, chronic, and autoimmune
diseases, including cardiovascular disease, hypertension,
Address for correspondence: D. Enette Larson-Meyer, Ph.D., R.D., FACSM, De-
partment 3354, 1000 E. University Avenue, University of Wyoming, Laramie,
WY 82071; E-mail: enette@uwyo.edu.
Submitted for publication February 2010.
Accepted for publication May 2010.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journals Web site (www.acsm-msse.org).
0195-9131/11/4302-0335/0
MEDICINE & SCIENCE IN SPORTS & EXERCISE
Copyright 2011 by the American College of Sports Medicine
DOI: 10.1249/MSS.0b013e3181eb9d4d
diabetes, inflammatory bowel disease, depression, multiple
sclerosis, rheumatoid arthritis, and certain types of cancer
(15,16,38). Furthermore, recent studies have found that
vitamin D up-regulates gene expression of antimicrobial
peptides (AMP) (12) and down-regulates expression of
several inflammatory cytokines, including tumor necrosis
factor > and interleukin 6 (24), and therefore may be an
important component in immune function and inflamma-
tory modulation (6,38). Although vitamin D is considered a
vitamin, it is unique in that it may be obtained from the
diet or synthesized in the skin in the presence of ultraviolet
B (UVB) light (290315 nm) (15,16). Unfortunately, only
a few foods such as oily fish naturally contain vitamin D,
APPLIED SCIENCES
whereas milk, selected fruit juices, breads, and cereals are
among the few fortified food sources (5,8,15). Although sun
exposure has the ability to provide the needed precursors
for adequate status, wintertime latitude greater than 37-
north or south (15,36), skin pigmentation (15), sunscreen
use (15,22), and excess adiposity (25,29) all decrease endog-
enous vitamin D synthesis and bioavailability.
Despite the large number of studies conducted in the gen-
eral population, much less is known about the vitamin D status
of athletes. The few studies conducted have documented a
surprisingly high percentage of vitamin D insufficiency or

335

Copyright 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 deficiency in athletes participating in outdoor (13,21; Willis,
2008, unpublished data) as well as indoor (2,13,19,20) sports.
On the basis of our current understanding of vitamin Ds
role in bone health, inflammation, and immunity, it is plau-
sible that suboptimal vitamin D status increases the risk of
overuse and inflammatory injuries as well as the susceptibility
to common upper respiratory tract infection (URI) and other
illnesses. These adverse consequences could negatively im-
pact athletic training and performance (in addition to im-
pacting long-term risk for chronic disease).
The purposes of this study were to evaluate the prev-
alence of vitamin D insufficiency in National Collegiate
Athletic Association (NCAA) Division I athletes throughout
the academic year and to determine whether circulating
concentrations of 25(OH)D are related to vitamin D intake,
sun exposure, and body composition. A secondary purpose
was to evaluate whether 25(OH)D concentration is linked
to bone density, development of overuse or inflammatory
injuries, and/or incidence of frequent illness. We hypothe-
sized that athletes participating in indoor sports would have
lower 25(OH)D concentrations compared with those partic-
ipating in outdoor sports. Within the entire group of ath-
letes, we further hypothesized that sun exposure, sunscreen
use, and vitamin D intake (from food and supplements)
would be predictive of 25(OH)D concentrations. In addition,
we hypothesized that lower concentrations of 25(OH)D at
any time point throughout the year would increase risk for
low bone density, overuse and/or inflammatory injuries, and
frequent illness.
METHODS
Subjects. All male and female NCAA Division I col-
lege athletes Q18 yr from the University of Wyoming (UW)
(2195 m, 41.3-N) were invited to participate in the study,
which was approved by both the institutional review board
and the athletic department at UW. Before participation,
interested athletes were fully informed about the study pro-
cedures and the possible risks before providing written
informed consent. All athletes had undergone a routine
preseason physical with the UW athletic department physi-
cian (KK) and were considered in good health. Participants
were classified as either indoor or outdoor athletes on the
basis of their sport. Athletes who trained and/or competed
outdoors (football, soccer, cross-country or track and field,
APPLIED SCIENCES
and cheerleading/dance) were considered outdoor athletes,
whereas athletes who trained and competed exclusively in-
doors (wrestling, swimming, and basketball) were consid-
ered indoor athletes. In accordance with NCAA regulations,
all athletes are allowed no more than 20 hIwkj1 to train and
to compete during their competitive season and 8 hIwkj1
during their off season.
Study design. This longitudinal study tracked the vita-
min D status of the athletes throughout the academic year.
Blood samples for analysis of vitamin D (serum 25(OH)D)
and parathyroid hormone (PTH) were collected in the fall
336 Official Journal of the American College of Sports Medicine
Copyright 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
(September/early October), winter (late February/early March),
and spring (late April/early May). A vitamin Dspecific ques-
tionnaire was administered at these same time points. At study
completion (spring only), body composition and bone density
of the hip, lumbar spine, and total body were evaluated via
dual energy x-ray absorptiometry (DEXA) using standard-
ized procedures. Illnesses and injuries that occurred in all UW
NCAA athletes, including study participants, were documented
throughout the academic year by the UW athletic training staff
and the team physician.
Vitamin D and PTH. At each testing point (fall, winter,
and spring), 5 mL of blood was collected in standard red
top tubes (no additives), allowed to clot for 3060 min at
room temperature, and centrifuged at 3500 rpm for 15 min.
Aliquots of serum were stored at j20-C until analysis. Se-
rum was later analyzed for 25-hydroxy vitamin D and PTH
via Diasorin 25(OH)D RIA and intact PTH IRMA, respec-
tively, in an external laboratory (BH, Charleston, SC).
Questionnaire and sun exposure during practice/
competition. The vitamin Dspecific questionnaire com-
pleted at each of the three collection points focused on die-
tary and lifestyle habits that could impact vitamin D status.
The questionnaire asked athletes how often (never or less
than one time per month, one to three times per month,
one time per week, two to four times per week, five to six
times per week, one time per day, two to three times per day,
four to five times per day, or six or more times per day)
they consumed various vitamin Dcontaining foods, multi-
vitamins (MVI), and other vitamin Dcontaining supple-
ments including cod liver oil. The vitamin Dcontaining
foods included cows milk, soy or rice milk, eggs, vitamin
Dfortified cereal, margarine, orange juice, and fatty fish
(see SDC 1, Vitamin D questionnaire for full list of foods
assessed in the study; http://links.lww.com/MSS/A43). In-
take of vitamin D was estimated by multiplying the fre-
quency midpoint by the average content of each vitamin
Dcontaining food and expressed as IU per day. The vitamin
D content of foods was obtained from Chen et al. (8), from
the national nutrient database for standard reference (33),
and from selected food labels. The questionnaire also
asked athletes about the frequency of leisure time spent
outside (never or G1 hImonthj1, 13 hImonthj1, 1 hIwkj1,
24 hIwkj1, 56 hIwkj1, 0.51 hIdj1, or 92 hIdj1), the
frequency of tanning bed use (never or G10, 1020, 2030,
3040, 4050, 5060, or 960 minIwkj1), the type and fre-
quency of sunscreen applied (never, sometimes, usually, or
always), and the type of clothing typically worn outdoors.
Information on sun exposure during practice or competition
was collected from records of team-specific training and
competitions, which varied by season in accordance with
the NCAA Division I regulations. For outdoor athletes,
estimates of weekly time spent outside during practice or
competition were estimated for fall (average of August,
September, and early October) and spring (April) but not
for winter (because little to no training occurred outdoors
during these months). For indoor athletes, weekly time spent
http://www.acsm-msse.org
outdoors during practice or competitions was assumed to be
zero. Total sun exposure was estimated from the sum of
estimated practice or competition sun exposure and reported
leisure time spent outdoors. At the first collection point
(fall), participants reported on their summer location; at the
second collection (winter), participants reported on their
winter break location; and at the third collection (spring),
participants reported on their spring break location.
Athletic injury and illness. Selected information con-
tained within the athletes medical charts, including injury
status and frequency of illnesses (URI, influenza, gastro-
enteritis, etc.) during the academic year, was collected by a
certified athletic trainer (JT) who was blinded to the vitamin
D status of the athletes. The total number of injuries that
were likely to be subacute or overuse injuries (such as stress
fractures and tendonitis) rather than the result of a specific
mechanism were tallied for each athlete.
Statistical procedures. Statistical analyses were per-
formed using the Statistical Package for the Social Sciences
for Windows analysis software (PASW Statistics Version
17.0, SPSS Inc., Chicago, IL). Pearson correlations were
used to assess the relations between serum 25(OH)D con-
centrations and continuous measured or estimated variables,
including body weight, body fat percentage, PTH concen-
trations, and vitamin D intake, whereas Spearman rank cor-
relations were used to assess the relations between serum
25(OH)D concentrations and noncontinuous variables, includ-
ing frequency of intake of vitamin Dcontaining foods and
supplements, leisure time spent outdoors, tanning bed use,
and frequency of illness. One-way ANOVA was used to test
differences between indoor versus outdoor and male versus
female athletes. Repeated-measures ANOVA was used to
assess differences over time (fall, winter, and spring). Alpha
was set at 0.05.
RESULTS
Eighteen men (mean T SD: age = 20.1 T 1.9 yr, height =
183.9 T 11.2 cm, weight = 88.0 T 19.6 kg, body mass index
[BMI] = 25.9 T 4.4 kgImj2, 1 black, 0 Hispanic, 17 white)
and 23 women (age = 19.9 T 1.5 yr, height = 168.1 T 9.6 cm,
weight = 59.6 T 10.2 kg, BMI = 20.9 T 1.9 kgImj2, 0 black,
1 Hispanic, 22 white) from a variety of intercollegiate ath-
letic teams initially volunteered to participate in the study.
The athletes who participated in basketball, wrestling, and
swimming (n = 12) were classified as indoor athletes,
whereas those that participated in soccer, football, cross-
country or track and field, and cheerleading or dance team
(n = 29) were classified as outdoor athletes. At the winter
testing point, data were not collected on eight athletes be-
cause they were either no longer part of UW athletics
(n = 4) or elected to discontinue participation in the study
(n = 4). At the spring testing point, data were not collected
on eight additional athletes because of scheduling conflicts
with final examinations or team or personal travel. The
study sample, therefore, was n = 41 in the fall, n = 33 in the
VITAMIN D STATUS IN COLLEGE ATHLETES
Copyright 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
winter, and n = 25 in the spring. Scheduling conflicts in the
spring also prohibited measurement of body composition or
bone density by DEXA in four of the 25 athletes (n = 21 for
DEXA analysis).
Vitamin D status. As shown in Figure 1, 25(OH)D
concentration changed significantly across time (P = 0.001)
and averaged 49.0 T 16.6 ngImLj1 in the fall, 30.5 T
9.4 ngImLj1 in the winter, and 41.9 T 14.6 ngImLj1 in the
spring. In the fall, 9.8% of athletes (n = 4) were vitamin D
insufficient (25(OH)D concentration G32 ngImLj1 but
920 ngImLj1) (17), whereas one (2.4%) had 25(OH)D
concentrations indicative of vitamin D deficiency (25(OH)D
G20 ngImLj1) (15,38). In the winter, 60.6% (n = 20) of
athletes were vitamin D insufficient and 3.0% (n = 1) were
vitamin D deficient. In the spring, 16.0% (n = 4) were
insufficient and 4.0% (n = 1) were deficient. Using a cut-
off of 40 ngImLj1, thought to be the lower limit of optimal
achieved by humans living naturally in a sun rich envi-
ronment (6), 75.6% (n = 31), 15.2% (n = 5), and 36.0%
(n = 9) of athletes had optimal vitamin D status in the
fall, winter, and spring, respectively. As shown in Figure 2,
vitamin D status was significantly higher in outdoor com-
pared with indoor athletes in the fall (53.1 T 17.4 vs 39.3 T
8.9 ngImLj1, P = 0.013) but not in the winter (31.9 T
10.2 ngImLj1, n = 25 vs 26.3 T 5.0 ngImLj1, n = 8;
P = 0.15) or spring (44.6 T 15.6 ngImLj1, n = 19 vs 33.1 T
4.8 ngImLj1, n = 6; P = 0.09). Vitamin D status did not
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FIGURE 1Box plots illustrating the distribution of 25(OH)D con-
centrations in college athletes assessed in the fall (n = 41), winter
(n = 33), and spring (n = 25). Box extents indicate the 25th and 75th
percentile, with the median indicated by a solid dark line and the mean
indicated by a dashed line. Central vertical lines (whiskers) extend up to
1.5 interquartile ranges from the end of the box. A circle or an asterisk
marks individual points outside of the whiskers. A circle marks a value
between 1.5 and 3.0 interquartile ranges of the box, and an asterisk
marks a value 93.0 interquartile ranges of the box. 25(OH)D concen-
trations G20 ngImLj1 are considered deficient, concentrations between
20 and 32 ngImLj1 are considered insufficient (solid horizontal line),
and concentrations 940 ngImLj1 (horizontal dashed line) are consid-
ered optimal.
Medicine & Science in Sports & Exercised 337

FIGURE 2Vitamin D status in indoor compared with outdoor
athletes in the fall, winter, and spring. *P G 0.05 indoor vs outdoor by
one-way ANOVA.
differ by sex at any of the time points (P = 0.10). In the
entire group, 25(OH)D concentration in the fall was corre-
lated with 25(OH)D concentrations in the winter (r = 0.85,
n = 33, P = 0.0001) and spring (0.76, n = 25, P = 0.0001).
PTH and relation with vitamin D status. Serum
PTH concentrations ranged between 7.7 and 54.4 pgImLj1
(23.8 T 10.9 pgImLj1) in the fall, between 9.4 and
50.8 pgImLj1 (25.4 T 9.3 pgImLj1) in the winter, and be-
tween 12.8 and 48.5 pgImLj1 (28.1 T 9.9 pgImLj1) in the
spring (normal range = 1254 pgImLj1) and did not change
significantly across time (P = 0.18). PTH concentrations
were not different between indoor and outdoor athletes in
the fall (24.8 T 12.5 vs 23.3 T 10.4 pgImLj1), winter
(25.2 T 12.1 vs 25.5 T 8.3 pgImLj1), or spring (22.6 T 11.1
vs 29.8 T 9.1 pgImLj1) ( P 9 0.10). As shown in Table 1,
PTH concentration was not correlated with 25(OH)D con-
centration at any time point.
Intake of vitamin Dcontaining foods and supple-
ments and relation with vitamin D status. Frequency
of consumption of selected vitamin Dcontaining foods and
supplements along with their vitamin D content is shown in
Table 2. Vitamin D status was correlated with MVI intake in
the winter (r = 0.39, P = 0.025, n = 33) but not in the fall
(r = 0.29, P = 0.062, n = 41) or spring (r = j0.14, P = 0.49,
n = 25). In the fall, consumption of orange juice was nega-
tively correlated with 25(OH)D status (j0.36, P = 0.02). No
other correlations were found between vitamin D status and
self-reported intake of vitamin Dcontaining foods.
Estimated vitamin D intake from food sources averaged
APPLIED SCIENCES
242 T 161, 282 T 206, and 204 T 171 IUIdj1 from food
sources in the fall, winter, and spring, respectively, and
averaged 553 T 471, 683 T 610, and 489 T 456 IUIdj1 when
TABLE 1. Correlations between vitamin D status in the fall, winter, and spring and PTH, body mass, and adiposity.
25(OH) D (ngImLj1) PTH (pgImLj1) Body Mass (kg)
Fall (n = 41) j0.16 (P = 0.33) j0.20 (P = 20)
Winter (n = 33) 0.28 (P = 0.12) j0.23 (P = 0.12)
Spring (n = 25) 0.16 (P = 0.46) j0.14 (P = 0.49)
a
Body fat was assessed in the spring in 21 of 25 athletes. Correlation with 25(OH)D concentrations in the fall and winter assume body fat did not vary across time.
PTH, parathyroid hormone; BMI, body mass index.
338 Official Journal of the American College of Sports Medicine
Copyright 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
vitamin D supplements (including an MVI) were included.
Neither total vitamin D intake nor intake from food alone
differed across time or with sex or training location
(indoor vs outdoor) ( P 9 0.05). Neither vitamin D intake from
food nor food plus supplements was significantly correlated
with vitamin D status in the fall (r = j0.05 and 0.03),
winter (r = 0.02 and 0.00), or spring (r = j0.10 and 0.17)
( P 9 0.05), respectively. A very small percentage of athletes
(4.9% in the fall, 6.1% in the winter, and 4% in the spring)
consumed the current RDA of 600 IU from food alone. This
increased to 26.8%, 18.2%, and 20% in the fall, winter, and
spring when supplements were included. Interestingly, with
the exception of two athletes during the winter, those who
consumed 91000 IUIdj1 from food plus supplements had
sufficient status (Q32 ngImLj1).
UV exposure and relation with vitamin D status.
Reported leisure time spent outdoors changed significantly
across time (P = 0.001) and averaged 4.5 T 1.8, 3.6 T 1.7,
and 4.0 T 1.8 hIwkj1 in the fall, winter, and spring, re-
spectively. Reported tanning bed use averaged 0.24 T 0.89,
0.03 T 0.17, and 0.24 T 0.66 hIwkj1 and did not vary sig-
nificantly across time (P = 0.08). Time spent outside during
practice or competition averaged 7.8 T 6.4, 0 T 0, and 4.9 T
4.7 hIwkj1 in the fall, winter, and spring, respectively. Lei-
sure time spent outdoors was not significantly ( P 9 0.10)
correlated with vitamin D status at any time point. How-
ever, tanning bed use was correlated with 25(OH)D con-
centrations in the spring (r = 0.48, P = 0.016) but not winter
(r = 0.20) or fall (r = 0.17) ( P 9 0.05), whereas time spent
outside during practice or competition and total time spent
outdoors were correlated with vitamin D status in the fall
(r = 0.40 and 0.42, P G 0.01) but not the spring (r = 30 and
0.21, P 9 0.05), respectively. Leisure time spent outdoors was
significantly lower in indoor versus outdoor athletes in the
winter (2.4 T 1.5 vs 3.9 T 1.6 hIwkj1, P = 0.02) and spring
(2.8 T 1.2 vs 4.4 T 1.8 hIwkj1, P = 0.068) but not in the
fall (4.1 T 1.5 vs 4.8 T 1.8 hIwkj1, P 9 0.05). Reported
tanning bed use, sunscreen use, or SPF typically applied
were not different between indoor versus outdoor athletes
at any time point.
Relation between vitamin D status and body
composition. Relations between vitamin D status and
body mass, BMI, and percentage body fat are shown in
Table 2. Pearson correlations between body mass or BMI
were not found at any time point, although 25(OH)D con-
centrations tended to be correlated with body fat percentage
in the fall and spring. When correlations were adjusted for
sex, however, the relation between body fat and 25(OH)D
Height (cm) BMI (kgImj2) Body Fat (%)a Fat Mass (kg)a
j0.27 (P = 0.09) j0.13 (P = 41) j0.40 (P = 0.07) j0.31 (P = 0.17)
j0.08 (P = 0.66) j0.27 (P = 0.21) j0.16 (P = 0.48) j0.20 (P = 0.40)
0.14 (P = 25) j0.22 (P = 0.28) j0.36 (P = 0.10) j0.23 (P = 0.31)
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TABLE 2. Major sources of reported dietary vitamin D in the fall, winter, and springa.
Number of Respondents
Food Vitamin D (IU) Fall (n = 41) Winter (n = 33) Spring (n = 25)
Milk (8 oz) (regular, soy, or rice)b,c 100 0 or G1 monthj1 = 2 0 or G1 monthj1 = 3 0 or G1 monthj1 = 2
13 timesImonthj1 = 4 13 timesImonthj1 = 1 13 timesImonthj1 = 2
1 timeIwkj1 = 1 1 timeIwkj1 = 1 1 timeIwkj1 = 3
24 timesIwkj1 = 8 24 timesIwkj1 = 7 24 timesIwkj1 = 5
56 timesIwkj1 = 4 56 timesIwkj1 = 5 56 timesIwkj1 = 2
1 timeIdj1 = 7 1 timeIdj1 = 3 1 timeIdj1 = 3
Q2 timesIdj1 = 15 Q2 timesIdj1 = 13 Q2 timesIdj1 = 8
Cereal (3/41 cup)c 40 0 or G1 monthj1 = 4 0 or G1 monthj1 = 1 0 or G1 monthj1 = 2
13 timesImonthj1 = 3 13 timesImonthj1 = 3 13 timesImonthj1 = 2
1 timeIwkj1 = 6 1 timeIwkj1 = 6 1 timeIwkj1 = 5
24 timesIwkj1 = 15 24 timesIwkj1 = 13 24 timesIwkj1 = 10
56 timesIwkj1 = 7 56 timesIwkj1 = 4 56 timesIwkj1 = 0
1 timeIdj1 = 6 1 timeIdj1 = 5 1 timeIdj1 = 4
Q2 timesIdj1 = 0 Q2 timesIdj1 = 1 Q2 timesIdj1 = 2
Orange juice (8 oz), vitamin D fortifiedb 100 0 or G1 monthj1 = 5 0 or G1 monthj1 = 2 0 or G1 monthj1 = 2
13 timesImonthj1 = 16 13 timesImonthj1 = 12 13 timesImonthj1 = 11
1 timeIwkj1 = 8 1 timeIwkj1 = 6 1 timeIwkj1 = 8
24 timesIwkj1 = 10 24 timesIwkj1 = 8 24 timesIwkj1 = 1
56 timesIwkj1 = 2 56 timesIwkj1= 2 56 timesIwkj1 = 3
1 timeIdj1 = 3
Egg, yolk (1)b 18 0 or G1 monthj1 = 7 0 or G1 monthj1 = 1 0 or G1 monthj1 = 2
13 timesImonthj1 = 6 13 timesImonthj1 = 6 13 timesImonthj1 = 7
1 timeIwkj1 = 7 1 timeIwkj1 = 8 1 timeIwkj1 = 4
24 timesIwkj1 = 9 24 timesIwkj1 = 7 24 timesIwkj1 = 8
56 timesIwkj1 = 8 56 timesIwkj1 = 3 56 timesIwkj1 = 2
1 timeIdj1 = 2 1 timeIdj1 = 5 1 timeIdj1 = 0
Q2 timesIdj1 = 2 Q2 timesIdj1 = 3 Q2 timesIdj1 = 2
Fatty fish (3.5 oz)a,b,d 2701360 0 or G1 monthj1 = 16 0 or G1 monthj1 = 11 0 or G1 monthj1 = 8
13 timesImonthj1 = 12 13 timesImonthj1 = 7 13 timesImonthj1 = 8
1 timeIwkj1 = 6 1 timeIwkj1 = 8 1 timeIwkj1 = 8
6 timesImonthj1 = 4 6 timesImonthj1 = 1 6 timesImonthj1 = 0
8 timesImonthj1 = 0 8 timesImonthj1 = 1 8 timesImonthj1 = 1
10 timesImonthj1 = 2 10 timesImonthj1 = 1 10 timesImonthj1 = 0
12 timesImonthj1 = 1 12 timesImonthj1 = 1 12 timesImonthj1 = 0
Q14 timesImonthj1 = 0 Q14 timesImonthj1 = 3 Q14 timesImonthj1 = 0
MVIc Q400 0 or G1 monthj1 =16 0 or G1 monthj1 = 9 0 or G1 monthj1 = 9
13 timesImonthj1 = 4 13 timesImonthj1 = 4 13 timesImonthj1 = 2
1 timeIwkj1 = 4 1 timeIwkj1 = 3 1 timeIwkj1 = 2
24 timesIwkj1 = 4 24 timesIwkj1 = 5 24 timesIwkj1 = 4
56 timesIwkj1 = 3 56 timesIwkj1 = 2 56 timesIwkj1 = 2
1 timeIdj1 = 9 1 timeIdj1 = 8 1 timeIdj1 = 5
Q2 timesIdj1 = 1 Q2 timesIdj1 = 2 Q2 timesIdj1 = 1
Vitamin D supplementc 1000 0 or G1 monthj1 = 31 0 or G1 monthj1 = 25 0 or G1 monthj1 = 19
13 timesImonthj1 = 3 13 timesImonthj1 = 0 13 timesImonthj1 = 1
1 timeIwkj1 = 1 1 timeIwkj1 = 2 1 timeIwkj1 = 1
24 timesIwkj1 = 1 24 timesIwkj1 = 3 24 timesIwkj1 = 2
56 timesIwkj1 = 2 56 timesIwkj1 = 0 56 timesIwkj1 = 1
1 timeIdj1 = 2 1 timeIdj1 = 2 1 timeIdj1 = 1
Q2 timesIdj1 = 1 Q2 timesIdj1 = 1 Q2 timesIdj1 = 0
Cod liver oil (1 tbsp)b 1360 0 or G1 monthj1 = 36 0 or G1 monthj1 = 29 0 or G1 monthj1 = 24
13 timesImonthj1 = 3 13 timesImonthj1 = 2 13 timesImonthj1 = 0
1 timeIwkj1 = 0 1 timeIwkj1 = 1 1 timeIwkj1 = 1
24 timesIwkj1 = 2 24 timesIwkj1 = 1 24 timesIwkj1 = 0
a
Data are a compilation of the frequency of several types of fatty fish including salmon, mackerel, sardines eel, and other fatty fish.
b
USDA national nutrient database for standard reference (33).
c
Chen et al. (8).
d
Food label values.
APPLIED SCIENCES
concentration was significant in the fall (partial r = 0.44, Relation between vitamin D status and illness
P = 0.05) but not the winter (P = 0.19, P = 0.41) or spring and injury. Seven of 33 athletes who remained in the study
(partial r = j0.33 P = 0.16). at the winter collection point developed overuse injuries
Relation between vitamin D status and bone den- that were not due to contusion. This included one case of
sity. Vitamin D status was not correlated (P Q 0.05) with Achilles tendonitis, five stress reactions (two in the shin, two
total body bone density (r = 0.02) or bone density in the in the foot, and one in the femur), and a fracture of the foot,
lumbar spine (r = 0.06) or dual femur (r = 0.02), which was five of which occurred in athletes participating in cross-
assessed only in the spring. PTH, however, was significantly country or track and field. Frequency of injury was not re-
correlated with bone density assessed in the total body lated to vitamin D status but was significantly negatively
(r = j0.66, P = 0.001), lumbar spine (r = j0.51, P = 0.03), correlated with total body bone mineral density (BMD;
and dual femur (r = j0.55, P = 0.01). r = j0.50, P = 0.02).

VITAMIN D STATUS IN COLLEGE ATHLETES Medicine & Science in Sports & Exercised 339

Copyright 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

FIGURE 3Vitamin D status in the winter (r = j0.33, P = 0.065) and
spring (r = j0.40, P = 0.048) in relation to frequency of documented
illness by Spearman rank correlation coefficient. Illness included the
common cold, flu, or other URI.
Thirteen of 33 athletes also contracted at least one docu-
mented illness, which included the common cold, flu, or
other URI, with 8 of the total contracting one illness, 3
contracting two different illnesses, and 2 contracting four.
Vitamin D status in the fall, winter, or spring was not sig-
nificantly correlated with incidence of injury but was sig-
nificantly correlated with frequency of illness in the spring
(r = j0.40, P = 0.048; Fig. 3) but not in the winter
(r = j0.33, P = 0.065; Fig. 3) or fall (r = 0.15, P = 0.39).
DISCUSSION
The purposes of this study were to examine the vitamin D
status of male and female college athletes during the uni-
versity academic year to determine if vitamin D status
(circulating concentrations of 25-hydroxy vitamin D) was
related to dietary intake, training, and lifestyle habits and/or
body composition and to evaluate whether insufficient status
APPLIED SCIENCES
was linked with compromised bone density or increased
risk for illness or inflammatory injuries. We found that
vitamin D status varied across the year, with a higher per-
centage of athletes having insufficient or deficient status
(25(OH)D G 32 ngImLj1) in the winter (63.6%) compared
with the fall (12.2%) and spring (20%). Interestingly, 75.6%
and 36.0% of athletes maintained status within the more
optimal range (940 ngImLj1) in the fall and spring com-
pared with only 15.2% in the winter. We also found that low
vitamin D status in the spring was correlated with frequency
of illnessincluding URI, the common cold, influenza, and
340 Official Journal of the American College of Sports Medicine
Copyright 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
gastroenteritis. Although vitamin D status was correlated
with outdoor practice or competition time in the fall and
spring, reported MVI consumption in the winter, and tan-
ning bed use in the spring, status was otherwise not signif-
icantly related to vitamin D intake, lifestyle habits, or body
composition.
The main finding from this study was that a surprisingly
low percentage of college athletes had insufficient status (de-
fined as a circulating 25(OH)D concentration G32 ngImLj1)
in the fall and spring and more importantly that a high per-
centage of those with sufficient status maintained stores in
the more optimal range (940 ngImLj1). In contrast to our
findings, several groups of researchers studying runners (19;
Willis, 2008, unpublished data), gymnasts (19,20), and other
athletes (2,13) found that at least 37%100% of athletes are
vitamin D insufficient and that 1%83% are deficient
(25(OH)D concentration G20 ngImLj1), depending on sport,
geographic location, and season tested. A recent study from
our laboratory, for example, found that 42% of distance
runners training in Baton Rouge, Louisiana (30.5-N), were
vitamin D insufficient and 1% had concentrations low
enough to be deficient (Willis, 2008, unpublished data). An-
other study in 93 Middle Eastern sportsmen training in Qatar
(25.4-N) found that 90% were vitamin D deficient (25(OH)D
G 20 ngImLj1). Although incidence of vitamin D insuffi-
ciency in the current study increased in the winter, as might
be expected in athletes living at 935-37- north or south
latitude (6,15), the low prevalence of insufficiency and the
high prevalence with optimal status in fall and spring may be
explained by the sunny and mild climate of Wyoming during
the spring, summer, and fall months. Such conditions allow
athletes to train and/or perform leisure activities outdoors at
close to solar noon when vitamin D synthesis is most effec-
tive (6). It is further possible that the lack of cloud cover and
pollution as well as Laramies elevation of 92195 m above
sea level (31) allows increased endogenous synthesis because
of an increased fractional strength of UVB radiation.
In support of our hypothesis, we found that athletes par-
ticipating in indoor sports such as wrestling, basketball, and
swimming had lower circulating vitamin D in the fall than
athletes participating in outdoor sports, including football,
soccer, cross-country or track and field, and cheerleading,
and that vitamin D status correlated with estimated weekly
outdoor practice time in fall and spring. This finding sug-
gests that athletes who practice indoors are at increased risk
for vitamin D insufficiency and deficiency, as are athletes
who practice outdoors only in the early evening (13) or early
morning (Willis, 2008, unpublished data) or who diligently
apply sunscreen (which can reduce cutaneous synthesis by
995% (22). Although we also expected that 25(OH)D con-
centration would correlate with reported leisure-time sun-
light exposure, we found that vitamin D status correlated
with reported frequency of tanning bed use, as previously
suggested (32), but only in the spring. Self-reported data
via questionnaires, however, may not be the most accu-
rate method for obtaining data on effective sun exposure
http://www.acsm-msse.org
(i.e., between the hours of 10:00 a.m. and 2:00 p.m., non-
daylight savings time) or tanning bed use. Effective sun
exposure is complicated by factors such as cloud cover and
sunscreen use (6,15), whereas commercial tanning beds vary
considerably with the type of UV light emitted (i.e., only
beds that emit adequate UVB promote cutaneous vitamin D
synthesis [15,32]). In future studies, the frequency and the
length of time spent in leisure time and practice or competi-
tion between 10:00 a.m. and 2:00 p.m. nondaylight savings
time and sunscreen application frequency and type should be
collected through more detailed questionnaires, logs, or direct
documentation. Direct measurement of UVB exposure with
UVB detection devices placed directly on skin would also be
of interest.
Our lack of a relation between vitamin D status and both
frequency of intake of vitamin Dcontaining foods and esti-
mated vitamin D intake from food is not surprising given that
vitamin D is limited in our food supply. Only a few foods,
including oily fish, naturally contain vitamin D, whereas milk,
some fruit juices, margarine, and ready-to-eat cereals are
among the few fortified food sources (5). In addition, food
intake tables for vitamin D are inadequate, which makes in-
take evaluation difficult (5). In the current study, reported
vitamin D intake from food alone averaged 242 T 161,
282 T 206, and 204 T 171 IUIdj1 in the fall, winter, and
spring and while higher than that previously reported in ath-
letic populations, including ski jumpers, gymnasts, soccer
players, ice skaters and runners (3,9,19,26,37), was lower
than the current RDA of 600 IU (27). When vitamin D from
supplements (including an MVI) was included, intake in-
creased to more than approximately 500 IUIdj1 in the fall and
spring and to almost 700 IUIdj1 in the winter, approaching
the higher intake level (of 10004000 IUIdj1) recommended
by researchers (4,6,16,17). The lack of a correlation with total
intake from vitamin D (including supplements), however, is
unexpected but may be explained by the food frequency
methodology and/or by the fact that most circulating
25(OH)D is thought to originate from sunlight exposure
rather than from dietary sources (6,15). We were intrigued,
however, by our weak but significant relation between fre-
quency of MVI intake and vitamin D status in the winter (and
tendency for this same association in the fall). Although these
findings suggest that a vitamin Dcontaining MVI may help
athletes maintain vitamin D status, it is important to stress that
previous studies indicate thatin the absence of sun expo-
surea daily MVI (which typically contains 400 IU) is not
enough to maintain 25(OH)D concentrations in the sufficient
range (14,16,19).
Vitamin D status in the current study also did not appear
to be significantly influenced by body weight or adiposity,
although the expected negative association with body fat
percentage tended to be present in the fall and spring. Pre-
vious studies in nonathletes have found that 25(OH)D con-
centrations are inversely correlated with body fat percentage
(within the typical range of sedentary individuals) (29) and
are commonly depressed with obesity (along with elevated
VITAMIN D STATUS IN COLLEGE ATHLETES
Copyright 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
PTH concentrations) (25,29). In a cohort of 302 healthy
adults, for example, Parikh et al. (25), found lower serum
concentrations of 25(OH)D in obese compared with non-
obese adults. The decrease in vitamin D bioavailability is
thought to be due to sequestration of vitamin D in adipose
tissue after cutaneous synthesis or dietary intake, although
the exact mechanism is not yet known. The reason for a
lack of a significant correlation between vitamin D status
and adiposity in the current study is most likely explained by
the reduced range of body fat of our collegiate athlete pop-
ulation. Future studies in larger athletic populations, how-
ever, should evaluate whether athletes with excessively high
body fat stores are at increased risk for vitamin D insuffi-
ciency, particularly during certain seasons of the year.
The final purpose of the current study was to evaluate
whether vitamin D status is linked to bone density, overuse
injury, or illness throughout the academic year. Studies in
healthy individuals have found that serum 25(OH)D con-
centrations correlate positively with BMD (4,34), with the
greatest BMD observed when serum concentrations are
close to 40 mgIdLj1 (4). Among military recruits, risk for
bone fracture is significantly associated with reduced serum
25(OH)D (11,28) and elevated PTH concentrations (35) and
is reduced by supplementation with 800 IUIdj1 of vitamin D
plus calcium (18). Although less is known about overuse
or inflammatory injuries, preliminary findings from our lab-
oratory found that the inflammatory marker tumor necrosis
factor > rises exponentially in runners when serum 25(OH)D
concentrations fall less than 32 ngImLj1 (Willis, 2008, un-
published data). A previous German report also documented
that athletes undergoing an extensive 6-wk program of UVB
irradiation experienced a reduction in chronic pain because
of sports injuries (30). Although the current study was unable
to provide evidence for a link between low vitamin D status
and compromised bone health and athletic injury, additional
studies are warranted because detection of injury due to
vitamin D deficiency was not ideal in our athletic population
that mostly maintained 25(OH)D concentrations more than
the 3240 ngImLj1 throughout the year. Our results, how-
ever, highlight the role of high-normal PTH (which is typi-
cally elevated when serum vitamin D concentrations fall
less than 2030 ngImLj1) (15,17) in bone health and the
probable link between bone density and bone fracture.
The finding that 25(OH)D concentrations in the spring
were significantly associated with frequency of illness, on
APPLIED SCIENCES
the other hand, is consistent with research, indicating that
vitamin D up-regulates naturally occurringand broad
spectrumAMP (6,12). AMPs exert a powerful immune
response by compromising the integrity of the cell membrane
of invading pathogens (10). These results are in agreement
with Aloia and Li-Ng (1), who found that supplementation
with vitamin D3 for 3 yr reduced self-reported incidence of
influenza and the common cold and in support of other evi-
dence that influenza epidemics and other wintertime infec-
tions may be brought on by seasonal deficiencies of AMP
secondary to seasonal deficiencies in vitamin D (7). Although
Medicine & Science in Sports & Exercised 341
 illness in the current study was documented as part of routine
medical care by a staff member who was unaware of the
athletes study participation or vitamin D status, further
evaluation in larger athletic populations is of interest. Future
studies should document the time course of illness in relation
to vitamin D status as well as the duration and the frequency
of illness.
In conclusion, the current study demonstrates that healthy
athletes can achieve adequate to optimal 25(OH)D concen-
trations in the nonwinter months through routine sun expo-
sure, dietary sources, and supplements (which surpass the
newly revised RDA of 600 IU) (27). Athletes living at dis-
tances away from the equator, however, need supplemental
vitamin D during the winter to prevent the seasonal reduc-
tion in serum 25(OH)D concentrations. Maintaining sufficient
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Funding support: None.
The authors thank the athletes who volunteered to participate
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Department of Family and Consumer Sciences.
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Medicine & Science in Sports & Exercised 343