Vitamin D status in female military personnel during combat training
© Andersen et al; licensee BioMed Central Ltd. 2010
Received: 8 September 2010
Accepted: 14 December 2010
Published: 14 December 2010
Vitamin D is an essential nutrient for maintaining bone health. Recent data suggest that vitamin D and calcium supplementation might affect stress fracture incidence in military personnel. Although stress fracture is a health risk for military personnel during training, no study has investigated changes in vitamin D status in Soldiers during United States (US) Army basic combat training (BCT). This longitudinal study aimed to determine the effects of BCT on 25-hydroxyvitamin D (25(OH)D) and parathyroid hormone (PTH) levels in female Soldiers. Serum 25(OH)D and PTH were assessed in 74 fasted Soldier volunteers before and after an 8-week BCT course conducted between August and October in Columbia, South Carolina. In the total study population, 25(OH)D levels decreased (mean ± SD) from 72.9 ± 30.0 to 63.3 ± 19.8 nmol/L (P < 0.05) and PTH levels increased from 36.2 ± 15.8 to 47.5 ± 21.2 pg/mL (P < 0.05) during BCT. Ethnicity affected changes in vitamin D status (ethnicity-by-time interaction, P < 0.05); 25(OH)D decreased (P < 0.05) in both Hispanic and non-Hispanic whites, but did not change in non-Hispanic blacks. Ethnicity did not affect BCT-induced changes in PTH. These data indicate that vitamin D status in female Soldiers may decline during military training in the late summer and early autumn months in the Southeastern US. Future studies should strive to determine the impact of military clothing and seasonality on vitamin D status, as well as the functional impact of declining vitamin D status on bone health.
Vitamin D is an essential nutrient for maintaining bone health. Sufficient levels of vitamin D, assessed by measuring 25-hydroxyvitamin D (25(OH)D) concentrations, can be defined as the 25(OH)D concentration that either prevents an increase in parathyroid hormone (PTH), a serum calcium regulator suppressed by 25(OH)D, or optimizes calcium absorption . Vitamin D sufficiency may prevent fractures in adults, while insufficiency may result in poor bone mineralization, pain, and rickets in children . According to data collected in the third National Health and Nutrition Examination Survey (NHANES III), women aged 14-30 years in the United States (US) consume less vitamin D from dietary and supplemental sources than other age groups . Suboptimal vitamin D intake and diminished vitamin D status may be particularly important during periods of intense physical activity such as military training, as compromised bone health could contribute to the development of stress fractures. Decrements in nutritional status during US Army basic combat training (BCT) have been documented in female Soldiers . As over 300,000 women serve in the US military, understanding the specific nutritional needs of this population during physical training is critical.
Poor vitamin D status has been associated with an increased incidence of stress fracture in Soldiers . Stress fractures are one of the most debilitating injuries in military recruits, and occur most often in military personnel beginning exercise regimens that include unaccustomed and physically-demanding activities. During military training regimens such as BCT, up to 21% of female recruits are diagnosed with at least one stress fracture . The impact of stress fractures on military readiness is notable; the attrition rate of female Soldiers with diagnosed stress fractures may be up to 60% [6, 7].
Exploring the effects of BCT on vitamin D status in female Soldiers may contribute to the development of improved guidance regarding sunlight exposure and dietary vitamin D intake for stress fracture prevention. The objective of this pilot study was to investigate the effects of military training on vitamin D status and PTH, an indirect vitamin D status indicator, in female military personnel . Previous studies indicate differences in both stress fracture prevalence and vitamin D status between ethnicities [6, 9]. Therefore, a secondary objective was to examine the relationship between vitamin D and PTH levels and ethnicity.
21 ± 4
162 ± 6
62 ± 9
62 ± 7
Basic combat training consists of both physical and military-specific training. The course is divided into three phases. The first phase consists of physical training and learning Army values and policies. The second phase involves weapons training and various assault courses. The final phase involves field exercises and the evaluation of skills taught during the first two phases. Physical training activities during BCT include road marching, distance running, and sprinting. Soldiers also participate in muscle strength training activities, including calisthenics, sit-ups, and push-ups. Military activities include obstacle courses, didactic classroom instruction, and standing in formation . Comprehensive measures of the ambulatory activity experienced during BCT have been reported elsewhere . During physical training activities, which typically occur in the early morning (0500-0700) hours, Soldiers are required to wear uniforms consisting of shorts and short-sleeved shirts. At all other times Soldiers are generally required to wear the Army Combat Uniform (ACU), which consists of boots, long pants, long-sleeved shirts, and caps. While wearing the ACU, only the hands and face are exposed to sunlight. Although the use of sun protection is recommended during BCT, data regarding the use of such products was not collected during this study.
Blood was collected from fasted Soldiers by antecubital venipuncture, processed on site, frozen, and shipped to USARIEM or the Pennington Biomedical Research Center (Baton Rouge, LA) for further analysis. Serum 25(OH)D (Immunodiagnostic Systems, Fountain Hills, AZ) and PTH (Siemens 2000, Los Angeles, CA) levels were determined using commercially available immunoassays. Self-reported ethnic characteristics were used to separate subjects into 3 groups (non-Hispanic white, n = 39; non-Hispanic black, n = 24; Hispanic white, n = 11) for statistical analysis.
Statistical analysis was performed using the Statistical Package for the Social Sciences v. 15.0 (SPSS Inc., Chicago, IL). A two-factor ANOVA with repeated measures was used to test for main effects of both ethnicity and time, as well as ethnicity-by-time interactions in 25(OH)D and PTH. When a significant ethnicity-by-time interaction was observed, post hoc analyses with Bonferroni adjustments were conducted to identify within- and between-group differences. Significance was set at P ≤ 0.05 for all tests.
Vitamin D is a critical nutrient for active populations, as it contributes to effective bone remodeling and calcium homeostasis. The major finding of this pilot study is that vitamin D status in female Soldiers declines during military training in the summer and early autumn months in the Southeastern US. This finding was unanticipated, as we expected the vitamin D status of female Soldiers to remain static or increase due to sunlight exposure during BCT, as much of the training occurs outdoors during daylight hours. Although further research is required to elucidate the mechanism, we hypothesize that the type of clothing worn during BCT, coupled with potentially inadequate dietary vitamin D intake may contribute to the observed decline in vitamin D status. Recent studies have utilized 25(OH)D values of ≤75 nmol/L as an indicator of suboptimal vitamin D status [8, 13, 14]. If this cutoff is applied to the data gleaned from the present study, 57% of subjects entered BCT with 25(OH)D levels <75 nmol/L, and 75% completed BCT below the cutoff value, indicating that the majority of Soldiers demonstrated suboptimal vitamin D status during BCT.
Our findings demonstrate ethnic differences in vitamin D status. Similar to previous reports, 25(OH)D levels were lowest in non-Hispanic blacks and tended to be highest in non-Hispanic whites [15–17]. Furthermore, vitamin D status declined significantly in non-Hispanic and Hispanic whites, but not in non-Hispanic blacks. We observed an increase in PTH levels within the total study population; however, PTH levels did not differ between ethnic groups. Although some studies have demonstrated higher PTH levels in blacks, this relationship appears to be inconsistent [15, 17]. It is possible that physical activity associated with BCT had an interactive effect on vitamin D and PTH levels, as others have described complex relationships between physical activity, vitamin D status, PTH levels, and bone health [18, 19].
To the best of our knowledge, this preliminary study is the first to describe a decline in vitamin D status in female military personnel during US Army training. Limitations of our study include a lack of data regarding the use of sun protection and the collection of data during only one cycle of BCT which occurred during the late summer and early autumn months. Future studies should aim to investigate the health and functional consequences of this decline, especially in relation to effects on bone strength and stress fracture incidence and its mechanism, as declines in vitamin D status may negatively influence calcium absorption and compromise bone health. For this reason, vitamin D and calcium supplementation may prove efficacious for preventing stress fracture during military training or other physical training regimes . Dietary intake assessment may help to illustrate the nutritional factors contributing to changes in vitamin D status during training and differences between ethnic groups, and may also provide support for recommending nutrition education or intervention during BCT. Furthermore, future studies should assess the effects of military uniforms coupled with the seasonal nature of changes in vitamin D status during military training.
This work was supported by the US Army Medical Research and Materiel Command. The authors wish to acknowledge the Soldier volunteers that participated in this study as well as the command staff at Fort Jackson, SC, for allowing access to Soldiers. Portions of this manuscript were presented in abstract form at Experimental Biology 2010, Anaheim, CA, April 24-28. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Army or the Department of Defense. Any citations of commercial organizations and trade names in this report do not constitute an official Department of the Army endorsement of approval of the products or services of these organizations.
- Aloia JF, Chen DG, Yeh JK, Chen H: Serum vitamin D metabolites and intestinal calcium absorption efficiency in women. Am J Clin Nutr. 2010, 92: 835-40. 10.3945/ajcn.2010.29553.PubMed CentralView ArticlePubMedGoogle Scholar
- Moore CE, Murphy MM, Holick MF: Vitamin D intakes by children and adults in the United States differ among ethnic groups. J Nutr. 2005, 135: 2478-2485.PubMedGoogle Scholar
- Moore C, Murphy MM, Keast DR, Holick MF: Vitamin D intake in the United States. J Am Diet Assoc. 2004, 104: 980-983. 10.1016/j.jada.2004.03.028.View ArticlePubMedGoogle Scholar
- McClung JP, Karl JP, Cable SJ, Williams KW, Young AJ, Lieberman HR: Longitudinal decrements in iron status during military training in female soldiers. Br J Nutr. 2009, 102: 605-609. 10.1017/S0007114509220873.View ArticlePubMedGoogle Scholar
- Ruohola JP, Laaksi I, Ylikomi T, Haataja R, Mattila VM, Sahi T, Tuohimaa P, Pihlajamaki H: Association between serum 25(OH)D concentrations and bone stress fractures in Finnish young men. J Bone Miner Res. 2006, 21: 1483-1488. 10.1359/jbmr.060607.View ArticlePubMedGoogle Scholar
- Jones BH, Thacker SB, Gilchrist J, Kimsey CD, Sosin DM: Prevention of lower extremity stress fractures in athletes and soldiers: a systematic review. Epidemiol Rev. 2002, 24: 228-247. 10.1093/epirev/mxf011.View ArticlePubMedGoogle Scholar
- Friedl KE, Evans RK, Moran DS: Stress fracture and military medical readiness: bridging basic and applied research. Med Sci Sports Exerc. 2008, 40 (Suppl 11): S609-S622.View ArticlePubMedGoogle Scholar
- Vieth R, Cole DE, Hawker GA: Wintertime vitamin D insufficiency is common in young Canadian women, and their vitamin D intake does not prevent it. Eur J Clin Nutr. 2001, 55: 1091-1097. 10.1038/sj.ejcn.1601275.View ArticlePubMedGoogle Scholar
- Harris SS: Vitamin D and African Americans. J Nutr. 2006, 136: 1126-1129.PubMedGoogle Scholar
- Karl JP, Lieberman HR, Cable SJ, Williams KW, Glickman EL, Young AJ, McClung JP: Poor iron status is not associated with overweight or overfat in non-obese pre-menopausal women. J Am Coll Nutr. 2009, 28: 37-42.View ArticlePubMedGoogle Scholar
- McClung JP, Karl JP, Cable SJ, Williams KW, Nindl BC, Young AJ, Lieberman HR: Randomized, double-blind, placebo-controlled trial of iron supplementation in female soldiers during military training: effects on iron status, physical performance, and mood. Am J Clin Nutr. 2009, 90: 1-8. 10.3945/ajcn.2009.27774.View ArticleGoogle Scholar
- Knapik JJ, Darakjy S, Hauret KG, Canada S, Marin R, Jones BH: Ambulatory physical activity during United States Army Basic Combat Training. Int J Sports Med. 2007, 28: 106-115. 10.1055/s-2006-924147.View ArticlePubMedGoogle Scholar
- Vieth R, Bischoff-Ferrari , Boucher BJ, Dawson-Hughes B, Garland CF, Heaney RP, Holick MF, Hollis BW, Lamberg-Allardt C, McGrath JJ, Norman AW, Scragg R, Whiting SJ, Willett WC, Zittermann A: The urgent need to recommend an intake of vitamin D that is effective. Am J Clin Nutr. 2007, 85: 649-650.PubMedGoogle Scholar
- Dawson-Hughes B, Heaney RP, Holick MF, Lips P, Meunier PJ, Vieth R: Estimates of optimal vitamin D status. Osteoporos Int. 2005, 16: 713-716. 10.1007/s00198-005-1867-7.View ArticlePubMedGoogle Scholar
- Looker AC, Dawson-Hughes B, Calvo MS, Gunter EW, Sahyoun NR: Serum 25-hydroxyvitamin D status of adolescents and adults in two seasonal subpopulations from NHANES III. Bone. 2002, 30: 771-777. 10.1016/S8756-3282(02)00692-0.View ArticlePubMedGoogle Scholar
- Nesby-O'Dell S, Scanlon KS, Cogswell ME: Hypovitaminosis D prevalence and determinants among African American and white women of reproductive age: third National Health and Nutrition Examination Survey, 1988-1994. Am J Clin Nutr. 2002, 76: 187-192.PubMedGoogle Scholar
- Dawson-Hughes B: Racial/ethnic considerations in making recommendations for vitamin D for adult and elderly men and women. Am J Clin Nutr. 2004, 80 (Suppl 6): S1763-S1766.Google Scholar
- Constantini NW, Dubnov-Raz G, Chodik G, Rozen GS, Giladi A, Ish-Shalom S: Physical activity and bone mineral density in adolescents with vitamin D deficiency. Med Sci Sports Exerc. 2009,Google Scholar
- Foo LH, Zhang Q, Zhu K, Ma G, Trube A, Greenfield H, Fraser DR: Relationship between vitamin D status, body composition and physical exercise of adolescent girls in Beijing. Osteoporos Int. 2009, 20: 417-425. 10.1007/s00198-008-0667-2.View ArticlePubMedGoogle Scholar
- Lappe J, Cullen D, Haynatzki G, Recker R, Ahlf R, Thompson K: Calcium and vitamin D supplementation decreases incidence of stress fractures in female navy recruits. J Bone Miner Res. 2008, 23: 741-749. 10.1359/jbmr.080102.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (<url>http://creativecommons.org/licenses/by/2.0</url>), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.