Songklanakarin Journal of Science and Technology SJST R1 Manimmanakorn. Vitamin D deficiency in student athletes in Thailand

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R Manuscript Type: Original Article Date Submitted by the Author: 0-Feb-0 Complete List of Authors: Buakwa, Duangjai ; Khon Kaen University Faculty of Medicine, Rehabilitation Medicine

1 Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn Vitamin D deficiency in student athletes in Thailand Journal: Songklanakarin Journal of Science and Technology Manuscript ID SJST-0-0.R Manuscript Type: Original Article Date Submitted by the Author: 0-Feb-0 Complete List of Authors: Buakwa, Duangjai ; Khon Kaen University Faculty of Medicine, Rehabilitation Medicine Manimmanakorn, Nuttaset; Rehabilitation Medicine Department Vichiansiri, Ratana ; Khon Kaen University Faculty of Medicine, Rehabilitation Medicine Manimmanakorn, Apiwan; Khon Kaen University Faculty of Medicine, Physiology Hamlin, Michael; Lincoln University, Department of Tourism, Sport and Society Keyword: vitamin D, deficiency, insufficiency, athlete, associated factors

2 Page of Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn Original Article Vitamin D deficiency in student athletes in Thailand Duangjai Buakwa, Nuttaset Manimmanakorn *, Ratana Vichiansiri, Apiwan Manimmanakorn, Michael John Hamlin Department of Rehabilitation Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 000, Thailand Department of Physiology, Faculty of Medicine, Khon Kaen University,Khon Kaen, 000, Thailand Department of Tourism, Sport and Society, Lincoln University, Lincoln,, Christchurch, New Zealand *Corresponding author, address: natman@kku.ac.th

3 Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn Page of Abstract This study aimed to evaluate the prevalence of hypovitaminosis D and the possible risk factors in Thai athletes. This cross-sectional study was conducted in student athletes ( males, females) aged 0 ±. years (mean ± SD) at the Institute of Physical Education Udonthani Thailand. Vitamin D ((OH)D) deficiency (<0 ng/ml) or insufficiency (0-0 ng/ml) was determined using a standard blood test. The prevalence of hypovitaminosis D was.% (.% for vitamin D deficiency,.% for vitamin D insufficiency). Factors related to hypovitaminosis D included being a female (OR=., %CI:.0-.0, p=0.0), and sun exposure of 0 minutes or less per day (OR=., %CI:.-.0, p=0.0). However, types of sport, sunscreen application and consuming high vitamin D foods were not significantly related to hypovitaminosis D prevalence. The relatively high prevalence of hypovitaminosis D in student athletes suggests these sport athletes (particularly the females) should consider increasing their exposure to vitamin D producing mechanisms. Keywords: vitamin D, deficiency, insufficiency, athlete, associated factors

4 Page of Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn Introduction Vitamin D has an important role in multi-organ functions particularly on the musculoskeletal system where it influences bone growth and remodeling, helps regulate gene expression and protein synthesis in muscle, and assists immune function (Ogan & Pritchett, 0). The majority of vitamin D is synthesized in the skin through the effects of ultraviolet radiation (sunlight), on the pre-cursor substance (-dehydrocholesterol), while the remaining vitamin D is sourced through the diet (Holick, 00; Nair & Maseeh, 0). The active form of vitamin D (,-dihydroxyvitamin D or (OH)D) which has had hydroxyl groups added first in the liver and then in the kidney, acts more like a hormone than a vitamin. Hypovitaminosis D (low vitamin D levels) is commonly found in different populations such as children, postmenopausal women, and elderly (Chailurkit, Kruavit, & Rajatanavin, 0; Gaugris et al., 00; Huh & Gordon, 00). Hypovitaminosis D also frequently occurs in athletes and has a number of detrimental effects including bone loss and increased risk of stress fractures, decreased muscle size, muscle mass and subsequent sport performance, and lowering immunity thereby increasing the risk of infection during the sport season (Ogan & Pritchett, 0). Hypovitaminosis D is related to lifestyle factors such as a lack of sun exposure, overuse of sunscreen lotion or too much sun protection (Constantini, Arieli, Chodick, & Dubnov-Raz, 00; Holick & Chen, 00; Lehtonen-Veromaa et al., ). In addition, a lack of dietary vitamin D intake, abnormal vitamin D absorption, diminished vitamin D synthesis in liver and kidney and some medications can reduce the vitamin D levels (Holick & Chen, 00). The prevalence of hypovitaminosis D in athletes has been observed in a number of countries including USA ( %), Australia (%), Spain and France %), UK and Ireland (0%) and the Middle East (%) (Farrokhyar et al., 0). In Thailand, the prevalence of

5 Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn Page of hypovitaminosis D has been reported in the general population at.%(chailurkit, Aekplakorn, & Ongphiphadhanakul, 0), and various sub-groups including elderly women ( - %) (Chailurkit et al., 0; Kruavit, Chailurkit, Thakkinstian, Sriphrapradang, & Rajatanavin, 0) and spinal cord patients (%) (Khammeree, Vichiansiri, Sawanyawisuth, & Manimmanakorn, 0). However, the prevalence of hypovitaminosis D in athletes has not been reported. Such information is important as vitamin D has a vital role to play in the potential performance and health of such athletes. Therefore, this study aimed to evaluate the prevalence of, and lifestyle factors related to, hypovitaminosis D in Thai athletes.. Materials and Methods. Study design and participants This cross-sectional descriptive study was conducted on student athletes from the Tertiary Institute of Physical Education, Udonthani. These athletes were years of age and completed exercise training for at least hours per day, times per week for year or more. Athletes with chronic disease such as renal failure, chronic kidney failure, chronic lung disease, gastrointestinal disease, uncontrolled psychiatric disease and neurological disease, and those who had bone cancer, were pregnant or taking medication including parathyroid hormone, estrogen, progesterone, steroids, thyroid hormone and vitamin D were excluded. This study was carried out in accordance with the recommendations of the Khon Kaen University Human Research Ethics guidelines. All participants gave their written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Human Research Ethics Committee, Khon Kaen University (HE ).

6 Page of Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn The data collection was conducted in March 0 at Udonthani province in the north east of Thailand. The athletes were interviewed and the researchers recorded details about their demographic data and hypovitaminosis D lifestyle-related factors including characteristics of sun exposure, food consumption, musculo-skeletal injury and upper respiratory tract infection (over last months). Athletes were asked to rate their consumption habits of vitamin D containing foods as follows; always consume food (e.g. - times/week), frequently consume food (- times/week), rarely consume food (less than time/week), and never consume food (no consumption). On the same day participant s anthropometric data such as age, height and weight were recorded. Age was calculated from the date of birth to the date of the recording. Height without shoes was measured to the nearest 0. cm by a wallmounted stadiometer. Weight, without shoes and with minimal clothing, was measured (to the nearest 0. kg) on an electronic scale. A -ml blood sample was taken from the brachial vein at the cubital fossa by certified nurses around 0.00 hours after an overnight fast. Participants were rested (seated) for at least 0 minutes prior to the blood being drawn. The sampled blood was deposited in a clotting blood gel tube Greiner Bio-one GmbH, Kremsmünster, Austria), and stored at - O c until it was sent to Srinagarind Hospital, Khon Kaen University Blood Laboratory within hours of being drawn. The measurement of (OH)D concentration in the serum was analyzed via an electro-chemiluminescense immunoassay kit (ECLIA, Roche Diagnostics International Ltd, Switzerland) using a Cobas 000 analyzer (Roche Diagnostics Corp., Indianapolis, IN, USA). The sum of serum (OH)D and (OH)D was used to determine total serum (OH)D. The inter-assay and intra-assay coefficients of variation of total serum (OH)D were.% and.% respectively.

7 Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn Page of This study defined the severity of hypovitaminosis D according to level of serum (OH)D into groups: vitamin D deficiency (serum (OH)D level < 0 ng/ml) and vitamin D insufficiency (serum (OH)D level 0-0 ng/ml) (Holick, 00).. Statistical analysis The prevalence of hypovitaminosis D and associated factors were calculated and analyzed by using STATA V.0 program. The data was presented as number, percentage, mean and standard deviation. To analyze the relationship between vitamin D and the associated factors, a univariate analysis was completed using a Chi-Square test, and a multivariate analysis was performed by multiple logistical regression. The degree of association between vitamin D and the associated factors is shown as an odds ratio (±% confidence interval) with the p value also given.. Results. Demographic data This study included participants, males (.0%) and females (.0%), with a mean BMI of.0±. kg/m, an average age of 0±. years (mean±sd), and all of them had reasonably dark skin. No one used vitamin D supplement or multivitamin. Most of participants normally trained outdoors (.%), were exposed to the sun more than times per week (.%), for more than 0 minutes per day (.%). More than half (.%) of the participants normally applied sunscreen lotion when training outdoors (.% applied it to the face and.%to the face and body). Approximately.% of the total population surveyed suffered a musculo-skeletal injury over the months prior to the survey, and most

8 Page of Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn of the injuries were related to muscle strains or tears (.%). About.% of the total participants had upper respiratory tract infections over the last months (Table ). The majority of participants frequently (i.e. - times per week) consumed eggs, cow milk or soybean milk, rarely (i.e. < time per week) consumed salmon, canned fish, liver, meat, mushroom, yogurt or fresh fish, and never consumed cod-liver oil. (Table ) Table around here Table around here. Vitamin D level The mean of serum (OH)D level of young athletes was. ±. ng/ml. The histogram of vitamin D levels is presented in Figure. The prevalence of hypovitaminosis D was.% (.% for vitamin D deficiency ((OH)D< 0 ng/ml) and.% for vitamin D insufficiency ((OH)D 0-0 ng/ml)). Figure around here. Hypovitaminosis D related factors Univariate analysis of dietary consumption and lifestyle factors associated with hypovitaminosis D are presented in Table and. The significant factors were being female

9 Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn Page 0 of and having only 0 minutes or less of sun exposure per day, while the consumption of high vitamin D foods such as cod-liver oil, salmon, canned fish, liver, meat, eggs, mushrooms, cow milk, soybean milk, yogurt and fresh fish were not related to hypovitaminosis D. The multiple logistic regression analysis showed that females were. times more likely to suffer hypovitaminosis D compared to males (%CI:.0-., p = 0.0) and athletes that only accumulated 0 minutes or less of sun exposure per day were. (%CI:.0.0, p = 0.0) times more likely to suffer hypovitaminosis D than those athletes that accumulated over 0 minutes of sun exposure per day. Table around here Table around here. Discussion The average vitamin D level of participants was.±. ng/ml, and the prevalence of vitamin D deficiency in student athletes at the Institute of Physical Education Udonthani was.% while vitamin D insufficiency was.% resulting in an overall prevalence of hypovitaminosis D in Thai athletes of.% which is higher than athletes in the USA, Spain and France, but lower than athletes in the UK, Ireland or Middle East (Farrokhyar et al., 0). The difference in the prevalence of hypovitaminosis D in various countries depends on a number of factors including ethnicity, climate, landscape, season and diet (Mithal et al., 00).

10 Page of Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn The prevalence of hypovitaminosis D in the Thai athletes in this study was similar to the Thai general population (.%). However, this study was conducted in the Northeast part of Thailand which has a prevalence of hypovitaminosis D much lower than the general Thailand population at. ±. ng/ml (Chailurkit, Aekplakorn, & Ongphiphadhanakul, 0). Since our athletes have a significantly higher levels of hypovitaminosis D than the general population of the area (Northeast) we would suggest these athletes consider ways to increase their vitamin D sources. This study found the factors that are associated with vitamin D level were sex and sun exposure time. The athletes who were female were. times more likely to have hypovitaminosis D than male athletes, which corresponds to national data indicating overall that females are more likely than males to suffer hypovitaminosis D (Chailurkit, Aekplakorn, & Ongphiphadhanakul, 0; Hashemipour et al., 00). Thai females are likely to wear more clothing and avoid expose to the sunlight than males. In addition, less sun exposure time increased the risk of hypovitaminosis D. times (%CI,.0-.0). Holick (00) suggested sunlight exposure to the arms and legs or the hands, arms, and face, for -0 minutes, or times per week combined with sufficient vitamin D intake would be adequate to prevent vitamin D deficiency (Holick, 00). However, Nair and Maseeh (0) stated people with dark skin need at least three to five times longer sun exposure than people with pale skin.(nair & Maseeh, 0). This study conducted in Thai athletes (who have moderate to dark brown skin), suggests students should receive at least 0 minutes of sunlight exposure per day. Other factors that we measured such as the frequency of sun exposure ( times per week), being involved in indoor or outdoor sport and the use of sun screen did not have large effects on Thai athletes hypovitaminosis D prevalence in this setting. Consuming food rich in vitamin D also was not significantly associated with prevalence to hypovitaminosis D.

11 Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn Page of Additionally, we did not find any increased incidence of musculoskeletal injury or respiratory tract infections in the hypovitaminosis D group compared to the normal vitamin D group. However this study was conducted in the summer when there is little athletic competition. Further research needs to investigate whether the lack of vitamin D during heavy competition phases of the season may result in increased prevalence of musculoskeletal injury or respiratory tract infection. The limitations of this study were that the participants were student athletes who were not representatives of all Thai athletes, and the fact that the study was conducted in summer when the athletes were in their non-competitive training phase. Additionally, the number of participants may be too small to detect all related factors.. Conclusions This study showed that the prevalence of hypovitaminosis D in student athletes in the Institute of Physical Education Udonthani was. % (.% for vitamin D deficiency and.% for vitamin D insufficiency). Factors that positively related to hypovitaminosis D prevalence were being female having 0 minutes or less of sun exposure per day. Acknowledgements Special thanks to all student athletes of the Institute of Physical Education Udonthani for participation in this research and Dr. Kaewjai Thepsuthamrat from Clinical Epidemiology Unit, Faculty of Medicine, Khon Kaen University for statistical analysis. This study was granted by Faculty of Medicine, Khon Kaen University, Thailand (Grant Number IN).

12 Page of Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn References Chailurkit, L., Aekplakorn, W., & Ongphiphadhanakul, B. (0). Regional variation and determinants of vitamin D status in sunshine-abundant Thailand. BMC Public Health,,. Chailurkit, L., Kruavit, A., & Rajatanavin, R. (0). Vitamin D status and bone health in healthy Thai elderly women. Nutrition (Burbank, Los Angeles County, Calif.), (), 0. Constantini, N. W., Arieli, R., Chodick, G., & Dubnov-Raz, G. (00). High prevalence of vitamin D insufficiency in athletes and dancers. Clinical Journal of Sport Medicine: Official Journal of the Canadian Academy of Sport Medicine, 0(),. Farrokhyar, F., Tabasinejad, R., Dao, D., Peterson, D., Ayeni, O. R., Hadioonzadeh, R., & Bhandari, M. (0). Prevalence of vitamin D inadequacy in athletes: a systematicreview and meta-analysis. Sports Medicine (Auckland, N.Z.), (),. Gaugris, S., Heaney, R. P., Boonen, S., Kurth, H., Bentkover, J. D., & Sen, S. S. (00). Vitamin D inadequacy among post-menopausal women: a systematic review. QJM: Monthly Journal of the Association of Physicians, (),. Hashemipour, S., Larijani, B., Adibi, H., Javadi, E., Sedaghat, M., Pajouhi, M., Booya, F. (00). Vitamin D deficiency and causative factors in the population of Tehran. BMC Public Health,,. Holick, M. F. (00). Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease. The American Journal of Clinical Nutrition, 0( Suppl), S S. Holick, M. F. (00). Vitamin D deficiency. The New England Journal of Medicine, (),.

13 Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn Page of Holick, M. F., & Chen, T. C. (00). Vitamin D deficiency: a worldwide problem with health consequences. The American Journal of Clinical Nutrition, (), 00S S. Huh, S. Y., & Gordon, C. M. (00). Vitamin D deficiency in children and adolescents: epidemiology, impact and treatment. Reviews in Endocrine & Metabolic Disorders, (), 0. Khammeree, T., Vichiansiri, R., Sawanyawisuth, K., & Manimmanakorn, N. (0). Vitamin D abnormalities in Thai patients with spinal cord injuries. Asian Biomedicine, 0, 0. Kruavit, A., Chailurkit, L., Thakkinstian, A., Sriphrapradang, C., & Rajatanavin, R. (0). Prevalence of vitamin D insufficiency and low bone mineral density in elderly Thai nursing home residents. BMC Geriatrics,,. Lehtonen-Veromaa, M., Möttönen, T., Irjala, K., Kärkkäinen, M., Lamberg-Allardt, C., Hakola, P., & Viikari, J. (). Vitamin D intake is low and hypovitaminosis D common in healthy - to -year-old Finnish girls. European Journal of Clinical Nutrition, (),. Mithal, A., Wahl, D. A., Bonjour, J.-P., Burckhardt, P., Dawson-Hughes, B., Eisman, J. A., IOF Committee of Scientific Advisors (CSA) Nutrition Working Group. (00). Global vitamin D status and determinants of hypovitaminosis D. Osteoporosis International: A Journal Established as Result of Cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 0(), 0 0. Nair, R., & Maseeh, A. (0). Vitamin D: The sunshine vitamin. Journal of Pharmacology & Pharmacotherapeutics, (),. Ogan, D., & Pritchett, K. (0). Vitamin D and the Athlete: Risks, Recommendations, and Benefits. Nutrients, (),.

14 Page of Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn Table. Characteristics and lifestyle-related factors (last months) of study participants. Participant characteristics and lifestyle factors Mean ± SD / number (percentage) Age (year) 0. ±. Weight (kg). ±. Height (cm). ±. BMI (kg,m - ).0 ±. Male Female Only train indoors Only train outdoors Train both indoors and outdoors Weekly sun exposure < times per week times per week Sun exposure time per day > 0 minutes 0 minutes Regularly use sunscreen No sunscreen Area sunscreen applied Face Face and body SPF of sunscreen used > unknown Recent musculo-skeletal injury Yes No Type of musculo-skeletal injury Fracture Muscle or tendon tear Muscle strain or tendinitis Body area of musculoskeletal injury Upper extremities Lower extremities Trunk (included back) Recent URI Yes No (.0%) (.0%) 0(.%) (.%) (.%) (.%) (.%) (.%) (.%) (.%) (.%) (.%) 0(.%) (.%) (.%) (.%) (.%) (.%) (.%) (.%) (.%) 0(.%) (.%) (0.%) (.%) (.%) (.%) Data is (mean ± SD or number (percentage)), SPF: sun protective factor, URI: upper respiratory tract infection

15 Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn Page of Table. Dietary consumption habits (last months) of study participants. Vitamin D containing food Cod-liver oil ml Always Frequently Rarely Never Canned fish Always Frequently Rarely Never Liver/Meat Always Frequently Rarely Never Eggs Always Frequently Rarely Never Mushrooms Always Frequently Rarely Dry sprats Always Frequently Rarely number (percentage) 0 (.%) (.%) 0 (.%) (.%) 0 (0.%) (.%) (.%) (.%) 0 (.%) (.%) (.%) (.%) (.%) (.%) 0 (.%) (.%) (.%) (.%) (.%) (.%) Data is number (percentage). Always, - times/week, Frequently, - times/week, Rarely, less than time/week, Never, no consumption over the last months.

16 Page of Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn Table. Relationship between dietary consumption factors (last months) and plasma Vitamin D levels Hypovitaminosis D Normal Vitamin D OR (%CI) p value Cod-liver oil ml 0. Never (.%) (.%) Rarely 0(.%) (.%).(0.-.) Frequently (.%) 0(0.0%) Canned fish 0. Never (.%) (.%) Rarely (.%) (.%) 0.(0.-.) Frequently (.%) (.%) 0.(0.-.) Always (.%) (.%) 0.(0.-.) Liver/Meat 0. Never (.%) (.%) Rarely (.%) (.%).(0.-.) Frequently (.%) (0.0%).(0.-.) Always 0(0.0%) (.%) Egg 0. Rarely (.%) 0(.%) Frequently (.%) (.%).(0.-.) Always (.0%) (0.0%).(0.-.) Mushrooms 0. Rarely (.%) (.%) Frequency 0(.%) (.%) 0.(0.-.) Always (.%) (.%).(0.-.0) Dry sprats 0. Rarely (.%) (.%) Frequency (.%) (0.0%).(0.-.) Always (.%) (.%) 0.(0.-.) Data is number (percentage). Always, - times/week, Frequently, - times/week, Rarely, less than time/week, Never, no consumption over the last months.

17 Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn Page of Table. Relationship between lifestyle factors (last months) and plasma Vitamin D levels Hypovitaminosis D Normal Vitamin D OR (%CI) Gender Male Female Training Only train indoors Only train outdoors Train both indoors and outdoors Weekly sun exposure times per week < times per week Sun exposure time per day > 0 minutes 0 minutes Sunscreen Regularly use sunscreen No sunscreen lotion Area sunscreen applied Face Face and body SPF of sunscreen used > Unknown Recent musculo-skeletal injury Yes No (.%) (.%) (.%) 0(.%) (.%) (.%) (.%) 0(.%) (.%) (.%) (.%). (.0-.) (.%) (.%) (.%) (.%) (.%) (.%) (.%) (.%) (.%) 0(.%) 0(.%) 0(.%) (.%) 0. (0.-.) (0.-.) (.%) (.%) 0. (0.-.) (.%) (.%). (.-.0) (.%) (.%) 0. (0.-.) (.%) (.%). (0.-.) (.%) (.%) (.%) (.%) (0.-.) (0.-.). (0.-.) (.%) (.%) 0.(0.-.) p -value Recent URI 0. Yes No (.%) 0(.%) (0.0%) (0.0%) 0. (0.-.) Data is number (percentage), SPF: sun protective factor, URI: upper respiratory tract infection *significant at p < * *

18 Page of Songklanakarin Journal of Science and Technology SJST-0-0.R Manimmanakorn x0mm ( x DPI)

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