Vitamin D and the athlete–patient: state of the art

Vitamin D deficiency is common in athletes. The conventional measurement of vitamin levels provides a general indicator body stores. However, there are nuances its interpretation as values 25(OH)D do not correlate absolutely with the amount ‘bioavailable’ to cells. should be regarded hormone and influences between 5% 10% our total genome. Determining precise effect vitamin, isolated from actions other cofactors, straightforward restricts complete understanding all actions. Deficiency has harmful effects on only bone muscle but also wider areas, including immunity respiratory neurological activities. More caution applied regarding ability supranormal elevate athletic performance. Hopefully, future research will shed more light optimal supplementation regimes, improved intracellular control genetic mechanisms how extrinsic modify activity. Much attention been paid global problem hypovitaminosis D. Over one billion people estimated deficient. In sports science medicine orthopaedic surgery, athletes during training performance, regard avoidance injury recovery treatments, investigated. This review look at sources D, supplementation. It investigate implications for sporting evidence causing injury, whether advantages supplementation, potential surgery. Most undertaken young, fit healthy. Many publications small cohort studies lacking highest scientific vigour. They indicate associations rather than causation. background many injuries illnesses multifactorial. Hypovitaminosis may contributors. Finally, must consider what meant by term ‘athlete’. Different vary their cardiovascular, respiratory, musculoskeletal requirements. elite athlete frequently displays extraordinary anatomy, physiology advantages. ‘weekend warrior’ comes wide age band less imposing intrinsic credentials. risk. have investigated high numbers found Dark skin tones, participation indoor living higher latitudes prominent risk factors. There no large population directly comparing sedentary groups same society. prevalence preoperative patients mirrors population. Risk factors include trauma, sports-related excessive sunscreen use, male gender surgery winter months.1Bogunovic L Kim AD Beamer BS et al.Hypovitaminosis scheduled undergo surgery: single-center analysis.J Bone Joint Surg Am. 2010; 92: 2300-230410.2106/JBJS.I.01231http://www.ncbi.nlm.nih.gov/pubmed/20926724Crossref PubMed Scopus (121) Google Scholar, 2Aujla RS Allen PE Ribbans WJ 577 consecutive elective foot & ankle patients.Foot Ankle Surgery. 2019; 25: 310-31510.1016/j.fas.2017.12.007Crossref (0) Scholar These trends confirmed shoulder3Inkrott BP Koberling JL Noel CR undergoing shoulder arthroplasty: analysis.Orthopedics. 2016; 39: e651-e65610.3928/01477447-20160606-04Crossref (10) surgical patients.2Aujla 4Michelson JD Charlson MD status an orthopedic population.Foot Int. 37: 186-19110.1177/1071100715609054Crossref 5DeFontes K Smith JT Surgical considerations surgery.Orthop Clin North 50: 259-26710.1016/j.ocl.2018.10.008http://www.ncbi.nlm.nih.gov/pubmed/30850083Abstract Full Text PDF (3) processes conversion cutaneous dietary precursors active metabolite subsequent activity shown figure 1. 25(OH)D, or calcidiol, inactive form half-life 21–30 days. A request estimation normally results this metabolite. represents As fat-soluble it stored adipose tissue. Fluctuations both intake seasonal changes that affect synthesis. undergoes second hydroxylation produce metabolite, 1,25(OH)D, calcitriol. enzyme responsible 1 α-hydroxylase (CYP27B1). CYP27B1 tissues. Its serum 4 15 hours. 1,25(OH)D laboratory usually involved expensive. 24,25(OH)D, formed kidneys. Figure 2 shows carried circulation. ‘free hypothesis’ theorises unbound can enter cells exert influence, some tissues admit bound binding protein (VDBP). activities VDBP influence bioavailability alter balance free fractions. such circumstances, 25(OH)D3 misleading. ‘Free’ measurements routinely available clinical practice. black Hispanic men, normal populations reported incidences D.1Bogunovic 6Maroon JC Mathyssek CM Bost JW al.Vitamin profile national football League players.Am J Sports Med. 2015; 43: 1241-124510.1177/0363546514567297Crossref (49) lower osteoporosis fractures. close relationship mineral density (BMD) clearer lighter darker tones.7Gutiérrez OM Farwell WR Kermah al.Racial differences density, parathyroid National health nutrition examination survey.Osteoporos 2011; 22: 1745-175310.1007/s00198-010-1383-2http://www.ncbi.nlm.nih.gov/pubmed/20848081Crossref (194) subjects function reduced related variations affecting vitamin.8Powe CE Ricciardi C Berg AH D-binding modifies D-bone relationship.J Miner Res. 26: 1609-161610.1002/jbmr.387Crossref (260) VDRs most organs, skin, placenta, bone, prostate, lung, breast, colon, pancreatic β cells, monocytes, lymphocytes, glands granuloma tissue.9Dusso AS Brown AJ Slatopolsky E D.Am Physiol Renal Physiol. 2005; 289: F8-2810.1152/ajprenal.00336.2004Crossref (995) 1,25(OH)D3 up 5%–10% genome.10Morris HA Anderson PH Autocrine paracrine D.Clin Biochem Rev. 31: 129-137http://www.ncbi.nlm.nih.gov/pubmed/21170259PubMed 3 outlines role VDR expression declines play part natural decline performance.11Bischoff-Ferrari Dawson-Hughes B Willett WC al.Effect falls: meta-analysis.JAMA. 2004; 291: 1999-200610.1001/jama.291.16.1999http://www.ncbi.nlm.nih.gov/pubmed/15113819Crossref (1124) major circulating form, measured nmol/L (or ng/mL). biologically present much smaller amounts pmol/L pg/mL). two precise. Conventional wisdom suggests fall <20 cause significant reduction 1,25(OH)D. Even below 40 nmol/L, (PTH) rise stimulates production. preserves intestinal calcium absorption.10Morris An Italian study 17% had levels<25 - indicating severe deficiency. 3% were severely deficient levels<18 pg/mL. low moderate deficiencies necessarily associated homeostasis disorders elevated PTH levels.12Cirillo M Bilancio G Guarino indices population: 25-hydroxyvitamin 1,25-dihydroxyvitamin D.Nutrients. 11177710.3390/nu11081777http://www.ncbi.nlm.nih.gov/pubmed/31374914Crossref (6) Severe was rarer could 25(OH)D. likely urinary calcium. dissociation metabolites considered when counselling patients. multifactorial, involving renal functions albumin reasonable relatively cheap primary screening tool reserves. suspected require detailed analysis. bioavailable ‘free’ concentrations, PTH, phosphorus, future, genotyping important stages delivery variations, enhance ‘vitamin status’ endocrine autocrine/paracrine activities.10Morris substrate secosteroid hormone. different pathways location various 4. consensus constitutes (table 1). Normal reflect effectively target sites. benefits muscle, organs host VDR. level excessively stimulate secondary hyperparathyroidism. unlikely reflects these aims.Table 1Vitamin (nmol/L) assessment populationNational Osteoporosis Society (UK)19Francis R Aspray T Fraser W al.And health: practical guideline patient management.National Society. 2018; ScholarInstitute Medicine (USA)18Ross AC Manson JE Abrams SA al.The 2011 report reference intakes Institute medicine: clinicians need know.J Endocrinol Metab. 96: 53-5810.1210/jc.2010-2704http://www.ncbi.nlm.nih.gov/pubmed/21118827Crossref (2655) ScholarEndocrine (USA)17Holick MF Binkley NC Bischoff-Ferrari al.Evaluation, treatment, prevention deficiency: practice guideline.J 1911-193010.1210/jc.2011-0385http://www.ncbi.nlm.nih.gov/pubmed/21646368Crossref (5731) Open table new tab athlete's deficient, insufficient replete (normal). 5 professional groups, researchers organisations defined address issues health, immunity, infection defence.13Newton Lewis N English sport position stand testing prescription supplements sport.English Sport publication. 2013; 14Cannell JJ Hollis BW Sorenson MB al.Athletic performance D.Med Sci Exerc. 2009; 41: 1102-111010.1249/MSS.0b013e3181930c2bhttp://www.ncbi.nlm.nih.gov/pubmed/19346976Crossref (168) 15Pollock Dijkstra P Chakraverty al.Low 25(OH) concentrations international UK track field athletes.S. Afr. j. med. 2012; 24: 55-5910.17159/2078-516X/2012/v24i2a336Crossref 16Houghton Wedatilake guidelines 2017.ECB Working Party. 2017; 17Holick 18Ross 19Francis very grows childhood repairs following constant structural repairs, haemopoietic activity, responds presence absence mechanical stimuli. dependent interaction multiple factors, those determining status. knowledge rickets children osteomalacia adults confirms D's importance health. link simple. Recent animal human work suggest which Rat experiments examined restricting structure Osteomalacia occurred restricted.20Morris O'Loughlin PD Experimental bone: review.Nutrients. 2: 1026-103510.3390/nu2091026Crossref (25) 21Anderson Iida S Tyson JHT al.Bone gene increased mineralising osteoblasts.J Steroid Mol Biol. 121: 71-7510.1016/j.jsbmb.2010.03.021http://www.ncbi.nlm.nih.gov/pubmed/20236619Crossref (32) When began hence absorption. experimental ablation genes 1-α hydroxylase enzymes (CYP27B1), diminishes absorption phosphate. development overcome phosphate.22Amling Priemel Holzmann al.Rescue skeletal phenotype receptor-ablated mice setting ion homeostasis: formal histomorphometric biomechanical Analyses1.Endocrinology. 1999; 140: 4982-498710.1210/endo.140.11.7110Crossref Conversely, studies, occur either individually.20Morris Clinically, non-vertebral fractures does until >80 nmol/L.23Bischoff-Ferrari Wong JB al.Fracture supplementation: meta-analysis randomized controlled trials.JAMA. 293: 2257-226410.1001/jama.293.18.2257http://www.ncbi.nlm.nih.gov/pubmed/15886381Crossref (1177) maximum strength >80–100 combined adequate intake.24Anderson Sawyer RK Moore depletion induces RANKL-mediated osteoclastogenesis loss rodent model.J 2008; 23: 1789-179710.1359/jbmr.080616http://www.ncbi.nlm.nih.gov/pubmed/18597628Crossref (67) appear similar. appears affected since >20 maintain activation related, occurs extremely animals.25Rowling MJ Gliniak Welsh al.High prevents hypocalcemia knockout mice.J Nutr. 2007; 137: 2608-261510.1093/jn/137.12.2608Crossref (77) mediated autocrine within vitro osteoclast osteoblasts osteocytes stimulated accelerate maturation mineralisation rising Furthermore, act asset upregulates 1α-hydroxylase encourages mineralisation. Theories osteoblast multiple. modelling signalling mechanisms, phosphate enhancing response loading. Peak mass achieved late teens early 20s shortly after peak height attainment.26Baxter-Jones ADG Faulkner RA Forwood MR accrual 8 30 years age: mass.J 1729-173910.1002/jbmr.412Crossref (341) 27Weaver Gordon Janz KF Foundation's statement lifestyle factors: systematic implementation recommendations.Osteoporos 27: 1281-138610.1007/s00198-015-3440-3Crossref (486) After that, plateaus then gradually declines. accelerates female postmenopausal period. Failure reach acceptable ramifications rest individual's life—particularly fracture depicted 6. supporting considered.27Weaver Level (strong evidence) included physical (moderate exercise structure, inclusion dairy products. At level, contraceptive injections (eg, Depo-Provera) adverse effect. lesser levels, beneficial fat, protein, fruit, vegetables fibre examined, well breast feeding. Similarly, detrimental carbonated drinks, caffeine, alcohol, cigarettes oral contraceptives reported. For women, another factor modifiable influences. menarche later mass. young delayed certain Long-distance runners, dancers triathletes into category. women menarche, BMD demonstrated even prepubertal period.28Chevalley Bonjour JP Ferrari pubertal timing acquisition: predetermined trajectory detectable five before menarche.J 94: 3424-343110.1210/jc.2009-0241http://www.ncbi.nlm.nih.gov/pubmed/19531591Crossref (55) Longitudinal association content velocity29McKay Bailey DA Mirwald RL HN al.Peak adolescent girls: 6-year longitudinal study.J Pediatr. 1998; 133: 682-68710.1016/S0022-3476(98)70112-XAbstract ultimate adults.30Gilsanz V Chalfant Kalkwarf H al.Age onset puberty predicts adulthood.J 158: 100-10510.1016/j.jpeds.2010.06.054http://www.ncbi.nlm.nih.gov/pubmed/20797727Abstract (81) Late-onset weakened resistance. Not increase adulthood adolescence.31Bonjour J-P Chevalley Timing Pubertal timing, acquisition, throughout life.Endocr 2014; 35: 820-84710.1210/er.2014-1007http://www.ncbi.nlm.nih.gov/pubmed/25153348Crossref advice sensibly supplement would reasonable. eventual marginal. adoption choices mentioned previously maximise strength. Athletes repetitive high-impact improve BMD. might help offset naturally partially explain oft-observed lack direct correlation limbs recreation, example, upper running low-impact sports, place similar risks pathology sites relationships exact. BMDs inadequate vice versa. especially true tones.32Hannan MT Litman HJ Araujo AB al.Serum racially ethnically diverse group men.J 93: 40-4610.1210/jc.2007-1217Crossref (127) 33Kremer Campbell PP Reinhardt final height, women.J 67-7310.1210/jc.2008-1575Crossref (164) Low blood parathyroids release increases This, turn, age-related decrease contribute accompany secretion. mode action probably Falling reduce cell regulates fall, increasing released.10Morris kidneys receptors. If absorbed gut, together (acting via receptors) stores reabsorption distal convoluted tubules. rationale use protecting suppression levels. (via osteoclastic releases turnover decreases needed suppress minimise resorption debated. Some plateau 75 nmol/L.34Dawson-Hughes Heaney RP Holick al.Estimates status.Osteoporos 16: 713-71610.1007/s00198-005-1867-7Crossref (1457) 35Holick deficiency.N Engl Med Overseas Ed. 357: 266-28110.1056/NEJMra070553Crossref Others describe 50 metabolism markers stabilise >45 nmol/L.36Sai Walters RW Fang X al.Relationship hormone, health.J E436-E44610.1210/jc.2010-1886http://www.ncbi.nlm.nih.gov/pubmed/21159838Crossref (185) clear significance >50 individuals markers. Various explanations reduction, deteriorating intake. Other race, gender, weight, leptin sex globulin. varying range maximally suppressed. receptor disease whereby respond lead Functional hypoparathyroidism Approximately 50% exhibit response. groups.37Sahota O Gaynor Harwood RH 'functional hypoparathyroidism’-the NoNoF (Nottingham Neck Femur) study.Age Ageing. 2001; 30: 467-47210.1093/ageing/30.6.467http://www.ncbi.nlm.nih.gov/pubmed/11742774Crossref Generally, older tend level. Supplementation effective functional hypoparathyroidism. several indicated BMDs. bestow protective effect.37Sahota 38Byun S-E Lee al.Pre