SPECIAL ISSUE

Trends in Vitamin D Status Around the World

Paul Lips,1 Renate T. de Jongh,1 and Natasja M. van Schoor2
1
Department of Internal Medicine, Endocrine Section, Amsterdam University Medical Centre, location VUMC, Amsterdam, The Netherlands
2
Department of Epidemiology and Data Science, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam Public Health
Research Institute, Amsterdam, The Netherlands

ABSTRACT
Vitamin D status varies across all continents and countries. Vitamin D status usually is adequate in Latin America and Australia, but in
contrast it is very low in the Middle East and some countries in Asia. Trends in vitamin D status, whether it improves or declines over
the years, carry important messages. Trends usually are small, but can be predictors and indicators of general health. Vitamin D status
has improved in the older population in the United States, and improvement relates to dairy use and vitamin D supplements. To the
contrary, vitamin D status has declined in the Inuit population of Canada due to a change from a traditional fish diet to a Western diet.
A large improvement was seen in Finland after mandatory fortification of dairy products was introduced. Determinants of decline are
less sun exposure, increased use of sunscreen, increase of body mass index (BMI), less physical activity, and poor socioeconomic
status. Determinants of increase are food fortification with vitamin D and vitamin D supplements. Food fortification can lead to a
population-wide increase in vitamin D status as shown by the Finnish example. © 2021 The Authors. JBMR Plus published by Wiley
Periodicals LLC on behalf of American Society for Bone and Mineral Research.

KEY WORDS: VITAMIN D STATUS; TRENDS; 25-HYDROXYVITAMIN D; SUPPLEMENTS; FOOD FORTIFICATION; DETERMINANTS

Introduction great stimulator of laboratory and clinical investigation, and was

a great mentor to many young scientists with always kind words
and stimulating remarks. This article shows that both positive
E xtensive reviews on vitamin D status in the world have been
published over the last decades. Although vitamin D status,
as reflected by circulating 25-hydroxyvitamin D (25(OH)D) con-
and negative trends in vitamin D status can occur, and these
may be a reassurance or a warning for public health and policy
centrations, can be considered satisfactory in some countries, makers.
vitamin D deficiency still is very common in many countries
throughout the world and in many risk groups. Guidelines have Methodological Issues
been published by the Institute of Medicine,(1) the Endocrine
Society,(2) the European Food Safety Authority,(3) and the We searched in PubMed articles on “trends”, “temporal
European Calcified Tissue Society.(4) What is apparent from these changes”, “vitamin D status”, “25-hydroxyvitamin D”, “determi-
documents is that no consensus exists on the definition of vita- nants” and “longitudinal studies”, covering the last 20 years.
min D deficiency and the desirable serum 25(OH)D concentra- Vitamin D status is usually assessed by measuring the serum
tion. Vitamin D status appears quite stable in most countries, 25(OH)D concentration. This is done by radioimmunological
and percentages of vitamin D–deficient subjects have varied methods, or, currently the gold standard, liquid chromatography
little during the past decades. Nevertheless, the use of supple- and tandem mass spectrometry (LC-MS/MS).(5) The results of
ments and the fortification of foods have generated important radioimmunoassays show a large variation, much more than
positive changes in some countries. On the other side, trends results of LC-MS/MS. This was demonstrated by a study using
of increasing body mass index (BMI) and decreasing physical quality control data of Vitamin D External Quality Assessment
activity may compromise vitamin D status. In this article we give Scheme (DEQAS) in which seven different methods were com-
an overview of changing trends in vitamin D status in different pared. Results for radioimmunological methods varied up to
regions and countries and the determinants that play a role in 15% from the mean, whereas results for LC-MS/MS varied
causing these changes. It is a narrative review. This article is part much less, around 5% from the mean.(6) The standardization
of a special issue of JBMR Plus as a tribute to Dr Anthony Norman, programme DEQAS has done excellent work to decrease
who made numerous contributions to the vitamin D field, was a variability,(7) and more recently the Vitamin D Standardization

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
Received in original form July 22, 2021; revised form November 18, 2021; accepted November 18, 2021.
Address correspondence to: Paul Lips, MD, PhD, Department of Internal Medicine, Endocrine Section, Amsterdam University Medical Centre, location VUMC,
P.O. Box 7057, 1007 MB Amsterdam, The Netherlands. E-mail: p.lips@amsterdamumc.nl
JBMR® Plus (WOA), Vol. 5, No. 12, December 2021, e10585.
DOI: 10.1002/jbm4.10585
© 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

1 of 6 n
Programme (VDSP) has brought this forward by using adequate significantly higher serum 25(OH)D around 2–7 nmol/L.(19) In
laboratory standards.(8) Longitudinal and trend studies are the Study of Women’s Health Across the Nation serum 25(OH)D
appropriate to compare current vitamin D status with vitamin was measured longitudinally in the same women in 1998–2000
D status one or more decades ago. Studies from different regions and 2009–2011. Serum 25(OH)D increased from 53.8 to
and time periods can be compared by remeasuring frozen sam- 70.0 nmol/L and the prevalence of vitamin D deficiency decreased
ples and standardized by VDSP.(8) Of course, global studies using from 20.4% to 9.7%.(20) This was mainly due to vitamin D supple-
a central laboratory facility for serum 25(OH)D can also be used ment use, which increased from 40.8% to 67.1%. A negative trend
to compare different countries.(9) Other methodological prob- was observed in Texas. The Dallas Heart Study included 2045 par-
lems arise from the assessment of sunshine exposure and vita- ticipants in which serum 25(OH)D was measured in 2000–2002
and in 2007–2009. Mean serum 25(OH)D decreased from 42.7 to
min D content of food.(10) Vitamin D–effective ultraviolet B
39.4 nmol/L. The prevalence of vitamin D deficiency (serum
(UVB) availability depends on latitude, time of the day, and atmo-
25(OH)D < 50 nmol/L) increased from 60% to 66% although vita-
spheric conditions, whereas the actual exposure and response of
min D supplementation increased from 7% to 23% in that time
the skin to this UVB in terms of vitamin D production is deter-
period. Predictors of a negative change were male sex, obesity,
mined by skin pigmentation, clothing, and sunscreen use. The and non-use of vitamin D supplements.(21) In general in the
use of vitamin D supplements can be very effective at increasing United States, the use of multivitamins decreased between 1999
circulating 25(OH)D, but lack of compliance decreases the and 2012, but the use of vitamin D supplements increased from
effect.(11) For this article, vitamin D deficiency is defined as serum 5.1% to 19%.(22) Sun protection behavior improved in adolescents
25(OH)D < 50 nmol/L, and severe vitamin D deficiency is defined between 1998 and 2004 with possible negative effects for vitamin
as serum 25(OH)D < 30 nmol/L. D status.(23) An increased prevalence of rickets was observed in
Minnesota during the last two decades.(24)
Current Vitamin D Status In Canada, vitamin D statuswas studied in the Canadian Multicen-
ter Osteoporosis Study during 10 years starting in 1995–1997.
Recent reviews of worldwide vitamin D status(12–14) show better Serum 25(OH)D increased by 9.3 nmol/L in women and by
vitamin D status in North and Latin America and Australia than in 3.5 nmol/L in men; serum 25(OH)D was lower than 50 nmol/L in
Europe, better vitamin D status in Southeastern Asia than in 29.7% in 1995–1997 and in 19.8% 10 years later.(25) A downward
India and Northern Asia, and better vitamin D status in Central trend was observed in Canadian children, 6–18 years old. In
Africa than in Northern and Southern Africa. The poorest vitamin 2007/2009, vitamin D deficiency (serum 25(OH)D < 50 nmol/L)
D status was generally observed in the Middle East. Within Europe, was found in 21%, whereas in 2012/2013 the prevalence increased
a better vitamin D status was observed in Northern Europe than in to 32%. Fish and milk consumption decreased in this time period,
Southern and Eastern European countries.(4) A global study on milk being the main dietary vitamin D source.(26) Vitamin D status
prevalence and disease burden of vitamin D deficiency showed was assessed in the Inuit population of Greenland in 1987 and
high percentages of severe vitamin D deficiency in infants in 2005–2010. Serum 25(OH)D decreased in all age groups from 32 to
India (61%), Iran (86%), and Turkey (51%), whereas vitamin D defi- 58% in this period. The lowest mean serum 25(OH)D was observed
ciency was present in 90% or higher in these countries.(15) in the 18–29 year group (30.7 nmol/L). Mean serum 25(OH)D
increased with age. Serum 25(OH)D was lower than 50 nmol/L in
77% of 18–29-year-olds.(27) A major determinant in this and other
Temporal and Regional Trends in Vitamin D
studies was traditional diet, consisting of fish, seal, and whale.(28)
Status The decrease in serum 25(OH)D over 20 years in the Inuit can be
explained by the replacement of the traditional diet by a Western
North America
diet. Two trials with food fortification of yogurt and cheddar cheese
The National Health and Nutrition Examination Survey (NHANES) in Canadese children showed small significant differences between
has been used to study trends. Ginde and colleagues(16) com- intervention and control group, but mean baseline serum 25(OH)D
pared serum 25(OH)D from NHANES collected from 1988 to in these children was around 60 nmol/L or higher.(29,30)
1994 with NHANES data from 2001 to 2004. A decrease of serum
25(OH)D in all age groups, both sexes and all ethnicities was
Latin America
observed, ranging from 7.5 to 17.5 nmol/L. Schleicher and col-
leagues(17) repeated and extended the study by using LC-MS/ Vitamin D status usually is better in Middle and South America
MS calibrated to a standard reference. All data were standardized than in North America, maybe with the exception of the more
and adjusted. According to this study, the serum 25(OH)D did southern latitudes.(14) Data on trends in vitamin D status, either
not show a time trend from 1988 to 2006, in contrast to the pre- decline or increase, are not available. The projected increase of
vious analysis. Thereafter the mean serum 25(OH)D from 2007 to the total ozone content of the atmosphere during the coming
2010 was 5–6 nmol/L higher. The largest increases (up to decades will lead to a decrease of the ultraviolet index at higher
11 nmol/L) were seen in older white women and in vitamin D latitudes in South America and Antarctica, and this can have a
supplement users.(17) The percentage at risk for vitamin D defi- negative impact on vitamin D status.(31)
ciency (in this study: serum 25(OH)D < 30 nmol/L) was also esti-
mated in NHANES in 2011–2014.(18) The percentage at risk for
Europe
deficiency was 0.5% in children of 1–5 years, 7.6% in adults from
20–39 years, and 2.9% in adults ≥40 years. The risk of deficiency In the UK, an increase in vitamin D status between 2008 and
was highest among blacks. From 2003 to 2014 there was no 2016 was attributed to the prescription of supplements by
change in the risk of vitamin D deficiency. The risk of inadequacy primary care doctors.(32) On the other side, an increase in rickets
(serum 25(OH)D 30–49 nmol/L) declined from 21% to 17.7%.(18) diagnosis was seen in hospital discharge data.(33) The increase
Milk consumption in participants of NHANES resulted in a was restricted to children with a non-Western immigrant background.

n 2 of 6 LIPS ET AL. JBMR Plus (WOA)

A sharp decrease in the prevalence of vitamin D deficiency from 30.9%, respectively). The causes are traditional clothing, low
55% in 2014 to 14% in Irish elite athletes was observed in Ireland, sunshine exposure, and lack of vitamin D–fortified foods.(44)
also attributed to the use of supplements.(34) In northern Sweden, Vitamin D deficiency still is common in Lebanon. A database
vitamin D status was assessed in more than 11,000 men and women of 9147 subjects evaluated between 2000–2004 and 2007–
between 1986 and 2014. The overall mean serum 25(OH)D was 2008 showed a prevalence of vitamin D deficiency (serum
49.8  23.8 nmol/L. There was no clear upward or downward trend 25(OH)D <50 nmol/L) of 58%–62% in children, 44%–60% in
in serum 25(OH)D concentration between 1986 and 2014.(35) In adults, and 41%–62% in the elderly. The mean serum 25(OH)
Poland, vitamin D status was assessed in more than 3000 neonates D increased 5–12 nmol/L in children and adults between
and infants (mean age 8 months). The mean 25(OH)D concentra- the two time periods. (45) A recent study of more than
tion was 129.5 nmol/L between 1981 and 1999. It decreased 150,000 serum samples standardized with cross-calibration
to 107 nmol/L in 2000–2001 and to 72 nmol/L in 2010–2011.(36) to LC-MS/MS confirmed the increase of serum 25(OH)D between
The decrease can be explained by a decrease of the supplementa- 2009 and 2016 of 2.2 nmol/L/year in children, 3 nmol/L/year in
tion advice from 2500 IU/d to 1000 IU/d (in breastfed children adults and 6.5 nmol/L/year in the elderly.(46) In a longitudinal
400 IU/d). A clear improvement of vitamin D status was shown in study in Iran, mean serum 25(OH)D increased from 51 nmol/L
a cohort of 1486 osteoporotic French women treated in a fracture in 2001 to 54 nmol/L in 2007 and to 62 nmol/L in 2013. The
liaison service. The mean serum 25(OH)D concentration increased prevalence of vitamin D deficiency (serum 25(OH)D <25 nmol/L)
from 17.6 to 48.4 nmol/L between 2005–2008 and 2009–2012 decreased from 30% to 24% in the time period of 12 years.(47)
due to vitamin D supplementation.(37) The positive trend was attributed to more awareness of
In the Longitudinal Aging Study Amsterdam, serum 25(OH)D vitamin D deficiency, more screening, and more vitamin D
was measured twice in the same participants. The mean serum supplementation.
25(OH)D at baseline was 56.5 nmol/L in the younger cohort
and 51.1 nmol/L in the older cohort. In the younger cohort, an
Africa
increase in the mean serum 25(OH)D levels of 4 nmol/L in 6 years
was observed; in the older cohort, a decrease in the mean serum A recent systematic review on the prevalence of vitamin D defi-
25(OH)D concentration of 4 nmol/L in 13 years was observed.(38) ciency reported a mean serum 25(OH)D of 67.8 nmol/L.(48)
In Germany, the results of three nationwide studies were stan- Serum 25(OH)D was lower than 30 nmol/L in 18.5% and lower
dardized according to VDSP.(39) The data of two studies in adults than 50 nmol/L in 34.2%. Mean serum 25(OH)D was lower in
18–79 years, in 1997–1999 and 2008–2011, respectively, and northern African countries than in sub-Saharan African countries
partially in the same subjects showed a similar percentage of and South Africa. For example, mean serum 25(OH)D was
severe vitamin D deficiency of 15%. However, the percentage 24.2 nmol/L in Algeria, 44.5 nmol/L in Morocco, and 46.5 nmol/L
of serum 25(OH)D between 30 and 50 nmol/L was higher in in Ethiopia.(48) Neither increasing nor decreasing trends in vita-
the more recent study (41%) than in the earlier study (27%), lead- min D status were observed. In Morocco a double blind study
ing to the conclusion that vitamin D status has not improved, but with fortified milk, 3 μg (120 IU) in 200 mL, led to a sharp
slightly deteriorated over this time interval.(39) decrease in vitamin D deficiency from 47.6% to 11.8% in the for-
The most interesting studies are from countries where a coun- tified group, whereas 33% of participants in the non-fortified
trywide strategy to improve vitamin D status was used. In Finland group were still deficient after 9 months.(49)
mandatory fortification of milk and dairy products was started in
2003 with 200 IU/L of milk and yogurt and after a few years it was
Asia
increased to 400 IU/L. Mean serum 25(OH)D increased from
48 nmol/L in 2000 to 65 nmol/L in 2011. In total, 91% of dairy An analysis of 26,339 serum 25(OH)D values, obtained in a tertiary
product consumers who did not use supplements reached a care hospital in New Delhi, India, showed an increase of the mean
serum 25(OH)D concentration >50 nmol/L. The prevalence of serum 25(OH)D from 48 nmol/L in 2008 to 54 nmol/L in 2016. The
vitamin D deficiency in supplement non-users decreased from prevalence of vitamin D deficiency (serum 25(OH)D <50 nmol/L)
58.5 to 13.7% within a few years.(40) In Turkey, a nationwide vita- decreased from 72% to 54% in women and from 57% to 52% in
min D supplementation campaign was started in 2005 to men. The improvement was attributed to greater awareness and
decrease the incidence of rickets in infants and toddlers. Vitamin more vitamin D supplementation.(50) In some countries a negative
D3 400 IU/d was given for free to all neonates. The incidence of trend in vitamin D status was observed. A study from South Korea
rickets decreased from 6% to 0.1% in a few years.(41) showed a very significant decrease of vitamin D status between
A randomized controlled trial with fortified milk in German 2008 and 2014.(51) The mean serum 25(OH)D in 2008 was
children showed an increase of serum 25(OH)D of 8 to 15 nmol/L 53 nmol/L in men and 46 nmol/L in women, decreasing in 2014
depending on season.(42) A similar randomized controlled trial to 43 nmol/L in men and 39 nmol/L in women. The prevalence
(RCT) in Swedish children of 400 and 800 IU added to 200 g of of vitamin D deficiency increased over the same time period.
milk showed mean increases of serum 25(OH)D of 13 nmol/L The cause of the decrease in vitamin D status is uncertain, but
and 24 nmol/L, respectively, after 3 months.(43) increased urbanization, air pollution, and less outdoor occupation
were mentioned by the authors. In the Murakami Cohort Study in
Japan, 1044 subjects were followed for 5 years. Serum 25(OH)D
Middle East
decreased 4.0 nmol/L in men and 0.4 nmol/L in women. The
The prevalence of vitamin D deficiency still is very high in the Mid- decline in men was related to more university education and to
dle East.(4) A recent study from Saudi Arabia in 10,709 patients less outdoor occupation.(52) A randomized controlled trial with
showed a prevalence of severe vitamin D deficiency (serum fortified milk (300 IU/710 mL) in Mongolian children showed
25(OH)D <25 nmol/L) of 31.5%. Vitamin D deficiency was more increases of serum 25(OH)D of 30 and 47 nmol/L after 1.6 months,
common in women than in men. Severe deficiency was more whereas serum 25(OH)D stayed at 20 nmol/L in the control group
prevalent in adolescents than in other age groups (49.2% and receiving non-fortified milk.(53)

JBMR® Plus WORLDWIDE TRENDS IN VITAMIN D STATUS 3 of 6 n

Fig. 1. Determinants of decline or increase in vitamin D status.

Australia, New Zealand, and Oceania unhealthy lifestyle increased, visible by increasing BMI and
decreasing physical activity.(70) Both factors may contribute to a
Vitamin D status is in general better in Australia and the Pacific decline in vitamin D status. In Japan, decline in vitamin D status
Islands than in Asian countries.(14) Vitamin D status is less in was less in men with an outdoor occupation and the highest phys-
New Zealand than in Australia due to the more southern latitude. ical activity.(52) Serum 25(OH)D also relates positively to socioeco-
Persons who tended to stay in the shade had lower serum nomic status as measured by a housing score, Houses Index.(71)
25(OH)D levels than those who never stayed in the shade (62.5 Nutritional changes may also cause a decline in vitamin D sta-
versus 68.8 nmol/L, respectively, p = 0.01), and this association tus. The Inuit in Canada changed from a traditional to a Western
remained in persons who spent <50% (p = 0.02), but not in those diet and vitamin D status deteriorated. The traditional Inuit diet
who spent ≥50% of their time outdoors.(54) Trends in sun protec- contains fish and sea mammals, both rich in vitamin D.(28) The
tion behavior were not observed in a study between 2007 and effects of the mandatory fortification of dairy products with vita-
2012, except an increase in sunscreen use.(55) In another study, min D was particularly well documented in Finland, where mean
a decline in skin covering around swimming pools and beaches serum 25(OH)D increased with 17 nmol/L.(40) The voluntary forti-
was observed between 2006 and 2019.(56) fication of dairy products in the United States may explain the
better vitamin D status in the United States than in Europe. Ran-
domized controlled trials with fortified milk, yogurt or cheese
Determinants of Change in Vitamin D Status were highly successful.(72) Vitamin D–fortified orange juice was
studied in the United States and increased serum 25(OH)D about
Trends in vitamin D status, either decline or increase, are deter- 25 nmol/L.(73) It now is available in many countries. Fortification
mined by many factors (Fig. 1). A negative trend of vitamin D sta- of flour and cooking oil is practiced in the Middle East,(74,75)
tus with aging was seen in the Longitudinal Aging Study and fortification of milk, oil, and rice with vitamin D is now prac-
Amsterdam (LASA).(38) Of course, vitamin D deficiency is very com- ticed in India.(76) Modeling of fortification policies lead to the
mon in the elderly.(57) Little data exists on trends in sun exposure. conclusion that several methods can be successful.(77) Of course,
Sun protection behavior increases somewhat according to Amer- the use of vitamin D supplements can also increase vitamin D
ican and Australian studies.(23,55) However, the Australian data are status (see temporal and regional trends in vitamin D status). A
ambiguous.(56) The use of sunscreen may increase, leading to very successful supplementation campaign was done among
lower vitamin D production.(58) Clothing style is an important neonates in Turkey to eradicate rickets.(41)
determinant of vitamin D status according to studies in the Middle
East, Jordan,(59) and Turkey.(60) Total skin covering clothes may
also explain the very poor vitamin D status in Saudi Arabia.(61,62) Conclusions
Urbanization also may decrease vitamin D status. Vitamin D status
usually is better in rural than in urban areas as observed in Trends in vitamin D status, either decline or increase, can be
Mexico,(63) Malaysia,(64) South Africa,(65) and Korea.(66) As vitamin observed in several countries under various circumstances. Usu-
D status is less in obese people,(67) increasing obesity may deteri- ally these trends are small, but they can be important predictors
orate vitamin D status. A very large multicenter survey found a for future development and indicators of general health change.
trend for increase of BMI in children and adolescents.(68) Contrary Small improvements of vitamin D status as observed in the
to expectation, BMI rose more in rural than in urban areas.(69) This United States can be caused by vitamin D supplement use. A
effect counteracts the higher vitamin D status in rural versus urban large improvement of vitamin D status as observed in Finland
areas. In LASA, subsequent cohorts from 1992/1993 to 2002/2003 is due to fortification of dairy products with vitamin D. A decline
to 2012/2013 of participants of 55–64 years of age showed that in vitamin D status can be caused by nutritional changes as is the

n 4 of 6 LIPS ET AL. JBMR Plus (WOA)

case in the Inuit population in Canada. In general, a decrease in 14. van Schoor N, Lips P. Global overview of vitamin D status. Endocrinol
vitamin D status can be due to an increase in BMI and decrease Metab Clin North Am. 2017;46(4):845-870.
in physical activity, usually associated with less time spent out- 15. Roth DE, Abrams SA, Aloia J, et al. Global prevalence and disease bur-
doors. Such a trend is a warning for health authorities and policy den of vitamin D deficiency: a roadmap for action in low- and middle-
income countries. Ann N Y Acad Sci. 2018;1430(1):44-79.
makers.
16. Ginde AA, Liu MC, Camargo CA Jr. Demographic differences and
trends of vitamin D insufficiency in the US population, 1988–2004.
Acknowledgment Arch Intern Med. 2009;169(6):626-632.
17. Schleicher RL, Sternberg MR, Lacher DA, et al. The vitamin D status of
Authors’ roles: PL: conception, drafting manuscript, supervision, the US population from 1988 to 2010 using standardized serum con-
final approval. RJ: interpretation of data, critically revising ms centrations of 25-hydroxyvitamin D shows recent modest increases.
Am J Clin Nutr. 2016;104(2):454-461.
and final approval. NS: interpretation of data, critically revising
ms and final approval. 18. Herrick KA, Storandt RJ, Afful J, et al. Vitamin D status in the
United States, 2011–2014. Am J Clin Nutr. 2019;110(1):150-157.
19. Torres-Gonzalez M, Cifelli CJ, Agarwal S, Fulgoni VL 3rd. Association
Conflict of Interest of milk consumption and vitamin D Status in the US population by
ethnicity: NHANES 2001–2010 analysis. Nutrients. 2020;12(12):3720.
PL reports a travel grant from Abiogen. RJ and NS do not have a 20. Mitchell DM, Ruppert K, Udupa N, et al. Temporal increases in
conflict of interest. 25-hydroxyvitamin D in midlife women: longitudinal results from
the Study of Women’s Health Across the Nation. Clin Endocrinol
(Oxf). 2019;91(1):48-57.
Peer Review 21. Mirfakhraee S, Ayers CR, McGuire DK, Maalouf NM. Longitudinal
changes in serum 25-hydroxyvitamin D in the Dallas Heart Study. Clin
The peer review history for this article is available at https:// Endocrinol (Oxf). 2017;87(3):242-248.
publons.com/publon/10.1002/jbm4.10585. 22. Kantor ED, Rehm CD, Du M, White E, Giovannucci EL. Trends in dietary
supplement use among US adults from 1999-2012. JAMA. 2016;
316(14):1464-1474.
References
23. Cokkinides V, Weinstock M, Glanz K, Albano J, Ward E, Thun M. Trends
in sunburns, sun protection practices, and attitudes toward sun
1. Ross AC, Manson JE, Abrams SA, et al. The 2011 report on dietary ref-
exposure protection and tanning among US adolescents, 1998–
erence intakes for calcium and vitamin D from the Institute of Medi-
2004. Pediatrics. 2006;118(3):853-864.
cine: what clinicians need to know. J Clin Endocrinol Metab. 2011;
96(1):53-58. 24. Thacher TD, Fischer PR, Tebben PJ, et al. Increasing incidence of nutri-
2. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treat- tional rickets: a population-based study in Olmsted County, Minne-
ment, and prevention of vitamin D deficiency: an Endocrine Society sota. Mayo Clin Proc. 2013;88(2):176-183.
clinical practice guideline. J Clin Endocrinol Metab. 2011;96(7):1911- 25. Berger C, Greene-Finestone LS, Langsetmo L, et al. Temporal trends and
1930. determinants of longitudinal change in 25-hydroxyvitamin D and para-
3. European Food Safety Authority EEFS. Scientific opinion on dietary thyroid hormone levels. J Bone Miner Res. 2012;27(6):1381-1389.
reference values for vitamin D. EFSA J. 2016;14(10):4547. 26. Munasinghe LL, Yuan Y, Willows ND, Faught EL, Ekwaru JP, Veugelers PJ.
4. Lips P, Cashman KD, Lamberg-Allardt C, et al. Management of endo- Vitamin D deficiency and sufficiency among Canadian children residing
crine disease: Current vitamin D status in European and Middle East at high latitude following the revision of the RDA of vitamin D intake in
countries and strategies to prevent vitamin D deficiency; a position 2010 - Corrigendum. Br J Nutr. 2017;117(7):1052-1054.
statement of the European Calcified Tissue Society. Eur J Endocrinol. 27. Beck-Nielsen SS, Jensen TK, Gram J, Brixen K, Brock-Jacobsen B. Nutri-
2019;180:23-54. tional rickets in Denmark: a retrospective review of children’s medical
5. Binkley N, Carter GD. Toward clarity in clinical vitamin D status assess- records from 1985 to 2005. Eur J Pediatr. 2009;168(8):941-949.
ment: 25(OH)D assay standardization. Endocrinol Metab Clin North 28. Andersen S, Laurberg P, Hvingel B, Kleinschmidt K, Heickendorff L,
Am. 2017;46(4):885-899. Mosekilde L. Vitamin D status in Greenland is influenced by diet
6. Barake M, Daher RT, Salti I, et al. 25-Hydroxyvitamin D assay variations and ethnicity: a population-based survey in an Arctic society in tran-
and impact on clinical decision making. J Clin Endocrinol Metab. 2012; sition. Br J Nutr. 2013;109:928-935.
97:835-843. 29. Brett NR, Lavery P, Agellon S, et al. Dietary vitamin D dose-response in
7. Carter GD, Berry J, Durazo-Arvizu R, et al. Hydroxyvitamin D assays: an healthy children 2 to 8 y of age: a 12-wk randomized controlled trial
historical perspective from DEQAS. J Steroid Biochem Mol Biol. 2018; using fortified foods. Am J Clin Nutr. 2016;103(1):144-152.
177:30-35. 30. Brett NR, Parks CA, Lavery P, et al. Vitamin D status and functional
8. Cashman KD, Dowling KG, Skrabakova Z, et al. Vitamin D deficiency in health outcomes in children aged 2-8 y: a 6-mo vitamin D random-
Europe: pandemic? Am J Clin Nutr. 2016;103(4):1033-1044. ized controlled trial. Am J Clin Nutr. 2018;107(3):355-364.
9. Lips P, Duong T, Oleksik A, et al. A global study of vitamin D status 31. Correa MP, Yamamoto ALC, Moraes GR, Godin-Beekmann S, Mahe E.
and parathryoid function in postmenopausal women with osteopo- Changes in the total ozone content over the period 2006 to 2100 and
rosis: baseline data from the Multiple Outcomes of Raloxifene Evalu- the effects on the erythemal and vitamin D effective UV doses for
ation Clinical Trial. J Clin Endocrinol Metab. 2001;86:1212-1221. South America and Antarctica. Photochem Photobiol Sci. 2019;
18(12):2931-2941.
10. Schmid A, Walther B. Natural vitamin D content in animal products.
Adv Nutr. 2013;4(4):453-462. 32. Wan M, Horsfall LJ, Basatemur E, Patel JP, Shroff R, Rait G. Vitamin D
prescribing in children in UK primary care practices: a population-
11. de Koning EJ, Lips P, Penninx B, et al. Vitamin D supplementation for
based cohort study. BMJ Open. 2019;9(12):e031870.
the prevention of depression and poor physical function in older per-
sons: the D-Vitaal study, a randomized clinical trial. Am J Clin Nutr. 33. Goldacre M, Hall N, Yeates DG. Hospitalisation for children with rickets
2019;110(5):1119-1130. in England: a historical perspective. Lancet. 2014;383(9917):597-598.
12. Wahl DA, Cooper C, Ebeling PR, et al. A global representation of vita- 34. Todd J, Madigan S, Pourshahidi K, et al. Vitamin D status and supple-
min D status in healthy populations. Arch Osteoporos. 2012;7: mentation practices in elite Irish athletes: an update from 2010/2011.
155-172. Nutrients. 2016;8(8):485.
13. Hilger J, Friedel A, Herr R, et al. A systematic review of vitamin D sta- 35. Summerhays E, Eliasson M, Lundqvist R, Soderberg S, Zeller T,
tus in populations worldwide. Br J Nutr. 2014;111(1):23-45. Oskarsson V. Time trends of vitamin D concentrations in northern

JBMR® Plus WORLDWIDE TRENDS IN VITAMIN D STATUS 5 of 6 n

 Sweden between 1986 and 2014: a population-based cross-sectional 56. Haynes A, Nathan A, Dixon H, Wakefield M, Dobbinson S. Sun-
study. Eur J Nutr. 2020;59(7):3037-3044. protective clothing and shade use in public outdoor leisure settings
36. Wojcik M, Jaworski M, Pludowski P. 25(OH)D concentration in neo- from 1992 to 2019: results from cross-sectional observational surveys
nates, infants, and toddlers from Poland-evaluation of trends during in Melbourne, Australia. Prev Med. 2020;139:106230.
years 1981–2011. Front Endocrinol (Lausanne). 2018;9:656. 57. Lips P. Vitamin D deficiency and secondary hyperparathyroidism in
37. Amouzougan A, Deygat A, Trombert B, et al. Spectacular improve- the elderly: consequences for bone loss and fractures and therapeu-
ment in vitamin D status in elderly osteoporotic women: 8-year anal- tic implications. Endocr Rev. 2001;22(4):477-501.
ysis of an osteoporotic population treated in a dedicated fracture 58. Passeron T, Bouillon R, Callender V, et al. Sunscreen photoprotection
liaison service. Osteoporos Int. 2015;26(12):2869-2875. and vitamin D status. Br J Dermatol. 2019;181(5):916-931.
38. van Schoor NM, Knol DL, Deeg DJ, Peters FP, Heijboer AC, Lips P. Longi- 59. Mallah EM, Hamad MF, Elmanaseer MA, et al. Plasma concentrations
tudinal changes and seasonal variations in serum 25-hydroxyvitamin D of 25-hydroxyvitamin D among Jordanians: effect of biological and
levels in different age groups: results of the Longitudinal Aging Study habitual factors on vitamin D status. BMC Clin Pathol. 2011;11:8.
Amsterdam. Osteoporos Int. 2014;25(5):1483-1491. 60. Buyukuslu N, Esin K, Hizli H, Sunal N, Yigit P, Garipagaoglu M. Clothing
39. Rabenberg M, Scheidt-Nave C, Busch MA, et al. Implications of stan- preference affects vitamin D status of young women. Nutr Res. 2014;
dardization of serum 25-hydroxyvitamin D data for the evaluation 34(8):688-693.
of vitamin D status in Germany, including a temporal analysis. BMC 61. Ardawi MS, Sibiany AM, Bakhsh TM, Qari MH, Maimani AA. High preva-
Public Health. 2018;18(1):845. lence ofvitaminD deficiencyamonghealthySaudiArabianmen: relation-
40. Jaaskelainen T, Itkonen ST, Lundqvist A, et al. The positive impact of ship to bone mineral density, parathyroid hormone, bone turnover
general vitamin D food fortification policy on vitamin D status in a markers, and lifestyle factors. Osteoporos Int. 2012;23(2):675-686.
representative adult Finnish population: evidence from an 11-y 62. Al Shaikh AM, Abaalkhail B, Soliman A, et al. Prevalence of vitamin D
follow-up based on standardized 25-hydroxyvitamin D data. deficiency and calcium homeostasis in Saudi children. J Clin Res
Am J Clin Nutr. 2017;105(6):1512-1520. Pediatr Endocrinol. 2016;8(4):461-467.
41. Hatun S, Ozkan B, Bereket A. Vitamin D deficiency and prevention: 63. Chavez-Courtois M, Godinez-Martinez E, Munoz-Manrique C, et al.
Turkish experience. Acta Paediatr. 2011;100(9):1195-1199. Vitamin D status and its determinants in Mexican pregnant women
42. Hower J, Knoll A, Ritzenthaler KL, Steiner C, Berwind R. Vitamin D for- from a rural and an urban area: a comparative study. Int J Environ
tification of growing up milk prevents decrease of serum Res Public Health. 2021;18(9):4571.
25-hydroxyvitamin D concentrations during winter: a clinical inter- 64. Nurbazlin M, Chee WS, Rokiah P, et al. Effects of sun exposure on
vention study in Germany. Eur J Pediatr. 2013;172(12):1597-1605. 25(OH) vitamin D concentration in urban and rural women in
43. Ohlund I, Lind T, Hernell O, Silfverdal SA, Karlsland Akeson P. Increased Malaysia. Asia Pac J Clin Nutr. 2013;22(3):391-399.
vitamin D intake differentiated according to skin color is needed to meet 65. Kruger MC, Kruger IM, Wentzel-Viljoen E, Kruger A. Urbanization of
requirements in young Swedish children during winter: a double-blind black South African women may increase risk of low bone mass
randomized clinical trial. Am J Clin Nutr. 2017;106(1):105-112. due to low vitamin D status, low calcium intake, and high bone turn-
44. Hussain AN, Alkhenizan AH, El Shaker M, Raef H, Gabr A. Increasing over. Nutr Res. 2011;31(10):748-758.
trends and significance of hypovitaminosis D: a population-based 66. Choi EY. 25(OH)D status and demographic and lifestyle determinants of
study in the Kingdom of Saudi Arabia. Arch Osteoporos. 2014;9:190. 25(OH)D among Korean adults. Asia Pac J Clin Nutr. 2012;21(4):526-535.
45. Hoteit M, Al-Shaar L, Yazbeck C, Bou Sleiman M, Ghalayini T, El Hajj 67. Snijder MB, van Dam RM, Visser M, et al. Adiposity in relation to vitamin D
Fuleihan G. Hypovitaminosis D in a sunny country: time trends, pre- status and parathyroid hormone levels: a population-based study in
dictors, and implications for practice guidelines. Metabolism. 2014; older men and women. J Clin Endocrinol Metab. 2005;90(7):4119-4123.
63(7):968-978.
68. Collaboration NCDRF. Worldwide trends in body-mass index, under-
46. Saad RK, Akiki VC, Rahme M, Ajjour S, Assaad M, El-Hajj Fuleihan G. weight, overweight, and obesity from 1975 to 2016: a pooled analysis
Time trends and predictors of hypovitaminosis D across the life of 2416 population-based measurement studies in 128.9 million chil-
course: 2009–2016. Metabolism. 2020;105:154138. dren, adolescents, and adults. Lancet. 2017;390(10113):2627-2642.
47. Khosravi-Boroujeni H, Sarrafzadegan N, Sadeghi M, et al. Prevalence and 69. Collaboration NCDRF. Rising rural body-mass index is the main driver of
trends of vitamin D deficiency among Iranian adults: a longitudinal the global obesity epidemic in adults. Nature. 2019;569(7755):260-264.
study from 2001-2013. J Nutr Sci Vitaminol (Tokyo). 2017;63(5):284-290.
70. Reinders I, van Schoor NM, Deeg DJH, Huisman M, Visser M. Trends in life-
48. Mogire RM, Mutua A, Kimita W, et al. Prevalence of vitamin D defi- style among three cohorts of adults aged 55-64 years in 1992/1993,
ciency in Africa: a systematic review and meta-analysis. Lancet Glob 2002/2003 and 2012/2013. Eur J Public Health. 2018;28(3):564-570.
Health. 2020;8(1):e134-e142.
71. Thacher TD, Dudenkov DV, Mara KC, Maxson JA, Wi CI, Juhn YJ. The rela-
49. Benjeddou K, Qandoussi L, Mekkaoui B, et al. Effect of multiple micro- tionship of 25-hydroxyvitamin D concentrations and individual-level
nutrient fortified milk consumption on vitamin D status among socioeconomic status. J Steroid Biochem Mol Biol. 2020;197:105545.
school-aged children in rural region of Morocco. Appl Physiol Nutr
72. Brand~ao-Lima PN, Santos BDC, Aguilera CM, Freire ARS, Martins-
Metab. 2019;44(5):461-467.
Filho PRS, Pires LV. Vitamin D food fortification and nutritional status
50. Raizada N, Goyal A, Singla R, Sreenivas V, Gupta N, Khadgawat R. Changing in children: a systematic review of randomized controlled trials. Nutri-
trend in vitamin D status from 2008 to 2016: an experience from a tertiary ents. 2019;11(11):2766.
Care Institute in North India. Indian J Endocrinol Metab. 2020;24(2):150-154.
73. Tangpricha V, Koutkia P, Rieke SM, Chen TC, Perez AA, Holick MF. Fortifi-
51. Park JH, Hong IY, Chung JW, Choi HS. Vitamin D status in cation of orange juice with vitamin D: a novel approach for enhancing
South Korean population: seven-year trend from the KNHANES. Med- vitamin D nutritional health. Am J Clin Nutr. 2003;77(6):1478-1483.
icine (Baltimore). 2018;97(26):e11032.
74. Nikooyeh B, Zargaraan A, Kalayi A, et al. Vitamin D-fortified cooking
52. Nakamura K, Kitamura K, Watanabe Y, et al. Predictors of decline in oil is an effective way to improve vitamin D status: an institutional
vitamin D status in middle-aged and elderly individuals: a 5-year efficacy trial. Eur J Nutr. 2020;59(6):2547-2555.
follow-up study. Br J Nutr. 2020;124(7):729-735. 75. Laleye LC, Wasesa AA, Rao MV. A study on vitamin D and vitamin A in
53. Rich-Edwards JW, Ganmaa D, Kleinman K, et al. Randomized trial of for- milk and edible oils available in The United Arab Emirates. Int J Food
tified milk and supplements to raise 25-hydroxyvitamin D concentra- Sci Nutr. 2009;60(Suppl 5):1-9.
tions in schoolchildren in Mongolia. Am J Clin Nutr. 2011;94(2):578-584. 76. Jan Y, Malik M, Yaseen M, et al. Vitamin D fortification of foods in
54. Jayaratne N, RussellA, van derPols JC. Sun protection andvitaminDstatus India: present and past scenario. J Steroid Biochem Mol Biol. 2019;
in an Australian subtropical community. Prev Med. 2012;55(2):146-150. 193:105417.
55. Koch S, Pettigrew S, Minto C, et al. Trends in sun-protection behav- 77. Cashman KD, O’Dea R. Exploration of strategic food vehicles for vita-
iour in Australian adults 2007–2012. Australas J Dermatol. 2017; min D fortification in low/lower-middle income countries. J Steroid
58(2):111-116. Biochem Mol Biol. 2019;195:105479.

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