Differences and determinants of vitamin D deficiency among UK biobank participants: A cross-ethnic and socioeconomic study

Published:November 24, 2020DOI:https://doi.org/10.1016/j.clnu.2020.11.019



      The public health relevance of true vitamin D deficiency is undisputed, although controversy remains regarding optimal vitamin D status. Few contemporary cross-ethnic studies have investigated the prevalence and determinants of very low 25-hydroxyvitamin D [25(OH)D] concentrations.


      We conducted cross-ethnic analyses on the prevalence and determinants of vitamin D deficiency (25(OH)D ≤ 25 nmol/L) using data from 440,581 UK Biobank participants, of which 415,903 identified as White European, 7880 Asian, 7602 Black African, 1383 Chinese, and 6473 of mixed ancestry. Determinants of vitamin D deficiency were examined by logistic regression.


      The prevalence of vitamin D deficiency was highest among participants of Asian ancestry (57.2% in winter/spring and 50.8% in summer/autumn) followed by those of Black African ancestry (38.5% and 30.8%, respectively), mixed (36.5%, 22.5%), Chinese (33.1%, 20.7%) and White European ancestry (17.5%, 5.9%). Participants with higher socioeconomic deprivation were more likely to have 25(OH)D deficiency compared to less deprived participants (P = <1 × 10−300); this pattern was more apparent among those of White European ancestry and in summer (Pinteraction ≤6.4 × 10−5 for both). In fully-adjusted analyses, regular consumption of oily fish was associated with reduced odds of vitamin D deficiency across all ethnicities, while outdoor-time in summer was less effective for Black Africans (OR 0.89, 95% CI 0.70, 1.12) than White Europeans (OR 0.40, 95% CI 0.38, 0.42).


      Severe vitamin D deficiency remains an issue throughout the UK, particularly in lower socioeconomic areas. In some groups, levels of deficiency are alarmingly high with one-half of Asian and one-third of Black African ancestry populations affected across seasons.

      Key messages

      The prevalence of vitamin D deficiency in the UK is alarming, with certain ethnic and socioeconomic groups considered particularly vulnerable.


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        • Bikle D.D.
        Extraskeletal actions of vitamin D.
        Ann N Y Acad Sci. 2016; 1376: 29-52https://doi.org/10.1111/nyas.13219
        • Nair R.
        • Maseeh A.
        Vitamin D: the “sunshine” vitamin.
        J Pharmacol Pharmacother. 2012; 3: 118https://doi.org/10.4103/0976-500X.95506
        • Wheeler B.J.
        • Snoddy A.M.E.
        • Munns C.
        • Simm P.
        • Siafarikas A.
        • Jefferies C.
        A brief history of nutritional rickets.
        Front Endocrinol. 2019; 10https://doi.org/10.3389/fendo.2019.00795
        • Mula-Abed W.-A.
        25- hydroxyvitamin D: explosion in clinical interest and laboratory requests.
        Oman Med J. 2009; https://doi.org/10.5001/omj.2009.49
        • Cashman K.D.
        Vitamin D in childhood and adolescence.
        Postgrad Med. 2007; 83 (https://dx.doi.org/10.1136%2Fpgmj.2006.052787): 230-235
        • Pilz S.
        • Zittermann A.
        • Trummer C.
        • Theiler-Schwetz V.
        • Lerchbaum E.
        • Keppel M.H.
        • et al.
        Vitamin D testing and treatment: a narrative review of current evidence.
        Endocr Connect. 2019; 8 (https://dx.doi.org/10.1530%2FEC-18-0432): R27-R43
        • Heaney R.P.
        • Holick M.F.
        Why the IOM recommendations for vitamin D are deficient.
        J Bone Miner Res. 2011; 26: 455-457https://doi.org/10.1002/jbmr.328
        • Minisola S.
        • Ferrone F.
        • Danese V.
        • Cecchetti V.
        • Pepe J.
        • Cipriani C.
        • et al.
        Controversies surrounding vitamin D: focus on supplementation and cancer.
        Int J Environ Res Publ Health. 2019; 16 (https://dx.doi.org/10.3390%2Fijerph16020189): 189
        • Tanner S.B.
        • Harwell S.A.
        More than healthy bones: a review of vitamin D in muscle health.
        Ther Adv Musculoskelet Dis. 2015; 7 (https://dx.doi.org/10.1177%2F1759720X15588521): 152-159
        • Pfotenhauer K.M.
        • Shubrook J.H.
        Vitamin D deficiency, its role in health and disease, and current supplementation recommendations.
        J Am Osteopath Assoc. 2017; 117: 301https://doi.org/10.7556/jaoa.2017.055
        • Goldacre M.
        • Hall N.
        • Yeates D.G.R.
        Hospitalisation for children with rickets in England: a historical perspective.
        Lancet. 2014; 383: 597-598https://doi.org/10.1016/s0140-6736(14)60211-7
        • Hyppönen E.
        • Power C.
        Hypovitaminosis D in British adults at age 45 y: nationwide cohort study of dietary and lifestyle predictors.
        Am J Clin Nutr. 2007; 85: 860-868https://doi.org/10.1093/ajcn/85.3.860
        • Lowe N.M.
        • Bhojani I.
        Special considerations for vitamin D in the south Asian population in the UK.
        Ther Adv Musculoskelet Dis. 2017; (https://doi.org/10.1177%2F1759720X17704430)
        • Preece M.
        • McIntosh W.
        • Tomlinson S.
        • Ford J.
        • Dunnigan M.
        • O'Riordan J.
        Vitamin-D deficiency among Asian immigrants to Britain.
        Lancet. 1973; 301: 907-910https://doi.org/10.1016/S0140-6736(73)91361-5
        • Bivins R.
        Ideology and disease identity: the politics of rickets, 1929-1982.
        Med Humanit. 2014; 40 (https://dx.doi.org/10.1136%2Fmedhum-2013-010400): 3-10
        • Itkonen S.
        • Erkkola M.
        • Lamberg-Allardt C.
        Vitamin D fortification of fluid milk products and their contribution to vitamin D intake and vitamin D status in observational studies—a review.
        Nutrients. 2018; 10 (https://dx.doi.org/10.3390%2Fnu10081054): 1054
        • Lips P.
        • Cashman K.D.
        • Lamberg-Allardt C.
        • Bischoff-Ferrari H.A.
        • Obermayer-Pietsch B.
        • Bianchi M.L.
        • et al.
        Current vitamin D status in European and Middle East countries and strategies to prevent vitamin D deficiency: a position statement of the European Calcified Tissue Society.
        Eur J Endocrinol. 2019; : P23-P54https://doi.org/10.1530/EJE-18-0736
        • Uday S.
        • Kongjonaj A.
        • Aguiar M.
        • Tulchinsky T.
        • Högler W.
        Variations in infant and childhood vitamin D supplementation programmes across Europe and factors influencing adherence.
        Endocr Connect. 2017; 6 (https://dx.doi.org/10.1530%2FEC-17-0193): 667-675
        • Sudlow C.
        • Gallacher J.
        • Allen N.
        • Beral V.
        • Burton P.
        • Danesh J.
        • et al.
        UK biobank: an open access resource for identifying the causes of a wide range of complex diseases of middle and old age.
        PLoS Med. 2015; 12https://doi.org/10.1371/journal.pmed.1001779
        • Watts G.
        UK Biobank gets 10% response rate as it starts recruiting volunteers.
        BMJ. 2007; 334 (https://dx.doi.org/10.1136%2Fbmj.39167.407616.DB): 659
        • UK Biobank
        UK Biobank: protocol for a large-scale prospective epidemilogical resource - protocol No: UKBB-PROT-09-06.
        • DiaSorin
        LIAISON - 25 OH vitamin D TOTAL assay.
        • UK Biobank
        Biomarker assay quality procedures: approaches used to minimise systematic and random errors (and the wider epidemiological implications).
        • Macdonald H.M.
        • Wood A.D.
        • Tang J.C.
        • Fraser W.D.
        Comparison of vitamin D2 and vitamin D3 supplementation in increasing serum 25-hydroxyvitamin D status: a systematic review and meta-analysis.
        Am J Clin Nutr. 2012; 96: 1152-1153https://doi.org/10.3945/ajcn.112.046110
        • L ehmann U.
        • Gjessing H.R.
        • Hirche F.
        • Mueller-Belecke A.
        • Gudbrandsen O.A.
        • Ueland P.M.
        • et al.
        Efficacy of fish intake on vitamin D status: a meta-analysis of randomized controlled trials.
        Am J Clin Nutr. 2015; 102: 837-847https://doi.org/10.3945/ajcn.114.105395
        • Nwosu B.U.
        • Kum-Nji P.
        Tobacco smoke exposure is an independent predictor of vitamin D deficiency in US children.
        PloS One. 2018; 13 (https://dx.doi.org/10.1371%2Fjournal.pone.0205342)
        • Bertrand K.A.
        • Giovannucci E.
        • Liu Y.
        • Malspeis S.
        • Eliassen A.H.
        • Wu K.
        • et al.
        Determinants of plasma 25-hydroxyvitamin D and development of prediction models in three US cohorts.
        Br J Nutr. 2012; 108 (https://dx.doi.org/10.1017%2FS0007114511007409): 1889-1896
        • Townsend P.
        • Phillimore P.
        • Beattie A.
        Health and deprivation: inequality and the.
        Routledge, North1988https://doi.org/10.1016/0168-8510(88)90006-1
        • Vickers D.
        • Rees P.
        Creating the UK National Statistics 2001 output area classification.
        J Roy Stat Soc. 2007; 170: 379-403https://doi.org/10.1111/j.1467-985X.2007.00466.x
        • Nuttall F.Q.
        Body mass index.
        Nutr Today. 2015; 50 (https://dx.doi.org/10.1097%2FNT.0000000000000092): 117-128
        • Manichaikul A.
        • Mychaleckyj J.C.
        • Rich S.S.
        • Daly K.
        • Sale M.
        • Chen W.-M.
        Robust relationship inference in genome-wide association studies.
        Bioinformatics. 2010; 26: 2867-2873https://doi.org/10.1093/bioinformatics/btq559
        • UK Biobank
        The Ethics and governance Council.
        • Holick M.F.
        • Binkley N.C.
        • Bischoff-Ferrari H.A.
        • Gordon C.M.
        • Hanley D.A.
        • Heaney R.P.
        • et al.
        Evaluation, treatment, and prevention of vitamin D deficiency: an endocrine society clinical practice guideline.
        J Clin Endocrinol Metab. 2011; 96: 1911-1930https://doi.org/10.1210/jc.2011-0385
        • Kroll M.H.
        • Bi C.
        • Garber C.C.
        • Kaufman H.W.
        • Liu D.
        • Caston-Balderrama A.
        • et al.
        Temporal relationship between vitamin D status and parathyroid hormone in the United States.
        PloS One. 2015; 10e0118108https://doi.org/10.1371/journal.pone.0118108
        • Shaw N.J.
        Vitamin D deficiency in UK Asian families: activating a new concern.
        Arch Dis Child. 2002; 86: 147-149https://doi.org/10.1136/adc.86.3.147
        • Webb A.
        • Aseem S.
        • Kift R.
        • Rhodes L.
        • Farrar M.
        Target the message: a qualitative study exploring knowledge and cultural attitudes to sunlight and vitamin D in Greater Manchester, UK.
        Br J Dermatol. 2016; 175: 1401-1403https://doi.org/10.1111/bjd.14800
        • Kift R.
        • Berry J.L.
        • Vail A.
        • Durkin M.T.
        • Rhodes L.E.
        • Webb A.R.
        Lifestyle factors including less cutaneous sun exposure contribute to starkly lower vitamin D levels in U.K. South Asians compared with the white population.
        Br J Dermatol. 2013; 169: 1272-1278https://doi.org/10.1111/bjd.12518
        • Engelsen O.
        • Brustad M.
        • Aksnes L.
        • Lund E.
        Daily duration of vitamin D synthesis in human skin with relation to latitude, total ozone, altitude, ground cover, aerosols and cloud thickness.
        Photochem Photobiol. 2005; 81: 1287https://doi.org/10.1562/2004-11-19-rn-375
        • Addison M.
        • Kaner E.
        • Johnstone P.
        • Hillier-Brown F.
        • Moffatt S.
        • Russell S.
        • et al.
        Equal North: how can we reduce health inequalities in the North of England? A prioritization exercise with researchers, policymakers and practitioners.
        J Publ Health. 2019; 41 (https://dx.doi.org/10.1093%2Fpubmed%2Ffdy170): 652-664
        • Yousaf S.
        • Bonsall A.
        UK Townsend deprivation scores from 2011 census.
        Economic and Social Research Council (ESRC), UK Data Service, 2017
        • Corscadden L.
        • Levesque J.F.
        • Lewis V.
        • Strumpf E.
        • Breton M.
        • Russell G.
        Factors associated with multiple barriers to access to primary care: an international analysis.
        Int J Equity Health. 2018; 17https://doi.org/10.1186/s12939-018-0740-1
        • Schofield L.
        • Walsh D.
        • Munoz-Arroyo R.
        • McCartney G.
        • Buchanan D.
        • Lawder R.
        • et al.
        Dying younger in Scotland: trends in mortality and deprivation relative to england and Wales, 1981–2011.
        Health Place. 2016; 40: 106-115https://doi.org/10.1016/j.healthplace.2016.05.007
        • Melamed M.L.
        • Michos E.D.
        • Post W.
        • Astor B.
        25-Hydroxyvitamin D levels and the risk of mortality in the general population.
        Arch Intern Med. 2008; 168: 1629-1637https://doi.org/10.1001/archinte.168.15.1629
        • Afzal S.
        • Brøndum-Jacobsen P.
        • Bojesen S.E.
        • Nordestgaard B.G.
        Genetically low vitamin D concentrations and increased mortality: mendelian randomisation analysis in three large cohorts.
        BMJ. 2014; 349: g6330https://doi.org/10.1136/bmj.g6330
        • Bambra C.
        • Barr B.
        • Milne E.
        North and South: addressing the English health divide.
        J Publ Health. 2014; 36: 183-186https://doi.org/10.1093/pubmed/fdu029
        • Aguiar M.
        • Andronis L.
        • Pallan M.
        • Högler W.
        • Frew E.
        The economic case for prevention of population vitamin D deficiency: a modelling study using data from England and Wales.
        Eur J Clin Nutr. 2019; https://doi.org/10.1038/s41430-019-0486-x
        • Leung G.
        • Stanner S.
        Diets of minority ethnic groups in the UK: influence on chronic disease risk and implications for prevention.
        Nutr Bull. 2011; 36: 161-198https://doi.org/10.1111/j.1467-3010.2011.01889.x
        • Uday S.
        • Fratzl-Zelman N.
        • Roschger P.
        • Klaushofer K.
        • Chikermane A.
        • Saraff V.
        • et al.
        Cardiac, bone and growth plate manifestations in hypocalcemic infants: revealing the hidden body of the vitamin D deficiency iceberg.
        BMC Pediatr. 2018; 18https://doi.org/10.1186/s12887-018-1159-y
        • UK Biobank
        Access matter: representativeness of the UK Biobank resource.
        • Fry A.
        • Littlejohns T.J.
        • Sudlow C.
        • Doherty N.
        • Adamska L.
        • Sprosen T.
        • et al.
        Comparison of sociodemographic and health-related characteristics of UK biobank participants with those of the general population.
        Am J Epidemiol. 2017; 186: 1026-1034https://doi.org/10.1093/aje/kwx246
        • Stamatakis E.
        • Ekelund U.
        • Wareham N.J.
        Temporal trends in physical activity in england: the health survey for england 1991 to 2004.
        Prev Med. 2007; 45: 416-423https://doi.org/10.1016/j.ypmed.2006.12.014