Clothing Practices and Vitamin D Status in Healthy Adults: A Systematic Review and Meta-Analysis

Winnie Bao; Leen Alhuneafat; Eunice Y. Chow

doi:10.53941/dss.2026.100009

Abstract

Vitamin D plays a vital role in bone health, immune function, and physiological well-being, with deficiency (VDD) being a widespread global concern. One proposed risk factor for VDD is body-covering clothing, including modest dress worn for religious, cultural, or personal reasons, which may reduce skin exposure to ultraviolet B radiation, potentially impairing endogenous vitamin D synthesis. This systematic review and meta-analysis examines the association between clothing practices and vitamin D in healthy adults. A literature search was conducted to identify studies from databases between 1 January 1975 and 1 January 2026. The inclusion criteria were healthy adults (18–65 years old), all genders, English-language, randomized controlled trials, observational studies, and full-text papers. The exclusion criteria included pregnancy, smoking, symptomatic VDD, acute illness, chronic diseases, and intake of medications affecting vitamin D metabolism. Overall, 2203 studies were identified, and 35 articles underwent full-text assessment. Twenty-seven studies were excluded due to ineligible populations and insufficient outcome data. Eight observational studies were included, comprising 1043 participants. In random-effects analysis, serum 25(OH)D was 12.8 nmol/L lower in covered than uncovered individuals (95% CI −21.7 to −3.8; z = −2.79, p = 0.005), with substantial heterogeneity (I² = 93.7%; τ² = 113.2; Q = 52.5, df = 5, p < 0.001). Newcastle-Ottawa assessment revealed three studies rated good, four fair, and one poor. This review highlights the need for targeted public health interventions, including supplementation and education, to mitigate VDD risk in individuals who wear modest clothing, particularly those residing in northern latitudes.

References

1.
Holick, M.F. Vitamin D deficiency. N. Engl. J. Med. 2007, 357, 266–281. https://doi.org/10.1056/nejmra070553.
2.
Wang, H.; Chen, W.; Li, D.; et al. Vitamin D and Chronic Diseases. Aging Dis. 2017, 8, 346–353. https://doi.org/10.14336/ad.2016.1021.
3.
Holick, M.F. The vitamin D deficiency pandemic: Approaches for diagnosis, treatment and prevention. Rev. Endocr. Metab. Disord. 2017, 18, 153–165. https://doi.org/10.1007/s11154-017-9424-1.
4.
Lips, P. Vitamin D deficiency and secondary hyperparathyroidism in the elderly: Consequences for bone loss and fractures and therapeutic implications. Endocr. Rev. 2001, 22, 477–501. https://doi.org/10.1210/edrv.22.4.0437.
5.
Rosen, C.J.; Adams, J.S.; Bikle, D.D.; et al. The nonskeletal effects of vitamin D: An Endocrine Society scientific statement. Endocr. Rev. 2012, 33, 456–492. https://doi.org/10.1210/er.2012-1000.
6.
Batieha, A.; Khader, Y.; Jaddou, H.; et al. Vitamin D status in Jordan: Dress style and gender discrepancies. Ann. Nutr. Metab. 2011, 58, 10–18. https://doi.org/10.1159/000323097.
7.
Passeron, T.; Bouillon, R.; Callender, V.; et al. Sunscreen photoprotection and vitamin D status. Br. J. Dermatol. 2019, 181, 916–931. https://doi.org/10.1111/bjd.17992.
8.
Engelsen, O. The relationship between ultraviolet radiation exposure and vitamin D status. Nutrients 2010, 2, 482–495. https://doi.org/10.3390/nu2050482.
9.
Statistics Canada. A Snapshot of the Muslim Population in Canada. 2025. Available online: https://www.statcan.gc.ca/o1/en/plus/7639-snapshot-muslim-population-canada (accessed on 30 March 2025).
10.
Environics Institute. Survey of Muslims in Canada 2016. 2016. Available online: https://environicsinstitute.org/wp-content/uploads/2016/06/final-report-2.pdf (accessed on 30 March 2025).
11.
Statistics Canada. The Canadian Census: A Rich Portrait of the Country’s Religious and Ethnocultural Diversity. 2022. Available online: https://www150.statcan.gc.ca/n1/daily-quotidien/221026/dq221026b-eng.htm (accessed on 30 March 2025).
12.
Staetsky, L.D. Haredi JEWS around the World: Population Trends and Estimates; Institute for Jewish Policy Research: London, UK, 2022.
13.
Seigelshifer, V.; Hartman, T. From Tichels to hair bands: Modern orthodox women and the practice of head covering. Women's Stud. Int. Forum 2011, 34, 349–359. https://doi.org/10.1016/j.wsif.2011.05.006.
14.
Webb, A.; Kline, L.; Holick, M. Influence of season and latitude on the cutaneous synthesis of vitamin D3: Exposure to winter sunlight in Boston and Edmonton will not promote vitamin D3 synthesis in human skin. J. Clin. Endocrinol. Metab. 1988, 67, 373–378. https://doi.org/10.1210/jcem-67-2-373.
15.
Wacker, M.; Holick, M.F. Sunlight and Vitamin D: A global perspective for health. Dermatoendocrinol 2013, 5, 51–108. https://doi.org/10.4161/derm.24494.
16.
Mohamed, S.H.; Alizadeh, S.; Tessema, M.; et al. Clothing type and vitamin D status: A systematic review and meta-analysis. Res. Sq. 2021, 1–13. https://doi.org/10.21203/rs.3.rs-376562/v1.
17.
Page, M.; McKenzie, J.; Bossuyt, P.; et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 2021, 372, n71. https://doi.org/10.1136/bmj.n71.
18.
Modesti, P.A.; Reboldi, G.; Cappuccio, F.P.; et al. Panethnic Differences in Blood Pressure in Europe: A Systematic Review and Meta-Analysis. PLoS ONE 2016, 11, e0147601. https://doi.org/10.1371/journal.pone.0147601.
19.
JASP Team. JASP, Version 0.98.1. JASP Team: Amsterdam, The Netherlands, 2026. Available online: https://jasp-stats.org (accessed on 14 July 2026).
20.
Wan, X.; Wang, W.; Liu, J.; et al. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med. Res. Methodol. 2014, 14, 135. https://doi.org/10.1186/1471-2288-14-135.
21.
Howick, J.; Chalmers, I.; Glasziou, P.; et al. The 2011 Oxford CEBM Levels of Evidence (Introductory Document). Oxford Centre for Evidence-Based Medicine. 2011. Available online: https://www.cebm.net/wp-content/uploads/2014/06/CEBM-Levels-of-Evidence-Introduction-2.1.pdf (accessed on 14 July 2026).
22.
Karras, S.N.; Michalakis, K.; Kypraiou, M.; et al. Predictors of Vitamin D Status in Religious and Intermittent Fasting: A Comparative Study in Orthodox Nuns and Women from the General Population. Nutrients 2025, 17, 1656. https://doi.org/10.3390/nu17101656.
23.
Buyukuslu, N.; Esin, K.; Hizli, H.; et al. Clothing preference affects vitamin D status of young women. Nutr. Res. 2014, 34, 688–693. https://doi.org/10.1016/j.nutres.2014.07.012.
24.
Sayed-Hassan, R.; Abazid, N.; Alourfi, Z. Relationship between 25-hydroxyvitamin D concentrations, serum calcium, and parathyroid hormone in apparently healthy Syrian people. Arch. Osteoporos. 2014, 9, 176. https://doi.org/10.1007/s11657-014-0176-1.
25.
Tsur, A.; Metzger, M.; Dresner-Pollak, R. Effect of different dress style on vitamin D level in healthy young Orthodox and ultra-Orthodox students in Israel. Osteoporos. Int. 2011, 22, 2895–2898. https://doi.org/10.1007/s00198-010-1492-y.
26.
Islam, M.; Akhtaruzzaman, M.; Lamberg-Allardt, C. Hypovitaminosis D is common in both veiled and nonveiled Bangladeshi women. Asia Pac. J. Clin. Nutr. 2006, 15, 81–87.
27.
Meddeb, N.; Sahli, H.; Chahed, M.; et al. Vitamin D deficiency in Tunisia. Osteoporos. Int. 2005, 16, 180–183. https://doi.org/10.1007/s00198-004-1658-6.
28.
Gannagé‐Yared, M.; Chemali, R.; Yaacoub, N.; et al. Hypovitaminosis D in a Sunny Country: Relation to Lifestyle and Bone Markers. J. Bone Miner. Res. 2000, 15, 1856–1862. https://doi.org/10.1359/jbmr.2000.15.9.1856.
29.
Dawodu, A.; Absood, G.; Patel, M.; et al. Biosocial Factors Affecting Vitamin D Status of Women of Childbearing Age in the United Arab Emirates. J. Biosoc. Sci. 1998, 30, 431–437. https://doi.org/10.1017/s0021932098004313.
30.
Whiting, S.; Bonjour, J.; Payen, F.; et al. Moderate amounts of vitamin D3 in supplements are effective in raising serum 25-hydroxyvitamin D from low baseline levels in adults: A systematic review. Nutrients 2015, 7, 2311–2323. https://doi.org/10.3390/nu7042311.
31.
Sempos, C.T.; Heijboer, A.C.; Bikle, D.D.; et al. Vitamin D assays and the definition of hypovitaminosis D: Results from the First International Conference on Controversies in Vitamin D. Br. J. Clin. Pharmacol. 2018, 84, 2194–2207. https://doi.org/10.1111/bcp.13652.
32.
Whiting, S.; Langlois, K.; Vatanparast, H.; et al. The vitamin D status of Canadians relative to the 2011 Dietary Reference Intakes: An examination in children and adults with and without supplement use. Am. J. Clin. Nutr. 2011, 94, 128–135. https://doi.org/10.3945/ajcn.111.013268.
33.
Valcour, A.; Blocki, F.; Hawkins, D.M.; et al. Effects of age and serum 25-OH-vitamin D on serum parathyroid hormone levels. J. Clin. Endocrinol. Metab. 2012, 97, 3989–3995. https://doi.org/10.1210/jc.2012-2276.
34.
Ojah, R.C.I.; Welch, J.M. Vitamin D and musculoskeletal status in Nova Scotian women who wear concealing clothing. Nutrients 2012, 4, 399–412. https://doi.org/10.3390/nu4050399.
35.
Schwalfenberg, G.K.; Genuis, S.J.; Hiltz, M.N. Addressing vitamin D deficiency in Canada: A public health innovation whose time has come. Public Health 2010, 124, 350–359. https://doi.org/10.1016/j.puhe.2010.03.003.
36.
Genuis, S.J.; Schwalfenberg, G.K.; Hiltz, M.N.; et al. Vitamin D status of clinical practice populations at higher latitudes: Analysis and applications. Int. J. Environ. Res. Public Health 2009, 6, 151–173. https://doi.org/10.3390/ijerph6010151.
37.
Statistics Canada. Geographic Attribute File, Reference Guide, Census Year 2021. 2021. Available online: https://www150.statcan.gc.ca/n1/pub/92-151-g/92-151-g2021001-eng.htm (accessed on 30 March 2025).
38.
Mendes, M.; Darling, A.; Hart, K.; et al. Impact of high latitude, urban living and ethnicity on 25-hydroxyvitamin D status: A need for multidisciplinary action? J. Steroid Biochem. Mol. Biol. 2019, 188, 95–102. https://doi.org/10.1016/j.jsbmb.2018.12.012.
39.
Brenner, M.; Hearing, V.J. The protective role of melanin against UV damage in human skin. Photochem. Photobiol. 2008, 84, 539–549. https://doi.org/10.1111/j.1751-1097.2007.00226.x.
40.
Webb, A.; Kazantzidis, A.; Kift, R.; et al. Meeting vitamin D requirements in White Caucasians at UK latitudes: Providing a choice. Nutrients 2018, 10, 497. https://doi.org/10.3390/nu10040497.
41.
Webb, A.; Kazantzidis, A.; Kift, R.; et al. Colour Counts: Sunlight and Skin Type as Drivers of Vitamin D Deficiency at UK Latitudes. Nutrients 2018, 10, 457. https://doi.org/10.3390/nu10040457.
42.
Kift, R.; Rhodes, L.E.; Farrar, M.D.; et al. Is Sunlight Exposure Enough to Avoid Wintertime Vitamin D Deficiency in United Kingdom Population Groups? Int. J. Environ. Res. Public Health 2018, 15, 1624. https://doi.org/10.3390/ijerph15081624.
43.
Wagner, W.; Sen, R.; Permanadeli, R.; et al. The veil and Muslim women’s identity: Cultural pressures and resistance to stereotyping. Cult. Psychol. 2012, 18, 521–541. https://doi.org/10.1177/1354067x12456713.
44.
Chan, I.L.; Cohen, S.; da Cunha, M.G.; et al. Characteristics and management of Asian skin. Int. J. Dermatol. 2019, 58, 131–143. https://doi.org/10.1111/ijd.14153.
45.
Mar, K.; Khalid, B.; Maazi, M.; et al. Treatment of Post-Inflammatory Hyperpigmentation in Skin of Colour: A Systematic Review. J. Cutan. Med. Surg. 2024, 28, 473–480. https://doi.org/10.1177/12034754241265716.
46.
Narla, S.; Heath, C.; Alexis, A.; et al. Racial disparities in dermatology. Arch. Dermatol. Res. 2023, 315, 1215–1223. https://doi.org/10.1007/s00403-022-02507-z.
47.
Gallagher, J.C. Vitamin D and aging. Endocrinol. Metab. Clin. N. Am. 2013, 42, 319–332. https://doi.org/10.1016/j.ecl.2013.02.004.
48.
Chalcraft, J.R.; Cardinal, L.M.; Wechsler, P.J.; et al. Vitamin D Synthesis Following a Single Bout of Sun Exposure in the Older and Younger Men and Women. Nutrients 2020, 12, 2237. https://doi.org/10.3390/nu12082237.
49.
Migliaccio, S.; Di Nisio, A.; Magno, S.; et al. Vitamin D deficiency: A potential risk factor for cancer in obesity? Int. J. Obes. 2022, 46, 707–717. https://doi.org/10.1038/s41366-021-01045-4.
50.
Tobias, D.K.; Luttmann-Gibson, H.; Mora, S.; et al. Association of Body Weight with Response to Vitamin D Supplementation and Metabolism. JAMA Netw. Open 2023, 6, e2250681. https://doi.org/10.1001/jamanetworkopen.2022.50681.
51.
Karras, S.; Georgopoulos, N.; Mouslech, Z.; et al. Comparative effects of vitamin D supplementation on serum calciotropic hormone profile, in Orthodox nuns with hypovitaminosis D in different regions of Greece, versus intermittent fasting and western diet in Lay Women. In Endocrine Abstracts, Proceedings of the 26th European Congress of Endocrinology, Stockholm, Sweden, 11–14 May 2024; BioScientifica: Bristol, UK, 2024. https://doi.org/10.1530/endoabs.99.p40.
52.
Hribar, M.; Pravst, I.; Pogačnik, T.; et al. Results of longitudinal Nutri-D study: Factors influencing winter and summer vitamin D status in a Caucasian population. Front. Nutr. 2023, 10, 1253341.
53.
Alzaheb, R.A.; Al-Amer, O. Prevalence and Predictors of Hypovitaminosis D among Female University Students in Tabuk, Saudi Arabia. Clin. Med. Insights Women’s Health 2017, 10, 1179562X17702391. https://doi.org/10.1177/1179562x17702391.
54.
Skaaby, T.; Husemoen, L.L.N.; Thuesen, B.H.; et al. Longitudinal associations between lifestyle and vitamin D: A general population study with repeated vitamin D measurements. Endocrine 2016, 51, 342–350. https://doi.org/10.1007/s12020-015-0641-7.
55.
Seraphin, G.; Rieger, S.; Hewison, M.; et al. The impact of vitamin D on cancer: A mini review. J. Steroid Biochem. Mol. Biol. 2023, 231, 106308. https://doi.org/10.1016/j.jsbmb.2023.106308.
56.
Albertelli, M.; Petolicchio, C.; Brasili, S.; et al. Impact of Vitamin D Deficiency on Tumor Aggressiveness in Neuroendocrine Neoplasms. Nutrients 2023, 15, 3771. https://doi.org/10.3390/nu15173771.
57.
Judd, S.E.; Tangpricha, V. Vitamin D deficiency and risk for cardiovascular disease. Am. J. Med. Sci. 2009, 338, 40–44. https://doi.org/10.1097/maj.0b013e3181aaee91.
58.
Levin, A.; Li, Y. Vitamin D and its analogues: Do they protect against cardiovascular disease in patients with kidney disease? Kidney Int. 2005, 68, 1973–1981. https://doi.org/10.1111/j.1523-1755.2005.00651.x.
59.
Balasooriya, N.N.; Elliott, T.M.; Neale, R.E.; et al. The association between vitamin D deficiency and multiple sclerosis: An updated systematic review and meta-analysis. Mult. Scler. Relat. Disord. 2024, 90, 105804. https://doi.org/10.1016/j.msard.2024.105804.
60.
Magro, R.; Saliba, C.; Camilleri, L.; et al. Vitamin D supplementation in systemic lupus erythematosus: Relationship to disease activity, fatigue and the interferon signature gene expression. BMC Rheumatol. 2021, 5, 53. https://doi.org/10.1186/s41927-021-00223-1.
61.
Kostoglou-Athanassiou, I.; Athanassiou, P.; Lyraki, A.; et al. Vitamin D and rheumatoid arthritis. Ther. Adv. Endocrinol. Metab. 2012, 3, 181–187. https://doi.org/10.1177/2042018812471070.
62.
Lee, S.B.; Jin, M.H.; Yoon, J.H. The contribution of vitamin D insufficiency to the onset of steatotic liver disease among individuals with metabolic dysfunction. Sci. Rep. 2024, 14, 6714. https://doi.org/10.1038/s41598-024-57380-9.
63.
Berridge, M.J. Vitamin D deficiency and diabetes. Biochem. J. 2017, 474, 1321–1332. https://doi.org/10.1042/bcj20170042.
64.
Palomer, X.; González-Clemente, J.; Blanco-Vaca, F.; et al. Role of vitamin D in the pathogenesis of type 2 diabetes mellitus. Diabetes Obes. Metab. 2008, 10, 185–197. https://doi.org/10.1111/j.1463-1326.2007.00710.x.
65.
Almuqbil, M.; Almadani, M.E.; Albraiki, S.A.; et al. Impact of Vitamin D Deficiency on Mental Health in University Students: A Cross-Sectional Study. Healthcare 2023, 11, 2097. https://doi.org/10.3390/healthcare11142097.
66.
Zhu, J.L.; Luo, W.W.; Cheng, X.; et al. Vitamin D deficiency and Schizophrenia in Adults: A Systematic Review and Meta-analysis of Observational Studies. Psychiatry Res. 2020, 288, 112959. https://doi.org/10.1016/j.psychres.2020.112959.
67.
Hassan, A.A.; Elbashir, M.I.; Al-Nafeesah, A.; et al. Association between Serum 25-Hydroxyvitamin D Concentrations and Academic Performance among Adolescent Schoolchildren: A Cross-Sectional Study. Nutrients 2023, 15, 4552. https://doi.org/10.3390/nu15214552.
68.
Głąbska, D.; Kołota, A.; Lachowicz, K.; et al. The Influence of Vitamin D Intake and Status on Mental Health in Children: A Systematic Review. Nutrients 2021, 13, 952. https://doi.org/10.3390/nu13030952.
69.
Tsenkova-Toncheva, L.; Hristova-Atanasova, E.; Iskrov, G.; et al. Prenatal Vitamin D Deficiency and Maternal and Fetal Health Outcomes. Cureus 2024, 16, e69508. https://doi.org/10.7759/cureus.69508.
70.
Aghajafari, F.; Letourneau, N.; Mahinpey, N.; et al. Vitamin D Deficiency and Antenatal and Postpartum Depression: A Systematic Review. Nutrients 2018, 10, 478. https://doi.org/10.3390/nu10040478.
71.
Lee, J.M.; Smith, J.R.; Philipp, B.L.; et al. Vitamin D Deficiency in a Healthy Group of Mothers and Newborn Infants. Clin. Pediatr. 2007, 46, 42–44. https://doi.org/10.1177/0009922806289311.
72.
Khan, F. Relocating the veil: The everyday lives of young hijabi Britons under ideological culturalism. Ethn. Racial Stud. 2022, 45, 501–522. https://doi.org/10.1080/01419870.2022.2105656.
73.
Shah, S. Voices That Matter: An Intersectional Analysis of Canadian Muslim Women. Canadian Council of Muslim Women. 2022. Available online: https://www.ccmw.com/wp-content/uploads/2026/04/Voicesthatmatter-3.pdf (accessed on 14 July 2026).
74.
Shah, S. Still Overqualified and Underemployed? Canadian Muslim Women’s Experiences of Employment Barriers and Facilitators. Canadian Council of Muslim Women. 2024. Available online: https://static1.squarespace.com/static/5b43ad2bf407b4a036d27f06/t/66a070b12d31df3ede160511/1721790651495/ASPIRE+Study+Report.pdf (accessed on 14 July 2026).
75.
Rohr, E.; Antebi, L.; Jarvis, G.E.; et al. “Sheltered and secure”: Facilitators and barriers toward recovery for Haredi Jewish women with mental illness. Psychiatr. Rehabil. J. 2025, 48, 54–61. https://doi.org/10.1037/prj0000625.
76.
Pinchas-Mizrachi, R.; Velan, B. The Effects of Sociocultural Transitioning on Accessibility to Healthcare: The Case of Haredi Jews Who Leave Their Communities. Contemp. Jew. 2022, 42, 139–156. https://doi.org/10.1007/s12397-022-09433-2.
77.
Leiter, E.; Greenberg, K.L.; Donchin, M.; et al. Cardiovascular disease risk factors and health behaviors of ultra-Orthodox Jewish women in Israel: A comparison study. Ethn. Health 2022, 27, 1031–1046. https://doi.org/10.1080/13557858.2020.1849567.
78.
Jacobson, A.; Spitzer, S.; Gorelik, Y.; et al. Barriers and enablers to vaccination in the ultra-orthodox Jewish population: A systematic review. Front. Public Health 2023, 11, 1244368. https://doi.org/10.3389/fpubh.2023.1244368.
79.
Schnall, E.; Kalkstein, S.; Gottesman, A.; et al. Barriers to mental health care: A 25‐year follow‐up study of the Orthodox Jewish community. J. Multicult. Couns. Dev. 2014, 42, 161–173. https://doi.org/10.1002/j.2161-1912.2014.00052.x.
80.
Amrein, K.; Scherkl, M.; Hoffmann, M.; et al. Vitamin D deficiency 2.0: An update on the current status worldwide. Eur. J. Clin. Nutr. 2020, 74, 1498–1513. https://doi.org/10.1038/s41430-020-0558-y.
81.
American College of Obstetricians and Gynecologists. Vitamin D: Screening and Supplementation during Pregnancy. Obstet. Gynecol. 2011, 118, 197–198. https://doi.org/10.1097/aog.0b013e318227f06b.
82.
Kaushal, M.; Magon, N. Vitamin D in pregnancy: A metabolic outlook. Indian J. Endocrinol. Metab. 2013, 17, 76–82. https://doi.org/10.4103/2230-8210.107862.

Scilight Press

Author Information

Abstract

Keywords

References

About Scilight

Journals

Publishing Policies

Contact Us