title: A retrospective cohort study on the influence of UV index and race/ethnicity on risk of stress and lower limb fractures.
abstract: BACKGROUND
  Low vitamin D status increases the risk of stress fractures. As ultraviolet (UV) light is required for vitamin D synthesis, low UV light availability is thought to increase the risk of vitamin D insufficiency and poor bone health. The purpose of this investigation was to determine if individuals with low UV intensity at their home of record (HOR) or those with darker complexions are at increased risk of developing stress fractures and lower limb fractures during U.S. Army Basic Combat Training (BCT).
  
  
  METHODS
  This was a retrospective cohort study using the Armed Forces Health Surveillance Center data repository. All Basic trainees were identified from January 1997 to January 2007. Cases were recruits diagnosed with stress fractures and lower limb fractures during BCT. The recruit's home of record (HOR) was identified from the Defense Manpower Data Center database. The average annual UV intensity at the recruits' HOR was determined using a U.S National Weather Service database and recruits were stratified into low (≤3.9); moderate (4.0-5.4), and high (≥5.5) UV index regions. Race was determined from self-reports.
  
  
  RESULTS
  The dataset had 421,461 men and 90,141 women. Compared to men, women had greater risk of developing stress fractures (odds ratio (OR) = 4.5, 95% confidence interval (95%CI) = 4.4-4.7, p < 0.01). Contrary to the hypothesized effect, male and female recruits from low UV index areas had a slightly lower risk of stress fractures (male OR (low UV/high UV) = 0.92, 95%CI = 0.87-0.97; females OR = 0.89, 95%CI = 0.84-0.95, p < 0.01) and were at similar risk for lower limb fractures (male OR = 0.98, 95%CI = 0.89-1.07; female OR = 0.93, 95%CI = 0.80-1.09) than recruits from high UV index areas. Blacks had lower risk of stress and lower limb fractures than non-blacks, and there was no indication that Blacks from low UV areas were at increased risk for bone injuries.
  
  
  CONCLUSIONS
  The UV index at home of record is not associated with stress or lower limb fractures in BCT. These data suggest that UV intensity is not a risk factor for poor bone health in younger American adults.
authors.affiliation: U.S. Army Research Institute of Environmental Medicine, Bldg. 42, Kansas St., Natick, MA 01760, USA. scott.montain@us.army.mil
authors.forename: Scott J
authors.initials: SJ
authors.lastname: Montain
authors.forename: Susan M
authors.initials: SM
authors.lastname: McGraw
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Ely
authors.forename: Tyson L
authors.initials: TL
authors.lastname: Grier
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Knapik
mesh_terms: D000293:Adolescent; D000328:Adult; D015331:Cohort Studies; D005006:Ethnicity / Q000208:ethnology; D005260:Female; D050723:Fractures, Bone / Q000175:diagnosis / Q000208:ethnology; D015775:Fractures, Stress / Q000175:diagnosis* / Q000208:ethnology*; D006801:Humans; D007869:Leg Injuries / Q000175:diagnosis* / Q000208:ethnology*; D008297:Male; D008889:Military Personnel; D044469:Racial Groups / Q000208:ethnology; D012189:Retrospective Studies; D012307:Risk Factors; D014466:Ultraviolet Rays; D014481:United States / Q000208:ethnology; D055815:Young Adult