Original Article Ethnic Dress, Vitamin D Intake, and Calcaneal Bone Health in Young Women in the United Kingdom Robert Knoss, * Lewis G. Halsey, and Sue Reeves Department of Life Sciences, Whitelands College, Roehampton University, London, United Kingdom Q1 Abstract Clothing styles that conceal skin from ultraviolet sun radiation contribute to vitamin D deficiency, especially in veiled female minorities in high latitudes. This is the first research into possible effects of ethnic dress on the os calcis and the first study outside North Africa and the Middle East to investigate whether discernible differences in bone quality exist between veiled and unveiled women. The limited previous research into clothing habits and bone health has been inconclusive. One hundred eight women aged 18e45 yr living in the United Kingdom (around 51  north) were analyzed. Forty-three consistently covered arms, hair, and neck when outdoors, whereas 65 consistently had arms, hair, neck, and possibly legs exposed. The quantitative ultrasound scanning (QUS) measurements at the calca- neus were speed of sound (SOS) and broadband ultrasound attenuation (BUA), which were translated into a single clinical value, stiffness index (SI). Dietary intake of vitamin D and calcium was estimated using a validated food frequency questionnaire, and several other risk factors were assessed. There was no significant difference in SI between veiled and unveiled participants (101.30  1.71 vs 99.98  1.86; p 5 0.721); SOS and BUA were also not significantly different. However, smoking and long-term use of steroid medication were significant predictors of calcaneal bone quality, confirming existing research. Our analysis suggests that clothing style alone does not lead to appreciable differences in the quality of the os calcis in young women in the United Kingdom as assessed by QUS. Key Words: Bone health; hypovitaminosis D; osteoporosis; QUS; skin concealment. Introduction The os calcis is easily accessible, weight bearing, has a high trabecular content, and is metabolically sensitive to systemic effects on the skeleton of aging, nutrition, physical activity, and disease (1). The pattern of bone loss is similar to the spine (2), and the acoustic properties of the calcaneus can predict osteoporosis and correlate well with radiological investigations (3). Osteoporosis is a complex and multifactorial metabolic bone disease with increasing incidence worldwide, character- ized by low bone mass and increased fracture risk. Endoge- nous synthesis in the skin accounts for the vast majority of vitamin D precursors in most individuals and is a key component for bone growth and development (4). Vitamin D deficiency in all age groups is widespread and extensive, and hypovitaminosis D is considered a global public health concern (5). The cutaneous production of vitamin D is influ- enced by the amount of solar ultraviolet B (UVB) radiation penetrating the skin, which, in turn, is a function of clothing habits, skin pigmentation, age, geographic latitude, altitude, cloud cover, topical application of UVB filters, air pollution, and time of day of the sun exposure (6). The photolysis of 7-dehydrocholesterol to form cholecalciferol is substantially diminished or completely prevented by textiles (7). Although a growing body of literature strongly suggests a link between clothing habits, inadequate UVB exposure, and low vitamin D levels in women living in sunny climates (8), limited research into the bone quality of women with differing styles of dress exists, and the role of habitual dress in bone formation warrants further enquiry. Thus far, studies in Morocco (9), Lebanon (10), and Turkey (11e14) have compared bone quality between veiled and unveiled women JOCD458_proof ■ 24 October 2011 ■ 1/5 Received 02/20/11; Revised 09/26/11; Accepted 09/26/11. *Address correspondence to: Robert Knoss, Department of Life Sciences, Whitelands College, Roehampton University, London SW15 4JD, United Kingdom. E-mail: robert_knoss@hotmail.com 1 Journal of Clinical Densitometry: Assessment of Skeletal Health, vol. -, no. -,1e5, 2011 Ó Copyright 2011 by The International Society for Clinical Densitometry 1094-6950/-:1e5/$36.00 DOI: 10.1016/j.jocd.2011.09.005 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108