Is Vitamin D Supplementation Necessary?
Written by Ben Bunting: BA, PGCert. (Sport & Exercise Nutrition) // Tactical Physical Training Instructor // Performance Coach.
If humans can naturally synthesise Vitamin D simply by stepping out into the sunlight, is a daily oral supplement truly necessary?
While the human body is fully capable of manufacturing this compound under ideal solar conditions, modern lifestyles, shifting climates, and regional geography frequently disrupt this natural process. Because Vitamin D behaves more like a master regulatory hormone than a standard micronutrient, maintaining suboptimal levels can cause a quiet cascade of performance deficits—including compromised recovery, weakened structural integrity, and depressed natural hormone production.
This comprehensive guide breaks down the biological role of Vitamin D, the physiological cost of a baseline deficiency, and how to strategically manage your intake using clean, bioavailable sources.
What is Vitamin D? The Pro-Hormone Distinction
Discovered in the early 20th century during historical efforts to combat industrial bone-mineralisation disorders in the United Kingdom, Vitamin D was initially classified alongside standard dietary vitamins. However, modern endocrinology recognises that "Vitamin D" is actually a misnomer.
Technically, Vitamin D functions as a pro-hormone—an inactive precursor that the body must structurally alter before it can be utilised.
[Dietary Ingestion / UV Skin Exposure]
│
▼
[Inert Vitamin D Compound]
│
▼ (First Hydroxylation in the Liver)
[25-Hydroxyvitamin D]
│
▼ (Second Hydroxylation in the Kidneys)
[Active Steroid Hormone: Calcitriol]
Unlike water-soluble vitamins that pass quickly through the system, Vitamin D is fat-soluble, allowing it to be stored within fatty tissues for extended use. When ultraviolet (UVB) rays strike the skin, they interact with stored cholesterol to initiate a complex conversion process. This process requires two sequential structural alterations—first in the liver, and then in the kidneys—to unlock calcitriol, the highly active steroid hormone that modulates hundreds of pathways throughout the human body.
Dietary Sources and the Fortification Gap
Securing sufficient Vitamin D solely from a whole-food diet is notoriously difficult, as very few whole foods contain it in significant amounts.
Primary Natural Food Sources:
-
Oily Fish: Salmon, trout, mackerel, sardines, and herring.
-
Animal Byproducts: Egg yolks and select enriched pasture-raised proteins.
-
Concentrated Marine Oils: Cod liver oil (traditionally used as a foundational nutrient-dense tonic).
Because these dietary sources are limited, many nations implement public food fortification programs. For example, the United States and Canada frequently fortify milk and breakfast cereals, while other regions focus on enriched grain products.
However, because fortification standards vary globally and whole-food sources are rarely consumed daily, relying on food alone often leaves active individuals well below their optimal physiological threshold.
The Global Deficiency Landscape
Hormonal deficits are far more common than many athletes realise. Large-scale epidemiological data indicate that a substantial portion of the global population has suboptimal circulating Vitamin D levels, a trend driven by clear environmental and biological factors.
[Geographic Latitude] ───► Reduced UVB Availability
▲
│
[Melanin Density] ───► Risk Factors for ───► [Sub-Optimal Hormone Baselines]
Deficiency
│
▼
[Modern Lifestyles] ───► Extended Indoor / Shift Work Hours
Primary Risk Profiles:
-
Geographic Latitude: Populations living above 37 degrees latitude (which includes most of Europe and North America) experience long winter windows where the sun’s angle filters out the UVB wavelengths required for skin synthesis.
-
Melanin Density: Higher concentrations of melanin in darker skin tones act as a natural solar filter, requiring longer duration UV exposure to produce the same volume of the pro-hormone as lighter skin tones.
-
Modern Work Patterns: Indoor occupations, shift work, and necessary tactical sun-safety practices (such as clothing coverage or consistent sunscreen use to prevent skin damage) drastically limit solar exposure.
-
Metabolic Adjustments: Elevated body mass indices (BMI) can physically bind circulating Vitamin D within adipose tissue, making it less accessible to the bloodstream.
Systemic Benefits: How Vitamin D Drives Performance
Maintaining optimal levels of circulating calcitriol provides systemic structural and performance advantages that directly impact training longevity and recovery.
Comprehensive Functional Impact of Optimal Vitamin D
| Physiological System | Primary Mode of Action | Training & Performance Benefit |
| Bone Mineralization | Regulates the active absorption of Calcium and Phosphorus within the intestine. | Preserves skeletal density, prevents stress fractures, and supports joint architecture. |
| Endocrine Function | Interacts with specialised receptors on hormone-producing cells. | Correlates with healthy baseline testosterone synthesis and lean mass management. |
| Immune Defense | Acts as an immunomodulator, supporting natural cellular defence pathways. | Supports upper respiratory tract health and seasonal immune resilience. |
| Neuromuscular Function | Optimises motor unit firing rates and neural signalling pathways. | Assists in maintaining explosive power output, cognitive clarity, and sleep efficiency. |
1. Endocrine Support & Testosterone Baselines
For athletes and tactical professionals, the connection between Vitamin D and natural testosterone production is highly critical. Sports medicine data show a direct link between low circulating Vitamin D concentrations and reduced baseline androgens.
Clinical studies have demonstrated that target groups optimising their Vitamin D status experience a corresponding up-regulation in healthy baseline testosterone levels. This biological synergy is supported by observed seasonal fluctuations, where natural testosterone patterns frequently mirror solar-driven Vitamin D trends.
2. Immune Modulation & Respiratory Health
Calcitriol is a potent immunomodulator. Rather than simply boosting immune responses indiscriminately, it helps organise cellular defences. Clinical reviews indicate that maintaining optimal Vitamin D status is a safe, cost-effective way to support overall respiratory tract health and protect systemic wellness during demanding training cycles.
3. Neuromuscular Recovery & Sleep Efficiency
Optimal Vitamin D levels are strongly associated with improved sleep architecture and reduced daytime fatigue. Studies tracking sleep metrics show a clear correlation between healthy Vitamin D levels and improved REM sleep efficiency, the foundational window during which neurological restoration and tissue repair occur.
Solar Synthesis vs. Controlled Supplementation
While the sun is an exceptional, free resource, it lacks the precision required for reliable, year-round performance optimisation.
⚠️ The Sun Safety Paradox
Protecting skin health requires balancing solar exposure with UV safety. Spending hours unprotected under intense UV rays to maximize Vitamin D synthesis introduces risks of cellular skin damage. Conversely, applying high-SPF sunscreen blocks the exact UVB wavelengths needed for pro-hormone synthesis.
Controlled oral supplementation resolves this paradox. It allows you to protect your skin from excessive UV exposure while ensuring your endocrine system receives a precise, predictable daily dose regardless of your local weather, work shifts, or geographic location.
Sourcing: Vitamin D2 vs. Vitamin D3 (The Vegan Matrix)
When selecting a supplement, it is vital to understand the difference between the two primary forms available:
-
Vitamin D2 (Ergocalciferol): Typically derived from irradiated plant or yeast sources. While functional, it is generally less efficient at sustaining long-term circulating hormone levels in human tissue.
-
Vitamin D3 (Cholecalciferol): The identical form manufactured naturally by human skin. It is significantly more bioavailable and efficient at raising systemic hormone baselines.
Navigating the Vegan Formula Cleanliness
Historically, supplemental Vitamin D3 was sourced exclusively from lanolin (sheep's wool), making it unsuitable for strictly plant-based or vegan athletes. However, modern sports nutrition has unlocked a clean, premium alternative: Lichen.
A lichen is a unique symbiotic organism (an algal-fungal combination) that naturally synthesises highly bioavailable Vitamin D3. This plant-based source delivers the exact performance benefits of traditional D3 while remaining entirely animal-free.
Furthermore, a clean supplement strategy requires auditing the capsule itself. Many standard options utilise cheap animal-derived gelatin shells. Utilising HPMC (Hydroxypropyl Methylcellulose) vegetable capsules ensures that the entire nutrient delivery system remains clean, plant-based, and highly stable.
Strategic Application for Tactical Readiness
To maintain consistent hormonal baselines, support your immune system, and accelerate structural recovery, you must back your physical training with clean, reliable nutrition.
For active-duty personnel, competitive athletes, and tactical professionals who cannot afford seasonal performance drops, Military Muscle offers an uncompromised, open-label solution.
Our professional-grade formula provides an exact, high-strength dose of premium Vitamin D3 sourced directly from Lichen, completely avoiding low-tier Vitamin D2 or animal-derived lanolin. Encapsulated in 100% plant-based HPMC shells and paired with a transparent matrix of natural adaptogens and essential trace elements, Military Muscle is manufactured exclusively in certified GMP facilities. It is completely free of banned substances and proprietary blends—delivering the precise environmental defence your body needs to protect your health and sustain elite operational readiness.

Strategic Public Health Guidelines and the Realities of Modern Scheduling
To combat widespread shortfalls, public health agencies have modernised their baseline advice. For instance, public health guidance in the United Kingdom recommends that every individual consider a daily supplement of at least 400 IU (10 micrograms) of Vitamin D, particularly during the autumn and winter months when ambient sunlight is insufficient for epidermal synthesis.
However, modern occupational demands frequently disrupt this natural solar equation. Extended shifts in office facilities, deep-cycle night-shift operations, and industrial work environments mean that millions of individuals rarely encounter direct sunlight during peak UVB hours.
Evaluating whether your daily routine allows for adequate solar exposure—while simultaneously calculating the precise exposure time required to synthesise a pro-hormone safely without accelerating cellular skin damage—makes relying on the sun an unpredictable strategy. A high-quality, year-round oral supplement removes this guesswork efficiently and cost-effectively.
Safety Profiles: Tolerability, Upper Limits, and Toxicity Realities
When adopting any daily nutritional strategy, understanding safety margins and potential side effects is paramount. Fortunately, clinical data confirms that Vitamin D intoxication is one of the rarest medical anomalies in modern sports nutrition.
The established Tolerable Upper Intake Level (UL) for daily Vitamin D consumption is widely recognised as 4,000 IU, though clinical reviews demonstrate that daily doses up to 10,000 IU ($250\ \mu\text{g}$) are easily tolerated by healthy adults without inducing adverse physiological effects.
True clinical toxicity is almost exclusively the result of severe, long-term accidental overdosing. For example, documented cases of extreme toxicity typically involve individuals mistakenly ingesting industrial-grade, unverified formulations exceeding 1,000,000 IU daily for a continuous period of six months or longer.
In rare instances, hyperaccumulation can trigger hypercalcemia (an over-saturation of calcium in the bloodstream). The clinical markers for this state include:
-
Early Indicators: Loss of appetite (anorexia), persistent nausea, frequent urination, acute vomiting, and unquenchable thirst.
-
Advanced Complications: Severe kidney dysfunction, ectopic calcium deposits in soft tissues, and altered mental clarity.
Because the human body naturally halts Vitamin D synthesis once it reaches saturation under the sun, and because the safety ceiling for oral supplements is remarkably high, the risk of adverse reactions under a standard, structured protocol is exceptionally low.
Demographic and Biological Variations: Hard Statistical Data
While Vitamin D deficiency is a global issue, it does not affect all human populations equally. Because the conversion process relies on UVB rays interacting with the skin, biological variations in melanin concentration play a massive role in how efficiently an individual synthesises this pro-hormone. Melanin acts as a natural solar barrier; higher concentrations filter out UV radiation, requiring significantly longer solar exposure to produce an equivalent volume of Vitamin D.
According to data collected via the National Health and Nutrition Examination Survey (NHANES), the prevalence of Vitamin D insufficiency and deficiency (typically defined as serum levels below 20 ng/mL) breaks down heavily along demographic lines:
Prevalence of Vitamin D Insufficiency by Demographic Group
| Demographic / Racial Cohort | Documented Insufficiency / Deficiency Rate | Primary Biological Driver |
| Non-Hispanic Black Americans | 82.1% | High melanin density provides intense natural UV filtration, drastically reducing solar synthesis rates in non-tropical latitudes. |
| Hispanic Americans | 49.2% | Moderate melanin levels require intermediate solar exposure windows to achieve optimal baseline conversion. |
| Non-Hispanic White Americans | 24.1% | Low melanin density allows for rapid solar synthesis, though modern indoor lifestyles still leave nearly a quarter of this population deficient. |
These concrete figures demonstrate that assuming a standard lifestyle or broad geographic location guarantees nutritional adequacy is a mistake. Tailoring your nutritional protocol to account for your specific biological profile, skin tone, and daily schedule is essential for maintaining optimal baseline health.
Tactical Optimisation: Performance Insights from Military Research
Because military personnel operate under extreme physical workloads, unpredictable sleep cycles, and harsh environmental stressors, defence organisations frequently conduct rigorous clinical research into Vitamin D baselines to preserve operational readiness.
1. Elite Operational Status and Endocrine Deficits
A landmark study evaluating operational Special Forces operators revealed that over 50% of the elite soldiers tested had insufficient Vitamin D status. Crucially, this deficiency was directly correlated with suppressed baseline testosterone levels—even when the operators were stationed at sunny southern latitudes. When high-tier operators experience a dual drop in calcitriol and androgens, it puts a hard ceiling on power output, muscle tissue preservation, and cognitive processing speed under pressure.
2. Submariners and Stress Fracture Mitigation
Submariners represent a unique operational group that experiences absolute solar deprivation during extended deployments. Clinical tracking found that implementing a daily protocol of 2,000 IU of Vitamin D successfully restored optimal serum concentration levels across deployment cycles. This intervention led to a statistically significant reduction in the incidence of debilitating stress fractures, demonstrating the vital role of calcitriol in protecting skeletal infrastructure under zero-sunlight conditions.
3. Marine Recruits and Immune Architecture
The initial training pipeline for the U.S. Marine Corps is designed to push human physiology to its absolute limits. When tracking recruits through these high-stress entry cycles, researchers determined that maintaining robust Vitamin D levels was directly tied to preserving immune resilience. Recruits with optimised baselines demonstrated substantially lower rates of acute respiratory infections and training downtime, highlighting the pro-hormone's role as a shield for the immune system during intense physical fatigue.
4. Latitude-Driven Depressive Symptoms
Military epidemiological research has established a distinct connection between service personnel stationed at high northern latitudes, low circulating serum Vitamin D, and an increased risk of developing depressive symptoms. When solar availability drops, the corresponding dip in calcitriol impacts neurotransmitter pathways in the central nervous system, proving that seasonal vitality is as much chemical as it is psychological.
5. Total Military Capability and Environmental Adaptation
Data synthesised by the Deployment Health Clinical Centre highlighted that low Vitamin D profiles in the blood are systematically linked to an increased risk of soft-tissue injuries, slow wound healing, chronic pain, immunodeficiency, and prolonged recovery timelines for mild traumatic brain injuries.
Interestingly, troops deployed to intense desert environments like the Middle East frequently presented with severe deficiencies. This paradox is driven by tactical necessities: wearing long-sleeved utility uniforms, consistently applying heavy sunscreens, executing high-volume night operations, and actively avoiding the midday heat. When you combine these protective habits with the heavy physical loads carried by modern operators, an uncorrected Vitamin D shortfall dramatically increases the risk of structural injury. The clinical brief concluded that oral supplementation is the cheapest, fastest, and most scalable method for restoring full operational capability across an entire force.
Conclusion
The clinical consensus across civilian sports science and military medicine is clear: Vitamin D deficiency has reached pandemic proportions, threatening athletic performance, metabolic recovery, and long-term musculoskeletal health.
Relying entirely on a whole-food diet is impractical due to the scarcity of naturally rich options, and relying on unregulated solar exposure introduces genuine skin-safety liabilities. Controlled, high-quality oral supplementation eliminates these operational variables. It is an exceptionally safe, clinically verified, and low-cost intervention that ensures your body maintains the exact pro-hormone architecture required to secure your hormonal baseline, protect your immune health, and sustain elite physical output.
Vitamin D is a foundational pillar of human endocrine health, skeletal strength, and immune function. Relying solely on unpredictable sun exposure or sparse dietary sources frequently leaves modern athletes operating in a functional deficit. By utilising a clean, scientifically validated, plant-based Vitamin D3 protocol, you can remove the variables of climate and lifestyle, secure your hormonal baseline, and build a resilient foundation for lifelong physical performance.
References:
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3899558/
[2] https://www.nhs.uk/conditions/vitamins-and-minerals/vitamin-d/
[3] https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/
[4] https://www.britannica.com/science/vitamin-D
[5] https://www.health.harvard.edu/staying-healthy/vitamin-d-and-your-health-breaking-old-rules-raising-new-hopes
[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3356951/
[7] https://extension.colostate.edu/topic-areas/nutrition-food-safety-health/fat-soluble-vitamins-a-d-e-and-k-9-315/
[8] https://pubmed.ncbi.nlm.nih.gov/15585792/
[9] https://pubmed.ncbi.nlm.nih.gov/26135347/
[10] https://ods.od.nih.gov/factsheets/VitaminD
[11] https://www.gov.scot/publications/vitamin-d-advice-for-all-age-groups/
[12] https://pubmed.ncbi.nlm.nih.gov/18400738/
[13] https://yaleglobal.yale.edu/content/world-population-2020-overview#:~:text=The%20world%20population%20now%20stands,just%20a%20few%20years%20ago.
[14] https://medlineplus.gov/vitaminddeficiency.html
[15] https://www.nhs.uk/conditions/vitamins-and-minerals/vitamin-d/
[16] https://www.bmj.com/content/369/bmj.m1548/rr-6
[17] https://www.diabetes.co.uk/news/2020/05/strong-circumstantial-evidence-suggests-vitamin-d-could-improve-covid-19-outcomes/
[18] https://publichealthreviews.biomedcentral.com/track/pdf/10.1007/BF03391602#:~:text=The%20vitamin%20D%20deficiency%20pandemic%20increases%20the%20entire%20world's%20population,infectious%20diseases%20(Figure%203).
[19] https://publichealthreviews.biomedcentral.com/articles/10.1007/BF03391602
[20] https://www.nhs.uk/conditions/rickets-and-osteomalacia/
[21] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4571149/
[22] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(85)91082-7/fulltext
[23] https://www.sciencedirect.com/science/article/abs/pii/S1043276003001887
[24] https://academic.oup.com/jn/article/135/11/2739S/4669900
[25] https://www.sciencedirect.com/science/article/abs/pii/S0300483X02002573
[26] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(01)06580-1/fulltext
[27] https://www.ahajournals.org/doi/10.1161/01.HYP.30.2.150
[28] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)60827-6/fulltext
[29] https://www.onlinejacc.org/content/41/1/105.abstract
[30] https://academic.oup.com/eurheartj/article/31/18/2253/483679
[31] https://jmvh.org/article/vitamin-d-correlation-with-testosterone-concentration-in-male-us-soldiers-and-veterans/
[32] https://www.researchgate.net/publication/49679775_Effect_of_Vitamin_D_Supplementation_on_Testosterone_Levels_in_Men
[33] http://www.ajandrology.com/article.asp?issn=1008-682X;year=2015;volume=17;issue=2;spage=324;epage=328;aulast=Tak
[34] https://pubmed.ncbi.nlm.nih.gov/23008220/
[35] https://pubmed.ncbi.nlm.nih.gov/21282589/
[36] https://www.nature.com/articles/nrneurol.2016.181.pdf?origin=ppub
[37] https://www.nejm.org/doi/full/10.1056/NEJM195205082461901
[38] https://pubmed.ncbi.nlm.nih.gov/24068787/
[39] https://link.springer.com/article/10.1007/s10072-013-1539-x
[40] https://www.nature.com/articles/nrneurol.2011.2
[41] https://pubmed.ncbi.nlm.nih.gov/19433889/
[42] https://jneuroinflammation.biomedcentral.com/articles/10.1186/1742-2094-9-244
[43] https://pubmed.ncbi.nlm.nih.gov/22503994/
[44] https://n.neurology.org/content/83/10/920.short
[45] https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/485359
[46] https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf;jsessionid=031FB4CEEFDB98533793CDFE6BA56F52?sequence=1
[47] https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.163.1.101
[48] https://pubmed.ncbi.nlm.nih.gov/14700448/
[49] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908269/#R52
[50] https://pubmed.ncbi.nlm.nih.gov/18761297/
[51] https://europepmc.org/article/med/10888476
[52] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908269/
[53] https://link.springer.com/article/10.1186/1475-2891-3-8
[54] https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2796.2008.02008.x
[55] https://www.who.int/elena/titles/vitamind_pneumonia_children/en/
[56] https://www.bmj.com/content/356/bmj.i6583
[57] https://core.ac.uk/download/pdf/81725299.pdf
[58] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5787780/
[59] http://isme.tamu.edu/JSCOPE97/Belenky97/Belenky97.htm
[60] https://jcsm.aasm.org/doi/10.5664/jcsm.2266
[61] https://www.jstage.jst.go.jp/article/jnsv/59/3/59_161/_article/-char/ja/
[62] https://academic.oup.com/sleep/article/38/8/1305/2417988
[63] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4013386/
[64] https://www.annfammed.org/content/10/6/547.short
[65] https://www.painphysicianjournal.com/current/pdf?article=MzAwNA%3D%3D&journal=99
[66] https://www.sciencedirect.com/science/article/abs/pii/S0304395913005411
[67] https://pubmed.ncbi.nlm.nih.gov/9797906/
[68] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4103214/
[69] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3349454/
[70] https://ods.od.nih.gov/factsheets/VitaminD-health%20Professional/#en6
[71] https://www.vegansociety.com/resources/nutrition-and-health/nutrients/vitamin-d
[72] http://archive.bio.ed.ac.uk/jdeacon/microbes/lichen.htm
[73] https://lup.lub.lu.se/search/ws/files/4763528/624375.pdf
[74] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6356661/
[75] https://www.sustain.ucla.edu/our-initiatives/food-systems/the-case-for-plant-based/
[76] https://pubmed.ncbi.nlm.nih.gov/28662556/#:~:text=Conclusion%3A%20Latitude%20was%20found%20to,risk%20for%20vitamin%20D%20deficiency.
[77] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5946242/
[78] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6151365/
[79] https://pubmed.ncbi.nlm.nih.gov/27651580/#:~:text=Babies%20of%2012%20patients%20(6,adverse%20maternal%20and%20fetal%20outcomes.
[80] https://www.bda.uk.com/resource/vitamin-d.html
[81] https://cdnsciencepub.com/doi/abs/10.1139/apnm-2020-0643?fbclid=IwAR1hP80O77aK8a6NAx1GqEMhpQp9jsDLmDXNj-UanS7mgY6Zor2RGXB4QF8
[82] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3897596/
[83] https://www.cancer.org.au/preventing-cancer/sun-protection/preventing-skin-cancer/
[84] https://www.britishskinfoundation.org.uk/sunlight-and-vitamin-d#:~:text=In%20simple%20terms%2C%20they%20have,25%2D40%20minutes%20is%20recommended.
[85] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/537616/SACN_Vitamin_D_and_Health_report.pdf
[86] https://www.gov.uk/government/publications/vitamin-d-supplementation-during-winter-phe-and-nice-statement
[87] https://jamanetwork.com/journals/jama/fullarticle/2748796
[88] https://sogacot.org/effects-of-vitamin-d-on-skeletal-muscle-and-athletic-performance/
[89] https://www.fasebj.org/doi/abs/10.1096/fasebj.29.1_supplement.733.5
[90] https://pubmed.ncbi.nlm.nih.gov/31268835/
[91] https://onlinelibrary.wiley.com/doi/abs/10.1111/sms.13467
[92] https://jissn.biomedcentral.com/articles/10.1186/s12970-019-0308-5
[93] https://academic.oup.com/milmed/article/181/9/1163/4159856



