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The Beverage Institute for Health & Wellness, The Coca-Cola Company, Houston, TX 77056;
* ENVIRON Health Sciences, Arlington, VA 22203; and
Department of Medicine, Section of Endocrinology, Nutrition, and Diabetes, Vitamin D, Skin, and Bone Research Laboratory, Boston University Medical Center, Boston, MA 02118
2To whom correspondence should be addressed. E-mail: caromoore{at}na.ko.com.
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ABSTRACT |
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 TOP ABSTRACT SUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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1 y old who participated in the 1999–2000 National Health and Nutrition Examination Survey (NHANES 1999–2000) were included in the analysis. Vitamin D intake by non-Hispanic (NH) white, NH black, Mexican American, and all individuals in the United States was estimated and compared with recommended levels. Vitamin D intakes were highest among children and teenagers, and lowest in the oldest age categories. Among children age 1–8 y, adequate intake (AI) levels for vitamin D from food were met or exceeded by 69% of Mexican American, 59% of NH white, and 48% of NH black subpopulations. Among adults 51 y old, only 4% met or exceeded the AI from food alone. Few women 19–50 y old or men and women 51 y old were estimated to consume recommended vitamin D levels from food. Mean dietary intakes of vitamin D from food plus supplements were consistently highest among NH white populations, although only small proportions of all those 51 y old had intakes above the recommended levels. The large discrepancy between vitamin D intake by older individuals from food plus supplements and recommended levels, especially for NH black and Mexican American adults, warrants intervention.
KEY WORDS: • vitamin D intake • ethnic groups
Vitamin D status concerns in the United States have resurfaced recently because of an increasing number of reports of the prevalence of vitamin D insufficiency and deficiency, particularly among people with darkly pigmented skin (1). Vitamin D represents either ergocalciferol (D-2) or cholecalciferol (D-3). The best clinical indicator of vitamin D status is circulating levels of 25-hydroxyvitamin D [25(OH)D]3 concentrations (1). When 25(OH)D levels remain below 20 nmol/L (8 µg/L), overt signs of a vitamin D deficiency such as bone pain and poor bone mineralization occur. The circulating 25(OH)D concentrations below which a subclinical vitamin D deficiency (vitamin D insufficiency) affects cellular function, but not bone mineralization, are controversial, with proposed cutoff values from 27.5 to 100 nmol/L (11–40 µg/L) (1).
Rickets, a disease characterized by soft and deformed bones due to vitamin D deficiency, was nearly eliminated in the United States when vitamin D fortification of milk was introduced in the 1930s (2). Several recent studies, however, have reported rickets among African American children (2–5) and have heightened the awareness of vitamin D insufficiency among these infants and mothers. Reports also indicated that adolescents and young adults are at an increased risk of vitamin D insufficiency (6–8). In an urban clinic, many U.S. adolescents were also found to be vitamin D deficient, with the highest deficiency occurring in African American teenagers, particularly during the winter, although the problem was also common across sex, season, and ethnicity (9). Other studies demonstrated that vitamin D deficiency is much higher in dark-pigmented persons and Asians due to a reduced ability to produce vitamin D in the skin (1,10,11). Overall, the elderly and institutionalized adults have the highest risk of vitamin D insufficiency or deficiency (12–14).
Recently, we estimated mean dietary intakes of vitamin D by the U.S. population using food consumption data collected in the third National Health and Nutrition Examination Survey (NHANES III, 1988–1994) and the 1994–1996, 1998 Continuing Survey of Food Intakes by Individuals (CSFII 1994–1996, 1998) (15). The lowest intakes of vitamin D from food were reported by female teenagers and women, whereas the highest intakes of vitamin D from food sources were reported by male teenagers. Although use of vitamin D–containing dietary supplements increased the number of individuals in the United States meeting or exceeding recommended adequate intake (AI) levels, nearly all older adults still did not consume recommended levels of vitamin D.
Utilizing a more recent release of the NHANES survey data (NHANES 1999–2000) (16) and our database of estimates of the vitamin D concentrations in foods in the U.S. food supply in 2000, we have now estimated vitamin D intakes in the United States by race and ethnicity, and the percentage of these populations consuming the recommended levels of vitamin D.
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SUBJECTS AND METHODS |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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60 y old, African Americans, and Mexican Americans were oversampled. Dietary intakes were collected primarily through in-person interviews using a computer assisted "multiple pass" 24-h dietary interview in Mobile Examination Centers (MECs). A subsample (
20%) of interviews was collected via telephone 4–10 d after the MEC health examination. A total of 8604 nonbreast-feeding individuals provided dietary recalls determined to be reliable and to meet overall quality and completeness criteria set by NCHS. Race and ethnic group classifications were self-reported by NHANES 1999–2000 respondents and coded by NCHS to one of the following categories: non-Hispanic (NH) white, NH black, Mexican American, other Hispanic, and other race (including multiracial).
Estimates of vitamin D concentrations in foods.
United States populations are largely dependent on fortified foods and supplements to meet vitamin D needs because foods that are naturally rich in vitamin D are not consumed frequently (1). The most concentrated natural sources of vitamin D are found in oily fish; other foods of animal origin including egg yolk, meat, and dairy fat provide less concentrated natural sources of vitamin D (17). In 1985 the FDA affirmed vitamin D as Generally Recognized As Safe (GRAS) with specific limitations as a direct human food ingredient, as set forth in 21 CFR 
184.1950 (18). This regulation allows for the addition of vitamin D to breakfast cereals, grain products and pastas, milk, milk products, margarine, and infant formula. In 2003 the allowable uses of vitamin D as a fortificant were expanded with the approval of vitamin D fortification of calcium-fortified juice and juice drinks at a maximum level of 2.5 µg (100 IU) per 240 mL (8 fl oz) serving (19).
The nutrient intake data reported in NHANES 1999–2000 are based on the USDA’s 1994–1996 and 1998 Survey Nutrient Databases and do not include nutrient data for vitamin D. Consequently, it was necessary to first develop estimates of the vitamin D concentrations in foods reported by survey respondents. In 2000 ENVIRON Health Sciences (ENVIRON) developed a database of estimates of the vitamin D concentrations in foods reflective of the food supply at that time. The vitamin D data sources used to compile the database included the USDA Nutrient Database for Standard Reference, Standard Release 13 (17); the Nutrient Data System for Research (NDS-R, version 4.02–30), a proprietary database developed by the Nutrition Coordinating Center of the University of Minnesota (20); the published literature; product information collected from manufacturers; information collected in Internet searches; and product labels observed between June and August, 2000. The database includes estimates of concentrations of naturally occurring vitamin D and vitamin D added as a nutrient fortificant (IU vitamin D/100 g food). The database does not differentiate sources of ergocalciferol from cholecalciferol. All natural animal sources of vitamin D are in the cholecalciferol form. The database does not differentiate between ergocalciferol and cholecalciferol provided by fortified foods.
Foods that were found to contain added vitamin D at the time the ENVIRON vitamin D database was developed include many brands of breakfast cereals, selected infant cereals and grain-based toddler foods, milk (fluid and dried), dairy-based beverages and beverage mixes including weight control beverages, major brands of margarines, infant formulas, weight control bars, soymilks, and infant cookies.
It was estimated that 98% of the fluid milk in the United States is fortified with vitamin D (21). In our vitamin D database, all fluid milk was assumed to contain 10 µg (400 IU) vitamin D/quart (946 mL), which is consistent with the standard of identity for fortified milk (22). Acceptable ranges for vitamin D in fluid milk are 10–15 µg (400–600 IU)/quart (23). Early studies in the 1990s suggested that milk rarely contained the amount of vitamin D stated on the label (either under- or overfortified) (24). A more recent study of the concentration of vitamin D in milk indicated that only 47.7% of 648 samples of fluid milk in New York state were within the acceptable range for vitamin D (25), and that most of the milk samples that were out of compliance were underfortified. Nevertheless, the vitamin D content of milk was assumed to be 10 µg (400 IU)/quart in this analysis. Analytical data recently reported by USDA indicated that the mean concentration of vitamin D in samples of whole, 2%, and skim milk ranged from 9.9 to 10.5 µg/quart, whereas the mean vitamin D concentration in 1% milk was 12.7 µg/quart (26).
The vitamin D concentration data compiled for naturally occurring and fortified sources of vitamin D were used to estimate the total amount of vitamin D/100 g of each food code reported in NHANES 1999–2000. The vitamin D concentrations in food mixtures containing ingredients with naturally occurring and/or added vitamin D were calculated using both USDA recipes and ENVIRON proprietary commodity level recipes by multiplying the vitamin D concentration of each ingredient by the percentage of the ingredient in the food and summing the results. The USDA recipes were based on the Primary Data Set ingredients (27), and the ENVIRON proprietary commodity level recipes were based on Raw Agricultural Commodities (28).
Dietary supplement data source. Intake of vitamin D from dietary supplements was estimated from the most recent quantitative data on dietary supplement intakes collected in NHANES 1999–2000 (16,29). Vitamin D–containing supplements were identified in the NHANES Dietary Supplement Database, and the intake of vitamin D (IU) from supplements was estimated for each respondent by linking self-reported information (number, form, and frequency of supplement intake) with supplement information compiled by NCHS, including recommended number of supplements and amount of vitamin D per supplement.
Estimates of vitamin D intakes. Vitamin D concentration data were linked to the food consumption data collected on d 1 of recall in NHANES 1999–2000 to generate estimates of mean daily vitamin D intake from all food sources, and from each of 4 source categories of vitamin D: fortified milk, fortified ready-to-eat (RTE) cereals, other fortified foods, and naturally occurring sources. Estimates of mean vitamin D intake also were calculated from food plus supplements. Estimates of mean vitamin D intake from food sources and from food plus supplements were calculated for all individuals and by race/ethnicity group for each of 7 sex/age groups. Estimates of vitamin D (IU) were converted to micrograms using the conversion: 1 µg = 40 IU vitamin D (30).
Estimates of vitamin D adequacy. To assess vitamin D intake adequacy, the percentage of the population whose vitamin D intake from food alone or from food plus supplements was at or above the AI level was determined. The vitamin D AI is 5 µg/d (200 IU) for individuals 1–50 y old, 10 µg/d (400 IU) for individuals 51–70 y old, and 15 µg/d (600 IU) for those > 70 y old (30).
Statistical analyses. Estimates of mean daily vitamin D intake were calculated for the total population and NH white, NH black, and Mexican American race/ethnicities. Estimates of vitamin D intake were not calculated for the other Hispanic group from the NHANES 1999–2000 survey because the sample was not designed to be representative of all non-Mexican American Hispanics (31). Comparisons of mean vitamin D intake estimates by race/ethnicity were completed using ANOVA. If the resulting overall F-test was significant, pairwise comparisons were completed, also using the F-test, to identify differences among means. All statistical analyses of mean intakes were completed using WesVar® Complex SamplesTM 3.0 software (SPSS) and replicate weights provided by NCHS to account for the complex sampling designs. The "leave-one-out" or JK-1 procedure was used in the analysis of the NHANES 1999–2000 data (31). A significance level of 0.05 was used for all analyses.
Estimates of the proportion of the NHANES 1999–2000 population consuming an amount of vitamin D that was equal to or greater than the AI for vitamin D was calculated using Iowa State University’s (ISU) Software for Intake Distribution Estimation (C-SIDE) version 1.02, which removes the within-person, day-to-day variability in intakes when estimating the distribution of usual intakes by a population. Use of this method to estimate usual intake requires assessment of intraindividual variability in nutrient intakes using a 2nd day of intake data from a subsample of individuals. At the time of this analysis, a 2nd day of intake data from NHANES 1999–2000 respondents was not publicly available. In the absence of replicate data from NHANES respondents, all adjustments for the NHANES 1999–2000 data were made using estimates of variance developed from the corresponding sex/age and race/ethnicity group in CSFII 1994–1996, 1998. Comparisons of percentages above the AI by race/ethnicity were completed by constructing Bonferroni intervals for each sex/age category and determining where the intervals did not overlap.
The CSFII 1994–1996, 1998 represents the most recent national food consumption data publicly available for multiple days from a nationally representative sample of individuals of all ages (27). In the CSFII, dietary intakes were collected through in-person interviews using 24-h recalls on 2 nonconsecutive days 3–10 d apart. A total of 21,662 individuals provided data for the 1st day; of those individuals, 20,607 provided data for a 2nd day. Respondents in CSFII 1994–1996, 1998 self-reported race and national origin classifications. The classifications were combined to create categories for NH white, NH black, Mexican American, and other Hispanic subpopulations.
All estimates were completed with NCHS- or USDA-provided weighting factors to adjust the individual data to account for unequal probabilities of selection, nonresponse, and coverage errors. Breast-feeding infants and children were excluded from the analysis.
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RESULTS |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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1 y old provided dietary recalls in NHANES 1999–2000 determined to be reliable and to meet overall quality and completeness criteria as determined by NCHS. Comparisons of mean vitamin D intakes by mode (dietary recall in-person vs. phone interview) for each race/ethnicity and sex/age group combination revealed few differences; therefore, data from individuals completing the in-person and phone interviews were combined for these analyses. A total of 20,033 nonbreast-feeding individuals 1 y old provided recalls on d 1 in CSFII 1994–1996, 1998; 19,043 of these individuals also provided a d 2 recall. Sample size by race/ethnicity and sex/age group for the NHANES and CSFII datasets are summarized (Table 1).
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Mean daily intake of vitamin D by females 9–18 or 19–50 y old did not differ by race/ethnicity. NH white women 51 y old were estimated to have higher mean vitamin D intakes from food sources compared with NH black or Mexican American women.
In all subpopulations, fortified foods provided the majority of dietary vitamin D, and fortified milk was the top contributor to vitamin D intake from the fortified food sources included in this analysis. Mexican American children consumed more vitamin D from milk than NH white and NH black children. In all other populations studied, intake of vitamin D from milk was comparable in NH white and Mexican American groups, and higher by these groups than by NH black populations.
In all children and adolescents in the United States (1–8 and 9–18 y old), ethnic groups did not differ in the food contribution of vitamin D from RTE cereals. Older (51 y old) NH white men were estimated to consume more vitamin D from fortified cereals than Mexican American men, and older NH white women had higher intakes from fortified cereals than either NH black and Mexican American women. Vitamin D intakes from natural sources did not differ by race/ethnicity.
Dietary supplement contribution. Vitamin D intakes from food plus dietary supplements by race/ethnicity in the United States from the NHANES 1999–2000 data were estimated (Table 3). In all subpopulations considered in this analysis, mean intakes by NH whites were higher than those by NH blacks and higher than or comparable to intakes by Mexican Americans of the same sex.
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60% consumed total vitamin D 5 µg/d. Mexican American children (69%) were most likely to meet or exceed the AI, whereas only 48% of non-Hispanic black children were estimated to meet or exceed the AI levels for vitamin D from food. The percentage of individuals meeting the AI from food declined with increasing age, and only 4% of adults 51 y old were meeting or exceeding the AI. NH white boys 1–8 y old and older men were more likely to meet the recommended intakes of vitamin D from food sources than NH black men, whereas the percentage of females meeting the AI did not differ due to race/ethnicity.
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30% of men and 32% of women met or exceeded the vitamin D AI from food plus supplement sources, and significantly more NH white men and women met the recommended intake than NH black and Mexican American individuals in this age group. Vitamin D intakes by race/ethnicity based on food consumption data reported on d 1 in CSFII 1994–1996, 1998 were estimated (Table 4). Similar to findings from the NHANES 1999–2000, the highest estimates of daily vitamin D intake from food sources were reported for children 1–8 y old and male adolescents and teenagers, whereas the lowest intakes were reported by adult women. In contrast to NHANES 1999–2000, significant differences among the race/ethnicity groups were not found for most sex-age groups in this analysis. This lack of difference is likely a result of the unequal sample sizes of the race/ethnicity groups in CSFII. The sample sizes for the NH black and 2 Hispanic populations were considerably smaller than the non-Hispanic white group. The resulting larger standard errors of the race/ethnicity groups compromises the ability of the statistical test to detect differences in vitamin D intake.
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DISCUSSION |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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51 y old met or exceeded the AI level of vitamin D from food sources, which is likely due in large part to the 2- to 3-fold increase in recommended vitamin D intakes for older adults (30). The daily intake of vitamin D from food sources differed by race/ethnicity, with lower intakes reported for some sex/age groups of NH blacks compared with other populations. When contributions of vitamin D from dietary supplements were considered, however, mean daily intakes of vitamin D estimated for NH blacks were consistently lower than intakes by NH whites and comparable to or lower than estimated intakes for Mexican Americans.
Similar mean intakes of vitamin D by age and ethnic groups for NHANES 1999–2000 and the earlier NHANES III (1988–1994) survey suggest that food intake patterns, and use of supplements from 1988 to 1994 to 1999–2000, have not changed markedly. In a recent study reporting intake of vitamin D by the general population and vulnerable groups (33) from the older NHANES III survey, Mexican Americans also had significantly higher intakes of vitamin D than African Americans and whites. In general, vitamin D intake from all sources in NHANES III was also higher for men than women (33).
Results of our study of the NHANES 1999–2000 and CSFII surveys are also consistent with findings based on NHANES III that a high proportion of premenopausal U.S. women age 20–50 y are underconsuming vitamin D (34).
Vitamin D intakes by race/ethnicity groups estimated using the NHANES 1999–2000 data also are consistent with other reports of vitamin D insufficiency patterns reflected by serum 25(OH)D concentration. Mean 25(OH)D levels in adolescents and adults participating in NHANES III were highest in NH whites, intermediate in Mexican Americans, and lowest in NH blacks (35). In another study utilizing NHANES III data, the prevalence of hypovitaminosis D as reflected by 25(OH)D levels 
37.5 nmol/L was 42% among African Americans compared with 4.2% among white women of reproductive age (11). Furthermore, a significant positive association was recently reported between 25(OH)D and total hip bone mineral density from NHANES III in both younger and older adult white, Mexican American, and black adults (36).
Fortified milk provided the largest source of vitamin D in the diets of Americans based on our analysis of NHANES 1999–2000. Results of our analysis suggest that fortified milk and RTE cereal combined accounted for a large portion of the daily vitamin D intake. Milk contributed 40–64% and RTE cereals contributed 5–10% of the vitamin D intake from foods. In total, fortified foods provided 65–86% of the vitamin D intake from foods, clearly indicating that consumption of fortified products played a critical role in the daily intake of this essential vitamin.
Although we observed similar trends in the estimated intakes of vitamin D in this analysis and previous analyses, it is difficult to make direct comparisons due to differences in survey methodologies and the source of the vitamin D concentration data. The data in this analysis may be most representative of current intakes in the United States, although limitations to the analysis should be mentioned. A small number of values in the vitamin D database for foods were based on analytical data, and these data were used to impute values for similar foods. The vitamin D concentration data for milk, RTE cereals, and other fortified foods such as margarine were based on the label declaration of vitamin D in foods observed in the marketplace in 2000. The strength of dietary supplements also was based on label values as compiled in the NCHS Dietary Supplement Database. In addition, there have been some changes in vitamin D fortification since the time of the survey. Notably, calcium-fortified juices now are permitted to contain 2.5 µg (100 IU) vitamin D/240 mL (8 fl oz) serving and several brands of yogurt now provide 1.5–2.0 µg (60–80 IU) vitamin D per single serving. Currently, however, few margarines appear to contain vitamin D (33).
Although our estimates of vitamin D intake by ethnic group utilized recent U.S. dietary intake data, the estimates were based on data collected in NHANES 1999–2000, which provided a rather small sample for each race/ethnicity group. Additionally, because a 2nd day of intake data was not available for the NHANES data, we used intraindividual variance estimates from the most recent CSFII (a survey in which most participants provided two 24-h recalls) to calculate usual vitamin D intakes in NHANES 1999–2000 and in turn the proportion of the populations meeting or exceeding the AI. We therefore assumed that the intraindividual variability of vitamin D intake was the same for each race/ethnicity group in these 2 surveys. Although our approach for estimating the proportion of each population that met the AI is reasonable, the estimates should be regarded as provisional until multiple days of intake data become available in newer surveys.
Typically, estimates of vitamin D intake from the NHANES 1999–2000 survey could be used to determine the prevalence of inadequate vitamin D intakes if recommended levels were determined from an established estimated average requirement (37). Because vitamin D recommendations are expressed as AI levels, there are limitations for assessing vitamin D intake adequacy among groups. The AI cannot be used to calculate the prevalence of inadequate nutrient intakes for groups. However, our comparison of the percentage of the population reaching the AI or above from food and food plus supplement sources does illustrate that for most older adults in the United States, and some race/ethnicity groups more than others, recommended vitamin D intakes are not being achieved even with supplement use.
Our findings indicate that the use of vitamin D–containing dietary supplements helped to increase the percentage of individuals meeting or exceeding the AI, although the majority of older individuals still failed to consume recommended amounts of vitamin D. The importance of vitamin D supplements on the total intake of vitamin D by adults 51 y old is particularly striking; vitamin D intake from dietary supplements contributed 40% for men and 50% for women of the total vitamin D intake from foods plus supplements. Based on a recent global review, it appears that the use of dietary supplements may contribute 6–47% of the average vitamin D intake in some countries (38).
Vitamin D requirements of all age groups can be met under conditions of adequate exposure to sunlight (39). Several factors, however, can reduce the production of vitamin D from the skin: use of sunscreens (40), increased skin pigmentation (41), normal aging (42), and insufficient exposure to sunlight (43). In addition, in northerly latitudes greater than the 35th parallel, seasonal changes in the duration and angle of incidence of natural sunlight do not permit adequate year-round exposure to the vitamin D–producing UV radiation (39). Vitamin D production is markedly reduced during winter or absent between the months of November through March in the Northern Hemisphere above 37°N (43).
The lower vitamin D intakes observed in our study by NH blacks may have been associated with an avoidance of fortified milk due to lactose maldigestion; its prevalence varies widely among ethnic groups within the United States. Generally, the highest prevalence is in Asians (100%), African Americans (75%), Native Americans (100%), and Hispanics (53%) (44). In contrast, estimates of maldigestion intolerance among Caucasians ranges from 6 to 22% (44). The usual treatment for lactose maldigestion is avoidance of dairy products that contain lactose, such as milk, although lactose-intolerant individuals can tolerate some lactose in their diet. Thus, the reduced vitamin D intake found in NHANES 1999–2000 among NH blacks compared with Mexican Americans and NH whites 9 y old may have been due in part to an avoidance of fortified milk associated with a perceived lactose maldigestion.
How much is an adequate intake of vitamin D? Recent data suggest that the 1997 recommended intakes for vitamin D of 5 µg/d for age 1–50 y, 10 µg/d for age 51–70 y, and 15 µg/d for 71 y are probably too low (45,46). Since the Institute of Medicine recommendation was established, studies have shown that 25(OH)D levels that were considered to be within the current reference ranges of adequate vitamin D status have reduced calcium absorptive performance (47). In a randomized controlled trial, treatment with vitamin D in dosages sufficient to raise 25(OH)D to levels above the current reference range resulted in decreased fracture risk at the hip, forearm, or spine by 30% (48). Thus, in the absence of exposure to sunlight, an adequate dietary intake of vitamin D may now be considered to be in the range of 20 to 25 µg (800 to 1000 IU) vitamin D/d (49,50). Furthermore, because African Americans produce less cholecalciferol in their skin and use dietary supplements less frequently than whites, intake to maintain desirable levels of 25(OH)D has similarly been estimated to average 25 µg (1000 IU)/d during the winter for African American adults (51).
Recently the U.S. FDA recognized that vitamin D intakes in the U.S. population were in many cases inadequate. In 2003 the FDA approved a food additive petition to increase dietary vitamin D intake through food fortification of calcium-fortified juices and juice drinks (19). New evidence demonstrated that vitamin D added to orange juice was bioavailable (50). Now, consumers can increase their vitamin D intake by 2.5 µg (100 IU) by drinking one 240 mL (8 fl oz) serving of calcium plus vitamin D-fortified juice. Given that key dietary sources of vitamin D have typically been limited to dairy products, the availability of vitamin D fortified juices and juice beverages provides a new option for individuals such as African Americans, Asians, and Mexican Americans who may avoid dairy products due to lactose intolerance.
Differences in vitamin D intakes from food and supplements among sex and race/ethnicity groups may be contributing to health status disparities in the United States. Despite recent efforts to increase vitamin D intakes through appropriate fortification, dietary guidance and advice on vitamin D supplementation would be beneficial. The 2004 U.S. Surgeon General’s Report on Bone Health and Osteoporosis clearly acknowledged the importance of vitamin D for maintenance of healthy bones and reduction of the risk of osteoporosis (52). The low vitamin D intake from food and food plus supplements compared with current recommended levels, especially for older NH black and Mexican American adults, warrants intervention. As an alternative to greater sun exposure, increasing the availability of fortified foods, supporting greater use of dietary supplements, and encouraging changes in dietary patterns to consume more food fortified with vitamin D should be considered to address this important health issue.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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3 Abbreviations used: AI, adequate intake; CFR, Code of Federal Regulations; CSFII, Continuing Survey of Food Intakes by Individuals; ENVIRON, ENVIRON Health Sciences; GRAS, Generally Recognized as Safe; MEC, Mobile Examination Center; NCHS, National Center for Health Statistics; NDS-R, Nutrient Data System for Research; NH, non-Hispanic; NHANES, National Health and Nutrition Examination Survey; RTE, ready-to-eat; Vitamin D, ergocalciferol and/or cholecalciferol; 25(OH)D, 25-hydroxyvitamin D.
Manuscript received 6 April 2005. Initial review completed 25 May 2005. Revision accepted 29 July 2005.
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LITERATURE CITED |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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