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. Author manuscript; available in PMC: 2012 Aug 19.
Published in final edited form as: Nutr Res. 2011 Aug 19;31(8):579–585. doi: 10.1016/j.nutres.2011.07.003

Ethnic differences in food sources of vitamin D in adolescent American girls: The National Heart, Lung, and Blood Institute Growth and Health Study (NGHS)

Linda V Van Horn 1, Robert Bausermann 2, Sandra Affenito 3, Douglas Thompson 4, Ruth Striegel-Moore 5, Debra Franko 6, Ann Albertson 7
PMCID: PMC3176437  NIHMSID: NIHMS312511  PMID: 21925342

Abstract

The National Heart, Lung, and Blood Institute Growth and Health Study (NGHS) was a 10-year longitudinal study of the development of obesity and CVD risk factors (including dietary, psychosocial, environmental and others) in 2,379 African-American and white females who were 9 or 10 years old at study entry. Current studies have documented a high prevalence of vitamin D insufficiency among healthy children, adolescents and young adults in the United States, especially among low-income, black and Hispanic children (defined as serum 25-hydroxyvitamin D concentrations of ≤ 20 ng/mL). Although the main source of vitamin D is direct exposure of the skin to ultraviolet rays from sunlight, certain foods contribute vitamin D including fortified milk, meat, eggs, oils and fortified cereals. Vulnerable subgroups that are especially at risk of inadequate intakes of vitamin D, include teenage girls and women. Research providing the prevalent food sources of vitamin D, especially in the diets of both white and African American female adolescents is limited. The purpose of this study is to document food sources of vitamin D reported by this biracial young cohort and compare potential ethnic or other differences that could enhance tailored dietary interventions that are particularly relevant to this vulnerable population subgroup.

Keywords: dietary vitamin D, adolescents, ethnic differences, dietary intake in girls, children

1. Introduction

Vitamin D is essential for maintaining calcium homeostasis and skeletal integrity [1]. Growing evidence further documents a role for vitamin D in reducing risk of chronic diseases including some cancers [2–5], type 1 [6, 7] and type 2 diabetes mellitus [8], and multiple sclerosis [9, 10] Vitamin D may also be protective against cardiovascular disease [CVD] [1, 11–13] myocardial dysfunction [14], and hypertension in middle-aged and older women [15]. In children, vitamin D is especially important because of its vital role in bone mineralization [16, 17], insulin sensitivity in obese children and adolescents [18], and cardiac health [19]. Maintaining sufficient intake of vitamin D during teenage years is recommended to improve long-term health outcomes [19–22], but a high prevalence of vitamin D insufficiency has been reported among healthy children, adolescents and young adults in the United States [17, 19, 23–26], especially among certain subgroups.

Among low-income, black and Hispanic preschool children in Atlanta, prevalence of vitamin D deficiency (defined as serum 25-hydroxyvitamin D concentrations of ≤ 20 ng/mL) was 22% [27]. In a Boston clinic, 24.1% of adolescents [24] and 36% of young adults were found to be deficient in serum levels of 25-hydroxyvitamin D vitamin D [26]. According to National Health and Nutrition Examination Data (NHANES) 2001–2004 data, 9% of the pediatric population (7.6 million U.S. children and adolescents) was 25-hydroxyvitamin D deficient (< 15 ng/mL) and 61% (50.8 million U.S. children and adolescents) were insufficient (15–29 ng/mL) [19]. Updated 2003–2006 NHANES data report that 47 % and 53%, respectively, of adolescent girls and boys older than 9 years meet the Adequate Intake (AI) levels (5 mcg/d) [28]. The highest deficiency of vitamin D occurs among African-American girls, particularly in the winter [24, 29–31].

The main source of vitamin D is direct exposure of the skin to ultraviolet rays in sunlight [32]. Food sources include vitamin D-fortified milk, meat (especially fatty fish), eggs, oils and fortified cereals [33–36] and these play an especially important role for dark-pigmented individuals, whose skin has a lower rate of vitamin D formation per unit of exposure time than light-pigmented individuals [32, 37]. Lowest intakes of vitamin D (unadjusted for energy) occur among teenage girls and women [34]. Research documenting prevalent food sources of vitamin D in white and African American girls can help identify potential areas of needed education and intervention.

2. Methods and Materials

2.1. Participants and Recruitment

The National Heart, Lung, and Blood Institute Growth and Health Study (NGHS) was a 10-year longitudinal study of the development of obesity and CVD risk factors (including dietary, psychosocial, environmental and others) in 2,379 African-American and white females who were 9 or 10 years old at study entry [38]. Participants were recruited at three sites (University of California at Berkeley, University of Cincinnati/Cincinnati Children’s Hospital Medical Center, and Westat, Inc./Group Health Association in Rockville, Maryland) from public and parochial schools or (in Maryland/DC only) from a membership listing of families enrolled in a large health maintenance organization and local Girl Scout troops. Eligible participants identified themselves (using census categories for race/ethnicity) as “black” or “white,” non-Hispanic, with racially concordant parents or guardians. All girls assented and their parents (or guardian) consented to their participation. In each race group, wide ranges of income (less than $10,000 to $75,000 or more) and educational levels (less than high school diploma to graduate degree) were represented (data not shown).

Due to variable annual participation rates, sample sizes varied from visit to visit. Retention rates (relative to the sample size of 2,379 at baseline) were very high at visits 2–4 [96%, 94%, 91%], declined to a low of 82% at visit 7, and increased to 89% at visit 10.

2.2. Measurements and Procedure

The NGHS procedures and measures have been reported elsewhere [38]. Briefly, data were collected annually at participating sites or, if the girl was unable to travel to the site, at her home. The protocol was approved by the Institutional Review Boards of all participating sites. Only instruments relevant to the present report are described and data from six annual visits (years 3, 4, 5, 7, 8 and 10) are reported here.

2.3. Food Diaries

Participants completed detailed food records at visits 1–5, 7, 8 and 10. Dietitians trained and certified by the University of Minnesota Nutrition Coordinating Center (NCC), and retrained in later years by staff at the Dietary Data Entry Center in Cincinnati, used age-appropriate materials to instruct girls to record all food and drink for 3 consecutive days (2 weekdays and 1 weekend day). Dietitians reviewed food records individually with the girls, using standard probes, labels and pictures to clarify incomplete responses and minimize default values. Food records were initially coded and analyzed for nutrients using Food Table Version 19 of the NCC nutrient database [38] and updated as the study progressed. Because rapid changes in vitamin D fortification have occurred more recently, these data may not have been completely represented in all cases and are specifically updated here. Diaries from visits 1 and 2 are excluded because foods were not measured in consistent quantities, but beginning in visit 3 and later, all food quantities were measured in grams.

2.4. Statistical Methods

Sources of vitamin D were analyzed as individual foods and as food categories (e.g., milk and milk products).

The proportion of group total vitamin D intake was calculated from each individual food by dividing the total vitamin D intake from reported foods for each girl and averaging this amount across girls. Supplemental vitamin D was excluded from this analysis. Sources of vitamin D from the major USDA food groups were assessed [39].

Using mixed models to adjust for repeated measures across time, vitamin D intake was examined in relationship to multiple participant characteristics to identify predictors of intake. Independent variables included demographic factors (race, parental education as an adjustment for socioeconomic status, two-parent household, and study site); eating patterns (total energy intake, breakfast eating, and family meals); BMI; and dieting (currently trying to lose weight and general frequency of dieting). Average daily vitamin D intake in micrograms was the dependent variable. All analyses were conducted using SAS version 9.1.3 [SAS Institute, Cary, NC].

3. Results

3.1. Food sources of vitamin D

Table 1 ranks the top 20 food sources of vitamin D as a percentage of total vitamin D intakes for all girls. This average does not refer to the vitamin D content of a standard serving size, but rather to the portions actually consumed by the girls as reported in their food diaries. Fortified milk (2% fat) contributed the greatest proportion of vitamin D to the diet of the “average girl” at all visits (Table 2). At visit 3, on average, girls obtained 24.1% of their food-based vitamin D intake from 2% milk but this declined over time to 15.6% at visit 10. Girls who drank 2% milk obtained an average of 83 IU (2.07) mcg of vitamin D per serving.

Table 1.

Top 20 food sources of vitamin D [mean percent of vitamin D intake] in the National Heart, Lung and Blood Institute Growth and Health Study.

NCC Food Name Vitamin D VISIT
Total % IU (mcg)/serving Overall rank 3 4 5 7 8 10
Milk, 2% fat 19.5 82.8 [2.07] 1 24.1 20.8 18.9 18.6 18.1 15.6
Milk, whole 9.4 81.2 [2.03] 2 9.6 9.8 9.9 9.1 9.0 9.0
Margarine, stick, brand unknown 7.6 37.7 [0.94] 3 7.4 7.1 6.8 7.3 7.3 9.3
Egg, whole 5.5 14.0 [0.35] 4 5.0 4.5 5.4 5.6 5.7 6.9
Milk, skim 5.4 100.0 [2.50] 5 4.0 5.0 4.7 5.8 5.9 7.2
Sausage, pork 3.2 30.0 [0.75] 6 3.4 3.2 4.3 3.1 3.1 2.3
Milk, 1% 3.1 105.2 [2.63] 7 1.0 3.0 3.7 3.9 4.0 3.3
Ground beef, regular 2.9 8.4 [0.21] 8 2.4 2.4 2.8 3.4 3.7 2.8
Chocolate milk, 2% fat 2.5 110.0 [2.75] 9 5.2 3.3 2.4 1.7 1.6 0.4
Milk, % fat unknown 2.4 10.0 [0.25] 10 2.4 2.4 2.5 2.2 2.4 2.5
Fish, total omega-3 <10% [e.g., flatfish] 1.5 63.2 [1.58] 11 1.7 1.5 1.7 1.0 1.2 1.5
Frankfurter, beef and pork 1.3 25.2 [0.63] 12 1.5 1.6 1.3 1.3 1.0 0.9
Tuna, canned, water packed 1.3 154.0 [3.85] 13 0.8 1.1 1.1 1.2 1.4 2.0
Cereals, dry, frosted flakes 1.2 105.2 [2.63] 14 1.3 1.3 1.2 1.5 1.0 1.2
Shrimp, cooked, w/o salt 1.0 50.8 [1.27] 15 0.8 1.0 0.8 1.2 1.0 1.2
Margarine, stick or tub, 80% fat 1.0 42.8 [1.07] 16 0.8 0.9 1.2 1.0 0.6 1.2
Tuna, canned, oil packed 0.8 132.0 [3.30] 17 1.2 1.0 0.7 0.7 0.8 0.5
Chocolate milk, 1% fat 0.8 102.4 [2.56] 18 1.6 1.2 1.0 0.3 0.3 0.2
Cereals, dry, corn flakes 0.4 78.4 [1.96] 19 0.9 0.8 0.6 0 0 0
Fish, total omega-3 <10% [e.g., mullet] 0.4 523.2 [13.08] 20 0.7 0.6 0.7 0.1 0.1 0.1
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Note: “Serving” refers to the average portion of each food actually reported in the food diaries, rather than standard serving sizes

Table 2.

Proportion of dietary vitamin D intake contributed by food categories (mean percent of vitamin D intake) in the National Heart, Lung and Blood Institute Growth and Health Study.

Food category Visit 3 Visit 4 Visit 5 Visit 7 Visit 8 Visit 10
Milk 51.0 48.9 47.0 45.3 45.2 42.2
Meat and Beans 20.0 19.8 21.6 19.8 20.2 20.7
Fats &Oils 14.2 15.4 16.5 17.9 17.7 19.9
Grains 10.0 10.4 9.4 10.8 11.2 11.8
RTE cereals [subset of grains] 9.2 9.3 8.3 9.0 8.6 9.6
Sweets and desserts 3.6 3.9 3.8 5.5 5.0 4.8
Miscellaneous 1.2 1.6 1.6 0.6 0.6 0.6
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Note: Numbers do not add to 100% within each column due to rounding and to the inclusion of RTE cereal [a subset of the grains category].

While many foods reported in the diaries contained some vitamin D, total vitamin D intake was highly concentrated in a very small number of foods. The top five foods alone contributed almost 50% of total vitamin D intake; the top ten foods, over 60%. Six varieties of fortified milk were in the top ten foods and contributed over 42% of all vitamin D.

As illustrated in Table 3, the meat and bean group (which includes fish sources rich in vitamin D) ranked second in contributing vitamin D across visits. The fats and oils category (including margarine, mayonnaise and salad dressing) was third, and its share of vitamin D intake increased steadily over time as milk drinking declined. Grains (mainly RTE vitamin-fortified cereals) were the fourth most important source across all visits.

Table 3.

Parameter estimates for predictors of total vitamin D intake in the National Heart, Lung and Blood Institute Growth and Health Study.

Effect Parameter estimates [IU/day of Vitamin D] Statistical Significance
Race (race=White is reference group) 56.30 p<.0001
Visit −6.88 p<.0001
Race*Visit −2.64 p=.014
Breakfast consumption 18.00 p<.0001
Energy (average calories per day) 0.072 p<.0001
Dieting frequency −2.60 p=.274
Parental education −4.44 p=.189
Site (site=3 is reference group) −7.56 [site 1], −8.36 [site 2] p=.069
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3.2. Predictors of vitamin D intake

Parameter estimates and standard errors were calculated for predictors of vitamin D intake. As shown in Table 4. Energy intake [average calories per day] was significantly related to increased vitamin D intake such that for every 100 additional calories consumed, vitamin D intake increased by 7.2 IU (0.18 mcg per day) [0.072*100]. The single strongest predictor was race, with white girls consuming significantly more vitamin D than African-American girls. The effect of breakfast consumption was an increase of 18 IU (0.45 mcg) per day; this effect is independent of total calories consumed, which is a separate term in the model. Visit (a marker for age), and the interaction of race and visit were also significant. Average vitamin D consumption decreased over time, and the racial gap in vitamin D consumption narrowed (the difference was 39.2 IU [0.98mcg] per day at Visit 3, but 26.8 IU [0.67mcg] per day at Visit 10).

Table 4.

Percentage of total vitamin D intake from food categories, by race, among girls in the National Heart, Lung and Blood Institute Growth and Health Study.

 Whites Visit 3 Visit 4 Visit 5 Visit 7 Visit 8 Visit 10
Milk 58.9 57.2 56.7 53.2 52.6 49.4
Meat and Beans 14.1 13.6 14.1 13.3 14.3 14.4
Fats &Oils 13.2 14.1 15.1 17.0 15.7 18.0
Grains 9.8 10.4 9.5 10.5 11.8 12.5
RTE cereals (subset of grains) 9.0 9.4 8.3 8.8 9.0 10.2
Sweets and desserts 3.3 3.8 3.6 5.2 4.8 5.0
Miscellaneous 0.8 1.0 1.1 0.8 0.7 0.7
 African-Americans
Milk 43.5 41.1 37.8 37.5 38.7 35.5
Meat and Beans 25.7 25.6 28.6 26.2 25.6 26.6
Fats &Oils 15.0 16.6 17.8 18.7 19.4 21.7
Grains 10.3 10.5 9.4 11.1 10.8 11.1
RTE cereals (subset of grains) 9.5 9.4 8.5 9.0 8.3 9.1
Sweets and desserts 3.9 4.1 4.1 6.0 5.1 4.6
Miscellaneous 1.5 2.1 2.2 0.5 0.5 0.5
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Note: Numbers do not add to 100% by race within each column due to rounding and to the inclusion of RTE cereal [a subset of the grains category].

3.3. Ethnic differences in individual foods and food categories as sources of vitamin D

African-American girls consistently consumed more vitamin D from the meats and beans group (mainly fish and some meats) than did the white girls, consuming nearly twice of these foods at some visits. They also consistently obtained more vitamin D from fats and oils than white girls did, although both groups showed increases over time. There were significant race effects for all food categories except grains, which had a significant race-visit interaction. Among the top 10 individual food sources of vitamin D (as a percent of all vitamin D intake), racial differences were especially salient for types of fortified milk (Table 5). White girls increasingly selected lower-fat varieties of fortified milk as they aged, while African-American girls consistently chose higher-fat varieties throughout adolescence.

Table 5.

Percentage of total vitamin D intake from top 10 individual food sources, by race [mean and standard deviation] among girls in the National Growth and Health Study.

Food source Group Visit 3 Visit 4 Visit 5 Visit 7 Visit 8 Visit 10
Milk, whole Whites 7.4[17.3] 6.4[16.8] 6.5[17.2] 4.9[15.9] 5.5[16.9] 5.5[16.0]
African Americans 11.1[18.6] 13.0[19.9] 13.0[21.1] 12.8[22.3] 12.1[21.3] 12.2[21.0]
Milk, 2% Whites 31.9 [27.5] 27.6 [27.5] 25.1 [28.6] 23.4 [28.9] 20.7 [27.2] 17.8 [25.1]
African Americans 16.7 [21.5] 14.4 [21.5] 13.2 [20.6] 13.8 [21.1] 15.7 [23.3] 13.6 [21.4]
Milk, 1% Whites 1.7 [8.9] 5.4 [16.0] 7.2 [18.9] 7.0 [19.3] 7.0 [19.1] 5.6 [17.1]
African Americans 0.4 [3.8] 0.8 [6.1] 0.4 [4.2] 1.0 [7.6] 1.2 [8.0] 1.3 [7.8]
Milk, skim Whites 6.4 [17.5] 8.1 [20.3] 8.1 [19.9] 10.3 [22.4] 10.6 [22.8] 13.1 [24.4]
African Americans 1.8 [8.3] 2.2 [10.0] 1.5 [7.8] 1.5 [7.9] 1.6 [7.9] 1.8 [9.1]
Milk, % unknown Whites 1.8 [3.3] 1.8 [3.6] 2.1 [4.8] 1.8 [4.4] 1.9 [5.8] 5.6 [17.1]
African Americans 2.9 [5.4] 3.0 [6.1] 2.8 [5.1] 2.7 [5.5] 2.9 [6.4] 3.0 [6.5]
Chocolate milk, 2% Whites 5.0 [12.0] 3.4 [10.1] 2.9 [10.3] 1.5 [7.8] 1.4 [7.2] 0.4 [4.4]
African Americans 5.3 [13.1] 3.2 [11.1] 2.0 [9.0] 2.0 [9.5] 1.7 [9.3] 0.3 [3.2]
Ground beef Whites 1.7 [3.9] 1.7 [4.6] 1.7 [5.0] 2.2 [5.6] 2.7 [7.7] 2.1 [6.8]
African Americans 3.1 [7.4] 3.1 [5.9] 3.9 [7.4] 4.5 [8.6] 4.6 [9.4] 3.6 [8.1]
Pork sausage Whites 2.1 [5.6] 1.8 [5.0] 2.4 [6.6] 1.6 [5.4] 1.8 [6.7] 1.4 [5.5]
African Americans 4.6 [10.1] 4.5 [10.1] 6.0 [12.8] 4.6 [9.4] 4.3 [9.5] 3.2 [8.6]
Whole eggs Whites 3.7 [5.9] 3.3 [6.4] 3.9 [7.0] 3.9 [7.6] 3.8 [7.3] 5.0 [9.6]
African Americans 6.2 [9.0] 5.7 [8.7] 6.7 [10.8] 4.3 [9.5] 7.4 [11.4] 8.6 [12.0]
Margarine Whites 6.2 [10.1] 5.4 [9.9] 5.7 [11.2] 6.7 [12.3] 6.8 [12.8] 8.1 [14.3]
African Americans 8.6 [13.4] 8.7 [14.6] 7.7 [14.1] 7.6 [14.5] 7.7 [13.7] 10.5 [16.2]
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3.4.. Supplements as a source of vitamin D

Vitamin supplement use was not collected consistently at visits 3 and 4 but was assessed in visits 5, 7, 8, and 10. Relatively few girls, ranging from 10.3% at visit 5 to a low of 7.0% at visit 8, reported using supplements containing vitamin D. Girls who reported taking supplements obtained more than half of their vitamin D intake from this source. To explore this, vitamin D intake was recalculated as the sum of dietary and supplementary vitamin D. Supplements contributed between 57.5% (at visit 8) and 62.2% (at visit 10) of total vitamin D intake among those who reported using them. When averaged across all girls in the study, supplements contributed 4–6% of total vitamin D consumed by the entire sample, with relatively few girls reporting supplement use at any visit and white girls being 2.5 times more likely to obtain vitamin D from supplements than black girls at the final visit.

4. Discussion

This study reports food sources of vitamin D among a large sample of African-American and white girls (ages 9–18) during 1987–1997 and the characteristics of girls that predicted individual differences in total daily vitamin D intake. Overall, total vitamin D intake was highly concentrated in milk and dairy products and fortified foods. There were age- and race-related differences in food sources of vitamin D with lower Vitamin D consumption by African-American girls at all visits. Breakfast consumption predicted higher vitamin D intake among all groups.

Very few foods contain vitamin D in its natural form and those that are the richest natural source of vitamin D (fatty fish and its oil) [33] are not frequently consumed [40], thus fortified foods (milk, margarine, cereals) can assist with vitamin D intake [33, 35, 36]. In the NGHS, fortified milk and milk products were the most common food sources of vitamin D; milk provided over 42% of all vitamin D at all visits. These findings are in accord with national data [16, 34, 36, 41, 42] demonstrating the important contribution of fortified milk to vitamin D intake in adolescence.

Meats (primarily fatty fish, pork) and beans (meat alternatives) provided the distant second richest supply of vitamin D, across all NGHS visits. Consistent with past research [43, 44] naturally rich sources of vitamin D in the meat and beans group (particularly fatty fish) were consumed by a small percentage of girls in the NGHS.

RTE fortified cereal, combining all brands, contributed approximately 9% of the mean vitamin D intake in the NGHS, comparable with the 5%–10% documented by the 1999–2000 National Health and Nutrition Examination Survey (NHANES) [34]. Since milk and RTE cereal are often consumed together, these foods provide over half of the vitamin D intake from foods. Previous studies reported that for both African-American and white females [24, 37], consumption of fortified food sources of vitamin D [milk and cereal] was associated reduced the occurrence of vitamin D insufficiency.

Ethnicity, breakfast consumption, age (represented by visit), and energy intake were factors that predicted differences in total vitamin D intake in girls in the NGHS. The current and previous NGHS findings [45] add to the growing evidence that racial disparities exist in vitamin D intake [31, 34, 46]. In agreement with past studies [37, 41, 47] African American girls consumed less fortified milk compared with their white counterparts, perhaps partly attributed to lactose intolerance known to be common in this ethnic group [31, 43]. White girls more often consumed lower-fat milks whereas African-American girls more often obtained vitamin D from higher fat milks, higher fat meats and meat alternatives (sausage, ground beef, eggs), and margarine. Improving vitamin D intake from low saturated fat and cholesterol sources, especially lowfat/nonfat milk, dairy products and possibly other fortified foods such as margarine and soymilk, may be especially helpful [44] among African Americans who are at higher cardiovascular risk but often avoid these foods [48, 49].

All girls reduced milk and dairy intake with age, suggested as possibly being associated with decreased family influence on dietary habits [50, 51]. Milk is increasingly displaced with soft drinks, fruit juices, and/or fruit drinks as children age [52–54]. Increased frequency of breakfast skipping also occurs in adolescence [55–57], especially among African-American girls [55, 58].

Few girls in NGHS used supplements and their use decreased over time ranging from approximately 10% to 7% from mid- to late-adolescence, respectively. Approximately one-third of adolescent girls in the 1999–2000 National Health and Nutrition Examination Survey and one-quarter of the 2,761 adolescents surveyed in the 2001–2002 Child and Adolescent Trial for Cardiovascular Health Study [59] reported using multi-vitamin, multi-mineral supplements Whether supplements should be recommended to improve vitamin D insufficiency requires further investigation.

Study limitations include the absence of data regarding sunlight exposure and the self-reported dietary intake data subject to recall errors and underreporting [60]. Also NGHS did not report serum levels of 25-hydroxyvitamin D that could further help to differentiate bioavailability of these self-reported dietary sources.

Strengths, including the longitudinal nature of this study, a high follow-up rate and detailed dietary intake data enhance the value of this study. Diet assessment was performed by trained and certified dietitians using validated three-day food records, including a weekend day and two week days. The longitudinal study design reduces both between and within-subject variability and implicitly controlled the seasonal component of dietary intake [61], because recruitment into the study and dietary recall collection occurred throughout the year.

Findings from the National Heart, Lung and Blood Institute Growth and Health Study document that milk and dairy products provided the majority of vitamin D intake with sources differing by race. African-American girls [33, 62] reported a significantly lower intake of vitamin D from both food sources and supplements, compared with white girls. Given the important function of vitamin D in skeletal health and its emerging role in the prevention of chronic diseases [32, 63], food and nutrition professionals should renew efforts to educate adolescents, especially African Americans, to consume a healthful diet by choosing a wide variety of nutrient-dense foods and beverages, especially those that provide vitamin D.

Acknowledgments

The authors express appreciation to the participants in the NGHS study and the original investigators who collected these data.

Abbreviations

NGHS

National Heart, Lung and Blood Institute Growth and Health Study

RTE

Ready to Eat

Footnotes

Conflict of interest

The funding organizations had no role in the design and conduct of the original study, nor collection, analysis or interpretation of these data.

Sandra Affenito, Sandra Affenito has received consultant fees from the Bell Institute of Health and Nutrition, General Mills, Inc.

Ann Albertson, Ms Albertson is an employee of General Mills, Bell Institute of Health and Nutrition, Minneapolis, MN.

Debra Franko, Debra Franko has received consultant fees from General Mills, Inc.; however, she was not paid for her involvement in this manuscript.

Ruth Striegel-Moore, Ruth Striegel-Moore reports no conflict of interest.

Douglas Thompson, Douglas Thompson has received consultant fees from General Mills, Inc.

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Contributor Information

Linda V. Van Horn, Email: lvanhorn@northwestern.edu.

Robert Bausermann, Email: rbauserman1965@gmail.com.

Sandra Affenito, Email: saffenito@sjc.edu.

Douglas Thompson, Email: doug.thompson@thompsonresearchconsulting.com.

Ruth Striegel-Moore, Email: rstriegel@wesleyan.edu.

Debra Franko, Email: d.franko@neu.edu.

Ann Albertson, Email: ann.albertson@genmills.com.

References

  • 1.Holick MF. Vitamin D deficiency. N Engl J Med. 2007 Jul 19;357(3):266–81. doi: 10.1056/NEJMra070553. [DOI] [PubMed] [Google Scholar]
  • 2.Giovannucci E. The epidemiology of vitamin D and cancer incidence and mortality: a review (United States) Cancer Causes Control. 2005 Mar;16(2):83–95. doi: 10.1007/s10552-004-1661-4. [DOI] [PubMed] [Google Scholar]
  • 3.Crew KD, Gammon MD, Steck SE, Hershman DL, Cremers S, Dworakowski E, Shane E, Terry MB, Desai M, Teitelbaum SL, Neugut AI, Santella RM. Association between plasma 25-hydroxyvitamin D and breast cancer risk. Cancer Prev Res (Phila) 2009 Jun;2(6):598–604. doi: 10.1158/1940-6207.CAPR-08-0138. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Huncharek M, Muscat J, Kupelnick B. Colorectal cancer risk and dietary intake of calcium, vitamin D, and dairy products: a meta-analysis of 26,335 cases from 60 observational studies. Nutr Cancer. 2009;61(1):47–69. doi: 10.1080/01635580802395733. [DOI] [PubMed] [Google Scholar]
  • 5.Luong K, Nguyen LT. The beneficial role of vitamin D and its analogs in cancer treatment and prevention. Crit Rev Oncol Hematol. 2010 Mar;73(3):192–201. doi: 10.1016/j.critrevonc.2009.04.008. [DOI] [PubMed] [Google Scholar]
  • 6.Ramos-Lopez E, Jansen T, Ivaskevicius V, Kahles H, Klepzig C, Oldenburg J, Badenhoop K. Protection from type 1 diabetes by vitamin D receptor haplotypes. Ann N Y Acad Sci. 2006 Oct;1079:327–34. doi: 10.1196/annals.1375.050. [DOI] [PubMed] [Google Scholar]
  • 7.Zipitis CS, Akobeng AK. Vitamin D supplementation in early childhood and risk of type 1 diabetes: a systematic review and meta-analysis. Arch Dis Child. 2008 Jun;93(6):512–7. doi: 10.1136/adc.2007.128579. [DOI] [PubMed] [Google Scholar]
  • 8.Pittas AG, Lau J, Hu FB, Dawson-Hughes B. The role of vitamin D and calcium in type 2 diabetes. A systematic review and meta-analysis. J Clin Endocrinol Metab. 2007 Jun;92(6):2017–29. doi: 10.1210/jc.2007-0298. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Holick MF. Vitamin D: important for prevention of osteoporosis, cardiovascular heart disease, type 1 diabetes, autoimmune diseases, and some cancers. South Med J. 2005 Oct;98(10):1024–7. doi: 10.1097/01.SMJ.0000140865.32054.DB. [DOI] [PubMed] [Google Scholar]
  • 10.Munger KL, Levin LI, Hollis BW, Howard NS, Ascherio A. Serum 25-hydroxyvitamin D levels and risk of multiple sclerosis. JAMA. 2006 Dec 20;296(23):2832–8. doi: 10.1001/jama.296.23.2832. [DOI] [PubMed] [Google Scholar]
  • 11.Martins D, Wolf M, Pan D, Zadshir A, Tareen N, Thadhani R, Felsenfeld A, Levine B, Mehrotra R, Norris K. Prevalence of cardiovascular risk factors and the serum levels of 25-hydroxyvitamin D in the United States: data from the Third National Health and Nutrition Examination Survey. Arch Intern Med. 2007 Jun 11;167(11):1159–65. doi: 10.1001/archinte.167.11.1159. [DOI] [PubMed] [Google Scholar]
  • 12.Dobnig H, Pilz S, Scharnagl H, Renner W, Seelhorst U, Wellnitz B, Kinkeldei J, Boehm BO, Weihrauch G, Maerz W. Independent association of low serum 25-hydroxyvitamin d and 1,25-dihydroxyvitamin d levels with all-cause and cardiovascular mortality. Arch Intern Med. 2008 Jun 23;168(12):1340–9. doi: 10.1001/archinte.168.12.1340. [DOI] [PubMed] [Google Scholar]
  • 13.Wang TJ, Pencina MJ, Booth SL, Jacques PF, Ingelsson E, Lanier K, Benjamin EJ, D’Agostino RB, Wolf M, Vasan RS. Vitamin D deficiency and risk of cardiovascular disease. Circulation. 2008 Jan 29;117(4):503–11. doi: 10.1161/CIRCULATIONAHA.107.706127. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Pilz S, Marz W, Wellnitz B, Seelhorst U, Fahrleitner-Pammer A, Dimai HP, Boehm BO, Dobnig H. Association of vitamin D deficiency with heart failure and sudden cardiac death in a large cross-sectional study of patients referred for coronary angiography. J Clin Endocrinol Metab. 2008 Oct;93(10):3927–35. doi: 10.1210/jc.2008-0784. [DOI] [PubMed] [Google Scholar]
  • 15.Wang L, Manson JE, Buring JE, Lee IM, Sesso HD. Dietary intake of dairy products, calcium, and vitamin D and the risk of hypertension in middle-aged and older women. Hypertension. 2008 Apr;51(4):1073–9. doi: 10.1161/HYPERTENSIONAHA.107.107821. [DOI] [PubMed] [Google Scholar]
  • 16.Food and Nutrition Board Institute of Medicine. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington DC: National Academics Press; 1997. [PubMed] [Google Scholar]
  • 17.Looker AC, Dawson-Hughes B, Calvo MS, Gunter EW, Sahyoun NR. Serum 25-hydroxyvitamin D status of adolescents and adults in two seasonal subpopulations from NHANES III. Bone. 2002 May;30(5):771–7. doi: 10.1016/s8756-3282(02)00692-0. [DOI] [PubMed] [Google Scholar]
  • 18.Alemzadeh R, Kichler J, Babar G, Calhoun M. Hypovitaminosis D in obese children and adolescents: relationship with adiposity, insulin sensitivity, ethnicity, and season. Metabolism. 2008 Feb;57(2):183–91. doi: 10.1016/j.metabol.2007.08.023. [DOI] [PubMed] [Google Scholar]
  • 19.Kumar J, Muntner P, Kaskel FJ, Hailpern SM, Melamed ML. Prevalence and associations of 25-hydroxyvitamin D deficiency in US children: NHANES 2001–2004. Pediatrics. 2009 Sep;124(3):e362–70. doi: 10.1542/peds.2009-0051. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Stoffman N, Gordon CM. Vitamin D and adolescents: what do we know? Curr Opin Pediatr. 2009 Aug;21(4):465–71. doi: 10.1097/MOP.0b013e32832da096. [DOI] [PubMed] [Google Scholar]
  • 21.Huh SY, Gordon CM. Vitamin D deficiency in children and adolescents: epidemiology, impact and treatment. Rev Endocr Metab Disord. 2008 Jun;9(2):161–70. doi: 10.1007/s11154-007-9072-y. [DOI] [PubMed] [Google Scholar]
  • 22.Kimball S, Fuleihan Gel H, Vieth R. Vitamin D: a growing perspective. Crit Rev Clin Lab Sci. 2008;45(4):339–414. doi: 10.1080/10408360802165295. [DOI] [PubMed] [Google Scholar]
  • 23.Rovner AJ, O’Brien KO. Hypovitaminosis D among healthy children in the United States: a review of the current evidence. Arch Pediatr Adolesc Med. 2008 Jun;162(6):513–9. doi: 10.1001/archpedi.162.6.513. [DOI] [PubMed] [Google Scholar]
  • 24.Gordon CM, DePeter KC, Feldman HA, Grace E, Emans SJ. Prevalence of vitamin D deficiency among healthy adolescents. Arch Pediatr Adolesc Med. 2004 Jun;158(6):531–7. doi: 10.1001/archpedi.158.6.531. [DOI] [PubMed] [Google Scholar]
  • 25.Sullivan SS, Rosen CJ, Halteman WA, Chen TC, Holick MF. Adolescent girls in Maine are at risk for vitamin D insufficiency. J Am Diet Assoc. 2005 Jun;105(6):971–4. doi: 10.1016/j.jada.2005.03.002. [DOI] [PubMed] [Google Scholar]
  • 26.Tangpricha V, Pearce EN, Chen TC, Holick MF. Vitamin D insufficiency among free-living healthy young adults. Am J Med. 2002 Jun 1;112(8):659–62. doi: 10.1016/s0002-9343(02)01091-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Cole CR, Grant FK, Tangpricha V, Swaby-Ellis ED, Smith JL, Jacques A, Chen H, Schleicher RL, Ziegler TR. 25-hydroxyvitamin D status of healthy, low-income, minority children in Atlanta, Georgia. Pediatrics. 2010 Apr;125(4):633–9. doi: 10.1542/peds.2009-1928. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Bailey RL, Dodd KW, Goldman JA, Gahche JJ, Dwyer JT, Moshfegh AJ, Sempos CT, Picciano MF. Estimation of total usual calcium and vitamin D intakes in the United States. J Nutr. 2010 Apr;140(4):817–22. doi: 10.3945/jn.109.118539. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Saintonge S, Bang H, Gerber LM. Implications of a new definition of vitamin D deficiency in a multiracial us adolescent population: the National Health and Nutrition Examination Survey III. Pediatrics. 2009 Mar;123(3):797–803. doi: 10.1542/peds.2008-1195. [DOI] [PubMed] [Google Scholar]
  • 30.Weng FL, Shults J, Leonard MB, Stallings VA, Zemel BS. Risk factors for low serum 25-hydroxyvitamin D concentrations in otherwise healthy children and adolescents. Am J Clin Nutr. 2007 Jul;86(1):150–8. doi: 10.1093/ajcn/86.1.150. [DOI] [PubMed] [Google Scholar]
  • 31.Harris SSD-HB, Calvo MS, Gunter EW, Sahyoun NR. Seasonal changes in plasma 25-hydroxyvitamin D concentrations of young American black and white women. Am J Clin Nutr. 1998;67:1232–6. doi: 10.1093/ajcn/67.6.1232. [DOI] [PubMed] [Google Scholar]
  • 32.Holick MF. Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease. Am J Clin Nutr. 2004 Dec;80(6 Suppl):1678S–88S. doi: 10.1093/ajcn/80.6.1678S. [DOI] [PubMed] [Google Scholar]
  • 33.Calvo MS, Whiting SJ, Barton CN. Vitamin D fortification in the United States and Canada: current status and data needs. Am J Clin Nutr. 2004 Dec;80(6 Suppl):1710S–6S. doi: 10.1093/ajcn/80.6.1710S. [DOI] [PubMed] [Google Scholar]
  • 34.Moore CE, Murphy MM, Holick MF. Vitamin D intakes by children and adults in the United States differ among ethnic groups. J Nutr. 2005 Oct;135(10):2478–85. doi: 10.1093/jn/135.10.2478. [DOI] [PubMed] [Google Scholar]
  • 35.Calvo MS, Whiting SJ. Public health strategies to overcome barriers to optimal vitamin D status in populations with special needs. J Nutr. 2006 Apr;136(4):1135–9. doi: 10.1093/jn/136.4.1135. [DOI] [PubMed] [Google Scholar]
  • 36.O’Donnell S, Cranney A, Horsley T, Weiler HA, Atkinson SA, Hanley DA, Ooi DS, Ward L, Barrowman N, Fang M, Sampson M, Tsertsvadze A, Yazdi F. Efficacy of food fortification on serum 25-hydroxyvitamin D concentrations: systematic review. Am J Clin Nutr. 2008 Dec;88(6):1528–34. doi: 10.3945/ajcn.2008.26415. [DOI] [PubMed] [Google Scholar]
  • 37.Nesby-O’Dell S, Scanlon KS, Cogswell ME, Gillespie C, Hollis BW, Looker AC, Allen C, Doughertly C, Gunter EW, Bowman BA. Hypovitaminosis D prevalence and determinants among African American and white women of reproductive age: third National Health and Nutrition Examination Survey, 1988–1994. Am J Clin Nutr. 2002 Jul;76(1):187–92. doi: 10.1093/ajcn/76.1.187. [DOI] [PubMed] [Google Scholar]
  • 38.The National Heart, Lung, and Blood Institute Growth and Health Study Research Group. Obesity and cardiovascular disease risk factors in black and white girls: the NHLBI Growth and Health Study. Am J Public Health. 1992 Dec;82(12):1613–20. doi: 10.2105/ajph.82.12.1613. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.US Department of Agriculture. [accessed July 2010];MyPyramid. Available from: http://www.mypyramid.gov.
  • 40.Moore C, Murphy MM, Keast DR, Holick MF. Vitamin D intake in the United States. J Am Diet Assoc. 2004 Jun;104(6):980–3. doi: 10.1016/j.jada.2004.03.028. [DOI] [PubMed] [Google Scholar]
  • 41.Calvo MS, Whiting SJ. Prevalence of vitamin D insufficiency in Canada and the United States: importance to health status and efficacy of current food fortification and dietary supplement use. Nutr Rev. 2003 Mar;61(3):107–13. doi: 10.1301/nr.2003.marr.107-113. [DOI] [PubMed] [Google Scholar]
  • 42.US Department of Agriculture Research Service Nutrient Data Laboratory. USDA National Nutrient Database for Standard Reference. 2009. Release 22. [Google Scholar]
  • 43.Jarvis JK, Miller GD. Overcoming the barrier of lactose intolerance to reduce health disparities. J Natl Med Assoc. 2002 Feb;94(2):55–66. [PMC free article] [PubMed] [Google Scholar]
  • 44.Harris SS. Optimizing vitamin D intake for populations with special needs: Barriers to effective food fortification and supplementation. J Nutr. 2006;136:1126–9. doi: 10.1093/jn/136.4.1114. [DOI] [PubMed] [Google Scholar]
  • 45.Affenito SG, Thompson DR, Franko DL, Striegel-Moore RH, Daniels SR, Barton BA, Schreiber GB, Schmidt M, Crawford PB. Longitudinal assessment of micronutrient intake among African-American and white girls: The National Heart, Lung, and Blood Institute Growth and Health Study. J Am Diet Assoc. 2007 Jul;107(7):1113–23. doi: 10.1016/j.jada.2007.04.014. [DOI] [PubMed] [Google Scholar]
  • 46.Lytle LA, Himes JH, Feldman H, Zive M, Dwyer J, Hoelscher D, Webber L, Yang M. Nutrient intake over time in a multi-ethnic sample of youth. Public Health Nutr. 2002 Apr;5(2):319–28. doi: 10.1079/PHN2002255. [DOI] [PubMed] [Google Scholar]
  • 47.Storey ML, Forshee RA, Anderson PA. Associations of adequate intake of calcium with diet, beverage consumption, and demographic characteristics among children and adolescents. J Am Coll Nutr. 2004 Feb;23(1):18–33. doi: 10.1080/07315724.2004.10719339. [DOI] [PubMed] [Google Scholar]
  • 48.Winkleby MA, Robinson TN, Sundquist J, Kraemer HC. Ethnic variation in cardiovascular disease risk factors among children and young adults: findings from the Third National Health and Nutrition Examination Survey, 1988–1994. JAMA. 1999 Mar 17;281(11):1006–13. doi: 10.1001/jama.281.11.1006. [DOI] [PubMed] [Google Scholar]
  • 49.Thompson DR, Obarzanek E, Franko DL, Barton BA, Morrison J, Biro FM, Daniels SR, Striegel-Moore RH. Childhood overweight and cardiovascular disease risk factors: the National Heart, Lung, and Blood Institute Growth and Health Study. J Pediatr. 2007 Jan;150(1):18–25. doi: 10.1016/j.jpeds.2006.09.039. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Larson NI, Nelson MC, Neumark-Sztainer D, Story M, Hannan PJ. Making time for meals: meal structure and associations with dietary intake in young adults. J Am Diet Assoc. 2009 Jan;109(1):72–9. doi: 10.1016/j.jada.2008.10.017. [DOI] [PubMed] [Google Scholar]
  • 51.Burgess-Champoux TL, Larson N, Neumark-Sztainer D, Hannan PJ, Story M. Are family meal patterns associated with overall diet quality during the transition from early to middle adolescence? J Nutr Educ Behav. 2009 Mar-Apr;41(2):79–86. doi: 10.1016/j.jneb.2008.03.113. [DOI] [PubMed] [Google Scholar]
  • 52.Nelson MC, Neumark-Sztainer D, Hannan PJ, Story M. Five-year longitudinal and secular shifts in adolescent beverage intake: findings from project EAT (Eating Among Teens)-II. J Am Diet Assoc. 2009 Feb;109(2):308–12. doi: 10.1016/j.jada.2008.10.043. [DOI] [PubMed] [Google Scholar]
  • 53.Striegel-Moore RH, Thompson D, Affenito SG, Franko DL, Obarzanek E, Barton BA, Schreiber GB, Daniels SR, Schmidt M, Crawford PB. Correlates of beverage intake in adolescent girls: the National Heart, Lung, and Blood Institute Growth and Health Study. J Pediatr. 2006 Feb;148(2):183–7. doi: 10.1016/j.jpeds.2005.11.025. [DOI] [PubMed] [Google Scholar]
  • 54.Nielsen SJ, Popkin BM. Changes in beverage intake between 1977 and 2001. Am J Prev Med. 2004 Oct;27(3):205–10. doi: 10.1016/j.amepre.2004.05.005. [DOI] [PubMed] [Google Scholar]
  • 55.Affenito SG, Thompson DR, Barton BA, Franko DL, Daniels SR, Obarzanek E, Schreiber GB, Striegel-Moore RH. Breakfast consumption by African-American and white adolescent girls correlates positively with calcium and fiber intake and negatively with body mass index. J Am Diet Assoc. 2005 Jun;105(6):938–45. doi: 10.1016/j.jada.2005.03.003. [DOI] [PubMed] [Google Scholar]
  • 56.Barton BA, Eldridge AL, Thompson D, Affenito SG, Striegel-Moore RH, Franko DL, Albertson AM, Crockett SJ. The relationship of breakfast and cereal consumption to nutrient intake and body mass index: the National Heart, Lung, and Blood Institute Growth and Health Study. J Am Diet Assoc. 2005 Sep;105(9):1383–9. doi: 10.1016/j.jada.2005.06.003. [DOI] [PubMed] [Google Scholar]
  • 57.Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD. Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. J Am Diet Assoc. 2005 May;105(5):743–60. doi: 10.1016/j.jada.2005.02.007. quiz 61–2. [DOI] [PubMed] [Google Scholar]
  • 58.Nicklas TA, Reger C, Myers L, O’Neil C. Breakfast consumption with and without vitamin-mineral supplement use favorably impacts daily nutrient intake of ninth-grade students. J Adolesc Health. 2000 Nov;27(5):314–21. doi: 10.1016/s1054-139x(00)00113-0. [DOI] [PubMed] [Google Scholar]
  • 59.Reaves L, Steffen LM, Dwyer JT, Webber LS, Lytle LA, Feldman HA, Hoelscher DM, Zive MM, Osganian SK. Vitamin supplement intake is related to dietary intake and physical activity: The Child and Adolescent Trial for Cardiovascular Health (CATCH) J Am Diet Assoc. 2006 Dec;106(12):2018–23. doi: 10.1016/j.jada.2006.09.001. [DOI] [PubMed] [Google Scholar]
  • 60.Ventura AK, Loken E, Mitchell DC, Smiciklas-Wright H, Birch LL. Understanding reporting bias in the dietary recall data of 11-year-old girls. Obesity (Silver Spring) 2006 Jun;14(6):1073–84. doi: 10.1038/oby.2006.123. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.Givens ML, Lu C, Bartell SM, Pearson MA. Estimating dietary consumption patterns among children: a comparison between cross-sectional and longitudinal study designs. Environ Res. 2007 Mar;103(3):325–30. doi: 10.1016/j.envres.2006.07.003. [DOI] [PubMed] [Google Scholar]
  • 62.Talwar SA, Swedler J, Yeh J, Pollack S, Aloia JF. Vitamin-D nutrition and bone mass in adolescent black girls. J Natl Med Assoc. 2007 Jun;99(6):650–7. [PMC free article] [PubMed] [Google Scholar]
  • 63.Meyer C. Scientists probe role of vitamin D: deficiency a significant problem, experts say. JAMA. 2004 Sep 22;292(12):1416–8. doi: 10.1001/jama.292.12.1416. [DOI] [PubMed] [Google Scholar]

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