Supplemental Material can be found at:

http://jn.nutrition.org/cgi/content/full/135/10/2478/DC1

Nutritional Epidemiology

Vitamin D Intakes by Children and Adults in the United States

Differ among Ethnic Groups1
Carolyn E. Moore,2 Mary M. Murphy,* and Michael F. Holick†
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

ABSTRACT Concerns about vitamin D status in the United States have resurfaced due to increasing reports of
insufficiency and deficiency. Few foods contain vitamin D naturally, and currently few foods are fortified in the
United States. Intakes of vitamin D in the United States from food and food plus supplements by age, sex, and
race/ethnicity group were estimated. Individuals ⱖ 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

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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
ⱖ 51 y old, only 4% met or exceeded the AI from food alone. Few women 19 –50 y old or men and women ⱖ 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 ⱖ 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. J. Nutr. 135: 2478 –2485, 2005.

KEY WORDS: ● vitamin D intake ● ethnic groups

Vitamin D status concerns in the United States have re-
surfaced 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 cholecal-
ciferol (D-3). The best clinical indicator of vitamin D status is
circulating levels of 25-hydroxyvitamin D [25(OH)D]3 con-
centrations (1). When 25(OH)D levels remain below 20
nmol/L (8 ␮g/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 ␮g/L) (1).
Rickets, a disease characterized by soft and deformed bones
1
Supplemental Tables 1 and 2 are available as Online Supporting Material
with the online posting of this paper at www.nutrition.org.
2
To whom correspondence should be addressed.
E-mail: caromoore@na.ko.com.
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 Examina-
tion 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 chole-
calciferol; 25(OH)D, 25-hydroxyvitamin D.
due to vitamin D deficiency, was nearly eliminated in the
United States when vitamin D fortification of milk was intro-
duced 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 vita-
min 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 Sur-
vey (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

0022-3166/05 $8.00 © 2005 American Society for Nutrition.

Manuscript received 6 April 2005. Initial review completed 25 May 2005. Revision accepted 29 July 2005.

2478
 U.S. VITAMIN D INTAKE BY RACE/ETHNICITY
reported by male teenagers. Although use of vitamin D– con-
taining dietary supplements increased the number of individ-
uals 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 vita-
min D.
SUBJECTS AND METHODS
Food consumption data source. Estimates of vitamin D intake
were based on food consumption data collected in NHANES 1999 –
2000, a recent nationwide survey. The Center for Disease Control
and Prevention’s National Center for Health Statistics (NCHS)
NHANES 1999 –2000 data release provides food consumption data
collected from a nationally representative sample of the U.S. popu-
lation (16). The NHANES is a complex, multistage probability
sample of the civilian noninstitutionalized population of the United
States designed to collect nationally representative reference data
and prevalence estimates for nutrition, health status, and health
condition measures. Beginning in 1999, the NHANES became a
continuous survey. In the NHANES data collected during 1999 and
2000, individuals of all ages were sampled, and low-income persons,
adolescents 12–19 y of age, persons ⱖ 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 deter-
mined 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 (in-
cluding 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 vita-
min D fortification of calcium-fortified juice and juice drinks at a
maximum level of 2.5 ␮g (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 Data-
bases and do not include nutrient data for vitamin D. Consequently,
it was necessary to first develop estimates of the vitamin D concen-
trations 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, Stan-
dard 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 manu-
facturers; information collected in Internet searches; and product
labels observed between June and August, 2000. The database in-
2479
cludes 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 ␮g (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
␮g (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
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content of milk was assumed to be 10 ␮g (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 ␮g/quart, whereas the mean
vitamin D concentration in 1% milk was 12.7 ␮g/quart (26).
The vitamin D concentration data compiled for naturally occur-
ring 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 contain-
ing 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 ␮g ⫽ 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 ␮g/d (200 IU) for
individuals 1–50 y old, 10 ␮g/d (400 IU) for individuals 51–70 y old,
and 15 ␮g/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
2480 MOORE ET AL.

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 Samples™
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 popula-
tion consuming an amount of vitamin D that was equal to or greater
than the AI for vitamin D was calculated using Iowa State Univer-
sity’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
mined 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 anal-
yses. A total of 20,033 nonbreast-feeding individuals ⱖ 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).
Dietary intake of vitamin D. Mean intakes of vitamin D
from food using NHANES 1999 –2000 consumption data were
estimated (Table 2). Among children 1– 8 y old, Mexican
American children reported the highest daily intake of vita-
min D from food, whereas NH black children were estimated
to have the lowest intakes.
Among adolescent and teenage boys (9 –18 y), the mean
intake of vitamin D was highest in the population of NH white
boys and lowest in the population of NH black boys. Data from
NHANES 1999 –2000 suggest that intake of vitamin D from
food sources alone was consistently lower among NH black

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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.
RESULTS
A total of 8276 individuals ⱖ 1 y old provided dietary
recalls in NHANES 1999 –2000 determined to be reliable and
to meet overall quality and completeness criteria as deter-
men compared with NH white men, and comparable to in-
takes reported by Mexican American men.
Mean daily intake of vitamin D by females 9 –18 or 19 –50
y old did not differ by race/ethnicity. NH white women ⱖ 51 y
old were estimated to have higher mean vitamin D intakes
from food sources compared with NH black or Mexican Amer-
ican 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 (ⱖ51 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.

TABLE 1
Sample size by race/ethnicity

NHANES 1999–2000 CSFII 1994–1996, 1998

NH NH Mexican NH NH Mexican Other

Sex1 Age, y Total2 White Black American Total2 White Black American Hispanic

M⫹F 1–8 1345 350 329 525 7884 4902 1177 686 644
M 9–18 1220 256 353 538 1069 700 146 91 81
M 19–50 1105 431 240 325 2726 2012 257 169 159
M 51⫹ 992 521 157 244 2402 1970 250 51 80
F 9–18 1229 256 371 511 1061 649 190 79 99
F 19–50 1361 527 277 416 2616 1844 336 153 160
F 51⫹ 1024 482 183 267 2275 1822 281 44 73
1
M ⫽ male; F ⫽ female.
2
Total includes race/ethnic groups not shown separately.
 U.S. VITAMIN D INTAKE BY RACE/ETHNICITY 2481

TABLE 2
Estimated daily intake of vitamin D from food sources by race/ethnicity in the United States, NHANES 1999 –20001

Mexican
Sex2 Age, y Vitamin D source Total3 NH White NH Black American

␮g/d

M⫹F 1–8 All food sources 5.9 ⫾ 0.18 5.9 ⫾ 0.29ab

5.2 ⫾ 0.16b 6.4 ⫾ 0.23a
Fortified milk 3.8 ⫾ 0.16 3.7 ⫾ 0.24b 3.0 ⫾ 0.13c 4.4 ⫾ 0.21a
Fortified RTEs 0.6 ⫾ 0.04 0.5 ⫾ 0.06 0.7 ⫾ 0.07 0.6 ⫾ 0.05
Other fortified sources 0.8 ⫾ 0.06 0.9 ⫾ 0.09a 0.8 ⫾ 0.07ab 0.6 ⫾ 0.04b
Natural sources 0.8 ⫾ 0.08 0.8 ⫾ 0.12 0.7 ⫾ 0.05 0.8 ⫾ 0.04
M 9–18 All food sources 6.0 ⫾ 0.22 6.6 ⫾ 0.31a 4.7 ⫾ 0.23c 5.6 ⫾ 0.30b
Fortified milk 3.5 ⫾ 0.19 4.1 ⫾ 0.27a 2.3 ⫾ 0.20b 3.4 ⫾ 0.25a
Fortified RTEs 0.6 ⫾ 0.07 0.7 ⫾ 0.11 0.5 ⫾ 0.07 0.6 ⫾ 0.07
Other fortified sources 0.7 ⫾ 0.07 0.7 ⫾ 0.09 0.6 ⫾ 0.07 0.4 ⫾ 0.06
Natural sources 1.1 ⫾ 0.06 1.1 ⫾ 0.08 1.3 ⫾ 0.09 1.1 ⫾ 0.08
M 19–50 All food sources 5.4 ⫾ 0.21 5.9 ⫾ 0.28a 4.7 ⫾ 0.34b 4.6 ⫾ 0.49b
Fortified milk 2.3 ⫾ 0.15 2.6 ⫾ 0.20a 1.4 ⫾ 0.17b 2.1 ⫾ 0.29a
Fortified RTEs 0.3 ⫾ 0.04 0.3 ⫾ 0.05 0.3 ⫾ 0.07 0.2 ⫾ 0.06
Other fortified sources 1.0 ⫾ 0.11 1.1 ⫾ 0.16a 0.9 ⫾ 0.11a 0.5 ⫾ 0.07b
Natural sources 1.9 ⫾ 0.09 1.9 ⫾ 0.12 2.1 ⫾ 0.19 1.8 ⫾ 0.27
M 51⫹ All food sources 5.3 ⫾ 0.16 5.5 ⫾ 0.20a 3.8 ⫾ 0.35b 4.8 ⫾ 0.40ab
2.2 ⫾ 0.13 2.4 ⫾ 0.16a 1.1 ⫾ 0.17b 2.3 ⫾ 0.29a

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Fortified milk
Fortified RTEs 0.3 ⫾ 0.04 0.4 ⫾ 0.05a 0.3 ⫾ 0.09ab 0.2 ⫾ 0.05b
Other fortified sources 1.1 ⫾ 0.07 1.1 ⫾ 0.08a 0.8 ⫾ 0.11b 0.7 ⫾ 0.15b
Natural sources 1.8 ⫾ 0.09 1.7 ⫾ 0.10 1.7 ⫾ 0.16 1.6 ⫾ 0.18
F 9–18 All food sources 4.4 ⫾ 0.22 4.6 ⫾ 0.33 3.8 ⫾ 0.18 4.9 ⫾ 0.68
Fortified milk 2.4 ⫾ 0.18 2.8 ⫾ 0.28a 1.7 ⫾ 0.13b 2.9 ⫾ 0.34a
Fortified RTEs 0.4 ⫾ 0.03 0.4 ⫾ 0.06 0.5 ⫾ 0.05 0.6 ⫾ 0.13
Other fortified sources 0.6 ⫾ 0.06 0.6 ⫾ 0.06 0.6 ⫾ 0.06 0.4 ⫾ 0.05
Natural sources 0.9 ⫾ 0.06 0.9 ⫾ 0.08 1.1 ⫾ 0.08 1.0 ⫾ 0.19
F 19–50 All food sources 4.2 ⫾ 0.18 4.3 ⫾ 0.24 3.7 ⫾ 0.22 4.1 ⫾ 0.30
Fortified milk 1.8 ⫾ 0.12 2.0 ⫾ 0.16a 1.1 ⫾ 0.17b 2.1 ⫾ 0.16a
Fortified RTEs 0.2 ⫾ 0.03 0.3 ⫾ 0.03 0.2 ⫾ 0.05 0.2 ⫾ 0.03
Other fortified sources 0.9 ⫾ 0.06 0.8 ⫾ 0.07 0.8 ⫾ 0.08 0.7 ⫾ 0.11
Natural sources 1.3 ⫾ 0.06 1.2 ⫾ 0.09 1.5 ⫾ 0.11 1.2 ⫾ 0.10
F 51⫹ All food sources 4.7 ⫾ 0.24 4.9 ⫾ 0.27a 3.7 ⫾ 0.35b 3.5 ⫾ 0.25b
Fortified milk 1.9 ⫾ 0.14 1.9 ⫾ 0.14a 1.0 ⫾ 0.13b 1.6 ⫾ 0.19a
Fortified RTEs 0.3 ⫾ 0.03 0.3 ⫾ 0.04a 0.2 ⫾ 0.05b 0.2 ⫾ 0.04b
Other fortified sources 1.0 ⫾ 0.07 1.1 ⫾ 0.09a 0.9 ⫾ 0.07a 0.6 ⫾ 0.07b
Natural sources 1.5 ⫾ 0.14 1.6 ⫾ 0.18 1.7 ⫾ 0.33 1.1 ⫾ 0.13
1
Values are mean ⫾ SEM; n is given in Table 1. Race/ethnic group means in a row with superscripts without a common letter differ, P ⬍ 0.05.
2
M ⫽ male; F ⫽ female.
3
Total includes race/ethnic groups not shown separately.

Vitamin D intakes from natural sources did not differ by

race/ethnicity. TABLE 3
Dietary supplement contribution. Vitamin D intakes
from food plus dietary supplements by race/ethnicity in the Estimated daily intake of vitamin D from food plus dietary
United States from the NHANES 1999 –2000 data were esti- supplements by race/ethnicity in the United States,
mated (Table 3). In all subpopulations considered in this NHANES 1999 –20001
analysis, mean intakes by NH whites were higher than those
by NH blacks and higher than or comparable to intakes by Mexican
Mexican Americans of the same sex. Sex2 Age, y Total3 NH White NH Black American
Vitamin D intakes compared with recommendations. Vi-
tamin D intake from food alone or food plus supplements was ␮g/d
compared with the AI (Fig. 1) (Supplemental Tables 1 and 2).
M⫹F 1–8 8.2 ⫾ 0.3 8.4 ⫾ 0.4a 6.9 ⫾ 0.3b 8.2 ⫾ 0.4a
Of children 1– 8 y old, ⬃60% consumed total vitamin D ⱖ 5 M 9–18 7.1 ⫾ 0.3 7.8 ⫾ 0.5a 5.2 ⫾ 0.3c 6.5 ⫾ 0.4b
␮g/d. Mexican American children (69%) were most likely to M 19–50 7.5 ⫾ 0.3 8.1 ⫾ 0.4a 6.0 ⫾ 0.4b 6.1 ⫾ 0.8b
meet or exceed the AI, whereas only 48% of non-Hispanic M 51⫹ 8.8 ⫾ 0.3 9.5 ⫾ 0.4a 5.3 ⫾ 0.7b 6.4 ⫾ 0.5b
black children were estimated to meet or exceed the AI levels F 9–18 5.6 ⫾ 0.3 6.1 ⫾ 0.5a 4.7 ⫾ 0.3b 6.1 ⫾ 0.7ab
for vitamin D from food. The percentage of individuals meet- F 19–50 7.1 ⫾ 0.3 7.8 ⫾ 0.4a 6.1 ⫾ 0.4b 5.7 ⫾ 0.4b
ing the AI from food declined with increasing age, and only F 51⫹ 9.5 ⫾ 0.4 10.3 ⫾ 0.5a 6.0 ⫾ 0.4b 6.9 ⫾ 0.4b
4% of adults ⱖ 51 y old were meeting or exceeding the AI. 1
Values are means ⫾ SEM; n is given in Table 1. Race/ethnic group
NH white boys 1– 8 y old and older men were more likely to means in a row with superscripts without a common letter differ, P
meet the recommended intakes of vitamin D from food sources ⬍ 0.05.
than NH black men, whereas the percentage of females meet- 2
M ⫽ male; F ⫽ female.
ing the AI did not differ due to race/ethnicity. 3
Total includes race/ethnic groups not shown separately.
2482 MOORE ET AL.

black girls met or exceeded the AI from food and supplements,

FIGURE 1 The percentage of the U.S. population by race/ethnic-
whereas 59% of NH white and 60% of Mexican American
girls met the AI level. In the populations of older adults (51⫹
y), ⬃30% of men and 32% of women met or exceeded the
vitamin D AI from food plus supplement sources, and signif-
icantly more NH white men and women met the recom-
mended intake than NH black and Mexican American indi-
viduals in this age group.
Vitamin D intakes by race/ethnicity based on food con-
sumption 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

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ity meeting the vitamin D AI from food and food plus supplements,
NHANES 1999 –2000. Percentages within a race/ethnic group with
superscripts without a common letter differ (P ⬍ 0.05); a or b refers to
vitamin D intake from food; A or B refers to vitamin D intake from food
plus supplements. AI for individuals 1–50 y old is 5 ␮g/d (200 IU), 51–70
y is 10 ␮g/d (400 IU), and ⱖ71 y is 15 ␮g/d (600 IU). Standard error for
the percentage meeting vitamin D AI from food ranged from 0.6 (M 51⫹
y, NH black) to 13.1 (F 9 –18 y, Mexican American) and from food plus
supplements, 2.4 (M 19 –50 y, NH white) to 9.3 (F 9 –18 y, Mexican
American). M ⫽ male; F ⫽ female.
The percentages of each population meeting the AI based
on vitamin D intakes from food plus supplements were deter-
mined (Fig. 1) (Supplemental Table 2). Among children 1– 8
y old, AI levels for vitamin D from food and supplements were
met or exceeded by 82% of Mexican American, 66% of NH
black, and 78% of NH white children. Approximately 75% of
NH white boys 9 –18 y old and men 19 –50 y old met or
exceeded the vitamin D AI from food plus supplement sources,
whereas significantly fewer NH black and Mexican American
males met the recommended intakes. Half of all adolescent
and teenage girls and 66% of women 19 –50 y old were
estimated to consume AI levels of vitamin D from food and
supplements. Among 9- to 18-y-old girls, only 38% of NH
the ability of the statistical test to detect differences in vitamin
D intake.
DISCUSSION
Children and adolescent/teenage males (9 –18 y) were most
likely to consume recommended levels of vitamin D from
foods. The lowest dietary intakes of vitamin D were reported
by teenage girls and women, whereas the highest intakes of
vitamin D from food sources were reported by teenage boys.
Nevertheless, lower vitamin D intake by young girls over time
relative to boys, controlling for overall energy intake, was
reported previously (32). Among adults, only 4% of men and
1% of women ⱖ 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 esti-
mated for NH blacks were consistently lower than intakes by

TABLE 4
Estimated daily intake of vitamin D from food by race/ethnicity in the United States, CSFII 1994 –1996, 19981

Mexican Other
Sex2 Age, y Total3 NH White NH Black American Hispanic

␮g/d

M⫹F 1–8 6.1 ⫾ 0.1 6.1 ⫾ 0.1 b

5.2 ⫾ 0.1c 6.5 ⫾ 0.2a 6.5 ⫾ 0.2ab
M 9–18 6.9 ⫾ 0.2 7.4 ⫾ 0.3a 5.1 ⫾ 0.3b 6.4 ⫾ 0.7ab 7.0 ⫾ 0.5a
M 19–50 5.2 ⫾ 0.1 5.3 ⫾ 0.1 4.9 ⫾ 0.4 5.1 ⫾ 0.5 5.2 ⫾ 0.4
M 51⫹ 5.3 ⫾ 0.1 5.4 ⫾ 0.1 5.0 ⫾ 0.3 4.2 ⫾ 0.5 5.7 ⫾ 0.6
F 9–18 4.8 ⫾ 0.1 4.9 ⫾ 0.1 4.5 ⫾ 0.4 4.9 ⫾ 0.4 4.7 ⫾ 0.3
F 19–50 3.8 ⫾ 0.1 3.8 ⫾ 0.1 3.5 ⫾ 0.3 3.5 ⫾ 0.4 3.6 ⫾ 0.3
F 51⫹ 4.1 ⫾ 0.1 4.1 ⫾ 0.1 3.7 ⫾ 0.3 3.5 ⫾ 0.5 3.6 ⫾ 0.5
1
Values are mean ⫾ SEM; n is given in Table 1. Race/ethnic group means in a row with superscripts without a common letter differ, P ⬍ 0.05.
2
M ⫽ male; F ⫽ female.
3
Total includes race/ethnic groups not shown separately.
 U.S. VITAMIN D INTAKE BY RACE/ETHNICITY
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 vita-
min 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 adoles-
cents 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 ⱕ 37.5 nmol/L was 42% among African
Americans compared with 4.2% among white women of re-
productive age (11). Furthermore, a significant positive asso-
ciation 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 in-
takes 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 con-
centration data. The data in this analysis may be most repre-
sentative 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 ␮g (100 IU) vitamin D/240 mL (8 fl oz) serving
and several brands of yogurt now provide 1.5–2.0 ␮g (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.
2483
Additionally, because a 2nd day of intake data was not avail-
able 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 vi-
tamin 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 vita-
min 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
Downloaded from jn.nutrition.org by on September 10, 2010
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 in-
dividuals 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 supple-
ments on the total intake of vitamin D by adults ⱖ 51 y old is
particularly striking; vitamin D intake from dietary supple-
ments 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 inci-
dence 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 Cau-
casians ranges from 6 to 22% (44). The usual treatment for
lactose maldigestion is avoidance of dairy products that con-
tain lactose, such as milk, although lactose-intolerant individ-
uals 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
ⱖ 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
2484 MOORE ET AL.
suggest that the 1997 recommended intakes for vitamin D of
5 ␮g/d for age 1–50 y, 10 ␮g/d for age 51–70 y, and 15 ␮g/d for
ⱖ 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 ␮g (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 ␮g
(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 ␮g (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 Amer-
icans, Asians, and Mexican Americans who may avoid dairy
products due to lactose intolerance.
Differences in vitamin D intakes from food and supple-
ments among sex and race/ethnicity groups may be contribut-
ing to health status disparities in the United States. Despite
recent efforts to increase vitamin D intakes through appropri-
ate 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 supple-
ments compared with current recommended levels, especially
for older NH black and Mexican American adults, warrants
intervention. As an alternative to greater sun exposure, in-
creasing 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.
ACKNOWLEDGMENTS
We acknowledge the statistical analysis assistance of Gabriel
Camaño-Garcı́a, Department of Statistics, Iowa State University, and
Ted Berner, Senior Science Manager, ENVIRON Health Sciences.
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