Racial/ethnic considerations in making recommendations for vitamin
D for adult and elderly men and women1– 4
Bess Dawson-Hughes
ABSTRACT
Vitamin D is acquired through diet and skin exposure to ultraviolet
B light. Skin production is determined by length of exposure, lati-
tude, season, and degree of skin pigmentation. Blacks produce less
vitamin D3 than do whites in response to usual levels of sun exposure
and have lower 25-hydroxyvitamin D [25(OH)D] concentrations in
winter and summer. Blacks in the United States also use dietary
supplements less frequently than do whites. However, blacks and
whites appear to have similar capacities to absorb vitamin D and to
produce vitamin D after repeated high doses of ultraviolet B light.
There is a growing consensus that serum 25(OH)D concentrations of
at least 75-80 nmol/L are needed for optimal bone health, on the basis
of studies of older white subjects living in Europe and the United
States. The studies show that increasing serum 25(OH)D concentra-
tions to this level decreases parathyroid hormone (PTH) concentra-
tions, decreases rates of bone loss, and reduces rates of fractures.
Among US blacks, low 25(OH)D concentrations are associated with
higher concentrations of PTH, which are associated with lower bone
mineral density. Vitamin D supplements decrease PTH and bone
turnover marker concentrations among blacks. These findings sug-
gest that improving vitamin D status would benefit blacks as well as
whites. On the basis of studies conducted in the temperate zone, the
intake of vitamin D3 needed to maintain a group average 25(OH)D
concentration of 80 nmol/L in winter is 앑1000 IU/d. Broad-based
vitamin D supplementation is needed to remove vitamin D insuffi-
ciency as a contributing cause of osteoporosis. Am J Clin Nutr
2004;80(suppl):1763S– 6S.
KEY WORDS Vitamin D, bone mineral density, fractures,
dietary requirement
INTRODUCTION
Osteoporosis is a common problem in the United States and
elsewhere. In its recent prevalence report, the National Osteo-
porosis Foundation indicated that, among those 욷 50 y of age,
20% of white women and 5% of black women have osteoporosis
and 52% of white women and 35% of black women have low
bone mass, defined as 1-2.5 SD below the young reference mean
(1). Seven percent of white men and 3% of black men have
osteoporosis, and 35% of white men and 19% of black men have
low bone mass. These values are in accord with recent estimates
of fracture rates for the 2 race groups. Barrett et al (2) reported
that the actuarial risks of hip fractures by age 85 y are 11.2% for
white women, 3.6% for black women, 4.1% for white men, and
2.0% for black men.
Am J Clin Nutr 2004;80(suppl):1763S– 6S. Printed in USA. © 2004 American Society for Clinical Nutrition
Vitamin D is known to be essential for bone health. It is also
well recognized that blacks have lower vitamin D concentrations
than do whites. The fact that blacks have higher bone mass and
lower fracture rates than do whites has led some to assign less
importance to defining the role of vitamin D in bone health for
blacks. The objectives of this report are to compare, for blacks
and whites, vitamin D physiologic processes, observational stud-
ies of vitamin D, and vitamin D intervention studies related to
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bone health. The issues of optimal 25-hydroxyvitamin D
[25(OH)D] concentrations and the vitamin D intake needed to
reach such concentrations are also addressed.
COMPARATIVE PHYSIOLOGIC FINDINGS
In addition to having higher bone mass than whites, blacks
have been reported to have higher circulating concentrations of
parathyroid hormone (PTH) (3, 4) and 1,25-dihydroxyvitamin D
[1,25(OH)2D] (3, 4), although these findings have not been ob-
served consistently (5). With dynamic testing involving citrate
infusions among black and white women, Fuleihan et al (6)
observed a mild degree of PTH elevation among black subjects.
A consistent finding is that blacks have lower urinary calcium
concentrations than do whites, when the 2 groups are studied with
the same calcium intakes (3, 5, 7). Black women were shown to
have similar levels of calcium absorption, compared with white
women; however, their circulating concentrations of
1,25(OH)2D were higher, which suggests that blacks may have
gut resistance to the actions of 1,25(OH)2D (8). Consistent with
this suggestion, a subsequent investigation revealed that the in-
crease in fractional calcium absorption in response to oral ad-
ministration of 1,25(OH)2D was reduced among blacks, com-
pared with whites (7).
Racial/ethnic differences in bone turnover have also been re-
ported. In a large observational study among premenopausal and
1
From the Bone Metabolism Laboratory, Jean Mayer US Department of
Agriculture Human Nutrition Research Center on Aging, Tufts University,
Boston.
2
Presented at the conference “Vitamin D and Health in the 21st Century:
Bone and Beyond,” held in Bethesda, MD, October 9 –10, 2003.
3
Supported by the US Department of Agriculture, under agreement 58-
1950-9001. Any opinions, findings, conclusions, or recommendations ex-
pressed in this publication are those of the author and do not necessarily
reflect the views of the US Department of Agriculture.
4
Address correspondence to B Dawson-Hughes, Bone Metabolism Lab-
oratory, Jean Mayer USDA Human Nutrition Research Center on Aging,
Tufts University, 711 Washington Street, Boston, MA 02111. E-mail:
bess.dawson-hughes@tufts.edu.
1763S
1764S
FIGURE 1. Plasma 25(OH)D concentrations among healthy, young,
American, black (solid line) and white (dashed line) women, according to
season, in Boston at latitude 42° N. Reprinted with permission from reference
13.
perimenopausal women, Finkelstein et al (9) observed that serum
osteocalcin concentrations were 11-24% higher among white
women than among black, Chinese, and Japanese women in the
United States. In that study, urinary N-telopeptide concentra-
tions were similar for the black and white women, being 9-18%
higher than values for the Chinese and Japanese women. In other
studies, blacks exhibited lower turnover rates than did whites (3,
4, 10). During dynamic testing involving PTH(1–34) infusions,
black and white women exhibited similar increases in the mark-
ers of bone formation but the white subjects demonstrated sig-
nificantly greater increases in biochemical markers of bone re-
sorption than did the black subjects (11). This resistance to the
bone-resorbing action of PTH may contribute to the higher bone
mass among black adults.
SERUM 25(OH)D CONCENTRATIONS AMONG BLACKS
AND WHITES
Serum 25(OH)D concentrations are generally lower among
blacks than among whites. This was observed in the third Na-
tional Health and Nutrition Examination Survey sample of
쏜 18 000 men and women (12). It was also noted in a study of 90
black and white women, 20-40 y of age, who were evaluated 4
times each in the course of 1 year in the Boston area, at latitude
42° N (13). Figure 1 displays serum 25(OH)D concentrations
for the 90 women according to season. Not only were 25(OH)D
concentrations generally lower among blacks but also the
changes in 25(OH)D concentrations with the seasons were at-
tenuated. This is consistent with the observation of Loomis (14)
that blacks produce less vitamin D than do whites at usual levels
of sun exposure. In that study, intakes of vitamin D were similar
among blacks (207 IU/d) and whites (232 IU/d).
Is there any evidence to suggest that blacks and whites have
different capacities to absorb or synthesize vitamin D? Matsuoka
et al (15) administered a single dose of 50 000 IU of vitamin D2
to young blacks and whites and measured their serum 25(OH)D
responses in the subsequent 24 h. For the black and white sub-
jects, peak responses (observed at 10 h after the dose) decreased
DAWSON-HUGHES
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FIGURE 2. Serum 25(OH)D and 24,25-dihydroxyvitamin D concentra-
tions in response to biweekly total-body exposure to suberythemal doses of
ultraviolet B radiation, among blacks (lower lines, ■) and whites (upper lines,
F). Reprinted with permission from reference 17.
along the same regression line, which suggests that absorption
characteristics were similar for the 2 groups. In both groups, the
percentage changes in serum 25(OH)D concentrations were in-
versely related to the starting 25(OH)D concentrations. Support-
ing evidence for this finding was found in an observational study
in which blacks and whites demonstrated similar positive asso-
ciations between self-reported intakes of vitamin D and serum
25(OH)D concentrations (16). Brazerol et al (17) defined and
compared the skin vitamin D synthetic capacity for black and
white subjects who were exposed to total-body, suberythemal,
ultraviolet B rays (280-315 nm) twice weekly for 6 wk. As shown
in Figure 2, the black subjects had lower starting 25(OH)D
concentrations than did the white subjects, but their increases in
response to ultraviolet B light exposure were similar to those of
the white subjects. Concentrations of the 25(OH)D metabolite
24,25-dihydroxyvitamin D also increased in parallel for the
black and white subjects (Figure 2). These studies suggest that
blacks and whites have similar capacities to absorb and synthe-
size vitamin D.
OBSERVATIONAL STUDIES OF THE CONSEQUENCES
OF LOW 25(OH)D CONCENTRATIONS
In a study of 246 elderly, black and white, low-income subjects
in Boston, serum PTH concentrations were somewhat higher
among the black subjects, but the associations of 25(OH)D con-
centrations with PTH concentrations were similar for the 2
groups (16). In this study population, there was a high prevalence
of secondary hyperparathyroidism, defined as fasting serum
 VITAMIN D AND RACE 1765S
similar for the black and white subjects with normal PTH con-
centrations.
Finally, among those subjects, heel bone mineral densities
were significantly lower among the black women with secondary
hyperparathyroidism than among the black women with normal
PTH concentrations (18). From these findings, we can conclude
that low 25(OH)D concentrations are associated with untoward
skeletal effects among blacks and whites.

VITAMIN D INTERVENTION STUDIES

Vitamin D intervention studies with fracture outcomes have
been conducted predominantly among European and American
whites. In 1996, Lips et al (19) reported that supplementation
with 400 IU/d vitamin D had no effect on the risk of hip fractures
among elderly men and women living in the Netherlands. Sup-
plementation with 100 000 IU of vitamin D every 4 mo (equiv-
alent to 833 IU/d) for a large group of community-dwelling
elderly men and women in the United Kingdom decreased the
risk of any first fracture by 앑30% (20). Three other studies of the
effects of combined calcium and vitamin D supplementation

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FIGURE 3. Serum osteocalcin and N-telopeptide (NTX) concentrations
among elderly American black and white women and men with elevated
(solid bars) and normal (hatched bars) serum PTH concentrations. Sample
sizes are given in parentheses. *Significant within-race differences (P 쏝
0.05). Reprinted with permission from reference 18. Copyright 2001. The
Endocrine Society.
PTH concentrations above the reference range of 1.1-6.9 pmol/L
(18). Among the black subjects, 40% of the women and 35% of
the men had secondary hyperparathyroidism; among the white
subjects, 23% of the women and 13% of the men had elevated
PTH concentrations.
With the same subjects as described above, we examined the
bone turnover rates for those with and without secondary hyper-
parathyroidism, within each racial group (18). As shown in Fig-
ure 3, black men and women with secondary hyperparathyroid-
ism had higher serum osteocalcin concentrations than did blacks
with normal PTH concentrations. The black women with sec-
ondary hyperparathyroidism also had higher serum
N-telopeptide concentrations than did black women with normal
PTH concentrations (Figure 3). Secondary hyperparathyroidism
was associated with higher serum osteocalcin and N-telopeptide
concentrations among the white women but not the men. Overall,
concentrations of biochemical markers of bone turnover were
showed reductions in rates of hip fractures (21) and all nonver-
tebral fractures (21–23), compared with placebo. The results of
those studies are summarized in Table 1. The published
25(OH)D concentrations in Table 1 refer to the concentrations
achieved with the vitamin D supplements. The standardized
25(OH)D values were adjusted to DiSorin equivalent values with
the use of data from a cross-calibration study by Lips et al (25).
The assay used by Trivedi et al (20) was not included in the
cross-calibration study but was reported by the authors (KT
Khaw, personal communication, 18 August 2003) to be an HPLC
method; therefore, values may be similar to the standardized
values. From the available fracture studies, it can be observed
that vitamin D doses of 욷 700 IU/d reduced fracture rates but a
dose of 400 IU/d was not effective. As expected, the serum
25(OH)D concentration achieved with 400 IU/d was lower (only
54 nmol/L) than the concentrations achieved with the higher
doses studied (71-99 nmol/L). The reductions in serum PTH
concentrations also appeared to be dose related. The reduction
was minimal with the dose of 400 IU/d and was substantial with
the higher doses. From these findings, it appears that 25(OH)D3
concentrations of 71-99 nmol/L are needed to decrease risks of
fractures and that 700-800 IU/d vitamin D3 brings the group
mean 25(OH)D concentration into this range. A higher intake
would be needed to ensure concentrations of 70-99 nmol/L

TABLE 1
Serum 25(OH)D and PTH concentrations and nonvertebral fracture rates in response to supplementation with vitamin D3

Published serum Standardized1 serum Effect on serum Preventive effect on

Dose of 25(OH)D 25(OH)D PTH fractures (hip and
Study Sex vitamin D3 concentrations concentrations concentrations others)

IU/d nmol/L nmol/L %

Chapuy et al (21, 24) F 800 100 71 Ҁ47 ѿ
Chapuy et al (23) F 800 100 71 Ҁ33 ѿ
Dawson-Hughes et al (22) M, F 700 112 99 F: Ҁ33; M: Ҁ23 ѿ
Trivedi et al (20) M, F 820 74 — — ѿ
Lips et al (19) M, F 400 54 54 Ҁ6 NS
1
Serum 25(OH)D3 concentrations were standardized to DiaSorin equivalent values (ie, HPLC, followed by a competitive protein-binding assay), on the
basis of a cross-calibration study (25). Reprinted from Nutritional Aspects of Osteoporosis, Burckhardt P, Dawson-Hughes B, Heaney R, eds., copyright 2004,
with permission from Elsevier.
1766S DAWSON-HUGHES
among older adults. None of these studies addressed the possi-
bility that higher doses of vitamin D might provide additional
benefits to the skeleton.
Vitamin D intervention studies with changes in bone mineral
density or fracture outcomes have not been reported for black
subjects. A small pilot study with black subjects revealed that
supplementation with 800 IU/d vitamin D for 12 wk decreased
serum PTH and urinary N-telopeptide concentrations (26). This
suggests that longer-term supplementation with vitamin D is
likely to have favorable effects on the skeleton among black
subjects, although direct evidence is needed.
CONCLUSIONS
Vitamin D is important for optimal bone health among blacks
and whites. Utilization of oral vitamin D appears to be similar for
blacks and whites. Blacks and whites appear to have similar
capacities to synthesize vitamin D in the skin but, at usual levels
of sun exposure, vitamin D synthesis is less efficient among
blacks because of their greater skin pigmentation. For white
adults, an average 25(OH)D concentration of 80 nmol/L is
needed for improved bone health and an intake of 800-1000 IU/d
vitamin D3 is required to bring the group mean 25(OH)D con-
centration to 80 nmol/L. The specific benefit to be gained from
increasing vitamin D intake remains to be defined for black
subjects.
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