1. Introduction
Vitamin D (calciferol) is a fat-soluble vitamin, photosynthesized in the skin by the action of solar ultraviolet (UV) B radiation. It is naturally found in only a few foods, such as fish-liver oils, fatty fishes, mushrooms, egg yolks, and liver [
1]. Vitamin D is known to regulate calcium and phosphorus absorption and, therefore, it has been traditionally associated with skeletal health, and its deficiency increases the risk of rickets in children, and osteoporosis, fractures and falls in adults [
1,
2,
3,
4,
5]. Emerging evidence suggests that vitamin D deficiency may also be linked to the development of cardiovascular disease, hypertension, diabetes, metabolic syndrome, cancer, multiple sclerosis, rheumatoid arthritis, and sarcopenia [
6,
7,
8,
9,
10,
11,
12,
13].
The United States (US) Centers for Disease Control and Prevention (CDC) Second National Report on Biochemical Indicators of Diet and Nutrition in the US population reported that, in 2003–2006, approximately 8% of the population aged 1 year and older were at risk for vitamin D deficiency (VDD), which varied by age, gender, or race/ethnicity, and was as high as 31% in non-Hispanic blacks [
14]. More recent analysis of NHANES 2011–2014 data, which oversampled Asian, non-Hispanic black, and Hispanic individuals to obtain reliable estimates for these population subgroups, indicated that 18.3% Americans aged 1+ years were at risk of vitamin D inadequacy (VDI) based on serum levels [
15]. While there were no significant gender differences, there was a quadratic trend for risk of VDI by age and was higher for adults 20–39 years than for children 1–5 years and for seniors ≥ 60 years [
15]. VDI also varied by ethnicity and was lowest among non-Hispanic White, followed by Hispanics and Asians, and was highest among non-Hispanic Blacks [
15]. Vitamin D levels in humans are assessed by the determining serum 25-hydroxyvitamin D (25(OH)D) concentrations. Serum 25(OH)D levels of less than 30 nmol/L (12 ng/mL) are considered at risk for deficiency, serum levels between 30 and less than 50 nmol/L (12 to less than 20 ng/mL) are considered at risk for inadequacy; serum levels between 50–75 nmol/L (20–30 ng/mL) are considered sufficient; serum levels greater than 125 nmol/L (50 ng/mL) may be of potential concern [
1].
Although, vitamin D is produced endogenously by exposure to sunlight, seasonal variations, cultural practices, and physiologic factors can impair sunlight-induced synthesis of vitamin D. The current usual dietary intakes of vitamin D among US adults aged 19+ years are 5.3 μg/d for males and 4.1 μg/d for females, and 92% males and over 97% females are below the Estimated Average Requirement (EAR) [
16]. Similarly, vitamin D intakes of 90 to 93% in male and 95 to over 97% in female children aged 4–18 years are also below the EAR [
16]. Accordingly, the 2015–2020 Dietary Guidelines for Americans (DGA) identified vitamin D as a “nutrient of public health concern” as it is under-consumed to an extent that may lead to adverse health outcomes [
17]. The Scientific Report of the 2020 Dietary Guidelines Advisory Committee reaffirmed vitamin D is under-consumed and is of public health concern [
18]. The EAR of vitamin D is 400 IU (10 μg) for ages 1+ years and the Recommended Dietary Allowance (RDA) is 600 IU (15 μg) for ages 1–70 years and 800 IU (20 μg) for ages 70+ years [
1]. Vitamin D can be acquired from fortified foods and dietary supplements [
1,
17]. In the American diet, fortified foods are a main source of the vitamin D [
1,
19,
20]. Varieties of foods fortified with vitamin D in the US include dairy products (mostly milk), cereals and fruit juices. Milk is voluntarily fortified with 400 IU per quart (or 385 IU/L) of vitamin D [
19] and almost all fluid milks are fortified with vitamin D in the US market [
21]. Indeed, DGA encourages a higher intake of food sources of vitamin D, such as milk, to meet the requirements [
17].
The objective of the present investigation was to determine the association of milk consumption and vitamin D status in the US population, and to examine if milk consumers have better vitamin D status as compared to non-consumers. We hypothesized that higher milk consumption is associated with better vitamin D status and that milk consumers, regardless of the type of milk consumed, have better vitamin D status compared to non-milk consumers across all age groups.
3. Results
Approximately 80% children aged 2–8 years, 57% children aged 9–18 years, 42% adults aged 19–70 years and 60% adults aged 71+ years were milk consumers. All milk (sum of all milk types) consumption was higher in child consumers (2–18 years), compared to adult consumers (19+ years). Adult consumers aged 71+ years consumed about 37% less milk than children consumers aged 9–18 years (1.12 cup eq/d vs. 1.77 cup eq/d, respectively) (
Table 2). Consumption of whole milk compared to non-fat milk was about 21% greater among children consumers aged 2–8 years but was 19% less among adult consumers aged 71+ years. Consumption of whole milk was similar to that of non-fat milk for children consumers aged 9–18 years and for adult consumers aged 19–70 years (
Table 2). Depending upon ethnicity, milk contributed about 61–71% among those aged 2–8 years, 49–62% among those aged 9–18 years, 24–42% among those aged 19–70 years, and 28–48% among those aged 71+ years of total vitamin D intake (
Table 3).
Serum vitamin D (serum 25(OH)D) was positively associated with milk intake in children aged 9–18 years and adults aged 19+ years (
p linear trend < 0.05). The association was also significant for both males and females of age 9+ years (
p linear trend < 0.05), except for 9–18-year-old males and for 71+ year- old females (
p linear trend > 0.05) (
Table 4). In children aged 2–8 years, consumers of whole milk, reduced fat milk, and low-fat milk had significantly higher (
p < 0.05) serum vitamin D (serum 25(OH)D) levels than non-consumers. Similarly, in children aged 9–18 years and adults aged 19+ years, consumers of reduced-fat milk, low-fat milk, and non-fat milk had higher (
p < 0.05) serum vitamin D (serum 25(OH)D) levels than non-consumers of same age group. Children (aged 9–18 years) and adult (aged 19–70 years) consumers of mixed milk also had higher (
p < 0.05) serum vitamin D (serum 25(OH)D) than respective non-consumers (
Table 5). Adjusting for data in
Table 2 and
Table 3 for dietary supplements, seafood, and other non-milk vitamin D sources did not change these results (
Table 4 and
Table 5).
Consumption of all milk (for all ages—i.e., 2+ years), whole milk (for ages 19–70 years), reduced-fat milk (for ages 9–70 years), low-fat milk (for those aged 19+ years), and non-fat milk (for those aged 9+ years) was associated with significantly higher probability of meeting serum vitamin D recommendations when the analysis was conducted by milk amount (
Table 6). Consumers of whole milk (of aged 2–8 years), reduced-fat milk (of all ages), low-fat milk (of all ages), non-fat milk (of aged 19+ years) and mixed milk (of aged 2–70 years) had a higher probability of meeting serum vitamin D recommendations in the analysis by milk type (
Table 6).
Table 7 shows the serum vitamin D (serum 25(OH)D) status by tertiles of all milk intake among different ethnic populations. Serum vitamin D (serum 25(OH)D) was positively associated with milk intake among children aged 9–18 years and adults aged 19+ years of Mexican American and of “other” ethnicity (
p linear trend < 0.05). The increase in serum vitamin D (serum 25(OH)D) status with increasing milk intake was also significant (
p linear trend < 0.05) among non-Hispanic Whites aged 19+ years, and non-Hispanic Blacks aged 2–18 years. Additional adjustment for dietary supplements, seafood, and other non-milk vitamin D sources did not change the results (
Table 7).
Table 8 presents the data on vitamin D status by milk type across different ethnic groups. Significantly (
p < 0.05) higher levels of serum vitamin D (serum 25(OH)D) levels were observed for consumers of whole milk, reduced fat milk, low-fat milk, non-fat milk and mixed milk among the different age and ethnic groups examined (
Table 6). Adjusting the data for dietary supplements, seafood, and other non-milk vitamin D sources did not modify the results (
Table 8).
4. Discussion
The current cross-sectional analysis of data from the NHANES 2001–2010 demonstrated a significant association between milk consumption and serum vitamin D (serum 25(OH)D) status. Additionally, the results showed that the probability of meeting the vitamin D recommendations was greater in milk consumers vs. non-consumers. To the best of our knowledge, this is first analysis of nationally representative, non-institutionalized population of US children and adults examining the association of milk intake with vitamin D levels.
Poor vitamin D status (low serum 25(OH)D levels) is a global public health concern as over 50% of population has less than adequate serum vitamin D status [
24]. In the US, about 18% of the US population aged 1+ years had insufficient serum vitamin D levels and were at risk of inadequacy (less than 50 nmol/L) according a recent analysis of NHANES 2011–2014 [
15]. Liu et al. [
25] estimated the prevalence of inadequate serum vitamin D levels in US adults to be 28.9% for VDD and 41.4% for VDI, from analysis of NHANES 2001–2010 and using the criteria recommended by the Endocrinology Society to define VDD as 25(OH)D <50 nmol/L and VDI as 25(OH)D <75 nmol/L [
26]. The present analysis showed that the average serum vitamin D levels ranged from 64 to 75 nmol/L depending on age and gender in representative population of US children and adults aged 2+ years. These average serum vitamin D levels are well with in the 50–75 nmol/L range and are considered sufficient by IOM definition [
1]. Vitamin D is a “nutrient of public health concern” as it is under-consumed to an extent that may lead to adverse health outcomes and higher intake of food sources are encouraged by DGA [
17].
In the present analysis, serum Vitamin D levels were significantly associated with the intake of milk, depending on the type. Milk consumers, especially those of low fat and reduced fat milk, had higher probability of meeting >50 nmol/L serum vitamin D level benchmark set by IOM [
1] than non-consumers; however, the mean serum vitamin D levels were always higher than 50 nmol/L. Although milk contains a low amount of naturally occurring vitamin D, almost all milk in the US is fortified with 100 IU/cup vitamin D irrespective of the type of milk [
1,
19,
21]. Effectiveness of milk and other fortified foods in improving serum vitamin D status has been demonstrated in both clinical and observational studies (see [
27,
28] for reviews). A recent systematic review and meta-analysis of randomized controlled trials showed that vitamin D fortified foods (mostly milk and dairy products) increased serum vitamin D levels by 1.2 nmol/L for each 1 µg/d increased intake of vitamin D [
27]. A cup of milk/d provides ∼2.5 µg of vitamin D. A review of observational studies also concluded that the intake of vitamin D fortified milk products was positively associated with vitamin D intake and serum vitamin D status and the association was stronger in countries with a national vitamin D fortification policy [
28]. However, this review included only five studies from US which had small sample sizes and included only certain population groups. In our present analysis, the intake of certain milk types (especially of whole milk) was not associated with an increase in serum vitamin D levels in all population sub-groups, which is not immediately understood.
Age and ethnicity have been shown to affect serum vitamin D status [
14,
15,
29,
30]. Vitamin D serum levels generally decrease with age, and non-Hispanic Blacks have the lowest vitamin D levels or highest prevalence of VDD, followed by Hispanics and Asians [
14,
15,
29,
30]. In contrast, non-Hispanic Whites have the highest vitamin D levels or lowest prevalence of VDD [
14,
15,
29,
30]. Lower intake of milk with age, which was also observed in our study, could potentially explain the inverse association of age with vitamin D. In regard to ethnicity and vitamin D status, differences in milk and overall vitamin D intake as well as skin pigmentation and other factors are potentially responsible for the ethnic differences in vitamin D status [
31]. For instance, studies have shown lower milk intake among non-Hispanic Blacks compared to non-Hispanic Whites [
32]. In the present analysis, serum vitamin D status was associated with both type and amount of milk intake depending upon the age and ethnicity. However, the effect of gender on serum vitamin D status has been reported to be insignificant or inconsistent [
14,
15,
30], but the associations between amount of milk intake and serum vitamin D status were mostly significant for both males and females in the present analysis. Therefore, continuing to encourage an increase in milk intake, especially among populations with VDD or VDI, could be an effective strategy to improve vitamin D status.
In addition to providing vitamin D, milk and dairy products, make significant nutrient contributions including nutrients under-consumed by most Americans—calcium and potassium—as well as magnesium, phosphorus, zinc, vitamin A, vitamin B12, riboflavin (B2), choline, high-quality protein and saturated fat; as such, the inclusion of dairy foods into healthy dietary patterns is associated with improving diet quality and reducing risk of obesity and chronic diseases [
17,
18,
33,
34,
35,
36].
A major limitation of our study is the inability to determine a cause–effect relationship due to the cross-sectional design of NHANES. Additionally, as with any study based on self-reported data, under- or over-reporting cannot be ruled out. Additionally, the results from this study may not specifically reflect the effect of milk consumption on vitamin D status, although we used vitamin D from dietary supplements, seafood, and other non-milk sources as covariates to adjust some of our results. Strengths of this study included the use of a large nationally representative sample achieved through combining several sets of NHANES data releases and adjusting for numerous covariates, but even with these covariates, some residual confounding may still exist.