Prevalence and Predictors of Low Serum 25-Hydroxyvitamin D among Female African-American Breast Cancer Survivors

Published:January 02, 2018DOI:



      African-American breast cancer survivors commonly demonstrate low serum 25-hydroxyvitamin D (25(OH)D). Decreased cutaneous conversion, high levels of adiposity, and even breast cancer treatment may influence vitamin D status. Previous investigations have analyzed African-American women in aggregate with other breast cancer survivors and have not comprehensively addressed these influential factors.


      To determine the prevalence of low serum 25(OH)D in an exclusively African-American cohort of female breast cancer survivors with overweight/obesity and to evaluate the role of ultraviolet (UV) light exposure, body composition, and dietary sources of vitamin D on serum 25(OH)D levels.




      Pre- and postmenopausal African-American breast cancer survivors (n=244) were recruited from various neighborhoods in the city of Chicago, IL, between September 2011 and September 2014 for a larger weight loss trial.

      Main outcome measures

      Demographic, clinical, anthropometric (body mass index [calculated as kg/m2], waist circumference, and hip circumference), blood specimen, dietary intake (food frequency questionnaire), and sun behavior data were collected by trained study personnel before trial participation. Dual-energy x-ray absorptiometry was used to quantify adiposity (total, percentage, regional, visceral) and lean mass. Serum 25(OH)D was used as the biomarker reflective of vitamin D status.

      Statistical analyses

      Mean (±standard deviation), frequencies, and multivariate linear regression modeling.


      The average participant was 57.4 years old (±10.0), 6.9 years (±5.2) from initial breast cancer diagnosis with a body mass index of 36.2 (±6.2). The majority of participants (60%) reported habitual oral vitamin D supplementation with mean intake of 327 IU (±169). Vitamin D deficiency was prevalent in 81% and 43%, when the cut points of the Endocrine Society (<30 ng/mL or <75 nmol/L) and the Institute of Medicine (<20 ng/mL or <50 nmol/L) were applied, respectively. A multivariate model adjusting for age, seasonality of blood draw, total energy intake, use of supplemental vitamin D, darker skin pigmentation, breast cancer stage, and waist-to-hip ratio was able to explain 28.8% of the observed variance in serum 25(OH)D concentrations. No significant associations were detected for body mass index or any dual-energy x-ray absorptiometry measures of body composition.


      Considering the number of women who endorsed use of vitamin D supplementation, the prevalence of vitamin D deficiency among these African-American breast cancer survivors was high. Vitamin D supplementation, sun behavior, and waist-to-hip ratio may serve as future points of intervention to improve the vitamin D status of this minority survivor population.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Holick M.F.
        Vitamin D deficiency.
        N Engl J Med. 2007; 357: 266-281
        • Lips P.
        Worldwide status of vitamin D nutrition.
        J Steroid Biochem Mol Biol. 2010; 121: 297-300
        • Chen W.Y.
        • Bertone-Johnson E.R.
        • Hunter D.J.
        • Willett W.C.
        • Hankinson S.E.
        Associations between polymorphisms in the vitamin D receptor and breast cancer risk.
        Cancer Epidemiol Biomarkers Prev. 2005; 14: 2335-2339
        • Wu X.
        • Zhou T.
        • Cao N.
        • Ni J.
        • Wang X.
        Role of vitamin D metabolism and activity on carcinogenesis.
        Oncol Res. 2014; 22: 129-137
        • Neuhouser M.L.
        • Sorensen B.
        • Hollis B.W.
        • et al.
        Vitamin D insufficiency in a multiethnic cohort of breast cancer survivors.
        Am J Clin Nutr. 2008; 88: 133-139
        • Trukova K.P.
        • Grutsch J.
        • Lammersfeld C.
        • Liepa G.
        Prevalence of vitamin D insufficiency among breast cancer survivors.
        Nutr Clin Pract. 2012; 27: 122-128
        • Villasenor A.
        • Ballard-Barbash R.
        • Ambs A.
        • et al.
        Associations of serum 25-hydroxyvitamin D with overall and breast cancer-specific mortality in a multiethnic cohort of breast cancer survivors.
        Cancer Causes Control. 2013; 24: 759-767
        • Schleicher R.L.
        • Sternberg M.R.
        • Lacher D.A.
        • et al.
        The vitamin D status of the US population from 1988 to 2010 using standardized serum concentrations of 25-hydroxyvitamin D shows recent modest increases.
        Am J Clin Nutr. 2016; 104: 454-461
        • Piotrowska A.
        • Wierzbicka J.
        • Zmijewski M.A.
        Vitamin D in the skin physiology and pathology.
        Acta Biochim Pol. 2016; 63: 89-95
        • Wortsman J.
        • Matsuoka L.Y.
        • Chen T.C.
        • Lu Z.
        • Holick M.F.
        Decreased bioavailability of vitamin D in obesity.
        Am J Clin Nutr. 2000; 72: 690-693
        • Cipriani C.
        • Pepe J.
        • Piemonte S.
        • Colangelo L.
        • Cilli M.
        • Minisola S.
        Vitamin D and its relationship with obesity and muscle.
        Int J Endocrinol. 2014; 2014: 841248
        • Okorodudu D.O.
        • Jumean M.F.
        • Montori V.M.
        • et al.
        Diagnostic performance of body mass index to identify obesity as defined by body adiposity: A systematic review and meta-analysis.
        Int J Obes (Lond). 2010; 34: 791-799
        • Stolley M.R.
        • Sharp L.K.
        • Fantuzzi G.
        • et al.
        Study design and protocol for moving forward: A weight loss intervention trial for African-American breast cancer survivors.
        BMC Cancer. 2015; 15: 1018
        • Zerwekh J.E.
        Blood biomarkers of vitamin D status.
        Am J Clin Nutr. 2008; 87: 1087S-1091S
      1. Centers for Disease Control and Prevention. Classifications of Obesity, Overweight and Underweight Adults. Accessed July 20, 2017.

      2. Centers for Disease Control and Prevention. National Health and Nutriton Examination Survey. Anthropometry Procedures Manual. Accessed April 6, 2017.

        • Kaul S.
        • Rothney M.P.
        • Peters D.M.
        • et al.
        Dual-energy x-ray absorptiometry for quantification of visceral fat.
        Obesity (Silver Spring). 2012; 20: 1313-1318
        • Mares-Perlman J.A.
        • Klein B.E.
        • Klein R.
        • Ritter L.L.
        • Fisher M.R.
        • Freudenheim J.L.
        A diet history questionnaire ranks nutrient intakes in middle-aged and older men and women similarly to multiple food records.
        J Nutr. 1993; 123: 489-501
        • Glanz K.
        • Yaroch A.L.
        • Dancel M.
        • et al.
        Measures of sun exposure and sun protection practices for behavioral and epidemiologic research.
        Arch Dermatol. 2008; 144: 217-222
        • Holick M.F.
        • Binkley N.C.
        • Bischoff-Ferrari H.A.
        • et al.
        Evaluation, treatment, and prevention of vitamin D deficiency: An Endocrine Society clinical practice guideline.
        J Clin Endocrinol Metab. 2011; 96: 1911-1930
        • Institute of Medicine
        Dietary Reference Intakes for Calcium and Vitamin D.
        National Academies Press, Washington, DC2010
      3. SAS [computer program]. Version 9.4. Cary, NC: SAS Institute, Inc; 2002-2012.

        • Forrest K.Y.
        • Stuhldreher W.L.
        Prevalence and correlates of vitamin D deficiency in US adults.
        Nutr Res. 2011; 31: 48-54
        • Friedman C.F.
        • DeMichele A.
        • Su H.I.
        • et al.
        Vitamin D deficiency in postmenopausal breast cancer survivors.
        J Womens Health (Larchmt). 2012; 21: 456-462
        • Jacobs E.T.
        • Kohler L.N.
        • Kunihiro A.G.
        • Jurutka P.W.
        Vitamin D and colorectal, breast, and prostate cancers: A review of the epidemiological evidence.
        J Cancer. 2016; 7: 232-240
        • Goodwin P.J.
        • Ennis M.
        • Pritchard K.I.
        • Koo J.
        • Hood N.
        Prognostic effects of 25-hydroxyvitamin D levels in early breast cancer.
        J Clin Oncol. 2009; 27: 3757-3763
        • Rose A.A.
        • Elser C.
        • Ennis M.
        • Goodwin P.J.
        Blood levels of vitamin D and early stage breast cancer prognosis: A systematic review and meta-analysis.
        Breast Cancer Res Treat. 2013; 141: 331-339
        • Yao S.
        • Ambrosone C.B.
        Associations between vitamin D deficiency and risk of aggressive breast cancer in African-American women.
        J Steroid Biochem Mol Biol. 2013; 136: 337-341
        • Chan J.
        • Jaceldo-Siegl K.
        • Fraser G.E.
        Determinants of serum 25 hydroxyvitamin D levels in a nationwide cohort of blacks and non-Hispanic whites.
        Cancer Causes Control. 2010; 21: 501-511
        • McCullough M.L.
        • Weinstein S.J.
        • Freedman D.M.
        • et al.
        Correlates of circulating 25-hydroxyvitamin D: Cohort Consortium Vitamin D Pooling Project of Rarer Cancers.
        Am J Epidemiol. 2010; 172: 21-35
        • Jacobs E.T.
        • Thomson C.A.
        • Flatt S.W.
        • Newman V.A.
        • Rock C.L.
        • Pierce J.P.
        Correlates of 25-hydroxyvitamin D and breast cancer stage in the Women's Healthy Eating and Living Study.
        Nutr Cancer. 2013; 65: 188-194
        • Lagunova Z.
        • Porojnicu A.C.
        • Lindberg F.
        • Hexeberg S.
        • Moan J.
        The dependency of vitamin D status on body mass index, gender, age and season.
        Anticancer Res. 2009; 29: 3713-3720
        • Vashi P.G.
        • Lammersfeld C.A.
        • Braun D.P.
        • Gupta D.
        Serum 25-hydroxyvitamin D is inversely associated with body mass index in cancer.
        Nutr J. 2011; 10: 51
        • Shirazi L.
        • Almquist M.
        • Malm J.
        • Wirfalt E.
        • Manjer J.
        Determinants of serum levels of vitamin D: A study of life-style, menopausal status, dietary intake, serum calcium, and PTH.
        BMC Womens Health. 2013; 13: 33
        • Prado C.M.
        • Heymsfield S.B.
        Lean tissue imaging: A new era for nutritional assessment and intervention.
        JPEN J Parenter Enteral Nutr. 2014; 38: 940-953
        • Baracos V.
        • Caserotti P.
        • Earthman C.P.
        • et al.
        Advances in the science and application of body composition measurement.
        JPEN J Parenter Enteral Nutr. 2012; 36: 96-107
        • Heymsfield S.B.
        • Wang Z.
        • Baumgartner R.N.
        • Ross R.
        Human body composition: Advances in models and methods.
        Annu Rev Nutr. 1997; 17: 527-558
        • Micklesfield L.K.
        • Goedecke J.H.
        • Punyanitya M.
        • Wilson K.E.
        • Kelly T.L.
        Dual-energy x-ray performs as well as clinical computed tomography for the measurement of visceral fat.
        Obesity (Silver Spring). 2012; 20: 1109-1114
        • Looker A.C.
        Body fat and vitamin D status in black versus white women.
        J Clin Endocrinol Metab. 2005; 90: 635-640
        • Nesby-O'Dell S.
        • Scanlon K.S.
        • Cogswell M.E.
        • et al.
        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; 76: 187-192
        • Samuel L.
        • Borrell L.N.
        The effect of body mass index on adequacy of serum 25-hydroxyvitamin D levels in US adults: The National Health and Nutrition Examination Survey 2001 to 2006.
        Ann Epidemiol. 2014; 24: 781-784
        • Carroll J.F.
        • Chiapa A.L.
        • Rodriquez M.
        • et al.
        Visceral fat, waist circumference, and BMI: Impact of race/ethnicity.
        Obesity (Silver Spring). 2008; 16: 600-607
        • Katzmarzyk P.T.
        • Heymsfield S.B.
        • Bouchard C.
        Clinical utility of visceral adipose tissue for the identification of cardiometabolic risk in white and African American adults.
        Am J Clin Nutr. 2013; 97: 480-486
        • Conway J.M.
        • Yanovski S.Z.
        • Avila N.A.
        • Hubbard V.S.
        Visceral adipose tissue differences in black and white women.
        Am J Clin Nutr. 1995; 61: 765-771
        • Kanaley J.A.
        • Giannopoulou I.
        • Tillapaugh-Fay G.
        • Nappi J.S.
        • Ploutz-Snyder L.L.
        Racial differences in subcutaneous and visceral fat distribution in postmenopausal black and white women.
        Metabolism. 2003; 52: 186-191
        • Bi X.
        • Seabolt L.
        • Shibao C.
        • et al.
        DXA-measured visceral adipose tissue predicts impaired glucose tolerance and metabolic syndrome in obese Caucasian and African-American women.
        Eur J Clin Nutr. 2015; 69: 329-336
        • Golan R.
        • Shelef I.
        • Rudich A.
        • et al.
        Abdominal superficial subcutaneous fat: A putative distinct protective fat subdepot in type 2 diabetes.
        Diabetes Care. 2012; 35: 640-647
        • Fraser W.D.
        • Milan A.M.
        Vitamin D assays: Past and present debates, difficulties, and developments.
        Calcif Tissue Int. 2013; 92: 118-127
        • Moon H.W.
        • Cho J.H.
        • Hur M.
        • et al.
        Comparison of four current 25-hydroxyvitamin D assays.
        Clin Biochem. 2012; 45: 326-330
        • Farrell C.J.
        • Martin S.
        • McWhinney B.
        • Straub I.
        • Williams P.
        • Herrmann M.
        State-of-the-art vitamin D assays: A comparison of automated immunoassays with liquid chromatography-tandem mass spectrometry methods.
        Clin Chem. 2012; 58: 531-542
        • van den Ouweland J.M.
        • Beijers A.M.
        • Demacker P.N.
        • van Daal H.
        Measurement of 25-OH-vitamin D in human serum using liquid chromatography tandem-mass spectrometry with comparison to radioimmunoassay and automated immunoassay.
        J Chromatogr B, Analyt Technol Biomed Life Sci. 2010; 878: 1163-1168
        • Lai J.K.
        • Lucas R.M.
        • Banks E.
        • Ponsonby A.L.
        • Ausimmune Investigator Group
        Variability in vitamin D assays impairs clinical assessment of vitamin D status.
        Intern Med J. 2012; 42: 43-50
        • Farrell C.
        • Soldo J.
        • Williams P.
        • Herrmann M.
        25-Hydroxyvitamin D testing: Challenging the performance of current automated immunoassays.
        Clin Chem Lab Med. 2012; 50: 1953-1963
        • Binkley N.
        • Wiebe D.
        Clinical controversies in vitamin D: 25(OH)D measurement, target concentration, and supplementation.
        J Clin Densitom. 2013; 16: 402-408
        • Flegal K.M.
        • Kruszon-Moran D.
        • Carroll M.D.
        • Fryar C.D.
        • Ogden C.L.
        Trends in obesity among adults in the United States, 2005 to 2014.
        JAMA. 2016; 315: 2284-2291
      4. American Council on Exercise. Accessed November 17, 2017.

        • Ganji V.
        • Zhang X.
        • Tangpricha V.
        Serum 25-hydroxyvitamin D concentrations and prevalence estimates of hypovitaminosis D in the U.S. population based on assay-adjusted data.
        J Nutr. 2012; 142: 498-507


      P. Sheean is an assistant professor, Loyola University Chicago, Marcella Niehoff School of Nursing, Maywood, IL.


      C. Arroyo is a clinical research coordinator, Clinical Research Center, University of Illinois at Chicago; at the time of the study, she was a project coordinator, University of Illinois at Chicago.


      J. Woo is a certified nurse midwife, a women's health nurse practitioner, and a clinical assistant professor, Baylor University, Dallas, TX; at the time of the study, she was a research assistant, Loyola University Chicago, Marcella Niehoff School of Nursing, University of Illinois at Chicago.


      L. Schiffer is a research data analyst, University of Illinois at Chicago.


      M. Stolley is a professor, Medical College of Wisconsin, Milwaukee.

      Linked Article

      • Erratum
        Journal of the Academy of Nutrition and DieteticsVol. 118Issue 7
        • Preview
          In Table 2 (p 574) of the article “Prevalence and Predictors of Low Serum 25-Hydroxyvitamin D among Female African-American Breast Cancer Survivors” in the April 2018 issue of the Journal of the Academy of Nutrition and Dietetics, two of the subheads under Institute of Medicine were mistakenly mislabeled. The authors regret this error. The Table 2, column 5 head should read: Sufficient 25(OH)D ≥20 ng/mL (≥50 nmol/L). The Table 2, column 6 head should read Insufficient 25(OH)D <20 ng/mL (<50 nmol/L).
        • Full-Text
        • PDF