Optimal Vitamin D Status for Colorectal Cancer Prevention. A Quantitative Meta Analysis

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DOI: 10.1016/j.amepre.2006.11.004 · Source: PubMed
Previous studies, such as the Women's Health Initiative, have shown that a low dose of vitamin D did not protect against colorectal cancer, yet a meta-analysis indicates that a higher dose may reduce its incidence. Five studies of serum 25(OH)D in association with colorectal cancer risk were identified using PubMed. The results of all five serum studies were combined using standard methods for pooled analysis. The pooled results were divided into quintiles with median 25(OH)D values of 6, 16, 22, 27, and 37 ng/mL. Odds ratios were calculated by quintile of the pooled data using Peto's Assumption-Free Method, with the lowest quintile of 25(OH)D as the reference group. A dose-response curve was plotted based on the odds for each quintile of the pooled data. Data were abstracted and analyzed in 2006. Odds ratios for the combined serum 25(OH)D studies, from lowest to highest quintile, were 1.00, 0.82, 0.66, 0.59, and 0.46 (p(trend)<0.0001) for colorectal cancer. According to the DerSimonian-Laird test for homogeneity of pooled data, the studies were homogeneous (chi(2)=1.09, df=4, p=0.90. The pooled odds ratio for the highest quintile versus the lowest was 0.49 (p<0.0001, 95% confidence interval, 0.35-0.68). A 50% lower risk of colorectal cancer was associated with a serum 25(OH)D level > or =33 ng/mL, compared to < or =12 ng/mL. The evidence to date suggests that daily intake of 1000-2000 IU/day of vitamin D(3) could reduce the incidence of colorectal with minimal risk.
Optimal Vitamin D Status for Colorectal
Cancer Prevention
A Quantitative Meta Analysis
Edward D. Gorham, MPH, PhD, Cedric F. Garland, DrPH, Frank C. Garland, PhD, William B. Grant, PhD,
Sharif B. Mohr, MPH, Martin Lipkin, MD, Harold L. Newmark, ScD, Edward Giovannucci, MD, ScD,
Melissa Wei, BS, Michael F. Holick, MD, PhD
Background: Previous studies, such as the Women’s Health Initiative, have shown that a low dose of
vitamin D did not protect against colorectal cancer, yet a meta-analysis indicates that a
higher dose may reduce its incidence.
Methods: Five studies of serum 25(OH)D in association with colorectal cancer risk were identified
using PubMed. The results of all five serum studies were combined using standard methods
for pooled analysis. The pooled results were divided into quintiles with median 25(OH)D
values of 6, 16, 22, 27, and 37 ng/mL. Odds ratios were calculated by quintile of the pooled
data using Peto’s Assumption-Free Method, with the lowest quintile of 25(OH)D as the
reference group. A dose–response curve was plotted based on the odds for each quintile of
the pooled data. Data were abstracted and analyzed in 2006.
Results: Odds ratios for the combined serum 25(OH)D studies, from lowest to highest quintile,
were 1.00, 0.82, 0.66, 0.59, and 0.46 (p
!0.0001) for colorectal cancer. According to the
DerSimonian-Laird test for homogeneity of pooled data, the studies were homogeneous
"1.09, df"4, p"0.90. The pooled odds ratio for the highest quintile versus the lowest
was 0.49 (p!0.0001, 95% confidence interval, 0.35– 0.68). A 50% lower risk of colorectal
cancer was associated with a serum 25(OH)D level !33 ng/mL, compared to "12 ng/mL.
Conclusions: The evidence to date suggests that daily intake of 1000 –2000 IU/day of vitamin D
reduce the incidence of colorectal with minimal risk.
(Am J Prev Med 2007;32(3):210–216) © 2007 American Journal of Preventive Medicine
he Women’s Health Initiative
that a low dose of vitamin D did not protect
against colorectal cancer within 7 years of
follow-up; however, a meta-analysis indicates that a
higher dose may reduce its incidence.
There were approximately 145,300 new cases and
56,300 deaths from colorectal cancer in the United
States during 2005.
An observation of higher age-
adjusted mortality rates of colorectal cancer in the
northern and northeastern United States compared to
the southwest, Hawaii, and Florida led to a theory that
vitamin D of mainly solar origin may reduce risk of
colorectal cancer
through a mechanism involving cal-
cium metabolism, intercellular adherence, and contact
inhibition. Since then, five observational studies have
explored the association of serum levels of the main
circulating form of vitamin D, 25-hydroxyvitamin D
(25[OH]D) with risk of colorectal cancer.
ever, an overall dose–response gradient for the effect of
serum levels of 25(OH)D on colorectal cancer risk has
not been determined. This meta-analysis provides an
estimated dose–response gradient that may be of help
in planning for a useful role of vitamin D in control of
colorectal cancer.
Study Inclusion
The PubMed database was searched for the period from
January 1966 to December 2005 by using the terms (“vitamin
From the University of California San Diego, Department of Family
and Preventive Medicine, School of Medicine (Gorham, C.F. Gar-
land, F.C. Garland, Mohr) La Jolla, California; SUNARC-Sunlight,
Nutrition and Health Research Center (Grant), San Francisco,
California; Strang Cancer Prevention Center (Lipkin), New York,
New York; Susan Lehman Cullman Laboratory for Cancer Research,
Rutgers, The State University of New Jersey (Newmark), Piscataway,
New Jersey, and Cancer Institute of New Jersey, New Brunswick, New
Jersey; Harvard School of Public Health, Departments of Nutrition
and Epidemiology (Giovannucci, Wei); and Vitamin D Laboratory,
Section of Endocrinology, Nutrition and Diabetes, Department of
Medicine, Boston University School of Medicine (Holick), Boston,
Address correspondence and reprint requests to: Edward D.
Gorham, PhD, Research Epidemiologist, Naval Health Research
Center (Code 24, Bldg 346), P.O. Box 85122, San Diego CA 92186-
5122. E-mail: gorham@nhrc.navy.mil.
210 Am J Prev Med 2007;32(3) 0749-3797/07/$–see front matter
© 2007 American Journal of Preventive Medicine Published by Elsevier Inc. doi:10.1016/j.amepre.2006.11.004
D,” or “25-hydroxyvitamin D”), and (“cohort” or “case–
control” or “case–cohort” or “incidence” or “occurrence” or
“epidemiology”) and “human” as medical subject heading
(MeSH) terms and words in the abstract. Articles were
included if they were published in medical journals and
included measures of association by quantile. A total of five
studies were identified and all five met the inclusion crite-
Information on study design, participant characteris-
tics, multivariate adjustment, and serum levels of 25(OH)D
was abstracted by two investigators. Data were abstracted and
analyzed in 2006.
Statistical Analysis for 25(OH)D
Summary odds ratio. A summary odds ratio of the highest
versus lowest quintile for all studies was obtained using Peto’s
Assumption-Free Method for combining odds ratios.
method provides a weighted average of the natural logarithms of
the odds ratios from each study. The weights were the inverse of
the variances of the logarithms of each odds ratio.
The p value for the summary odds ratio was calculated
using a z-test, where the numerator was the natural logarithm
of the pooled odds ratio and the denominator was the
standard error of the pooled odds ratio, which is the
standard method for calculating the p value when using
Peto’s Assumption-Free Method.
Odds ratios comparing
the highest with the lowest quantiles for each study were
displayed in a forest plot.
Confidence intervals were
computed using the method of Woolf.
The DerSimonian-
Laird statistic was calculated to assess homogeneity.
calculations were performed using Rev Man (Oxford, En-
gland: The Cochrane Collaboration).
Dose–response gradient. A data set was created consisting of
one record per participant in each study. The records in this
data set identified whether the participant was a case or
noncase, the median or midpoint of the participant’s quantile
of serum 25(OH)D at baseline, in ng/mL, a number identi-
fying the study, and a serial number for each individual. If the
median value was provided by the study,
it was used. If
midpoint values were calculated by computing the
arithmetic mean of the upper and lower bounds of the
Data presented in nmol/L were converted to ng/mL using
the conversion factor 1 ng/mL"2.5 nmol/L. The records
were put into order by serum 25(OH)D level, then divided
into five quintiles, with each quintile containing approxi-
mately one fifth of the records.
Odds ratios were then calculated for the association be-
tween quintile of serum 25(OH)D and risk of colorectal
cancer in the pooled data, using the lowest quintile as the
reference group. Confidence intervals were computed using
the method of Woolf.
A dose–response curve was then
plotted using the odds ratios for each quintile of the pooled
A least-squares trend line was constructed to examine
the dose–response relationship
; p values for trend were
calculated using the Mantel-Haenszel chi
25(OH)D concentrations associated with a 50% reduction in
colorectal cancer risk, compared to the lowest quintile of
25(OH)D, were obtained by drawing a vertical line from the
point on the dose–response curve corresponding to an odds
ratio 0.50 to the point of intersection with the horizontal axis.
Computations were performed using SAS, Version 9.1 (SAS
Institute, Cary NC, 2004).
When the upper limit of the top quantile was not provided,
the median of that quantile was estimated based on an assump-
tion that the median of the values above the lower limit were so
close to that limit that the value of the lower limit that was
provided was the best available estimate of the median of the
quantile. This is an adaptation of a general procedure for
handling open intervals.
Further corrections might have raised
the assumed value of this limit by 1%–2%, which would have had
virtually no detectable effect on the slope of the doseresponse
Five studies of the association of serum 25(OH)D with
risk of colorectal cancer were identified.
All were
nested case– control studies of prediagnostic serum
collected from healthy volunteer donors who were then
followed from 2–25 years for incidence (Table 1).
Three studies reported statistically significant trends
toward lower odds ratios in individuals with higher
levels of 25(OH)D,
while two reported trends in the
same direction that were of borderline significance or
not significant.
All studies were included in the
The anatomic site of interest was the colon for the
studies by Garland et al.
and Braun et al.,
and colon
and rectum combined for the studies by Feskanich et al.
and Wactawski-Wende et al.
The association reported by
Tangrea et al.
was limited to the distal colon.
There was a downward linear gradient in risk of
colorectal cancer with increasing serum 25(OH)D in
the meta-analysis (R
"0.98, p for trend !0.0001) (Fig
ure 1). The odds ratios for the pooled data were, from
lowest to highest quintile: 1.00, 0.82, 0.66, 0.59, and
0.46 (p trend !0.0001 (Table 1).
A serum 25(OH)D !33 ng/mL (83 nmol/L) was
associated with a 50% lower risk of colorectal cancer
incidence, compared with !12 ng/mL (Figure 1). The
five studies were homogeneous (DerSimonian-Laird
"1.09, df"4, p"0.90). The overall Peto odds ratio
summarizing the estimated risk in the highest com-
pared to the lowest quantile across all studies was 0.49
(p!0.0001) (Figure 2).
A meta-analysis increases power by combining the
results of many studies. All known published studies of
serum 25(OH)D and risk of colorectal cancer were
included, and the results were homogenous. Pooling of
such independent studies increases precision, because
random fluctuation in any one study tends to be
counterbalanced by results of other studies.
The data from two different studies of serum
25(OH)D in the Johns Hopkins cohort in Washington
County MD had trends that were uneven but consistent
March 2007 Am J Prev Med 2007;32(3) 211
with lower risk of colon cancer in association with
higher serum 25(OH)D. One of these reported on the
first 8 years of follow-up
and another reported on later
The slightly stronger association that was
present in the first study suggests that 25(OH)D may
exert an effect on cancer risk rather quickly, in the
promotional stage.
Because data on serum 25(OH)D in individuals were
not available from each study, midpoints of the quan-
tiles were used for pooling. As a result, estimates of risk
for each quantile may have been less accurate than if
data points on each individual had been used. This is
unlikely to have affected the overall dose–response
relationship, but it may have obscured some of the
detail in the highest and lowest quantiles of the distri-
bution, such as changes in the shape of the dose–
response curve at the high and low extremes.
Previous studies have reported lower risk of colorectal
cancer in association with intense physical activity.
has been suggested that the association of physical activity
with risk of colon cancer could be indirect,
and possibly
a result of higher serum 25(OH)D levels in people who
have high levels of physical activity, if the exercise is
performed outdoors and is associated with greater UVB
exposure. Alternatively, intensive physical activity may
have a beneficial role on risk of colorectal cancer that is
independent of serum 25(OH)D, through an as yet
unidentied mechanism.
The study by Feskanich et al.
controlled for physical activity, and reported that there
was no inuence of physical activity on the association
between serum 25(OH)D and risk of colorectal cancer,
although physical activity was independently predictive of
risk in this cohort.
Calcium intake also is associated with lower risk of
colorectal cancer.
There is some correlation
(r "#0.33) between total oral intake of vitamin D and
because certain foods in the United States
that contain substantial amounts of calcium, such as
milk, are fortified with vitamin D. However, because
90%–95% of circulating vitamin D and its metabolites
in general result from exposure to solar UVB,
there is little correlation between intake of calcium and
serum 25(OH)D levels. Feskanich et al.
controlled for
calcium intake and this did not influence the results for
25(OH)D. Tangrea et al.
found that calcium intake
was identical (1300 mg/day) in cases and controls, and
therefore could not account for the inverse association
of serum 25(OH)D with risk. Results of the other
studies were not adjusted for calcium intake.
Women are four times more likely than men to take
calcium supplements,
yet the associations of 25(OH)D
with colorectal cancer were about the same in men
as in
Table 1. Serum 25-hydroxyvitamin D [25(OH)D] concentration associated with colorectal cancer, according to
observational studies
Authors (year) ref Cancer site Gender
Quantile cutpoints
(25(OH)D, ng/mL) Total
Odds ratio by
p for
Garland et al. (1989)
Colon Both 4–19, 20–26, 27–32, 33–41,
1.00, 0.48, 0.25,
0.21, 0.73
No. of cases per quintile 9, 7, 5, 4, 9 34
No. of noncases per quintile 8, 13, 18, 17, 11 67
Braun et al. (1995)
Distal colon
and rectum
Both !17, 18–20, 21–24, 25–29,
1.00, 0.33, 0.54,
0.70, 0.41
No. of cases per quintile 16, 8, 11, 13, 9 57
No. of noncases per quintile 18, 26, 23, 21, 25 113
Tangrea et al. (1997)
Distal colon
and rectum
Men !10, 10–13, 14–18, 19# 1.00, 0.83, 0.61,
No. of cases per quartile 33, 29, 23, 18 103
No. of noncases per quartile 47, 50, 54, 53 204
Feskanich et al. (2004)
Colorectal Women 16, 22, 27, 31, 40
1.00, 0.86, 0.68,
0.55, 0.55
No. of cases per quintile 53, 47, 35, 29, 29 193
No. of noncases per quintile 77, 79, 75, 77, 75 383
Wactawski et al. (2005)
Colorectal Women 12, 14.7, 20.2, 23.4
1.00, 0.73, 0.71,
No. of cases per quintile 42, 45, 34, 27 148
No. of noncases per quintile 28, 41, 32, 45 146
Pooled data 6, 16.2, 21.8, 26.8, 37 1.00, 0.82, 0.66,
0.59, 0.46
95% confidence intervals
for odds ratios
(0.59–1.14), (0.47–0.92),
(0.41–0.82), (0.32–0.64)
No. of cases per quintile 129, 121, 107, 98, 80 535
No. of noncases per quintile 151, 172, 190, 195, 205 913
All were nested case– control studies.
Medians of quantiles are shown; cut points were not provided.
Dash (—) denotes no statistically significant association (p$0.05).
212 American Journal of Preventive Medicine, Volume 32, Number 3 www.ajpm-online.net
Therefore, the inverse association of 25(OH)D
with risk of colorectal cancer could not have been ac-
counted for solely by an effect of the calcium content of
supplements that contain both calcium and vitamin D.
Evidence from oral intake studies of vitamin D is
supportive of the serum results. A majority of observa-
tional studies have demonstrated an inverse association
between intake of vitamin D and risk of colorectal
Many studies that found an association of oral
intake of vitamin D with risk of colorectal cancer were
conducted in populations that may have had a high
prevalence of vitamin D inadequacy, such as popula-
tions living mainly at latitudes $40 degrees.
ies of oral vitamin D intake that had equivocal findings
had either adjusted for calcium
or had vitamin D
intake mainly from fish products that may have con-
tained nitrosoamines, which would tend to increase the
risk of colorectal cancer.
Because vitamin D forti-
fication is uncommon in Europe, these studies also had
very low oral vitamin D intakes. One observational
and a clinical trial using a low dose of vitamin
found no association with colorectal cancer, proba-
bly because of the low dose.
Classical dose–response curves for micronutrients
are either linear
or have a predominantly linear
middle segment.
This appears to be true for most
functions of vitamin D.
More studies of effects at
higher vitamin D intakes are needed. In the meantime,
our results suggest that a serum 25(OH)D level of !33
ng/mL could be associated with 50% lower incidence
of colorectal cancer, compared to serum 25(OH)D
!12 ng/mL.
Absence of Toxicity
According to an analysis of 30 studies reporting any
adverse effect of high serum 25(OH)D in adults, no
reproducible toxicity was reported below 100 ng/mL.
The median minimum threshold for toxicity in all
studies was 197 ng/mL. Therefore, the projected serum
25(OH)D level of approximately 33 ng/mL would be
below the threshold for minimal toxicity by a safety
factor of 6.
A “No Adverse Effect Level” (NoAEL) level of 2000
IU/day of vitamin D has been established by the
National Academy of Sciences (NAS).
The NAS re-
ported that no illness from vitamin D intoxication has
been described for intakes !3800 IU/day. One study
reported that no cases of toxicity have ever been
documented at doses !40,000 IU per day.
A vitamin D3 intake of 1000–2000 IU/day, and a target
of 33 ng/mL of serum 25(OH)D, are the most practical
estimates now available for decision makers who wish to
weigh the potential benefits compared to risks of actions
that could reduce incidence of colon cancer. This trans-
lation of oral intake of vitamin D to serum 25(OH)D was
computed from data on conversion of radiolabeled vita-
min D
to 25(OH)D following its administration to vol
Although the volunteers were White, it is likely
that the findings would apply to those of other ethnicities,
because the rate of conversion of vitamin D
to 25(OH)D
is approximately the same in people of different ethnic
Raising the current estimated median intake of
250–300 IU/day
of vitamin D to the current recom-
mended daily intake of the National Academy of Sciences
of 400 IU/day for mature adults
would increase median
Figure 1. Dose–response gradient for colorectal cancer ac-
cording to serum 25(OH)D concentration, all five studies
The five points are the odds ratios for each
quintile of 25(OH)D based on combined data from the five
studies. (The anatomic site was the colon for studies by
Garland et al.
and Braun et al.,
the distal colon and rectum
for Tangrea et al.,
and the colon and rectum for Feskanich
et al.
and Wactawski-Wende et al.
Figure 2. Forest plot of all studies of serum 25(OH)D and
risk of colorectal cancer.
The upper and lower 95%
confidence limits on the odds ratio are denoted by horizontal
lines for each study, and the 95% confidence limits for the
combined estimate for all studies are denoted by the points of
the diamond. The odds ratios compare the highest quintile to
the lowest.
March 2007 Am J Prev Med 2007;32(3) 213
serum 25(OH)D by only 5 ng/mL.
By contrast, an
increase of the intake to 1000 IU/day of vitamin D3 would
boost serum 25(OH)D by approximately 13 ng/mL,
raising the estimated median level in the population to 33
ng/mL, which would keep virtually all of the population
at levels below those associated with hypercalcemia or
adverse health effects.
Although a daily intake of 1000 IU would raise the
median population serum levels to 33 ng/mL, this
could be less than optimal because 50% of the popula-
tion would still be below this median level. By contrast,
an intake of 2000 IU/day, would raise the population
median to 46 ng/mL. This is well below an intake level
that would induce even mild hypervitaminosis.
vitaminosis would be a concern, with intakes of 5000
10,000 IU per day and possibly higher, but not with
2000 IU per day.
Although every effort should be
made to reduce the occurrence of mild hypervitamin-
osis, the consequences of vitamin D inadequacy are
important enough that toleration of a small increase in
the risk of mild hypervitaminosis may be needed.
The studies cited in this analysis are based on Whites.
Intake of vitamin D should be greater for Black people
and other individuals with more skin pigmentation
than is typical in Whites, because such individuals have
lower rates of photosynthesis of vitamin D3 in the
However, the NAS has not provided separate
guidelines for intake of vitamin D according to skin
pigmentation, and therefore a recommendation for
intake of $2000 IU per day cannot be made at this
Any effect of vitamin D on risk of colorectal cancer is
not likely to occur in isolation. Other research has
suggested that calcium and vitamin D tend to be
somewhat synergistic in reducing incidence of colorec-
tal cancer.
Low vitamin D status and low intake
of calcium may contribute jointly to the high incidence
of cancer of the colon and rectum in individuals who
consume the typical Western diet in the United States
and Europe.
In addition, the time period required
to observe an effect on colorectal cancer risk following
an increase in vitamin D intake is not known, but some
evidence suggests that this could require !10 years.
The findings of the study by Tangrea et al.
that the
strongest association was for the distal colon and rec-
tum suggest that the mechanism of vitamin D anticar-
cinogenesis may differ somewhat according to ana-
tomic site in the large bowel. Cancers of the distal colon
and rectum account for approximately two thirds of
colorectal cancer,
and the high cancer incidence in
these anatomic sites in individuals with low serum
25(OH)D may account for much of the overall associ-
ation of vitamin D inadequacy with risk of colorectal
Overall, this meta-analysis supported the theory that
there is an inverse association between serum 25(OH)D
and risk of colorectal cancer. Although confounding is
possible, there are three lines of epidemiologic evi-
dence that support a causal basis for the association: the
geographic gradient with latitude and solar UVB irra-
observational studies linking deficient
serum 25(OH)D levels with increased risk,
studies linking low oral intake of vitamin D with in-
creased risk.
Also, vitamin D receptor poly-
morphisms that interfere with vitamin D utilization may
increase risk of colorectal cancer, particularly in com-
bination with low levels of serum 25(OH)D.
incidence of colorectal cancer is higher in African
who synthesize less vitamin D per minute
spent in the sun.
It seems unlikely that a single
confounder could account for all of these associations.
The epidemiologic findings regarding vitamin D and
colon cancer are supported by numerous studies of the
mechanisms in vivo and vitro.
For example, an exper-
iment using human colon cancer cells (MC-26) grafted
into Balb/C mice found that dietary vitamin D reple-
tion reduced the volume of colon cancer-derived tu-
mors by 40%.
Another experiment found that dietary
vitamin D repletion reduced the volume of colon
cancer xenografts in Balb/C mice by 60%.
Vitamin D metabolites such as 1,25(OH)
D are pleio
tropic agents that induce cell cycle arrest and apoptosis
in cancer cell lines vitro and to show antitumor activity
against a variety of tumors in animal models.
experiments have revealed that increasing levels of
serum 25(OH)
D are associated with reduced epithe
lial cell proliferation and increased apoptosis in hu-
D is also effective in reducing the
incidence of aberrant crypt foci induced by azoxymeth-
ane in rats.
Based on overall consideration of results from obser-
vational and laboratory studies, the existing evidence is
consistent with the hypothesis that increasing vitamin
intake to 1000 –2000 IU per day or raising the serum
level of 25(OH)D to 33 ng/mL or higher would be
associated with substantially lower incidence rates of
colorectal cancer, with only minimal risks.
This research was supported by a Congressional allocation to
the Hollings Cancer Center of the Medical University of
South Carolina, Charleston SC, through the Department of
the Navy, Bureau of Medicine and Surgery, under Work Unit
No. 60126. The views expressed in this report are those of the
authors and do not represent an official position of the
Department of the Navy, Department of Defense, or the U.S.
Government. The sponsor did not participate in study design,
data collection, analysis, interpretation of data, writing of the
report, or the decision to submit the paper for publication.
W.B.G., on behalf of SUNARC, has received consulting
fees, honoraria, speaking fees, and has given legal advice on
the primary risk factors for chronic diseases.
No other financial conflict of interest was reported by the
authors of this paper.
214 American Journal of Preventive Medicine, Volume 32, Number 3 www.ajpm-online.net
1. Wactawski-Wende J, Kotchen JM, Anderson GL, et al. Calcium plus vitamin
D supplementation and the risk of colorectal cancer. N Engl J Med
2. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2006. CA Cancer J Clin
3. Garland C, Garland F. Do sunlight and vitamin D reduce the likelihood of
colon cancer? Int J Epidemiol 1980;9:227–31.
4. Garland C, Comstock G, Garland F, Helsing K, Shaw E, Gorham E. Serum
25-hydroxyvitamin D and colon cancer: eight-year prospective study. Lancet
1989;2:1176 8.
5. Braun MM, Helzlsouer KJ, Hollis BW, Comstock GW. Colon cancer and
serum vitamin D metabolite levels 10–17 years prior to diagnosis. Am J
Epidemiol 1995;142:608–11.
6. Tangrea J, Helzlsouer K, Pietinen P, et al. Serum levels of vitamin D
metabolites and the subsequent risk of colon and rectal cancer in Finnish
men. Cancer Causes Control 1997;8:615–25.
7. Feskanich D, Ma J, Fuchs CS, et al. Plasma vitamin D metabolites and risk
of colorectal cancer in women. Cancer Epidemiol Biomarkers Prev
8. Deeks J, Altman D, Bradburn M. Statistical methods for examining
heterogeneity and combining results from several studies in a meta-analysis.
In: Egger M, Davey Smith G, Altman D, editors. Systematic reviews and
health care: meta-analysis in context. London: BMJ Publications; 2002:
9. Breslow NE, Day NE. Statistical methods in cancer research. Volume I: the
analysis of case– control studies, vol. 32. Lyon. IARC Sci Publ 1980:5–338.
10. Lewis S, Clarke M. Forest plots: trying to see the wood and the trees. BMJ
2001;322:1479 80.
11. Yeh J, D’Amico F. Forest plots: data summaries at a glance. J Fam Pract
12. Fleiss J. Statistical methods for rates and proportions. New York: Oxford;
13. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials
14. Carpenter J. A method for presenting and comparing dose–response
curves. J Pharmacol Methods 1986;15:283–303.
15. Steenland K, Deddens J. A practical guide to dose–response analyses and risk
assessment in occupational epidemiology. Epidemiology 2004;15:63–70.
16. Mantel N. Chi-square tests with one degree of freedom; extensions of the
Mantel-Haenszel procedure. J Am Stat Assoc 1963;58:690 –700.
17. Schlesselman J. Case– control studies: design, conduct, analysis. New York:
Oxford; 1982.
18. Slattery ML, Schumacher MC, Smith KR, West DW, Abd-Elghany N.
Physical activity, diet, and risk of colon cancer in Utah. Am J Epidemiol
19. Fredriksson M, Bengtsson NO, Hardell L, Axelson O. Colon cancer,
physical activity, and occupational exposures. A case–control study. Cancer
1989;63:1838 42.
20. White E, Jacobs EJ, Daling JR. Physical activity in relation to colon cancer
in middle-aged men and women. Am J Epidemiol 1996;144:42–50.
21. Hardman AE. Physical activity and cancer risk. Proc Nutr Soc 2001;60:107–13.
22. Colbert LH, Hartman TJ, Malila N, et al. Physical activity in relation to
cancer of the colon and rectum in a cohort of male smokers. Cancer
Epidemiol Biomarkers Prev 2001;10:265– 8.
23. Gorham E, Garland C, Garland F. Physical activity and colon cancer risk.
Int J Epidemiol 1989;18:728 –9.
24. Garland C, Shekelle RB, Barrett-Connor E, Criqui MH, Rossof AH, Paul O.
Dietary vitamin D and calcium and risk of colorectal cancer: a 19-year
prospective study in men. Lancet 1985;1:307–9.
25. Slattery M, Sorenson A, Ford M. Dietary calcium intake as a mitigating
factor in colon cancer. Am J Epidemiol 1988;128:504 –14.
26. Garland C, Garland F, Gorham E. Colon cancer parallels rickets. In: Lipkin
M, Newmark H, Kelloff G, eds. Calcium, vitamin D, and prevention of
colon cancer. Boca Raton FL: CRC Press; 1991:81–111.
27. Garland C, Barrett-Connor E, Holick M, et al. Serum 25-hydroxyvitamin D
levels in older healthy women in San Diego, California. Preliminary
unpublished data. 1991.
28. Potter J, Slattery M, Bostick R, Gapstur S. Colon cancer: a review of the
epidemiology. Epidemiol Rev 1993;15:499 –545.
29. Garland C, Garland F, Gorham E. Calcium and vitamin D: their potential
roles in cancer prevention. Ann NY Acad Sci 1999;889:107–19.
30. Lipkin M, Reddy B, Newmark H, Lamprecht SA. Dietary factors in human
colorectal cancer. Annu Rev Nutr 1999;19:545– 86.
31. Flood A, Peters U, Chatterjee N, Lacey J Jr, Schairer C, Schatzkin A.
Calcium from diet and supplements is associated with reduced risk of
colorectal cancer in a prospective cohort of women. Cancer Epidemiol
Biomark Prev 2005;14:126 –32.
32. Adams JS, Clemens TL, Parrish JA, Holick MF. Vitamin-D synthesis and
metabolism after ultraviolet irradiation of normal and vitamin-D-deficient
subjects. N Engl J Med 1982;306:722–5.
33. Heaney RP, Davies KM, Chen TC, Holick MF, Barger-Lux MJ. Human
serum 25-hydroxycholecalciferol response to extended oral dosing with
cholecalciferol. Am J Clin Nutr 2003;77:204 –10.
34. Holick MF. Vitamin D: a millennium perspective. J Cell Biochem 2003;
35. Radimer K, Bindewald B, Hughes J, Ervin B, Swanson C, Picciano MF.
Dietary supplement use by U.S. adults: data from the National Health and
Nutrition Examination Survey, 1999–2000. Am J Epidemiol 2004;160:33949.
36. Gorham E, Garland C, Garland F, et al. Vitamin D and prevention of colon
cancer. J Steroid Biochem Mol Biol 2005;97:179 –94.
37. Lebrun JB, Moffatt ME, Mundy RJ, et al. Vitamin D deficiency in a
Manitoba community. Can J Public Health 1993;84:394 6.
38. Punnonen R, Gillespy M, Hahl M, et al. Serum 25-OHD, vitamin A and
vitamin E concentrations in healthy Finnish and Floridian women. Int J Vit
Nutr Res 1988;58:37–9.
39. Rockell JE, Skeaff CM, Williams SM, Green TJ. Serum 25-hydroxyvitamin D
concentrations of New Zealanders aged 15 years and older. Osteoporos Int
40. Peters RK, Pike MC, Garabrant D, Mack TM. Diet and colon cancer in Los
Angeles County, California. Cancer Causes Control 1992;3:457–73.
41. Kampman E, Slattery M, Caan B, Potter J. Calcium, vitamin D, sunshine
exposure, dairy products and colon cancer risk (United States). Cancer
Causes Control 2000;11:459 66.
42. Terry P, Baron JA, Bergkvist L, Holmberg L, Wolk A. Dietary calcium and
vitamin D intake and risk of colorectal cancer: a prospective cohort study
in women. Nutr Cancer 2002;43:39 46.
43. Jarvinen R, Knekt P, Hakulinen T, Aromaa A. Prospective study on milk
products, calcium and cancers of the colon and rectum. Eur J Clin Nutr
44. Pietinen P, Malila N, Virtanen M, et al. Diet and risk of colorectal cancer in
a cohort of Finnish men. Cancer Causes Control 1999;10:387–96.
45. Knekt P, Jarvinen R, Dich J, Hakulinen T. Risk of colorectal and other
gastrointestinal cancers after exposure to nitrate, nitrite and N-nitroso
compounds: a follow-up study. Int J Cancer 1999;80:852– 6.
46. Ferraroni M, La Vecchia C, D’Avanzo B, Negri E, Franceschi S, Decarli A.
Selected micronutrient intake and the risk of colorectal cancer. Br J Cancer
47. Moore L, Loring-Bradlee M, Singer M, Rothman K, Milunsky A. Folate
intake and the risk of neural tube defects: an estimation of dose–response.
Epidemiology 2003;14:200–5.
48. Vieth R, Chan PC, MacFarlane GD. Efficacy and safety of vitamin D3 intake
exceeding the lowest observed adverse effect level. Am J Clin Nutr
49. Vieth R. Why the optimal requirement for Vitamin D3 is probably much
higher than what is officially recommended for adults. J Steroid Biochem
Mol Biol 2004;89 –90:575–9.
50. Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concentrations,
and safety. Am J Clin Nutr 1999;69:842–56.
51. National Academy of Sciences, Institute of Medicine, Food and Nutrition
Board. Dietary reference intakes for calcium, phosphorus, magnesium,
vitamin D, and fluoride. Washington DC: National Academy Press; 1997.
52. Dawson-Hughes B. Racial/ethnic considerations in making recommenda-
tions for vitamin D for adult and elderly men and women. Am J Clin Nutr
2004;80(6 Suppl):1763S–6S.
53. Feskanich D, Willett WC, Colditz GA. Calcium, vitamin D, milk consump-
tion, and hip fractures: a prospective study among postmenopausal women.
Am J Clin Nutr 2003;77:504 –11.
54. Honkanen R, Alhava E, Parviainen M, Talasniemi S, Monkkonen R. The
necessity and safety of calcium and vitamin D in the elderly. J Am Geriatr
Soc 1990;38:862–6.
55. Vieth R. Vitamin D nutrition and its potential health benefits for bone,
cancer and other conditions. J Nutr Environ Med 2001;11:275–91.
56. Bell NH, Greene A, Epstein S, Oexmann MJ, Shaw S, Shary J. Evidence for
alteration of the vitamin D-endocrine system in blacks. J Clin Invest
57. Jacobs ET, Martinez ME, Alberts DS. Research and public health implica-
tions of the intricate relationship between calcium and vitamin D in the
prevention of colorectal neoplasia. J Natl Cancer Inst 2003;95:1736–7.
March 2007 Am J Prev Med 2007;32(3) 215
58. Armas LA, Hollis BW, Heaney RP. Vitamin D2 is much less effective than
vitamin D3 in humans. J Clin Endocrinol Metab 2004;89:5387–91.
59. Newmark HL, Lipkin M, Maheshwari N. Colonic hyperplasia and hyper-
proliferation induced by a nutritional stress diet with four components of
Western-style diet. J Natl Cancer Inst 1990;82:491– 6.
60. Martinez ME, Giovannucci EL, Colditz GA, et al. Calcium, vitamin D, and
the occurrence of colorectal cancer among women. J Natl Cancer Inst
61. Devesa SS, Chow WH. Variation in colorectal cancer incidence in the
United States by subsite of origin. Cancer 1993;71:3819 –26.
62. Freedman D, Dosemeci M, McGlynn K. Sunlight and mortality from breast,
ovarian, colon, prostate, and nonmelanoma skin cancer: a composite death
certificate based case– control study. Occup Environ Med 2002;59:257– 62.
63. Mizoue T. Ecological studies of solar radiation and cancer mortality in
Japan. Health Phys 2004;87:532– 8.
64. Grant WB. An estimate of premature cancer mortality in the U.S. due to
inadequate doses of solar ultraviolet-B radiation. Cancer 2002;94:1867–75.
65. Grant WB. Ecologic studies of solar UV-B radiation and cancer mortality
rates. Recent Results Cancer Res 2003;164:371–7.
66. Grant W, Garland C. The association of solar ultraviolet B with reducing
risk of cancer: multifactorial ecological analysis of geographic variation in
age-adjusted cancer mortality rates. Anticancer Res 2006;26:2687–99.
67. Benito E, Stiggelbout A, Bosch F, et al. Nutritional factors in colorectal
cancer risk: a case– control study in Majorca. Int J Cancer 1991;49:161–7.
68. Kearney J, Giovannucci E, Rimm EB, et al. Calcium, vitamin D, and dairy
foods and the occurrence of colon cancer in men. Am J Epidemiol
69. Pritchard RS, Baron JA, Gerhardsson de Verdier M. Dietary calcium,
vitamin D, and the risk of colorectal cancer in Stockholm, Sweden. Cancer
Epidemiol Biomarkers Prev 1996;5:897–900.
70. LaVecchia C, Braga C, Negri E, et al. Intake of selected micronutrients and
risk of colorectal cancer. Int J Cancer 1997;73:525–30.
71. Marcus PM, Newcomb PA. The association of calcium and vitamin D, and
colon and rectal cancer in Wisconsin women. Int J Epidemiol 1998;27:788–93.
72. Bostick RM, Kushi LH, Wu Y, Meyer KA, Sellers TA, Folsom AR. Relation of
calcium, vitamin D, and dairy food intake to ischemic heart disease mortality
among postmenopausal women. Am J Epidemiol 1999;149:151–61.
73. McCullough ML, Robertson AS, Rodriguez C, et al. Calcium, vitamin D,
dairy products, and risk of colorectal cancer in the Cancer Prevention
Study II Nutrition Cohort (United States). Cancer Causes Control
74. Slattery ML, Sweeney C, Murtaugh M, et al. Associations between vitamin
D, vitamin D receptor gene and the androgen receptor gene with colon
and rectal cancer.. Int J Cancer 2006;118:3140 6.
75. Slattery ML, Neuhausen SL, Hoffman M, et al. Dietary calcium, vitamin D,
VDR genotypes and colorectal cancer. Int J Cancer 2004;111:7506.
76. National Cancer Institute. Surveillance, Epidemiology, and End Results
Program (SEER) Web site (data for 1992–2001). http://seercancergov
(Accessed 2005).
77. Matsuoka LY, Wortsman J, Chen TC, Holick MF. Compensation for the
interracial variance in the cutaneous synthesis of vitamin D. J Lab Clin Med
78. Irby K, Anderson WF, Henson DE, Devesa SS. Emerging and widening
colorectal carcinoma disparities between Blacks and Whites in the United
States (1975–2002). Cancer Epidemiol Biomarkers Prev 2006;15:792–7.
79. Lamprecht SA, Lipkin M. Chemoprevention of colon cancer by calcium,
vitamin D and folate: molecular mechanisms. Nat Rev Cancer 2003;3:601–14.
80. Tangpricha V, Spina C, Yao M, Chen TC, Wolfe MM, Holick MF. Vitamin
D deficiency enhances the growth of MC-26 colon cancer xenografts in
Balb/c mice. J Nutr 2005;135:2350 4.
81. Spina C, Tangpricha V, Yao M, et al. Colon cancer and solar ultraviolet B
radiation and preven tion and trea tment of colon cancer in mice with
vitamin D and its Gemini analogs. J Steroid Biochem Mol Biol
82. Fernandez-Garcia NI, Palmer HG, Garcia M, et al. 1alpha,25-
Dihydroxyvitamin D3 regulates the expression of Id1 and Id2 genes and
the angiogenic phenotype of human colon carcinoma cells. Oncogene
2005;24:6533– 44.
83. Holt P, Arber N, Halmos B, et al. Colonic epithelial cell proliferation
decreases with increasing levels of serum 25-hydroxy vitamin D. Cancer
Epidemiol Biomarkers Prev 2002;11:113–9.
84. Miller EA, Keku TO, Satia JA, Martin CF, Galanko JA, Sandler RS. Calcium,
vitamin D, and apoptosis in the rectal epithelium. Cancer Epidemiol
Biomarkers Prev 2005;14:525– 8.
85. Murillo G, Mehta RG. Chemoprevention of chemically-induced mammary
and colon carcinogenesis by 1alpha-hydroxyvitamin D5. J Steroid Biochem
Mol Biol 2005;97:129 –36.
Notice to reviewers for AJPM manuscripts
At the end of each calendar year, AJPM publishes a list of health professionals who have
helped with the peer-review process during that year. Because this information has to be
sent to the publisher each October for the December issue, the list is compiled at that
time. If you reviewed for AJPM between October and December of any year, your name
will appear in the list the following year. The editors apologize to any reviewers who
noticed that their names were not listed. Your assistance is always appreciated.
216 American Journal of Preventive Medicine, Volume 32, Number 3 www.ajpm-online.net
    • "Probably, the most convincing results on the association of vitamin D with malignant transformation come from colorectal cancer. It was shown that the risk of colorectal cancer inversely correlated with serum vitamin D concentration and its dietary intake [40,[46][47][48][49]. A number of studies suggest also a link between breast cancer and vitamin D, although some data are inconsistent. "
    [Show abstract] [Hide abstract] ABSTRACT: Ultraviolet (UV) radiation is involved in almost all skin cancer cases, but on the other hand, it stimulates the production of pre-vitamin D3, whose active metabolite, 1,25-dihydroxyvitamin D3 (1,25VD3), plays important physiological functions on binding with its receptor (vitamin D receptor, VDR). UV-induced DNA damages in the form of cyclobutane pyrimidine dimers or (6-4)-pyrimidine-pyrimidone photoproducts are frequently found in skin cancer and its precursors. Therefore, removing these lesions is essential for the prevention of skin cancer. As UV-induced DNA damages are repaired by nucleotide excision repair (NER), the interaction of 1,25VD3 with NER components can be important for skin cancer transformation. Several studies show that 1,25VD3 protects DNA against damage induced by UV, but the exact mechanism of this protection is not completely clear. 1,25VD3 was also shown to affect cell cycle regulation and apoptosis in several signaling pathways, so it can be considered as a potential modulator of the cellular DNA damage response, which is crucial for mutagenesis and cancer transformation. 1,25VD3 was shown to affect DNA repair and potentially NER through decreasing nitrosylation of DNA repair enzymes by NO overproduction by UV, but other mechanisms of the interaction between 1,25VD3 and NER machinery also are suggested. Therefore, the array of NER gene functioning could be analyzed and an appropriate amount of 1.25VD3 could be recommended to decrease UV-induced DNA damage important for skin cancer transformation.
    Full-text · Article · Apr 2016
    • "Vitamin D deficiency is common in cancer patients and correlates with disease progression. In observational studies, vitamin D deficiency is associated with increased incidence of breast and colon cancer, as well as with an unfavorable course of non-Hodgkin lymphoma [30,919293949596. A recent meta-analysis found a 12% (95% CI = 3%–22%) reduction of lung cancer incidence with respect to 25(OH)D concentrations for an increase from 20 to 50 nmol/L. "
    [Show abstract] [Hide abstract] ABSTRACT: Nutritional supplements are widely used among patients with cancer who perceive them to be anticancer and antitoxicity agents. Depending on the type of malignancy and the gender 30%-90% of the cancer patients supplement their diets with antioxidant and immuno-stabilizing micronutrients, such as selenium, vitamin C, and vitamin D, often without the knowledge of the treating physician. From the oncological viewpoint, there are justifiable concerns that dietary supplements decrease the effectiveness of chemotherapy and radiotherapy. Recent studies, however, have provided increasing evidence that treatment is tolerated better-with an increase in patient compliance and a lower rate of treatment discontinuations-when micronutrients, such as selenium, are added as appropriate to the patient's medication. Nutritional supplementation tailored to an individual's background diet, genetics, tumor histology, and treatments may yield benefits in subsets of patients. Clinicians should have an open dialogue with patients about nutritional supplements. Supplement advice needs to be individualized and come from a credible source, and it is best communicated by the physician.
    Full-text · Article · Mar 2016
    • "Vitamin D plays an essential role in health. Its deficiency increases the risk of osteoporosis as well as contributes to cardiovascular diseases, diabetes and cancers123. Skin synthesis of vitamin D from sunlight exposure is the major source of vitamin D [4]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Vitamin D deficiency is highly prevalent in both temperate as well as tropical countries. Obesity is one of the factors contributing to vitamin D deficiency. As our country has a high prevalence of overweight and obesity, we aimed to study serum 25-hydroxyvitamin D (25(OH)D) level and its association with adiposity using various adiposity indicators; and to study other risk factors that affect serum 25(OH)D level among multi-ethnic adults in Kuala Lumpur, Malaysia. Methods This was a cross sectional study conducted with a multistage sampling. All permanent teachers working in government secondary schools in Kuala Lumpur were invited for the study. The data collection included serum 25(OH)D, Parathyroid Hormone (PTH), body fat percentage, waist circumference, body mass index (BMI) and blood pressure. Demographic characteristics, sun avoidance, sun exposure and physical activity were enquired from the participants using a self-administered questionnaire. The data was analyzed using a complex sample analysis. Results A total of 858 participants were recruited. Majority of them were Malays, females and had tertiary education. The overall prevalence of vitamin D deficiency (<20 ng/ml) was 67.4 %. Indian participants (80.9 %) had the highest proportion of vitamin D deficiency, followed by Malays (75.6 %), others (44.9 %) and Chinese (25.1 %). There was a significant negative association between serum 25(OH)D level with BMI (β = −0.23) and body fat percentage (β = −0.14). In the multivariate linear regression analysis, Malays, Indians and females (p < 0.001); higher BMI and larger waist circumference (p < 0.05) were significantly associated with lower serum 25(OH)D level. The full model explained 32.8 % of the variation between participants in the serum 25(OH)D level. The two most influential factors affecting serum 25(OH)D level were ethnicity and gender. Conclusions The prevalence of vitamin D deficiency among our participants was high. Adiposity was associated with serum 25(OH)D level. Skin pigmentation and gender based behaviours were more dominant in contributing to serum 25(OH)D level. Health education should be targeted in weight management, gender based behaviours on sun exposure, as skin pigmentation is non-modifiable.
    Full-text · Article · Mar 2016
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