IOM Updates Guidance on Vitamin D, Calcium: A Pediatrician's Perspective on What Health Professionals Need to Know

A Conversation with Dr. Steven Abrams, Pediatric Bone Health Nutrition Expert

In recent years, studies suggesting potential health benefits of calcium and vitamin D beyond bone health have received a great deal of media coverage. But, how strong is the scientific evidence, and in particular, what does it mean for children's health and dietary recommendations?

To help answer these questions, the U.S. and Canadian governments asked the U.S. Institute of Medicine (IOM) to convene an expert scientific committee to review new and existing research related to health outcomes associated with calcium and vitamin D and revise, as needed, the dietary recommendations for these nutrients, last updated in 1997. The result of the committee’s work is the 2011 Dietary Reference Intakes (DRI) for Calcium and Vitamin D.

The Coca-Cola Company Beverage Institute for Health and Wellness (BIHW) recently spoke with noted pediatric nutrition researcher Steven Abrams, MD, who served on the IOM committee, who provided insight about conclusions and implications of the new calcium and vitamin D recommendations, especially as they apply to infants, children and adolescents.

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  • What are the key differences between the 2011 DRIs for calcium and vitamin D and the 1997 recommendations, especially as they apply to children?

    • Dr. Abrams: First, the DRIs differ because the research supporting the roles of calcium and vitamin D for bone health is more extensive than it was in 1997, the committee was able to ‘upgrade’ the calcium and vitamin D recommendations for most age groups from the less precise Adequate Intakes (AIs) established in 1997 to Recommended Dietary Allowances (RDAs).This is important because RDAs are calculated to meet the needs of 97.5% of the population, based on Estimated Average Requirements (EARs). (For more information, see Key Definitions.)

      Infants are the only age group for which the vitamin D recommendation remains an AI. However, the recommendation for this age group doubled from 200 per day to 400 International Units (IU) per day, and is now consistent with recent recommendations from the American Academy of Pediatrics and the Pediatric Endocrine Society.

      Perhaps the most significant change is in the vitamin D recommendations for children ages one to 18, which was tripled from the 1997 AI of 200 IU per day to an RDA of 600 IU. This is the highest vitamin D recommendation the IOM has ever made for children. (See DRI Table for Calcium and Vitamin D for age- and gender-specific recommendations.) Close

  • You said that the changes in the IOM recommendations for calcium and vitamin D are based on the levels of these nutrients needed to support bone health. Was the potential role of these nutrients in other health concerns also considered when developing the new recommendations?

    • Dr. Abrams: The committee examined numerous other potential relationships between vitamin D and health. After an exhaustive review, the committee concluded that existing calcium and vitamin D evidence was quite strong to support public health recommendations related to bone health, but that for other health issues, the currently available scientific evidence was not strong enough to affect dietary intake recommendations.

      Keep in mind that the IOM’s dietary recommendations for nutrients are set for healthy populations. Of course, practitioners can make interpretations based on the needs of individual patients. Close

  • Why does the new IOM report only focus on calcium and vitamin D, when the 1997 report also updated recommendations for other bone-health nutrients like magnesium and fluoride?

    • Dr. Abrams: Over the past 10 years, the public has heard conflicting information about the benefits of calcium and, especially, vitamin D. Therefore, the U.S. and Canadian governments asked the IOM to assess research about health outcomes specifically related to these two nutrients only. That’s not to say that other nutrients are not important for bone health; they just weren’t addressed in this new report. Close

  • As a pediatrician specializing in calcium research, could you put the new calcium and vitamin D recommendations into perspective as they relate to children’s bone health?

    • Dr. Abrams: The research is very clear that calcium and vitamin D work together to promote bone health. So, even though there are separate recommendations for these two nutrients, we need to remember that they work together. And because the data we used for the new recommendations are much more extensive than those used in 1997, the scientific consensus in the form of revised DRIs, which include an RDA, is more precise about the amounts of calcium and vitamin D required for bone health.

      Even though the new report focuses on calcium and vitamin D, other nutrients and lifestyle factors are still very important. Children need other micronutrients such as magnesium, fluoride and vitamin K as well as adequate protein: In other words, an overall balanced diet that includes plenty of fruits and vegetables, whole grains and lean proteins, in addition to sources of calcium and vitamin D. In addition, it’s important to remember that physical activity plays a major role in bone health. Close

  • What did the IOM learn about actual intakes of calcium and vitamin D? Are certain groups more likely to fall short of meeting the recommendations?

    • Dr. Abrams: With the exception of girls ages nine to 18, the research shows that most Americans and Canadians consume adequate amounts of calcium, while intakes of vitamin D fall slightly short of the new, higher recommendations. However, the IOM also determined that, with the exception of breastfed infants (who require supplementation), healthy people can meet their vitamin D requirements through diet, although acknowledged that to do so will require more reliance on dairy products, as well as fortified foods and beverages, especially for children. Close

  • What did the IOM committee determine is the best way for people, especially children, to meet the recommendations for calcium and vitamin D?

    • Dr. Abrams: Most children can and should rely on foods and beverages to meet the RDAs for calcium and vitamin D. The one exception is breastfed infants, who need a vitamin D supplement. The possibility of high dose maternal vitamin D as an alternative exists, but for now, the IOM and AAP recommend directly supplementing the breastfed infant.

      Major food sources of calcium in North America include dairy products as well as fortified foods and beverages (including fortified juices, dairy foods and soy products) and fish with bones (such as sardines). See Calcium Sources. Additionally, calcium is provided in smaller amounts in legumes, nuts and some green vegetables, such as broccoli, kale and mustard greens, which are not high in oxalates. (Oxalates, naturally occurring in certain vegetables and legumes, such as spinach, Swiss chard and kidney beans, bind to calcium making the mineral less available for absorption. Thus, if people are relying on plant-based foods for calcium, they need to pay attention to oxalate levels in those foods.) Primary sources of vitamin D include fortified dairy products, other fortified foods and beverages (including fortified juices, and fatty fish). See Vitamin D Sources.

      With regard to toddlers, it is certainly possible that adequate vitamin D can be consumed via foods or beverages as they are introduced to the diet. However, in the U.S., these children will likely need to consume an increased amount of dairy products, and fortified foods and beverages to meet the new vitamin D RDA.

      High-dose supplements of calcium and vitamin D are not generally recommended for healthy children as they may not be needed nor have benefits for this population. Getting too much calcium and vitamin D typically occurs only when people take high-dose supplements and may be harmful. Close

  • How did the committee address potential adverse effects from high doses of calcium and vitamin D?

    • Dr. Abrams: The IOM asks its expert committees to establish a Tolerable Upper Intake Level (UL) if a nutrient has the potential to cause toxicity or adverse effects. The UL is set at the highest level of daily intake thought to pose no risk of adverse health effects for almost all individuals in the general population, and includes total intake from all sources, including foods, beverages (including water) and supplements.

      We’ve known about adverse effects from high intakes of calcium and vitamin D for some time. For example, high calcium intakes (above the UL) can be associated with high blood and urine levels of calcium, kidney stones and calcification of blood vessels and soft tissue. Vitamin D intakes above the UL can be associated with high blood levels of calcium which can be harmful to the heart as well as other organs.

      The 2011 recommendations updated the ULs for the calcium and vitamin D based on the evidence available. For example, the new UL for calcium varies from 1,000 to 3,000 mg per day in the new recommendations based on age or reproductive status, while the 1997 recommendations set a UL of 2,500 mg per day for everyone over the age of one. The new vitamin D UL for ages nine and older has been raised to 4,000 IU per day, but the ULs for younger age groups remain lower.

      It’s important to stress that intakes above the RDA are not proven to be beneficial in healthy populations. Consuming intakes at or below the UL should be safe, but should be guided by a medical professional for specific indications. Close

  • Should the new RDAs and ULs for calcium and vitamin D affect the way health professionals think about dietary supplements for these nutrients?

    • Dr. Abrams: Diet—through foods and beverages—should be the primary source of calcium and vitamin D for almost everyone. As mentioned earlier, breastfed infants need vitamin D supplements. Although some people, such as pregnant women and older adults, may need vitamin D and calcium supplements to meet the new RDAs, health professionals should be cautious about high doses of calcium supplements among the elderly and high doses of vitamin D supplements for all age groups. Close

  • Did the committee take into consideration vitamin D production from sun exposure?

    • Dr. Abrams: In making our recommendation for vitamin D, we assumed minimal sun exposure. Although vitamin D is produced in the skin with UV exposure, sun exposure varies greatly from one person to another. In addition, people, especially children, are advised to reduce risk of skin cancer by avoiding unprotected sun exposure. Close

  • Blood tests for vitamin D are now common. How well do they correlate with vitamin D intakes? Did the committee make any recommendations regarding interpreting these tests?

    • Dr. Abrams: The level of circulating vitamin D in the blood serum, called 25-hydroxyvitamin D, is a reliable indication of overall vitamin D exposure from all sources (sunshine, dietary sources, supplements). However, vitamin D blood test results can be confusing because different standards exist. The committee report does not address guidelines regarding use of vitamin D blood tests in medical management and screening.

      With regard to blood levels of vitamin D, however, the committee did conclude that a level of 25-hydroxyvitamin D in the blood of at least 20 nanograms per milliliter (ng/ml) covers the vitamin D requirement of nearly all healthy people. This is consistent with the Pediatric Endocrine Society’s target level in children. The committee’s vitamin D recommendations are based on achieving this blood level with minimal sun exposure. Close

  • What are the greatest research needs in terms of calcium, vitamin D and health?

    • Dr. Abrams: Research in the past decade has greatly improved our understanding of calcium and vitamin D, especially related to bone health. But we still need to understand more about calcium and vitamin D in relation to other health outcomes, adverse effects, sun exposure, basic physiology, dose-response relationships and intake assessment. In particular, we need large-scale randomized clinical trials, especially in children, to test the effects of various levels of vitamin D on skeletal and non-skeletal outcomes and to identify possible adverse effects. Additionally, we need a better understanding of the influence of genetics, ethnicity, gender, body composition and sun exposure on vitamin D status. Finally, vitamin D blood tests should be standardized. Close

  • What’s the bottom line regarding calcium and vitamin D?

    • Dr. Abrams: Keep in mind that calcium and vitamin D work together. It’s important for children to accumulate enough calcium in the bones to maximize bone health, which requires appropriate intakes of both calcium and vitamin D. However, people do not need high doses of these nutrients. Even taking into account minimal sun exposure, most people (with the exception of breastfed infants requiring supplemental vitamin D) can meet their requirements for calcium and vitamin D through the diet, including dairy products, and fortified foods and beverages. Close

  • References
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Biography

Steve Abrams, MD

Steve Abrams, MD, is professor of pediatrics, Baylor College of Medicine, Houston, Texas. He served on the committees for both the 2011 Dietary Reference Intakes for Calcium and Vitamin D and the 1997 Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Dr. Abrams’ research expertise is the metabolism of nutritionally important minerals including calcium, magnesium, zinc, and iron. His current studies focus specifically on growing infants and children in an attempt to evaluate dietary recommendations for nutritionally important minerals. Dr. Abrams was not compensated for his participation in this interview.

Also of interest:

Beverages & Bone Health: Harmful, helpful or no effect? A Conversation with Dr. Robert P. Heaney, Bone Health Expert

Report Brief, Dietary Reference Intakes for Calcium and Vitamin D, Food and Nutrition Board, Institute of Medicine, National Academy Press, Washington, D.C., November 30, 2010.

DRI Table for Calcium and Vitamin D1

  Calcium Vitamin D
Life Stage Group Estimated Average Requirement (mg/day) Recommended Dietary Allowance (mg/day) Upper Level Intake (mg/day) Estimated Average Requirement (IU/day) Recommended Dietary Allowance (IU/day) Upper Level Intake (IU/day)
Infants 0 to 6 months * * 1,000 ** ** 1,000
Infants 6 to 12 months * * 1,500 ** ** 1,500
1-3 years old 500 700 2,500 400 600 2,500
4-8 years old 800 1,000 2,500 400 600 3,000
9-13 years old 1,100 1,300 3,000 400 600 4,000
14-18 years old 1,100 1,300 3,000 400 600 4,000
19-30 years old 800 1,000 2,500 400 600 4,000
31-50 years old 800 1,000 2,500 400 600 4,000
51-70 year old males 800 1,000 2,000 400 600 4,000
51-70 year old females 1,000 1,200 2,000 400 600 4,000
> 70 years old 1,000 1,200 2,000 400 800 4,000
14-18 years old, pregnant/lactating 1,100 1,300 3,000 400 600 4,000
19-50 years old, pregnant/lactating 800 1,000 2,500 400 600 4,000
* For infants, Adequate Intake is 200 mg/day for 0 to 6 months of age and 260 mg/day for 6 to 12 months of age.
** For infants, Adequate Intake is 400 IU/day for 0 to 6 months of age and 400 IU/day for 6 to 12 months of age.

Key Definitions2

Dietary Reference Intakes (DRIs): In the mid-1990s, the DRIs replaced the Recommended Dietary Allowance (RDA) in the United States and the Recommended Nutrient Intake (RNI) in Canada. The DRIs are actually a set of several reference values that include values related to both adequate intakes and upper levels of intakes.

Recommended Dietary Allowances (RDAs): RDAs are set to meet the needs of almost all (97 to 98 percent) individuals in a group.

Adequate Intakes (AIs): For healthy breastfed infants, the AI is the mean intake. The AI for other life stage and gender groups is believed to cover needs of all individuals in the group, but lack of data or uncertainty in the data prevent being able to specify with confidence the percentage of individuals covered by this intake.

Estimate Average Requirement (EAR): An EAR is the average daily nutrient intake level estimated to meet the requirements of half of the healthy individuals in a group.

Tolerable Upper Intake Level (UL): A UL is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population. Unless otherwise specified, the UL represents total intake from food, water, and supplements.

Selected Food Sources Ranked by Calcium3

Food Standard portion size Calories in standard portiona Calcium in standard portiona (mg)
Fortified ready-to-eat cereals (various) ¾–1 cup (about 1 ounce) 100–210 250–1,000
Orange juice, calcium fortified 1 cup 117 500
Plain yogurt, nonfat 8 ounces 127 452
Romano cheese 1½ ounces 165 452
Pasteurized process Swiss cheese 2 ounces 189 438
Evaporated milk, nonfat ½ cup 100 371
Tofu, regular, prepared with calcium sulfate ½ cup 94 434
Plain yogurt, low-fat 8 ounces 143 415
Fruit yogurt, low-fat 8 ounces 232 345
Ricotta cheese, part skim ½ cup 171 337
Swiss cheese 1½ ounces 162 336
Sardines, canned in oil, drained 3 ounces 177 325
Pasteurized process American cheese food 2 ounces 187 323
Provolone cheese 1½ ounces 149 321
Mozzarella cheese, part-skim 1½ ounces 128 311
Cheddar cheese 1½ ounces 171 307
Low-fat milk (1%) 1 cup 102 305
Muenster cheese 1½ ounces 156 305
Skim milk (nonfat) 1 cup 83 299
Soymilk, original and vanilla, with added calcium 1 cup 104 299
Reduced fat milk (2%) 1 cup 122 293
Low-fat chocolate milk (1%) 1 cup 158 290
Low-fat buttermilk (1%) 1 cup 98 284
Rice milk, with added calcium 1 cup 113 283
Whole chocolate milk 1 cup 208 280
Whole milk 1 cup 149 276
Plain yogurt, whole milk 8 ounces 138 275
Reduced fat chocolate milk (2%) 1 cup 190 272
Ricotta cheese, whole milk ½ cup 216 257
Tofu, firm, prepared with calcium sulfate and magnesium choloride ½ cup 88 253
a. Data source: U.S. Department of Agriculture, Agricultural Research Service, Nutrient Data Laboratory. 2009. USDA National Nutrient Database for Standard Reference, Release 22. Available at: http://www.ars.usda.gov/ba/bhnrc/ndl.

Selected Food Sources Ranked by Vitamin D4

Food Standard portion size Calories in standard portiona Vitamin D in standard portiona, b (mcg)
Salmon, sockeye, cooked 3 ounces 184 19.8
Salmon, smoked 3 ounces 99 14.5
Salmon, canned 3 ounces 118 11.6
Rockfish, cooked 3 ounces 103 6.5
Tuna, light, canned in oil, drained 3 ounces 168 5.7
Orange juicec 1 cup 118 3.4
Sardine, canned in oil, drained 3 ounces 177 4.1
Tuna, light, canned in water, drained 3 ounces 99 3.8
Whole milkc 1 cup 149 3.2
Whole chocolate milkc 1 cup 208 3.2
Reduced fat chocolate milk (2%)c 1 cup 190 3.0
Milk (nonfat, 1% and 2%)c 1 cup 83–122 2.9
Low-fat chocolate milk (1%)c 1 cup 158 2.8
Soymilkc 1 cup 104 2.7
Evaporated milk, nonfatc ½ cup 100 2.6
Flatfish (flounder and sole), cooked 3 ounces 99 2.5
Fortified ready-to-eat cereals (various)c ¾–1¼ cup (about 1 ounce) 92–190 92–190
Rice drinkc 1 cup 113 2.4
Herring, pickled 3 ounces 223 2.4
Pork, cooked (various cuts) 3 ounces 153–337 0.6–2.2
Cod, cooked 3 ounces 89 1.0
Beef liver, cooked 3 ounces 149 1.0
Cured ham 3 ounces 133–207 0.6–0.8
Egg, hard-boiled 1 large 78 0.7
Shiitake mushrooms ½ cup 41 0.6
Canadian bacon 2 slices (about 1½ ounces) 87 0.5
a. Source: U.S. Department of Agriculture, Agricultural Research Service, Nutrient Data Laboratory. 2009. USDA National Nutrient Database for Standard Reference, Release 22. Available at: http://www.ars.usda.gov/ba/bhnrc/ndl.
b. 1 mcg of vitamin D is equivalent to 40 IU.
c. Vitamin D fortified.

Table and Sidebar References

1 Report Brief, Dietary Reference Intakes for Calcium and Vitamin D, Food and Nutrition Board, Institute of Medicine, National Academy Press, Washington, D.C., November 30, 2010. http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/Report-Brief.aspx

2 Dietary Reference Intakes Tables and Application, Food and Nutrition Board, Institute of Medicine, National Academy Press, Washington, D.C., 2001. http://www.iom.edu/Activities/Nutrition/SummaryDRIs/DRI-Tables.aspx, accessed January 4, 2011.

3 Dietary Guidelines for Americans 2010, US Department of Agriculture, US Department of Health & Human Services., Washington DC, January 31, 2011. http://www.cnpp.usda.gov/DGAs2010-PolicyDocument.htm, accessed February 2, 2011.

4 Dietary Guidelines for Americans 2010, US Department of Agriculture, US Department of Health & Human Services., Washington DC, January 31, 2011. http://www.cnpp.usda.gov/DGAs2010-PolicyDocument.htm, accessed February 2, 2011.

The views and opinions expressed by the experts and organizations quoted in this article are their own and do not necessarily represent the views of any institution or association to which they belong, nor The Coca-Cola Company.