Whats next for the Dietary Reference Intakes for Bone Metabolism Related Nutrients beyond Calcium: Phosphorus,

Magnesium, Vitamin D and Fluoride?

Christine Bergman1, Darlene Gray-Scott2, Jau-Jiin Chen3, Susan Meacham4

Christine Bergman1 and Susan Meacham4 are Associate Professors in the Department of Food and Beverage Management1 and the School of Life Sciences4. Jau-Jiin Chen3 is an Assistant Professor in the Department of Nutrition Sciences, and Darlene Gray-Scott2 completed a Masters degree in the Department of Health Promotion, all at the University of Nevada Las Vegas. Address correspondence to: Susan L. Meacham, 4505 Maryland Parkway, Box 454004, Las Vegas, NV 89154-4004, fax 702-895-3915, email susan.meacham@unlv.edu

Abstract The science supporting the Dietary Reference Intakes (DRI) for phosphorus, magnesium, vitamin D, and fluoride was examined in this review. Along with the previous article on calcium in this series both of these reviews represent all the DRI for nutrients considered essential for bone metabolism and health, as reported in the Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (Institute of Medicine, Food and Nutrition Board, 1997). The Recommended Dietary Allowances (RDA) or adequate intake (AI), and the tolerable upper intake level (UL) were recommended for each of these essential nutrients. For adults and in the case of fluoride, for infants as well, UL were calculated since all of these nutrients have the potential for mild to detrimental side effects. Dietary intake data and controversies regarding the role these nutrients may play in other chronic diseases have also been discussed. Advances and controversies reported since publication of the DRI for these nutrients were also addressed in this review. A recent Dietary Reference Intake Research Synthesis Workshop report identified an extensive range of suggested future research directions needed to improve our understanding of these bone related nutrients and their contributions to human health.

Key words: Dietary Reference Intakes, Recommended Dietary Allowances, Adequate Intakes, Tolerable Upper Intake Levels, Bone Nutrients, Phosphorus, Magnesium, Vitamin D, and Fluoride

Introduction Dietary Reference Intakes (DRI) The Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (Institute of Medicine, Food and Nutrition Board (FNB), 1997) were values calculated with the goal of maintaining health and avoiding potential risks from nutrient toxicity. A panel of scientists and nutrition experts from the United States and Canada developed the dietary recommendations based on analysis of the currently available scientific literature (see Figure 1). This review summarizes the work of the FNBs DRI committee, its expert panel on calcium, phosphorus, magnesium, vitamin D and fluoride, its subcommittee on upper reference levels of nutrients, and the FNB. The science-based evidence used to establish the DRIs for calcium, as well as the other bone related nutrients, examined the role of these nutrients in the development and maintenance of bones and teeth. At the time, some consideration was also given to data describing potential biological roles for these nutrients in the prevention of other chronic diseases. But relatively little emphasis was given to these data since the FNB were unable to develop conclusions that could be agreed upon. This was not surprising since chronic disease is known to result from complex interactions among genetic, dietary, and other environmental factors. The review of the latest dietary requirements of some nutrients important to bones and teeth, along with a previous report on dietary calcium, summarizes the latest recommendations and what has been learned about bone related nutrients since the FNB report was published. Since an Adequate Intake (AI), and not a Recommended Dietary Allowance (RDA), was set for vitamin D and fluoride, and the youngest life stages for phosphorus and magnesium in 1997, it is time to revisit, ten years later, the controversies that surrounded the

original second tier recommendations for these essential bone related nutrients. What science based evidence is needed? What have we learned since making our last recommendation? Also, considering the economic, marketing, pharmacological and educational effort invested in bone health, what interactions do these nutrients have with calcium? There are many entities that have a stake in knowing which way a committee might go with the next revisions? Up? Down? Or stay the same? Potential changes may impact many, including school lunch budgets, menus, hospital menus, and educational materials. Phosphorus Overview The primary function of phosphorus, as carbon phosphate, in the human body is its structural role in bone as a component of hydroxyapatite, which accounts for 85% of the phosphorus in the body. The remainder of body phosphorus is in the soft tissues, blood, and extracellular fluid. In tissue membranes, phosphorus occurs as phospholipids, and in other capacities phosphorus helps to maintain pH, acts as a temporary storage and transfer of energy, and is a cofactor activates many enzymes. Unlike calcium, there is no adaptive mechanism for differential absorption rates with varying dietary intake. Also, unlike calcium, which is highly hormonally regulated and involving bone, intestines and kidney, the method of phosphorus regulation is primarily through the kidney (Lotz et al., 1968). Inadequate phosphorus intakes in the U.S. are rarely a concern, as phosphorus is available in many foods thus these deficiencies are seldom seen. However, persons recovering from prolonged illnesses or receiving parenteral nutrition for extended periods of time may be at risk (Lotz et al., 1968). Inadequate phosphate intake can result in low blood levels of phosphorus and depleted levels in extracellular fluid. Traditionally, the resulting consequences of severely

depleted body phosphorus are anorexia, anemia, muscle weakness, bone pain, rickets, osteomalacia, depressed immune function, paresthesias, ataxia, confusion, or death. More recently concerns regarding high calcium supplementation have been purported to bind food phosphorus inhibiting intestinal absorption. While phosphorus intakes are often two times the recommended intakes, 10-15% of older women consume less than 70% of the recommendation. In these women, if also receiving anabolic osteoporosis treatment modalities that require a positive phosphorus balance, taking high calcium supplements may exacerbate phosphorus deficiencies (Heaney, 2004). Phosphorus Recommendations Phosphorus dietary recommendations were set using phosphorus balance studies and serum inorganic phosphate concentrations. Since hypo- and hyperphosphatemia can result in dysfunction or disease, the panel concluded that the level required to maintain serum levels within an optimal range is the most logical indicator of phosphorus nutriture. Since these values have not been established for infants and children, estimates based on a factorial approach, recognizing the need for phosphorus during growth, were used. AIs are available for infants, while RDAs are available for the remaining life-stage groups (Table 1). The current DRI are slightly higher, 50 mg, than previous recommendations for boys and girls 11 to18 years of age and young pregnant and lactating women 14-18 years of age. However, phosphorus recommendations for all other life-stage and gender groups have been lowered, by as much as 66% for infants (National Research Council, Committee on Dietary Allowances, 1989). Tolerable upper intake levels have been set for phosphorus because of the reported complications resulting from hyperphosphatemia: alteration in hormonal control of calcium, calcification of the kidney, increased porosity of the skeleton, and reduction in calcium

absorption. Though high phosphate levels have the potential for altering calcium levels in the body, the panel concluded that these effects can be minor, particularly if calcium intake is adequate and thus do not provide evidence for estimating the UL. Metastatic calcification can occur in individuals with end-stage renal disease whose phosphorus levels are not controlled (Institute of Medicine FNB, 1997). There has also been concern about high dietary phosphorus interfering with calcium absorption. Based on the evidence the panel concluded that the potential for phosphorus to interfere is not of concern as long as calcium intake is adequate, as discussed previously. In humans, the committee concluded that high phosphorus intakes do not result in negative calcium balance or increased bone resorption (Institute of Medicine FNB, 1997). A recent workshop reviewed the findings of the DRI committees and suggested research recommendations. For phosphorus there is a need to define the intake needed to optimize bone accretion in children 1to 18 years. For children and adults serum values should be assessed to define the relationship between phosphorus intake and phosphorus levels in blood. (Dietary Reference Intakes Research Synthesis: Workshop Summary, 2006). A critical review by Sax (2001) has made suggestions as to research needed prior to unequivocally being able to state that the ratio between calcium and phosphorus intake does not impact bone health. The questions that Sax indicates need to be answered include: (1) Do diets with a low calcium-to-phosphorus ratio affect bone density in children and adolescents differently than in adults and (2) do diets with a low calcium-to-phosphorus ratio affect bone density in human females differently than in males? These questions are stated to stem from reliance of the FNB on studies performed using adult males for phosphorus to calcium ratio recommendations for adult women, adolescents and children. These questions appear to be

especially worth investigating since women and children today are consuming more phosphoruscontaining soft drinks and less calcium-containing milk than 25 years ago (French et al., 2003; USDA, Economic Research Service, 2004). Factors Affecting Infant Phosphorus Requirements The phosphorus in cows milk and soy formulas is absorbed with more difficulty by human infants than that absorbed from breast milk. To compensate for this physiological difference, infant formulas contain considerably greater amounts of phosphorus than in human milk to offset the lower absorption rate. Another concern previously considered for infants was whether or not to determine adequate calcium to phosphorus ratio for infants. The DRI panel reviewed the literature and concluded that there was little or no evidence to support setting a ratio for the dietary relationship between these nutrients for healthy infants (Institute of Medicine FNB, 1997). Dietary Intake and Sources of Phosphorus It has been estimated that approximately 20-30% of daily phosphorus intake comes from processed foods and soft drinks. There has been uncertainty about the phosphorus content in highly processed foods, which today are more abundant than they were 20 years ago. Thus, questions arise regarding the reliability of phosphorus estimates in nutrient databases (Institute of Medicine FNB, 1997). Given this uncertainty, the DRI panel still concluded that according to national intake data, mean intakes for phosphorus seemed adequate for most adults. Phosphorus is considered a limiting nutrient in the biosphere, however, the primary sources of dietary phosphorus for most adults are readily available and abundant in the food supply; milk, cheese, meat, bread; cereal, bran, eggs, nuts, and fish. Phosphorus content of some common foods is presented in Table 2. Because of the efficiency of absorption, ranging from

55% to 80% in the intestine, and its abundance in foods, phosphorus deficiencies are not common (Heaney, 2004). This should also hold true for some individuals ingesting high calcium supplements as carbonates or citrates, and if they remain attentive to their meat and dairy intake, particularly when taking advantage of bone rebuilding therapies low intakes of phosphorus (Heaney, 2004). Magnesium Magnesium is an essential mineral that is needed for hundreds of metabolic reactions in the body. Its primary functions include maintenance of muscle and nerve function, normal cardiac rhythm, nucleotide synthesis, sodium, potassium-ATPase activity, and bone strength. More than half of the magnesium in the body is combined with calcium and phosphorus in the bone, while the rest is in other tissues and organs (Institute of Medicine FNB, 1997; Sardesai, 2003). Magnesium and Disease Bone, a dynamic and complex structure, is composed of numerous minerals, including magnesium. Magnesium deficiency may contribute to osteoporosis because of its metabolic influence on calcium. Rude et al. (2004, 2005, 2006) demonstrated the role of dietary magnesium depletion in bone health when intakes at 50, 20 and 10% of recommendations were fed to rats; trabecular bone volume decreased, osteoclast number increased, and tumor necrosis factor-alpha increased. Conversely, magnesium supplementation may improve bone density (Institute of Medicine FNB, 1997). There is considerable evidence that magnesium may play an important role in regulating blood pressure. Diets rich in potassium and magnesium are associated with lower blood pressure levels. One of the largest, multi-site studies to support this concept is the DASH trial (Ascherio

et al., 1998; Joint Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, 1997; NIH & NHLBI, 1999; Sacks et al., 1999; Svetkey et al., 1999). These studies indicated hypertension can be improved using a diet low in sodium, total and saturated fat, and high in magnesium, potassium, and calcium. Diets rich in lean proteins, low-fat dairy foods, and fruits and vegetables can provide this nutrient profile. Magnesium deficiency may be associated with cardiac abnormalities and stroke, while higher dietary intakes and plasma levels of magnesium have been associated with a lower risk of heart disease and stroke (Ford, 1999; Liao et al., 1998; Schulze and Hu, 2005). Similarly, hypomagnesemia has been reported in individuals with poorly controlled type-one and type-two diabetes. The FNB reported that magnesium likely plays a role in the release and action of insulin (Institute of Medicine FNB, 1997). Since the FNB report, others have discussed the possible preventive effect of magnesium on type-two diabetes development. For example, amongst other compounds, the beneficial effect of long-term coffee consumption on the development of type-two diabetes has proposed to be due to additional magnesium consumption (Qureshi and Melonakos, 1996). Studies designed to evaluate this hypothesis are needed. Magnesium Recommendations Several indicators have been used in the literature to estimate magnesium requirement. Serum magnesium may not reflect intracellular magnesium content, nor has it been validated as a reliable indicator of magnesium status. However, it is the most readily available technique and has been commonly used in research trials. Taking into account all available literature, including various other methods of determining magnesium status the panel calculated an RDA for magnesium (Table 1) (Institute of Medicine FNB, 1997). Similar to phosphorus, AI are reported for infants, and RDA for all other groups. The DRI are slightly higher or lower than the

previously reported RDAs (National Research Council, Committee on Dietary Allowances, 1989). High doses of magnesium can have a laxative effect or in more severe cases can result in kidney failure (ADA, 1992; Institute of Medicine FNB, 1997). Because of the potential effects of toxicity, the panel has set UL for magnesium (Table 1). Additional Factors Affecting Magnesium Requirement Ingestion of certain substances may cause excessive renal losses of magnesium. Alcohol, loop and thiazide diuretics, the cancer drug Cisplatin and some antibiotics such as Gentamicin, Amphotericin, and Cyclosporin may increase magnesium loss and require a patient to be prescribed magnesium supplements. Any disease that results in malabsorption may also require additional magnesium intake. People with poorly controlled diabetes may also have increased magnesium loss and may need to be evaluated by their physician (Gropper et al., 2005). Other factors affecting magnesium requirement involve nutrient-nutrient interactions. Diets very high in phosphate or fiber, and thus phytates, may decrease intestinal absorption of magnesium. It appears however, that calcium has a negligible effect on magnesium absorption. Low protein intakes may result in impaired magnesium absorption, while high protein intakes may increase renal excretion of the mineral. However, the increased excretion does not appear to be detrimental as long as intakes are adequate (Institute of Medicine FNB, 1997). Dietary Intake and Food Sources of Magnesium The panel reported mean dietary intakes for adult men to be close to the RDA, while it is slightly lower than the RDA for women. Intakes tend to decline for individuals after the age of 70 (Institute of Medicine FNB, 1997).

The chlorophyll molecule contains magnesium and therefore green vegetables are a rich source. Other good sources include nuts, seeds, legumes, and some whole grains and seafoods, in addition to a number of beverages such as coffee, tea, cocoa, and hard water (Garland et al., 1985). Magnesium content is generally low in processed foods. Since the quantity in most foods is relatively small, it is wise to eat a variety of magnesium-rich foods on a regular basis. Magnesium content of some common foods is presented in Table 3. Future research is needed to identify the magnesium intake needed for optimal accretion of bone in children and for the preservation of bone in adults. Also, studies are needed to identify associations between magnesium intake and chronic diseases, i.e., hypertension, cardiovascular disease and diabetes. Likewise, serum values may not be the best indicators of magnesium status, thus research is needed to identify a valid and accurate assessment protocol for magnesium (Dietary Reference Intakes Research Synthesis: Workshop Summary, 2006). Vitamin D Vitamin D, commonly recognized as a fat soluble vitamin is also referred to as calciferol and calcitriol. The vitamin plays an important role in a hormone-like fashion, maintaining serum calcium and phosphorus concentrations by enhancing the efficiency of absorption in the small intestine. Some question whether vitamin D is a true hormone since it can be synthesized in the skin from sunlight, activated in the liver (25-hydroxy cholecalciferol) and kidneys (1, 25dihydroxy cholecalciferol) and then affect metabolic functions in the small intestine. The active form of vitamin D promotes the absorption of calcium in the small intestine and aids in bone mineralization with a number of other nutrients and hormones. Inadequate amounts of vitamin D can result in thin, brittle, soft, or misshapen bones referred to as rickets in children and osteomalacia in adults (Garland et al., 1985).

Vitamin D and Cancer Epidemiological data suggest that vitamin D deficiency may be associated with an increased risk of developing colon, breast, and, prostate cancer (Garland et al., 1990; Konety et al., 1999; Mahan and Escott-Stump, 2000; Sardesai, 2003; Schwartz and Hulka, 1990). More clinical trials need to be completed in order to establish a stronger association between vitamin D and cancer. At this time it is not prudent to promote cancer prevention by advising individuals to take vitamin D, a fat soluble vitamin with tolerable upper levels set for daily intakes. Vitamin D Recommendations The panel concluded that the best indicators for determining vitamin D nutriture are serum levels and the evaluation of skeletal health. Both serum concentrations of the vitamin are not good indicators of adequacy since the short half life and tight regulation by other factors modulate serum concentrations. In children serum levels of vitamin D and other hormones were considered when the daily intake recommendations to prevent rickets were determined. The amount of vitamin D required for optimal calcium metabolism and bone health is also complicated by the synthesized of the vitamin in skin with sunlight exposure. Furthermore, the vitamin D content in foods, including government-mandated fortification of milk, is highly variable (Institute of Medicine FNB, 1997). The AI and UL for vitamin D are presented in Table 1. AIs are reported for all lifestage groups. The current DRI are lower than the previous RDA (National Research Council, Committee on Dietary Allowances, 1989) except for individuals over the age of 50 years. The DRI for this group is two (51-70y) to three (>70y) times greater than the previous RDA of 5 g/day. As with other bone related nutrients discussed, there is a tolerable upper intake set for Vitamin D. Conservative intakes are advised to prevent hypervitaminosis potentially resulting in

hypercalcemia leading to a host of debilitating effects. The bodys mechanism to concentrate urine is impaired in the kidney, glomerular filtration rate and renal tubule reabsorption are decreased and calcification of soft tissues has been reported. Other reported side effects include anorexia, nausea, and vomiting (Institute of Medicine FNB, 1997). Recently, a collectively written editorial shared the opinions of all the major vitamin D researchers worldwide. They proposed that the dietary intakes of vitamin D are currently, too low. Through a strong singular voice they shared their intention by writing an editorial stating that current findings are supporting higher recommendations for dietary intakes of vitamin D than are currently consumed (Vieth et al., 2007). Factors Affecting Vitamin D Requirement Vitamin D synthesis in skin declines with advancing age, and possibly absorption from the small intestine, placing the elderly at risk for vitamin D deficiencies (Wardlaw, 2003). Other conditions that are associated with intestinal malabsorption of vitamin D are Crohns disease, Whipples disease, and Tropical Sprue (Lukert and Raisz, 1990). Often patients with numerous inflammatory medical conditions require the chronic use of corticosteroid medications to manage their symptoms. Consequently, the potential side effects of a drug-nutrient interaction include decreased calcium absorption and possible impairment of vitamin D metabolism. These patients may need to increase vitamin D intake with food or supplements (Sato et al., 1998). Many people with Alzheimers disease have an increased number of hip fractures, possibly because they are homebound or institutionalized, and sunlight deprived. This population may also benefit from increased vitamin D intake (O'Dell and Sunde, 1997). Vitamin D Intake and Sources

Vitamin D intake is difficult to assess because of the variable amounts in fortified foods and because some of the national surveys do not include vitamin D. Vitamin D occurs naturally in few food sources- some fish liver oils, flesh of some fatty fish, and eggs from hens fed vitamin D. Other foods like milk, infant formulas, and cereals are fortified. The ability to make vitamin D from sunlight depends on season, latitude, skin color, time of day, cloud cover, smog, and sunscreens. If sun exposure is limited by either time (less than 10-15 minutes per day) or environmental conditions, it is important to consume foods or supplements in amounts consistent with the current AI (Institute of Medicine FNB, 1997). Fluoride About 95% of body fluoride is found in bones and teeth (O'Dell and Sunde, 1997). Fluoride is present in the body as a trace element and is generally 100% absorbable when consumed as sodium fluorosilicate in fluoridated water or as sodium fluoride or monofluorophosphate in toothpaste or tablets. When consumed with foods and beverages, fluoride complexes with proteins and other minerals such as calcium and magnesium reducing absorption to about 50-80%. Fluoride absorption is rapid, uniquely diffusing across the stomach wall into the blood, with absorption continuing in the small intestine, the primary site of absorption for most nutrients (O'Dell and Sunde, 1997). Clinical Significance of Fluoride Fluoride is not directly associated with diseases due to deficiencies or toxicities (O'Dell and Sunde, 1997). Clinically, fluoride has a high affinity for the tissue of bone and teeth. Fluoroapatite is important for hardening tooth enamel and contributes to the stability of bone mineral matrix. Fluoride has some enzyme related effects in soft tissue enzymes but the physiological significance of these actions is not known. Fluorohydroxyapatite significantly

reduces the likelihood of enamel dissolution by acids produced by cariogenic bacteria. These effects can not be reproduced by any of the other 25 trace elements found in tooth enamel. The benefits of fluoride for children during tooth formation are best at preeruptive stages of development, lifetime benefits are derived from the effects of fluoride on the remineralization of surface enamel. Acute toxicities present with nausea, vomiting, diarrhea, acidosis, and cardiac arrhythmias. Chronic toxicity, resulting in fluorosis, alters bone, kidney, and possibly nerve and muscle function. The most common manifestation of excess fluoride is dental fluorosis or mottling of teeth observed in children receiving high fluoride intakes. Like most minerals death has been reported at excessive ingestion levels. Fluoride Recommendations The new DRIs have developed an adequate intake recommendations (Table 1) and upper intake levels for fluoride. The AI is the intake value that reduces the occurrence of dental caries maximally in a group of individuals without causing unwanted side effects. With fluoride, the data are strong on risk reduction, but the evidence upon which to base an actual requirement is scant, thus driving the decision to adopt an AI as the reference value (Institute of Medicine FNB, 1997). The tolerable upper intake level for fluoride ranges from 1.3 mg/d for children 1 to 3 years to 10 mg/d for children older than 8 years and adults. Factors Affecting Fluoride Requirements Interactions of fluoride with other nutrients have been reported (Gropper et al., 2005). Aluminum (particularly Al in antacids), calcium, magnesium and chloride reduce fluoride uptake and uses. Phosphate and sulfate increase fluoride uptake. Sodium chloride decreases skeletal uptake of fluoride. Dietary proteins and fats have been reported to improve fluoride absorption.

These factors influence the bioavailability of fluoride from different food sources, requiring intake ranges to account for this uncertainty in absorption. Some studies have reported using fluoride as a therapeutic agent in the treatment of osteoporosis, to arrest bone mineral loss. Other studies have suggested this treatment as ineffective, with only 55-75% (Ref) of patients responding to fluoride treatment, or even problematic, for example, bone tissues forming that are not as strong as regular bone. Additionally, there is a small range between the beneficial effects of fluoride on dental caries reduction and prevalence of dental fluorosis. School-age children have four potential sources of extra fluoride beyond food and water sources, possibly contributing to an increased prevalence of dental fluorosis school fluoridation programs, home dietary fluoride supplements, mouth rinse, and toothpaste. A recent study of fluoride ingestion from food and dentrific products was conducted with 33 children in a fluoridated community in Brazil (Simes de Almeida, 2007. Most of the children were ingesting more than the recommended amount, with about 80% coming from the dentrifice (toothpaste) and the remainder coming primarily from water and milk. However, determining fluoride using fingernail analysis was considered not sensitive enough to detect changes in fluoride ingestion through two seasonally dietary duplicate plate collections and body status assessed through fingernail analysis (Simes de Almeida et al., 2007). Dietary Intake and Food and Water Sources of Fluoride Recent estimates determine total fluoride intakes to vary depending upon the region. For young adults in nonfluoridated areas (<0.3 ppm fluoride in water) intakes have been estimated to be 0.9 mg/day and 1.85 mg/day for adults living in cities fluoridating (>0.7 ppm) water. Beverages and water contribute such a high percentage of total fluoride intakes of high

availability; it is easy to dismiss the importance of the fluoride content of food. Foods high in fluoride, such as marine fish, clams, lobster, crab, shrimp, and tea, will contribute significantly to daily fluoride intake. Additionally, foods prepared with fluoridated water at home, will also add significantly to daily fluoride intake, for example, infant formulas, powdered milk, soups, cereals, juices, and vegetables. Conclusion A number of reviews have appeared regarding nutrition and bone health since the DRI on bone related nutrients was released in 1997 (Palacios, 2006). This review focused on the research supporting the DRI for some of the bone-health associated essential nutrients along with a discussion of recent related findings. Essential dietary nutrient research has expanded from a prior focus on amounts needed to eliminate deficiency diseases to include the amount required to minimize the onset and impact of chronic diseases. Thus, as stated in the previous review in this series, definitions for optimal intakes of specific essential nutrients are becoming increasingly harder to define. Some of this difficulty will likely come from our expanding knowledge of the role nonnutritive compounds play in preventing chronic diseases such as osteoporosis and synergistic actions between essential nutrients and nonessential nutrients such as soy isoflavones. Determining the individual and synergistic activity of and between these essential nutrients and nonessential compounds in maintaining bone health will be a great challenge. In addition we are becoming increasingly aware that differences between individuals genetic make-up impacts the effect of essential and nonessential dietary compounds on health. Therefore, by the time the DRIs for bone-related nutrients are revisited the FNB task will likely be even more difficult than that which the previous panel faced.

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 Estimated Average Requirement (EAR) is the average daily intake value for a particular nutrient for a given life stage and gender group. It is estimated to satisfy the nutrient intakes of approximately 50% of the persons in that particular life stage and gender group.

Recommended Dietary Allowance (RDA) The average daily intake level has not changed in definition from previous years. It is the intake level of a specific nutrient that will provide approximately all (97 to 98%) of the persons in a life stage and gender group with sufficient daily quantities to meet body needs.

Adequate Intake (AI) When data are not available to determine a specific EAR, needed to determine the RDA, the AI is set as the average amount of a nutrient expected to be sufficient to maintain health.

Tolerable Upper Intake Level (UL) To avoid nutrient toxicities, the highest amount of a nutrient that can be expected to be ingested safely, daily and not cause health risks or adverse reactions to almost all individuals in the general population is known as the UL.

Figure 1. Dietary Reference Intakes Reference Categories. Dietary intake recommendation categories developed for the purpose of setting estimated average intakes, recommended intakes, adequate intakes, tolerable upper limits for various populations on the basis of age, gender and physiological state in the United States and Canada (Food and Nutrition Board, 1997).

Table 1. Dietary Reference Intakes (DRI) for Magnesium, Vitamin D, Fluoride, Adequate Intakes (AI) and Tolerable Upper Levels (UL) for U.S. and Canadian Populations by Life stage and Gender.
Phosphorus Magnesium mg/day mg/day Group *AI/RDA UL *AI/RDA UL Infant 0-6 mo 100* NE 30* NE 7-12 mo 275* NE 75* NE Children 1-3 y 460 3.0g 80 65 4-8 y 500 3.0g 130 110 Boys 9-13 y 1250 4.0g 240 350 14-18 y 1250 4.0g 410 350 Girls 9-13 y 1250 4.0g 240 350 14-18 y 1250 4.0g 360 350 Men 19-30 y 700 4.0g 400 350 Women 19-30 y 700 4.0g 310 350 Men 31-50 y 700 4.0g 420 350 Women 31-50 y 700 4.0g 320 350 Men 51-70 y 700 4.0g 420 350 Women 51-70 y 700 4.0g 320 350 Men >70 y 700 3.0g 420 350 Women >70 y 700 3.0g 320 350 Pregnancy 14-18 y 1250 3.5g 400 350 19-30 y 700 3.5g 350 350 31-50 y 700 3.5g 360 350 Lactation 14-18 y 1250 4.0g 360 350 19-30 y 700 4.0g 310 350 31-50 y 700 4.0g 320 350 *AI=Adequate Intakes established for these life stage groups NE= not possible to establish; UL for Mg = supplementary Mg. DRI Life stage Vitamin D g/day AI UL 5 25 5 25 5 50 5 50 5 50 5 50 5 50 5 50 5 50 5 50 5 50 5 50 10 50 10 50 15 50 15 50 5 50 5 50 5 50 5 50 5 50 5 50 Fluoride mg/day AI UL 0.01 0.7 0.5 0.9 0.7 1.3 1.0 2.2 2.0 10.0 3.0 10.0 2.0 10.0 3.0 10.0 4.0 10.0 3.0 10.0 4.0 10.0 3.0 10.0 4.0 10.0 3.0 10.0 4.0 10.0 3.0 10.0 3.0 10.0 3.0 10.0 3.0 10.0 3.0 10.0 3.0 10.0 3.0 10.0

Food and Nutrition Board. 1997. Standing Committee on the Scientific Evaluation of Dietary Reference Intake, Institute of Medicine, Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D and fluoride. National Academy Press, Washington, D.C.

Table 2. Phosphorus Content of Selected Foods Commonly Consumed in the U.S. in Common Serving Sizes. NDB_No Description Measure Calcium (mg) 20082 Wheat flour, white, all[purpose, self-rising, 1 cup 744 enriched 19062 Snacks, trail mix, regular, w/ chocolate chips, 1 cup 565 salted nuts and seeds 21005 Fast foods, biscuit, with egg and sausage 1 biscuit 490 15037 Fish, Halibut, Atlantic, Pacific, cooked, dry heat fillet 453 01037 Cheese, ricotta, part skim milk 1 cup 450 01118 Yogurt, plain, skim milk, 13 g protein/ 8 oz. 8 oz. 356 21111 Fast foods, hamburger, regular, double patty w/ 1 sandwich 284 condiments 10011 Pork, fresh, ham, lean, cooked, roasted 3 oz. 239 09298 Raisins, seedless 1 cup 146 01128 Egg, whole, cooked, fried 1 large 96 11724 Beans, snap, yellow, cooked, boiled, drained 1 cup 49 09206 Orange juice, raw 1 cup 42 U.S. Department of Agriculture, Agricultural Research Service. 2006. USDA National Nutrient Database for Standard Reference, Release 18. Nutrient Data Laboratory http://www.nal.usda.gov/fnic/foodcomp/Data/SR18/nutrlist/sr18w305.pdf49, access as of Mar 10, 2007.

Table 3. Magnesium Content of Selected Foods Commonly Consumed in the U.S. in Common Serving Sizes. NDB_No 20080 19062 11546 16025 12061 16120 11674 14210 09298 01037 09040 11206 Description Wheat flour, whole-grain Snacks, trail mix, tropical Tomato products, canned, paste, w/o salt Beans, great northern, mature seeds, boiled, w/o salts Nuts, almonds Soy milk, fluid Potato, baked, flesh and skin, without salt Coffee, brewed, espresso, restaurantprepared Raisin, seedless Cheese, ricotta, part skim milk Bananas, raw Cucumber, peeled, raw Measure 1 cup 1 cup 1 cup 1 cup 1 oz, 24 nuts 1 cup 1 potato 10.6 fl oz 1 cup 1 cup 1 banana 1 cup Magnesium (mg) 166 134 110 89 78 61 57 48 46 37 32 14

U.S. Department of Agriculture, Agricultural Research Service. 2006. USDA National Nutrient Database for Standard Reference, Release 18. Nutrient Data Laboratory http://www.nal.usda.gov/fnic/foodcomp/Data/SR18/nutrlist/sr18w304.pdf, access as of Mar 10, 2007.