ICAN: Infant, Child, & Adolescent Nutrition February 2012

Practice Roundtable

Calcium and Vitamin D Each issue, we ask different pro-

fessionals a set of questions about
Supplementation in an aspect of their practice or a spe-
cific problem or disease condition
Adolescents they encounter. This months topic
is Nutritional Supplementation. Our
A Practical participants are Steven A. Abrams, MD;
Connie M. Weaver, PhD; and Mary Pittaway,
Review of the New MA, RD. Full bios for each of the con-
Recommendations tributors can be found at the end of
this article.

The role of Vitamin D in to the topic of this discussion, adolescents,

regulating the uptake of was that the calcium recommendation
calcium is well known. from 1997 included an Adequate Intake
Vitamin D requirements have value of 1300 mg/day, which is the current food manufacturers producing fortified
undergone recent scrutiny recommended dietary allowance (RDA) foods, increased consumption of vita-
with new recommendations value. The IOM also established an esti- min D and calcium rich foods and bever-
from the AAP and other mated average requirement (EAR) of 1100 ages, and overall improvement of bone
agencies. In your opinion what mg. Adequate Intakes are used when there mineral intake among adolescents. Long-
impact will the new vitamin is not enough scientific evidence to set an term population-based studies would be
D recommendations have on RDA, which is used for individuals and needed to assess the impact of changes
recommendations for calcium meets the needs of almost the whole pop- in fortification patterns.
intake? What are some of ulation. The EAR is used for groups and Furthermore, there is little if any evi-
the trends that will inform meets the needs of half the population. dence that once adolescents reach the
any decision to revise the The establishment of calcium intake targeted vitamin D intake of 600 IU/day
current recommendations for guidelines for adolescents was done that further increasing vitamin D would
calcium in young people? based on an assumption of vitamin D increase calcium absorption efficiency.
adequacy. The new RDA of 600 IU/day It might be true that for adolescents
Abrams: The Institute of Medicine (IOM) for vitamin D intake for adolescents is who are obese or have chronic illnesses
provided new recommendations for well above the current typical intake of higher vitamin D intakes than the current
dietary calcium at the same time they did 200 to 300 IU/day. Therefore, one could RDA would enhance calcium absorption
for vitamin D (released November 2010 be concerned about calcium intake ade- efficiency, but this has not been demon-
but officially known as the 2011 IOM quacy in the presence of insufficient strated and would need a careful risk
recommendations). The AAP released vitamin D intake. However, this con- benefit assessment for each situation.
new vitamin D recommendations in cern would not be readily translated into Further research is needed related to vita-
2008 (Pediatrics. 2008;122:1128-1138) a specific recommendation for calcium min D intake and calcium absorption in
but have not yet updated the 2006 cal- intake. In other words, the solution to an adolescents before guidance can be given
cium intake recommendations (Pediatrics. inadequate individual intake or popula- to specific groups of adolescents.
2006;117:578-585). Those 2006 calcium tion intake for vitamin D would not be It is extremely unlikely that the IOM
recommendations were based on the 1997 to recommend a higher calcium intake, will revise its calcium recommendation
IOM recommendations. On the whole, but would be to recommend meeting the for a number of years having just done so
the IOM values in 2011 for calcium intake vitamin D intake goal. The new recom- this year. The AAP may review its 2006
were not substantially changed from the mendations and public interest in vita- calcium intake and 2008 vitamin D intake
1997 ones. The major change, as related min D and calcium may lead to more recommendations and consider aligning
DOI: 10.1177/1941406411434581. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
For reprints and permissions queries, please visit SAGEs Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright 2012 The Author(s)

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vol. 4 no. 1
them more closely with the recent IOM
recommendations. Other groups through-
out the world are also considering their
calcium and vitamin D recommendations
for adolescents based on national data in
their countries.
Weaver: The Institute of Medicine set
requirements for calcium independent of
requirements for vitamin D, although they
recognized the interdependence of these
2 nutrients. Therefore, the new vitamin D
recommendations will not likely influ-
ence calcium intake. One trend that may
influence a decision to revise the current
recommendation for calcium for young
people is research on various popula-
tion groups that may lead to personalized
nutrition recommendations. For example,
new data show calcium intakes need not
be as high in Asian adolescents as for
white adolescents.
Pittaway: We know that vitamin D ade-
quacy helps improve utilization of cal-
cium for bone health, but so far the
pediatric calcium recommendations have
not changed. We may find that achieving
vitamin D adequacy for infants and chil-
dren results in lowering the overall cal-
cium RDA.
Disorders of bone, such as osteoporosis
(reduced bone density), have remained
a major public health concern for years.
The traditional role of vitamin D involves
calcium absorption and skeletal health,
and this function of vitamin D in reg-
ulating the uptake of calcium is well
known. The IOM recommendations for
increased vitamin D are somewhat anach-
ronistically related to the prevention of rick-
ets. Even though we know that vitamin
D adequacy helps improve utilization of
calcium for bone health, the calcium rec-
ommendations have not changed. Sadly,
many of Americas children still do not
get enough of dietary calcium to pro-
mote optimal peak bone mass. In pub-
lic health, we have seen a proliferation of
beverages marketed to parents and chil-
dren, and often these beverages provide
fewer nutrients relative to calories than
traditional beverages such as unflavored
low fat or skim cows milk.
The nonbone health effects of
vitamin D may occur along different
concentration-dependence curves and
require a reevaluation of what defines
adequate daily intake. At present, how-
ever, much of what we are learn-
ing about vitamin D requirements and
effects in humans is based on epidemi-
ologic data. Vitamin D deficiency and
insufficiency have been defined as a
25-hydroxyvitamin D <20 ng/mL and 21
to 29 ng/mL, respectively. For every 100
IU of vitamin D ingested the blood level
of 25-hydroxyvitamin D, the measure
of vitamin D status, increases by 1 ng/
mL. It is estimated that children need at
least 400 to 1000 IU of vitamin D a day
whereas teenagers and adults need at
least 2000 IU of vitamin D a day to sat-
isfy their bodys vitamin D requirement
(Holick, 2011).
Beverage consumption trends have
changed so much in the past few years.
Well intentioned, but sometimes misin-
formed, parents remove cows milk form
their childrens diet for unsound rea-
sons, for example, decrease mucus, treat
asthma, or improve attention.
Beverages ranging from sweetened soft
drinks, sports drinks, fruit drink, sweetened
teas to various other milks made from
hemp, rice, oats, just to name a few, con-
fuse consumers into believing that there
are nutritional advantages to these drinks.
Advertising to children, sales, and promo-
tion of sweetened beverages (carbonated,
noncarbonated, diet, and regular) have
succeeded in further reducing dietary cal-
cium and vitamin D intake in that they
replace milk in American childrens diets.
Dietary calcium continues
to be at risk for certain
groups of young people. In
your opinion, what group do
you see as being most at
risk? What is being done to
reach populations at risk?
What more would you like
to see done and why?
Abrams: Dietary calcium intake is of con-
cern for adolescents, where typical dietary
intakes are well below recommenda-
tions. Using the standard cut-point method
for determining inadequate intakes, even
including supplement intake, between 40%
and 75% of adolescents 9 to 18 years of age
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ICAN: Infant, Child, & Adolescent Nutrition
have a calcium intake below the EAR, with
higher percentages in that range occurring
among females. The new RDA for calcium
for 4 to 8 year olds is 1000 mg/day with
an EAR of 800 mg/day. This RDA is higher
than the previous Adequate Intake for this
age group of 800 mg/day and about 20%
to 35% of 4- to 8-year-old children do not
reach this intake level of calcium.
Increasing calcium intake in this popu-
lation requires an approach that uses var-
ious sources of calcium and evaluation of
calcium intakes to meet targeted intakes.
Important in this regard is an empha-
sis on dairy sources whenever possi-
ble. When dairy is not possible or not
desired, other milks, including lactose-
free milk or soy and almond milk, may
be considered. Fortified foods and bev-
erages such as some breads, cereals, and
juices should be used as well. Ultimately,
however, it is up to the primary caregiver,
such as the childs pediatrician, to dis-
cuss calcium intake with their adolescent
patients and determine if referral to a
registered dietitian is needed or if a small
calcium supplement in needed. Currently,
it is possible to obtain both calcium and
vitamin D from many different supple-
ment sources. The use of supplements
should not be the first choice in meeting
calcium requirements, but can be consid-
ered if diet alone is not adequate.
Weaver: An age group that is particularly
important for healthy nutrition and exer-
cise is adolescence because almost half
of adult bone mass is acquired during
the short period. Furthermore, some life-
long habits are formed in childhood and
adolescence. There are some national
campaigns to encourage milk drinking
and exercise. Access to both dairy prod-
ucts and physical activity is a key factor.
Unfortunately, there are current threats to
access to both. Many schools are remov-
ing flavored milk from the menu over
concern of added sugars, which is asso-
ciated with a dramatic decrease in milk
consumption. Physical education has
declined in schools. We put our resources
in the elite few athletes rather than the
health of the masses.
Pittaway: I work in maternal and child
health, as well as with people with
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 ICAN: Infant, Child, & Adolescent Nutrition
intellectual disability. In the public
health setting, we find that throughout
the life span, individuals in general do
not consume adequate amounts of cal-
cium and vitamin D. In fact, NHANES
documents the steady decline in indi-
viduals consuming optimal levels of
these nutrients.
As a country, we make a good start, as
data from NHANES show that very few
infants and toddlers have suboptimal cal-
cium intake. Is this because over half
the babies born in the United States are
enrolled in WIC? But beyond that, the
problems begin to show up. The most
recent national survey shows that dietary
calcium intake is variable in children and
adolescents, with about half consum-
ing less than the intake recommended
by the RDA. Only 15% of 9- to 13-year-
old females and less than 10% of females
14 to 18 years of age met the Adequate
Intake for calcium from diet alone.
As beverage choices proliferate, the
consumption of calcium and vitamin D
plummet. I and fellow public health nutri-
tionists are aware of these trends, and as
one colleague mentioned, I sound like
a broken record, trying to help parents
understand the why and how to provide
food choices for their family that promote
health, not disease. In my opinion, any
significant work to help improve the cal-
cium and vitamin D intake will happen
in the policy arena. Implementing food
and beverage nutrition standards, such as
those presented by the IOM for schools,
on all municipal campuses, not only in
schools, will help improve the nutrient
intake for students. Revisions of the farm
bill, including restructuring the tax sub-
sidies, to correlate with the US dietary
guidelines will help.
Calcium status and bone health
are more routinely assessed
in adults than in pediatric
populations. What type of
assessment would make sense
for the pediatric population?
Would it be cost effective?
Abrams: It would be helpful for pedia-
tricians and other primary care providers
for children if there were readily avail-
able a screening tool that could be used
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rapidly to assess dietary calcium and
other key nutrients, such as iron and vita-
min D. Although such screening tools
exist, they are not readily included in a
standard pediatric assessment often due to
time constraints. Even when screening is
done, the information is not readily trans-
lated into action. A number of Web sites,
both governmental and nongovernmen-
tal, are available freely on the Internet
to assist youth in determining their usual
calcium intake or in making changes to
it, but it is far from clear how useful they
are or whether they are reaching high-
risk populations. Overall, increased avail-
ability of quick and easy-to-use screening
tools, both for pediatric caregivers and
via the Internet, would be of value. Bone
density scans, as are used commonly in
adults, are not cost effective in healthy
adolescents without a strong family history
of early onset osteoporosis or other rea-
son to perform the scan. Scans would
need to be repeated, and although gen-
erally safe, they would be difficult to jus-
tify as a routine screening tool in healthy
adolescents. There are no data to support
any form of routine biochemical testing
of healthy children or adolescents related
specifically to bone health.
Weaver: It would be good to return to
annual visits to the school nurse for a
measure of body weight and body mass
index with instruction on meeting dietary
guidelines recommendations.
Pittaway: The use of peripheral ultra-
sound screening for adults has advanced
the early diagnosis and intervention for
low bone mass. Because of the nature
of bone growth in children, for exam-
ple, bones lengthen, then get denser,
then lengthen, and so on. The ultrasound
results depend on the timing of the
test. Until a validated database is devel-
oped for ultrasound testing, the only reli-
able test is with DXA (dual-energy X-ray
absorptiometry) but the test is expensive,
and routine x-ray of children for screen-
ing is undesirable. Because of the sig-
nificance of vitamin D in promotion of
bone health, a simple finger stick blood
test for vitamin D may help in assess-
ment of the bone health of children. A
low-cost, simple test for measuring serum
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February 2012
25(OH)D will enable us to target our rec-
ommendations to the needs to the indi-
vidual patient. Such systems are being
developed and tested, and when avail-
able, the time between assessment, nutri-
tion education, and intervention can be
decreased.
When health care professionals
talk about nutrition and
bone health, they primarily
discuss Calcium and Vitamin
D supplementation. What are
some of the other nutrients
that you think deserve more
attention in this area? What
are some of the trends that
will bring these nutrients
to the attention of health
care professionals?
Abrams: Bone health requires adequate
intake of a number of minerals, including
phosphorus, zinc, and magnesium. Boron
appears to also be a crucial trace mineral
for adequate bone health. Much attention
has been given to concerns about excess
phosphorus in the diet of some adoles-
cents, although there is little convinc-
ing evidence that this contributes to poor
bone health. Magnesium-deficient intakes
are likely to be of concern and increased
efforts to focus on magnesium would
be of value, although this is difficult due
to the range of magnesium concentra-
tions in commonly consumed foods. One
important change that could be done is
to have more foods provide the intake
of all the minerals and key vitamins on
the package. Currently, this is not per-
mitted for the Nutrition Facts label.
However, revision of the rules related to
the Nutrition Facts label has been recom-
mended, and much more could be done
to assist consumers in understanding the
contribution of specific foods to their
bone mineral requirement.
Weaver: It is true that the medical model
for patient care is to prescribe drugs and
pills. Nutritionists and exercise physiolo-
gists are more likely to recommend pri-
mary prevention. Following the Dietary
Guidelines for Americans gives dietary
guidance that meets all the essential nutri-
ent requirements and physical activity
vol. 4 no. 1 ICAN: Infant, Child, & Adolescent Nutrition

recommendations. This guidance can
be accessed at MyPlate.gov. New social
marketing opportunities surrounding
MyPlate.gov will hopefully assist getting
important messages to the public and to
health care professionals.
Pittaway: As RDs we know that it is the
overall diet that contributes to or detracts
from human health. All known nutri-
ents are known to promote bone health.
Although calcium and vitamin D are the
primary bone health markers, numer-
ous other vitamins, minerals, proteins,
photochemicals, and hormones contrib-
ute to bone health. AAP and ADA recom-
mend that nutrients for healthy children
be consumed from foods. For nutritionally
vulnerable populations, multivitamin
mineral supplements can help meet
nutrition needs. Vulnerability may
include use of a variety of prescribed
medications, which result in the need for
increased doses of vitamin D to achieve
adequacy. For example, antiseizure and
gluccocorticoid medications are known
to negatively affect bone health, due to
the acceleration of bone turnover and/
or impaired conversion of vitamin D in
the liver.
Bone mineral density in later life
depends largely on the peak bone mass
achieved in childhood and young adult-
hood. Reduced bone density is associ-
ated with increased fracture risk in adults
as well as in children. Pediatric low bone
density is more frequently a compli-
cation of a chronic disease or its treat-
ment. Since bone health during the first
2 decades contributes to the lifetime risk
of osteoporosis, there is no time like
the present to optimize overall nutri-
tion with emphasis on calcium, vitamin D
intake, as well as physical activity for our
children.
A better question is how much sup-
plemental vitamin D is needed to bring
an individuals 25-hydroxyvitamin D, or
25(OH)D, blood level up to the opti-
mal level, to promote health and pre-
vent disease. Thirty nanograms (30 ng/
mL) of serum 25(OH)D will prevent
rickets. Current research in the United
States and abroad is showing that a level
of 50 ng/mL serum 25(OH)D is associ-
ated with reduction in some chronic dis-
eases, autoimmune disorders, and some
cancers. So depending on the individu-
als test results, serum 25(OH)D can be
expected to rise by about 1 ng/mL
(2.5 nmol/L) for every 100 IU of additional
vitamin D each day (Heaney, 2008).
Recommended vitamin D supple-
mentation depends on individual fac-
tors including blood level of vitamin D,
age, body weight, percentage of body
fat, latitude, skin color, season, use of
sun block, sun exposure, the presence
or absence of illness, and use of var-
ious medications. Old people need
more than young people, big people
need more that little people, heavier
people need more than skinny people,
northern people need more than south-
ern people, dark-skinned people need
more than fair-skinned people, winter
people need more than summer peo-
ple, sun block lovers need more than
sun block haters, sun-phobes need
more than sun worshipers, and ill
people may need more than well
people.
References
Holick M. Vitamin D: Evolutionary, physiological
and health perspectives. Curr Drug Targets.
2011;12:4-18.
Heaney R. Vitamin D in Health and Disease.
Clinical Journal of the American Society of
Nephrology. 2008;3:1535-1541

Steven A. Abrams, MD, is a board-certied pediatrician and neonatologist.

He graduated from The Ohio State University College of Medicine and Future Roundtable Topics
has been a faculty member, now professor of pediatrics, at Baylor College The editor is looking for contributors from
of Medicine. He practices neonatology at Texas Childrens Hospital in all disciplines on the topics listed below. If
Houston, Texas. His research is related to the mineral requirements of you have any interest in participating, please
children, for preterm infants through adolescents, and how they are contact the editor via e-mail at lheller@chla
affected by genetic and other factors. .usc.edu.
Connie M. Weaver, PhD, is distinguished professor and head of the Department Breastfeeding Disparities
of Nutrition Science at Purdue University, West Lafayette, Indiana. Her Enteral Feeding in the Pediatric Homecare
research interests include mineral bioavailability, calcium metabolism, and Multidisciplinary Management of the
bone health. She was a member of the National Academy of Sciences Home TPN Patient
Food and Nutrition Board Panel to develop 1997 recommendations for Breastfeeding the Child With Cardiac
requirements for calcium and related minerals. She received a PhD in food Defect
science and human nutrition from Florida State University.
Nutrition and the Medical Home for
Children
Mary Pittaway, MA, RD, has worked in public health for 35 years. She
serves as a Clinical Global Advisor for Bone Health with Special Olympics Treatment Options for Pancreatitis
International. Her expertise in osteoporosis prevention includes training Accommodating Special Dietary Needs in
health care providers in the delivery of bone density screening, education, the School Aged Child
and referral services throughout the United States and abroad. She lives in Treatment Options for Hyperlipidemia in
Missoula Montana and can be reached at 406-544-3969, mpitt59802@aol Children
.com, or through bonehealthmontana.com.

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