Commentaiy
Use and Misuse of Balance Studies
WALTER MERTZ
U.S. Department of Agriculture, ARS Beltsville Human Nutrition Research Center, Beltsville, AID 20705
ABSTRACT Balance studies are inadequate tools to de
termine human requirements for minerals and trace ele
ments. At best, they estimate the amount of an element
in a specified diet that maintains the existing pool size of
the test subject. The relevance of pool size to health re
mains to be established by different and independent
means. J. Nutr. 117: 1811-1813, 1987.
INDEXING KEY WORDS:
•balance studies trace elements •diet
•pool size
The following discussion of balance studies will be
restricted to minerals and trace elements. Although
some of the principles to be discussed should be valid
for other elements as well, such as nitrogen and carbon,
the differences between inorganic and organic com
pounds are such that the inclusion of the latter would
transcend not only the available space but also the ex
pertise of the author. Balance studies have been used
for two purposes: to help define nutrient requirements
and to measure the availability of nutrients for absorp
tion. My attempt to examine the legitimate uses of the
balance approach will end with the conclusion that the
determination of human trace element or mineral re
quirements by this method is neither legitimate nor
useful. That conclusion is not new; Hegsted had warned
long ago against deriving mineral requirements from
balance studies (1). That his warning has had little ef
fect may serve as one justification for the present dis
cussion.
The technical difficulties inherent in balance studies
(e.g., ensuring completeness of collection, assessment
of cutaneous losses and use of fecal markers, etc.) are
well known and need not be discussed here. Less ap
preciated is the fact that few analytical methods give
a coefficient of variation as good as 5%, especially in
complex matrices such as food, urine or feces (2).Most
methods, therefore, will be unable to detect the small
but nutritionally important differences that one can
0022-3166/87 $3.00 ©1987 American Institute of Nutrition.
expect in studies with elements of low intestinal ab
sorption efficiency. This alone eliminates several ele
ments from consideration. Yet, the following discus
sion would be valid even in the absence of any technical
problem.
At first it appears perfectly logical that an intake of
a nutrient less than the sum of the daily losses must
at some time result in deficiency and that such an in
take must therefore be considered inadequate. This is
Downloaded from jn.nutrition.org by on October 20, 2010
obviously not the case; clinical, pronounced deficien
cies that would be expected, according to that assump
tion, are extremely rare in developed countries, in spite
of intakes well below those resulting in zero or positive
balance. The following brief review of a few simple,
well-established facts will try to delineate the proper
interpretation of results from balance studies.
Cotzias (3) and collaborators in pioneering studies of
manganese metabolism demonstrated in humans and
animals that the loss of manganese from the intact
organism can be described by a series of first-order equa
tions. Expressed in the simplest terms, the amount of
daily loss of manganese from the organism is a function
of the existing body stores and can be described in terms
of percentage of the existing stores. In reality, because
the excretion kinetics are multicompartmental, we are
dealing with a number of different rates of loss of which
the first is usually fast and of short duration, whereas
subsequent ones are slower and of longer duration. It
is not known whether any of the compartments iden
tified by kinetic studies correspond with any anatom
ical or biochemical entity in the organism, but it can
be assumed that the first two (perhaps also the third)
compartments are metabolically more active and pos
sibly nutritionally more significant than the later ones,
which may function as sinks and participate little in
metabolism. Cotzias and collaborators reported several
observations that proved the validity of their model.
Among them was the demonstration that the excretion
of previously administered, radioactive manganese was
strongly accelerated by the administration of stable
manganese.
Since then similar excretion kinetics have been es
tablished for zinc (4) and chromium [5], calcium (6),
Received 24 July 1987. Accepted 27 July 1987.
1811
1812
magnesium (7), selenium (8) and possibly others. This
model may not be fully applicable to iron for which the
amount of losses appears to be much less subject to
regulation and to depend largely on the amount of iron
sequestered in the intestinal mucosa.
Notwithstanding the multicompartmental nature of
excretion kinetics a simplified statement can be made,
probably applicable to many trace elements, that the
amount of daily loss from the body pool is some func
tion of the size of that pool. Intakes that result in an
excess of absorbed trace element over the prevailing
daily loss will increase the pool until the daily loss
equals the daily input. At that time a steady state is
reached. Should the intake now be diminished, the daily
loss would initially exceed the inflow, resulting in a
diminution of the pool until at some time the smaller
daily outflow would again equal the inflow and a new
equilibrium would be established. Thus, expressed in
practical terms, the amount of available nutrient in the
diet determines the pool size with time, but does not
predict a priori deficiency or toxicity. It must be under
stood, of course, that the regulation of body pools of
trace elements is much more complicated than sug
gested by this simple model (9). There are exogenous
and endogenous factors affecting the rate of inflow into
the pool and endogenous controls of rates of daily loss
(Table 1).
PHYSIOLOGICAL INTERPRETATION OF
BALANCE STUDIES
Time is a decisive factor in the interpretation of data
from balance studies. When the daily intake of an ele
ment is small relative to the total pool size, it will take
more time to establish a new equilibrium after changes
of intake than for an element whose intake is large
relative to the body pool. The daily turnover of iron is
only 1/5000 of the body content; thus, changes in the
pool size and establishment of a new equilibrium would
be expected to take many months. In contrast, the daily
turnover of selenium in North Americans could be as
much as 1/200 of the body content, resulting in a faster
rate of changes and of attainment of a new equilibrium.
These examples demonstrate how some elements are
TABLE 1
Factors affecting mineral balance
Inflow Outflow
Amount eaten Pool size
Gastrointestinal luminal events: Hormones
pH, dietary interactions, Kidney function
chemical form of nutrient Intestinal function
Rate of transit
Mucosal regulation: absorption
efficiency depending on pool size
Hormones; cephalic influences (?]
MERTZ
well buffered against the consequences of intake changes,
whereas others are subject to more rapid changes in
pool size. The important physiological conclusion is
that negative balances do not persist (provided the in
take is above the minimum obligatory loss), and that
the equilibrium will establish itself, even if it takes
years. The pool size at which the new equilibrium is
established depends on the intake.
Although the foregoing discussion has postulated that
a trace element balance can be achieved with a variety
of intakes and pool sizes, there are limits to balance on
both extremes of intake. High exposures may exceed
the excretion capacity of the organism and result in a
persistent positive balance and a continuing accumu
lation. That is the concern with certain heavy metals
in the environment, such as lead and cadmium, and
even with the essential element, iron. On the other
hand, extremely low intakes may not compensate for
minimal obligatory losses and result in deficiency.
(Minimal obligatory losses are those persisting in sub
jects who are adapted to a diet severely deficient in the
Downloaded from jn.nutrition.org by on October 20, 2010
element under investigation.)
With intakes between those extremes, a positive or
negative balance would indicate that the experimental
diet fed is different in amount, composition and bio-
availability from the subject's habitual diet. A positive
(or negative) balance indicates that the intake and/or
bioavailability of the element under study from the test
diet is greater (smaller) than the habitual intake and
that the pool size is increasing (decreasing) until a new
equilibrium is reached. A zero balance indicates that
the intake during the study of the available element is
equal to the habitual intake, namely, that amount nec
essary to maintain the existing pool size. Thus, a bal
ance study does not determine "the" requirement for
a mineral element, but the intake required to maintain
the existing pool size.
PRACTICAL ASPECTS
Although balance studies have been used widely in
the past to estimate requirements for minerals and trace
elements, their suitability for that purpose has been
questioned long ago, when Hegsted discussed the widely
different calcium intakes required to maintain balance
and bone health in Americans versus those in Peruvi
ans (1). The situation with selenium is similar: Lev-
ander has shown that on average 1 jig of selenium/kg
body weight maintains a zero balance and selenium
pools in Americans. Approximately one-tenth of that
intake maintains a balance in subjects living in low-
selenium areas of China (10). Whereas in these latter
people the risk of selenium deficiency and the resulting
Keshan disease is significant, the slightly larger selen
ium stores of New Zealand women (11), maintained by
an intake of approximately 20 M-g/d/have not been as
sociated with increased health risk.
 USE AND MISUSE OF BALANCE STUDIES
Thus, we must conclude that the results of balance
studies bear no direct relationship to criteria of health.
They do relate to the pool size of the nutrient under
study (and that size can be calculated from balance data
if the turnover rate is known), but the relevance of pool
size to human and animal health remains to be deter
mined individually for each element.
LEGITIMATE USES OF BALANCE STUDIES
The results of balance studies can be used to estimate
the "habitual" nutrient intake of people. It can be as
sumed that a person's pool of a nutrient reflects, next
to body size, the amount and bioavailability of the nu
trient consumed over extended periods of time. A diet
that results in a zero balance in a person and, by defi
nition, maintains the existing pool size, therefore ap
proximates closely the diet history of that person for
the amount and bioavailability of the nutrient under
study. Only in that connection, as an estimator of ha
bitual dietary intakes, and only if the status of the nu
trient in question has been proved adequate by inde
pendent methods, can the results of balance studies be
used as a basis for dietary recommendations. In that
case, adding an increment as a safety factor to the es
timated requirement, as is usually done for RDAs, is
unnecessary. It would result in unrealistically high rec
ommendations that would be difficult to implement.
Balance studies can be used to compare the biological
availability of different elemental species with each
other. A highly available species, such as the heme iron,
will produce a more positive or less negative balance
than one poorly available, such as the non-heme iron
category. Balance studies can also be helpful in the
quantification of complex nutrient interactions as they
influence bioavailability. Sandstead has fed diets with
different contents of protein, phosphorus and calcium,
etc., and expressed the effects of those nutrients on the
requirement for trace elements to establish a zero bal
ance in regression equations (12). Such studies are best
performed with low or intermediate intakes of the test
1813
substance and in subjects with a low or intermediate
pool size to magnify the effect on absorption. They
should be of relatively short duration and should be
terminated before a balance is established eventually
for substances both of high and low bioavailability.
LITERATURECITED
1. HEGSTED,D. M. (1973) Calcium and phosphorus. In: Modern
Nutrition in Health and Disease, 5th ed. (Goodhart, R. S. & Shils,
M. E., eds.), pp. 268-286, Lea and Febiger, Philadelphia.
2. HORWITZ,W., KAMPS,L. R. & BOYER,K. W. (1980) Quality
assurance in the analysis of foods for trace constituents. /. Assoc.
Off. Anal. Chem. 63: 1344-1354.
3. COTZIAS,G. C. (1962) Manganese. In: Mineral Metabolism:
An Advanced Treatise, vol. 2B (Comar, C. L. & Bronner, F., eds.),
pp. 403-442, Academic, New York.
4. AAMODT,R. L., RUMBLE,W. F., JOHNSTON,G. S., FOSTER,D. &
HENKIN,R. I. (1979) Zinc metabolism in humans after oral
and intravenous administration of Zn-69m. Am. J. Clin. ÑutÃ-.
32: 559-569.
Downloaded from jn.nutrition.org by on October 20, 2010
5. SARGENT,T., m, LIM, T. H. & JENSON,R. L. (1979) Reduced
chromium retention in patients with hemochromatosis, a pos
sible basis of hemochromatotic diabetes. Metabolism 28: 70-
79.
6. BRONNER,F. (1974) Dynamics and functions of calcium. In:
Mineral Metabolism, vol. 2A (Comar, C. L. & Bronner, F., eds.),
pp. 342-444, Academic, New York.
7. AVIOLI,L. V. & BERMAN,M. (1966) Mg28 kinetics in man. /.
Appi Physiol 21: 1688-1694.
8. GRIFFITH, N. M., STEWART, R. D.H. & ROBINSON,M. F. (1976) The
metabolism of 75Se-selenomethionine in four women. Br. f. Nutr.
35: 373-382.
9. SOLOMON,A. K. (1960) Compartmental methods of kinetic
analysis. In: Mineral Metabolism, vol. 1A (Comar, C. L. & Bron
ner, F., eds.), pp. 119-167, Academic, New York.
10. LEVANDER, O. A. (1986) Selenium. In: Trace Elements in Hu
man and Animal Nutrition, 5th ed. (Mertz, W., ed.), pp. 209-
279, Academic, New York.
11. STEWART, R. D. H., GRIFFITH, N. M., THOMSON, C. D. & ROBINSON,
M. F. (1978) Quantitative selenium metabolism in normal New
Zealand women. Br. J. Nutr. 40: 45-54.
12. SANDSTEAD, H. H. (1985) Are estimates of trace element re
quirements meeting the needs of the user? In: Trace Elements
in Man and Animals (TEMA-5) (Mills, C. F., Bremner, I. & Ches-
ters, f. K., eds.), pp. 875-878, Commonwealth Agricultural Bur
eaux, Farnham Royal, U.K.