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The 2011 Dietary Reference Intakes for Calcium and Vitamin D: What
Dietetics Practitioners Need to Know

Article in Journal of the American Dietetic Association · April 2011

DOI: 10.1016/j.jada.2011.01.004 · Source: PubMed

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 RESEARCH
Commentary
The 2011 Dietary Reference Intakes for Calcium
and Vitamin D: What Dietetics Practitioners
Need to Know*
A. CATHARINE ROSS, PhD; JOANN E. MANSON, MD, DrPH; STEVEN A. ABRAMS, MD; JOHN F. ALOIA, MD; PATSY M. BRANNON, PhD, RD;
STEVEN K. CLINTON, MD, PhD; RAMON A. DURAZO-ARVIZU, PhD; J. CHRISTOPHER GALLAGHER, MD; RICHARD L. GALLO, MD, PhD;
GLENVILLE JONES, PhD; CHRISTOPHER S. KOVACS, MD, FRCPC, FACP; SUSAN T. MAYNE, PhD; CLIFFORD J. ROSEN, MD; SUE A. SHAPSES, PhD

IU/day for ages 1 to 70 years and 800 IU/day for 71 years

ABSTRACT and older, corresponding to serum 25-hydroxyvitamin D
The Institute of Medicine Committee to Review Dietary (25OHD) levels of 16 ng/mL (40 nmol/L) for EARs and 20
Reference Intakes for Calcium and Vitamin D compre- ng/mL (50 nmol/L) or more for RDAs. Prevalence of vita-
hensively reviewed the evidence for both skeletal and min D inadequacy in North America has been overesti-
nonskeletal health outcomes and concluded that a causal mated based on serum 25OHD levels corresponding to
role of calcium and vitamin D in skeletal health provided the EAR and RDA. Higher serum 25OHD levels were not
the necessary basis for the 2011 Estimated Average Re- consistently associated with greater benefit, and for some
quirement (EAR) and Recommended Dietary Allowance outcomes U-shaped associations with risks at both low
(RDA) for ages older than 1 year. For nonskeletal out- and high levels were observed. The Tolerable Upper In-
comes, including cancer, cardiovascular disease, diabetes, take Level for calcium ranges from 1,000 to 3,000 mg
infections, and autoimmune disorders, randomized clini- daily, based on calcium excretion or kidney stone forma-
cal trials were sparse, and evidence was inconsistent, tion, and from 1,000 to 4,000 IU daily for vitamin D,
inconclusive as to causality, and insufficient for Dietary based on hypercalcemia adjusted for uncertainty result-
Reference Intake (DRI) development. The EAR and RDA ing from emerging risk relationships. Urgently needed
for calcium range from 500 to 1,100 and 700 to 1,300 mg are evidence-based guidelines to interpret serum 25OHD
daily, respectively, for ages 1 year and older. For vitamin levels relative to vitamin D status and intervention.
D (assuming minimal sun exposure), the EAR is 400 J Am Diet Assoc. 2011;111:524-527.
IU/day for ages older than 1 year and the RDA is 600

*This article is a summary of the Institute of Medicine Division of Medical Oncology, The Ohio State Univer-
report entitled Dietary Reference Intakes for Calcium and sity, Columbus. R. A. Durazo-Arvizu is an associate pro-
Vitamin D (available at http://www.iom.edu/Reports/ fessor of preventative medicine and epidemiology,
2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin- Stritch School of Medicine, Loyola University Chicago,
D.aspx) for dietetics practitioners; a similar summary for Maywood, IL. J. C. Gallagher is a professor of medicine,
clinicians has also been published (Ross AC, Manson JE, Creighton University Medical Center, Omaha, NE. R. L.
Abrams SA, Aloia JF, Brannon PM, Clinton SK, Durazo- Gallo is a professor of medicine and pediatrics, Univer-
Arvizu RA, Gallagher JC, Gallo RL, Jones G, Kovacs CS, sity of California, San Diego. G. Jones is the Crane Pro-
Mayne ST, Rosen CJ, Shapses SA. The 2011 report on Di- fessor and head of the Department of Biochemistry,
etary Reference Intakes for calcium and vitamin D from Queens University, Kingston, ON, Canada. C. S. Kovacs
the Institute of Medicine: What clinicians need to know. is a professor of medicine (endocrinology), Health Sci-
J Clin Endocrinol Metab. 2011;96:53-58). ences Centre, Memorial University of Newfoundland, St
A. C. Ross is a professor of nutrition and occupant of John’s, NL, Canada. S. T. Mayne is a professor, Divi-
the Dorothy Foehr Huck Chair in Nutrition, The Penn- sion of Chronic Disease Epidemiology, Yale School of
sylvania State University, University Park, and is the Public Health, and associate director, Yale Comprehen-
chair, Institute of Medicine Committee to Review Di- sive Cancer Center, New Haven, CT. C. J. Rosen, is a
etary Reference Intakes for Vitamin D and Calcium. senior scientist, Maine Medical Center Research Insti-
J. E. Manson is a professor of medicine and the Eliza- tute, Scarborough, ME. S. A. Shapses is a professor, De-
beth Brigham Professor of Women’s Health, Harvard partment of Nutritional Sciences, Rutgers University, New
Medical School, Brigham & Women’s Hospital, Boston, Brunswick, NJ.
MA. S. A. Abrams is a professor of pediatrics, Baylor Address correspondence to: Patsy M. Brannon, PhD,
College of Medicine, Houston, TX. J. F. Aloia is chief RD, Cornell University, 225 Savage Hall, Ithaca, NY
academic officer, Department of Academic Affairs, Win- 14853. E-mail: pmb22@cornell.edu
throp-University Hospital, and professor of medicine Manuscript accepted: December 15, 2010.
and associate dean, SUNY at Stony Brook, Mineola, Copyright © 2011 by the American Dietetic
NY. P. M. Brannon is a professor, Division of Nutri- Association.
tional Sciences, Cornell University, Ithaca, NY. S. K. 0002-8223/$36.00
Clinton is a professor, Department of Internal Medicine, doi: 10.1016/j.jada.2011.01.004

524 Journal of the AMERICAN DIETETIC ASSOCIATION © 2011 by the American Dietetic Association
T
he Institute of Medicine released the Dietary Refer- Quality systematic review of 2009 (4) also concluded that
ence Intakes for Calcium and Vitamin D report (1) the evidence for an association between these nutrients
(available at www.iom.edu/vitamind) on November and nonskeletal outcomes was inconsistent and inconclu-
30, 2010. The Institute of Medicine, at the request of sive.
agencies of the US and Canadian governments, assem- Challenges encountered in the evidence included: the
bled a committee of 14 scientists with the necessary strong interrelationship between calcium and vitamin D
range of expertise to review the increasing body of re- and the difficulty in separating their effects in many
search on these nutrients over the past 14 years and studies; the limited data allowing for assessment of dose-
update the 1997 Dietary Reference Intakes (DRIs) (2). response relationships; the complexity arising from en-
Detailed in the report and summarized in this article is dogenous and dietary sources for vitamin D; and the
the DRI process, following a Risk Assessment Framework potential for confounding in observational studies due to
by which the Committee (a) identified health outcome obesity, physical activity, race/skin pigmentation, and
“indicators” that are consistently and causally linked to nutritional status including supplementation practices.
calcium or vitamin D; (b) determined the Estimated Av- Further, despite the usefulness of serum 25OHD as a
erage Requirement (EAR) that meets the needs of 50% of marker of exposure, the Committee understood its limi-
the healthy population (the median) and the Recom- tations as a biomarker of effect. The fact that correlation
mended Dietary Allowance (RDA) that meets the needs of does not prove causation underscored the need for cau-
97.5% of the healthy population; and (c) identified the tion in interpretation of observational study findings.
health outcome “indicators” of adverse effect and the Tol- These potential biases were carefully considered in inter-
erable Upper Intake Level (UL) corresponding to the pretation of observational studies, and the Committee
highest daily intake that likely poses no risk of adverse was aware that promising effects of many other micronu-
effect. In addition, the Committee assessed the dietary trients in observational studies (eg, beta carotene, vita-
intakes of calcium and vitamin D in the US and Canadian mins C and E, folic acid, and selenium) did not withstand
populations and identified research needs and public rigorous testing in clinical trials (5,6).
health implications.
2011 ADEQUATE INTAKES, ESTIMATED AVERAGE
ASSESSMENT OF HEALTH OUTCOMES REQUIREMENTS, AND RECOMMENDED DIETARY ALLOWANCES
The Committee extensively and comprehensively re- The DRIs for each nutrient shown in the Table are in-
viewed the existing evidence on vitamin D and calcium in takes based on bone health, assuming adequate intake
relation to diverse health outcomes. It used two key sys- for the other nutrient. New evidence available since the
tematic reviews conducted by the Agency for Healthcare 1997 DRIs allowed estimation of EARs and RDAs for all
Research and Quality in 2007 (3) and 2009 (4) on calcium life-stage groups except infants, for whom Adequate In-
and vitamin D regarding both skeletal and nonskeletal take is provided based on the calcium intakes from hu-
chronic disease outcomes. The Committee considered a man milk and intakes to maintain vitamin D stores,
wide range of chronic disease and other outcomes (re- respectively. The EAR and RDA for calcium, based on
viewed in detail in the report), including bone health calcium-balance studies for ages 1 to 50 years and obser-
(bone mineral content and density, fracture risk, rickets/ vational and clinical trial evidence after age 50 years,
osteomalacia, calcium absorption and balance, and mea- range from 500 to 1,100 mg/day and 700 to 1,300 mg/day,
sures such as serum 25-hydroxyvitamin D [25OHD] and respectively. For vitamin D, based primarily on the inte-
parathyroid hormone), cancer prevention and site-specific gration of bone health outcomes, 25OHD levels of 16
neoplasms, cardiovascular disease, hypertension, diabe- ng/mL (40 nmol/L) and more than 20 ng/mL (50 nmol/L)
tes, metabolic syndrome, falls and physical performance, provide the EAR and RDA, respectively. Vitamin D in-
autoimmune disorders, infectious diseases, neuropsycho- takes to achieve these serum 25OHD concentrations are
logical functioning (including autism, cognition, and de- shown in the Table, based on a simulation of available
pression), and disorders of pregnancy (preeclampsia, ob- data across ages under conditions of minimal sun expo-
structed delivery, and intrauterine growth retardation). sure (due to the variation in endogenous synthesis as well
After careful evaluation of the evidence, the Committee as the public health concerns about sun exposure and
concluded that bone health was the only outcome for skin cancer). After age 1 year, the RDA is 600 IU/day for
which causality was established and sufficient dose-re- all life-stage groups except men and women age 71 years
sponse evidence was available to meet the criteria as a and older, for whom the RDA is 800 IU/day. The Com-
health outcome “indicator” and support DRI develop- mittee did not find compelling evidence that serum
ment. Serum 25OHD levels were considered the most 25OHD levels or dietary intakes more than these levels
useful marker of total vitamin D exposure from both were associated with greater benefit for bone health or
endogenous synthesis and dietary intake from foods, for- other outcomes. The 2011 RDAs for vitamin D are less
tified products, and/or supplements. For other health out- than those proposed by some in the current literature; the
comes considered (cancer, cardiovascular disease, diabe- latter are based on higher target serum 25OHD levels
tes, falls, physical performance, autoimmune disorders, that the Committee found were not justified by the evi-
and other nonskeletal chronic disease), the evidence was dence.
inconsistent, inconclusive as to causality, and insufficient
to serve as a basis for DRI development. Randomized trial
evidence was also sparse, and few studies had been done TOLERABLE UPPER INTAKE LEVELS
with these nonskeletal outcomes as the primary prespeci- To determine Tolerable Upper Intake Levels (UL), the
fied outcomes. The Agency for Healthcare Research and Committee considered the “indicators” of hypercalcemia,

April 2011 ● Journal of the AMERICAN DIETETIC ASSOCIATION 525

 Table. 2011 Dietary Reference Intakes for calcium and vitamin D by life stage
Vitamin D

Calcium Serum 25OHD Serum 25OHD

for the EARe for the RDAf
Life stage groupa EARb mg/d RDAc mg/d ULd mg/d EAR IU/d ng/mL RDA IU/d ng/mL UL IU/d

1-3 y (M⫹F) 500 700 2,500 400 16 600 20 2,500

4-8 y (M⫹F) 800 1,000 2,500 400 16 600 20 3,000
9-13 y (M⫹F) 1,100 1,300 3,000 400 16 600 20 4,000
14-18 y (M⫹F) 1,100 1,300 3,000 400 16 600 20 4,000
19-30 y (M⫹F) 800 1,000 2,500 400 16 600 20 4,000
31-50 y (M⫹F) 800 1,000 2,500 400 16 600 20 4,000
51-70 y (M) 800 1,000 2,000 400 16 600 20 4,000
51-70 y (F) 1,000 1,200 2,000 400 16 600 20 4,000
71⫹ y (M⫹F) 1,000 1,200 2,000 400 16 800 20 4,000
Pregnant or Lactating (F)
14-18 y 1,100 1,300 3,000 400 16 600 20 4,000
19-50 y 800 1,000 2,500 400 16 600 20 4,000
Infants (M⫹F)
0-6 mo 200g 1,000 400g 1,000
6-12 mo 260g 1,500 400g 1,500
a
M⫽male; F⫽female.
b
Estimated Average Requirement (EAR) for intake that meets the needs of 50% of the North American population (median).
c
Recommended Dietary Allowance (RDA) intake that meets the needs of 97.5% of the North American population.
d
Tolerable Upper Intake Level (UL) above which there is risk of adverse events. The UL is not intended as a target intake (no consistent evidence of greater benefit at intake levels more
than the RDA).
e
Measure of serum 25-hydroxyvitamin D (25OHD) level corresponding to the EAR and covering the needs of 50% of the North American population.
f
Measure of serum 25OHD level corresponding to the RDA and covering the needs of ⱖ97.5% of the population.
g
Adequate Intake (AI) reference value; no RDAs established for infants 0 to 12 months.

hypercalciuria, vascular and soft tissue calcification, than 16 ng/mL (40 nmol/L) are at increased risk of ad-
nephrolithiasis, and, for vitamin D, emerging evidence of verse health outcomes, which will be useful to dietetics
a U-shaped relationship for all-cause mortality, cardio- practitioners as they consider assessment and manage-
vascular disease, vascular calcification, pancreatic can- ment of patients/clients. For upper levels of serum
cer, falls, frailty, and fractures (1,7-11), with increased 25OHD, sparse data are available, particularly regarding
risk at low and high levels and lowest risk at moderate long-term effects of chronically high concentrations.
levels of serum 25OHD. The 2011 ULs for calcium range Thus, serum 25OHD levels chronically more than 50
from 1,000 to 3,000 mg/day (Table). For vitamin D, the ng/mL (125 nmol/L) should cause concern among dietetics
UL is 4,000 IU/day for ages 9 years and older, but is lower practitioners about potential adverse effects.
for infants and young children (Table). This UL was de-
rived from the acute toxicity for vitamin D of 10,000
IU/day, adjusted for uncertainty based on chronic disease DIETARY INTAKE ASSESSMENTS
outcomes and all-cause mortality as well as emerging
Based on national surveys in the United States and Can-
concerns about risks at serum 25OHD levels more than
ada, most groups have adequate intakes of calcium (as
50 ng/mL (125 nmol/L). This is because acute toxicity is
defined by intakes more than the EAR), with the excep-
not the appropriate basis for a UL that is intended to
reflect long-term chronic intake and to be used for public tion of girls age 9 to 18 years, who need to increase their
health. calcium intake. In contrast, among postmenopausal
women, high supplemental calcium intake may be con-
cerning. Average vitamin D intake tends to be less than
IMPLICATIONS OF SERUM 25OHD LEVELS 400 IU/day, but mean serum 25OHD levels are more than
Guidelines regarding the interpretation of serum 25OHD 20 ng/mL (50 nmol/L), the level consistent with the RDA.
relative to vitamin D status in nutrition assessment, Thus, the majority of the North American population is
management of individuals, and screening were beyond meeting their needs for vitamin D, although not neces-
the scope of the Committee’s charge, and evidence-based sarily through foods or supplements. Nonetheless, some
consensus guidelines are not available. However, these subgroups, particularly those living at northerly lati-
issues should be addressed by appropriate federal agen- tudes, in institutions, or who have dark skin pigmenta-
cies and professional organizations in light of the findings tion, may be at increased risk of not meeting their needs,
in this report. Consistent with the application of the EAR, especially if their serum 25OHD levels are less than 16
however, those individuals with serum 25OHD levels less ng/mL (40 nmol/L).

526 April 2011 Volume 111 Number 4

FUTURE RESEARCH NEEDS Joann E. Manson, MD, DRPH, and Patsy M. Brannon,
The Committee identified a particular priority for rigor- PhD, RD, contributed greatly to the development of this
ous large-scale randomized clinical trials to test the ef- article, which serves as a summation for dietetics practi-
fects of vitamin D on nonskeletal outcomes, as well as to tioners of the Committee’s report.
identify threshold effects and possible adverse effects if
present. Elucidating the biology of the diverse effects of
vitamin D, as well as possible mediating effects of sun References
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STATEMENT OF POTENTIAL CONFLICT OF INTEREST: 8. Stolzenberg-Solomon RZ, Jacobs EJ, Arslan AA, Qi D, Patel AV,
No potential conflict of interest was reported by the au- Helzlsouer KJ, Weinstein SJ, McCullough ML, Purdue MP, Shu XO,
thors. Snyder K, Virtamo J, Wilkins LR, Yu K, Zeleniuch-Jacquotte A,
Zheng W, Albanes D, Cai Q, Harvey C, Hayes R, Clipp S, Horst RL,
FUNDING/SUPPORT: None. Irish L, Koenig K, Le Marchand L, Kolonel LN. Circulating 25-hy-
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Hector DeLuca at the University of Wisconsin, and the levels and the risk of mortality in the general population. Arch Intern
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Yaktine, Senior Program Officer; Heather B. Del Valle, 11. Visser M, Deeg DJ, Puts MT, Seidell JC, Lips P. Low serum concen-
Associate Program Officer; and Heather Breiner, Pro- trations of 25-hydroxyvitamin D in older persons and the risk of
gram Associate. nursing home admission. Am J Clin Nutr. 2006;8:616-622.

April 2011 ● Journal of the AMERICAN DIETETIC ASSOCIATION 527

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