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4
Review of Potential Indicators of Adequacy and Selection of Indicators: Calcium and Vitamin D

APPROACH

The first step in the decision-making process associated with the development of Dietary Reference Intakes (DRIs) is the identification of potentially useful measures—indicators—that reflect a health outcome associated with the intake of the nutrient. As described in Chapter 1, this is classically referred to as hazard identification, the first step of risk assessment. The available data are examined to determine their relevance and validity as well as strengths and limitations for elucidating a relationship between the health outcome of interest (including chronic disease risk) and the intake of the nutrient.

In considering reference values for calcium and vitamin D, there are challenges in organizing a data review to examine these nutrients independently, because they act in concert and are often administered together in experimental studies. To the extent possible, the independent effects of these nutrients were explored and taken into account; when this was not possible or not appropriate, the combined effect was considered. This chapter reviews evidence for calcium and vitamin D jointly to avoid redundancy. Evidence related to potential indicators for adverse effects of excess intake of calcium and vitamin D is reviewed separately in Chapter 6.

Identification of Potential Indicators for Calcium and Vitamin D

The array of potential health outcomes to be considered for these two nutrients was identified using five sources:



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4 Review of Potential Indicators of Adequacy and Selection of Indicators: Calcium and Vitamin D APPROACH The first step in the decision-making process associated with the de- velopment of Dietary Reference Intakes (DRIs) is the identification of potentially useful measures—indicators—that reflect a health outcome associated with the intake of the nutrient. As described in Chapter 1, this is classically referred to as hazard identification, the first step of risk assess- ment. The available data are examined to determine their relevance and validity as well as strengths and limitations for elucidating a relationship between the health outcome of interest (including chronic disease risk) and the intake of the nutrient. In considering reference values for calcium and vitamin D, there are challenges in organizing a data review to examine these nutrients indepen- dently, because they act in concert and are often administered together in experimental studies. To the extent possible, the independent effects of these nutrients were explored and taken into account; when this was not possible or not appropriate, the combined effect was considered. This chapter reviews evidence for calcium and vitamin D jointly to avoid redun- dancy. Evidence related to potential indicators for adverse effects of excess intake of calcium and vitamin D is reviewed separately in Chapter 6. Identification of Potential Indicators for Calcium and Vitamin D The array of potential health outcomes to be considered for these two nutrients was identified using five sources: 125

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126 DIETARY REFERENCE INTAKES FOR CALCIUM AND VITAMIN D 1. Agency for Healthcare Research and Quality (AHRQ) evidence report issued in 2007 (Cranney et al., 2007), hereafter referred to in this chapter as AHRQ-Ottawa without a reference citation; and 2. AHRQ evidence report issued in 2009 (Chung et al., 2009), here- after referred to in this chapter as AHRQ-Tufts without a reference citation; 3. The Institute of Medicine (IOM) report Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (IOM, 1997); 4. Literature searches conducted by the committee; 5. Publicly available input from stakeholders either through writ- ten submissions to the committee or as presented during the information gathering workshop. As outlined in Chapter 1, the ARHQ analyses are highly relevant to DRI development. Evidence-based systematic reviews have been identified as a useful tool for the purposes of dietary reference value development (Russell et al., 2009), and the work of this committee was enhanced by the availability of these two high-quality evidence reports from AHRQ. The ap- proach used, questions asked, data search criteria, and the detailed results from the AHRQ-Ottawa and AHRQ-Tufts can be found in Appendixes C and D. In sum, the focus of AHRQ-Ottawa was on the: • Association of specific circulating 25-hydroxyvitamin D (25OHD) concentrations with bone health outcomes in children, women of reproductive age, postmenopausal women, and elderly men; • Effect of vitamin D dietary intake (fortified foods and/or supple- ments) and sun exposure on serum 25OHD levels; • Effect of vitamin D on bone mineral density (BMD) and fracture or fall risk; and • Identification of potential harms associated with vitamin D expo- sures above current reference intakes. The AHRQ-Tufts evidence report analyzed data related to calcium and vitamin D with respect to a broader spectrum of health outcomes. AHRQ-Tufts also served to update and expand AHRQ-Ottawa. Specifically, AHRQ-Tufts focused on the: • Relationship between vitamin D and growth, cardiovascular dis- ease (CVD), body weight, cancer, immunological outcomes, bone health, all-cause mortality, hypertension/blood pressure, and BMD and bone mineral content (BMC); and

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127 POTENTIAL INDICATORS OF ADEQUACY AND SELECTION OF INDICATORS • Relationship between calcium and growth, CVD, body weight, and cancer. Neither AHRQ report reviewed calcium alone as a factor in bone health. A key component of systematic reviews of scientific literature is a speci- fication of the quality of the available data. The AHRQ grading system is summarized in Box 4-1. In the case of the systematic analysis carried out by AHRQ-Ottawa, the Jadad scale (Jadad et al., 1996) was used for quality assessments of randomized controlled trials (RCTs). The Jadad scale is a validated scale designed to assess the methods used to generate random assignments and double blinding. The scale also scores whether there is a description of dropouts and withdrawals by intervention group. Jadad scores range from 1 to 5, and a total score of 3 and above indicates studies of higher quality. Further, to assess the quality of the observational stud- ies, a grading system adapted from R. P. Harris et al. (2001) was used. In the case of the AHRQ-Tufts analysis, a three-category grading system (“A,” “B,” or “C”) was adapted from the AHRQ Methods Reference Guide for Effectiveness and Comparative Effectiveness Reviews (AHRQ, 2007). This system defines a generic grading system that is applicable to each type of study design including interventional and observational studies; it is sum- marized in Box 4-1. The committee’s literature search identified relevant evidence outside the scope of, or not included in, the two AHRQ reports as well as newer data available after the cutoff date of the AHRQ-Tufts analysis in 2009. The nature of the literature search is outlined in Appendix E. The literature base that was included in the 1997 report of the IOM committee tasked with DRI development for calcium and vitamin D (IOM, 1997) was also considered. Additionally, information gathered as part of a public work- shop and several open committee sessions (see Appendix J) and a white paper requested by the committee (Towler, 2009) were taken into account. Through use of the five data sources listed above, health outcomes of potential interest were identified. They are listed alphabetically in Table 4-1 and are grouped by general outcome. In addition, there is the possibility of intermediate variables that are not validated biomarkers of effect for health outcomes, but which may have the potential to be useful in the development of DRIs. Two such variables were considered: serum 25OHD concentrations and levels of parathyroid hormone (PTH). Review of Data General Principles Within the scientific and clinical literature, there is a general hierar- chy of study design. The lowest form of evidence is the idea or opinion,

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128 DIETARY REFERENCE INTAKES FOR CALCIUM AND VITAMIN D BOX 4-1 AHRQ Critical Appraisal and Grading of Evidence Grading system used by AHRQ-Ottawa: Basic Jadad score is assessed based on the answer to five questions listed below. Questions that are answered with a “yes” gain 1 point; questions answered with a “no” receive 0 points; the maximum score is 5. A score of 0 to 2 points is considered “low” quality, and a score of 3 to 5 points is considered “high” quality. 1. Was the study described as random? 2. Was the randomization scheme described and appropriate? 3. Was the study described as double-blind? 4. Was the method of double-blinding appropriate? (Were both the patient and the assessor appropriately blinded?) 5. Was there a description of dropouts and withdrawals? Grading system used by AHRQ-Tufts (based on criteria below): A = highest quality Studies have the least bias and results are considered valid. These studies adhere mostly to the commonly held concepts of high quality, including the following: a formal study design; clear description of the population, setting, interventions, and comparison groups; appropriate measurement of outcomes; appropriate statistical and analytical methods and reporting; no reporting er- rors; less than 20 percent dropout; clear reporting of dropouts; and no obvious bias. Studies must provide valid estimation of nutrient exposure from dietary assessments and/or biomarkers with reasonable ranges of measurement errors and justifications for approaches to control for confounding in their design and analyses. B = medium quality Studies are susceptible to some bias, but not sufficient to invalidate the results. They do not meet all the criteria in category “A”; they have some deficiencies, but none likely to cause major bias. The study may be missing information, making it difficult to assess limitations and potential problems. C = low quality Studies have significant bias that may invalidate the results. These studies have serious errors in design, analysis, or reporting; there are large amounts of missing information or discrepancies in reporting. SOURCES: Jadad et al., 1996; Cranney et al., 2007; Chung et al., 2009.

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129 POTENTIAL INDICATORS OF ADEQUACY AND SELECTION OF INDICATORS TABLE 4-1 Alphabetical Listing of Potential Indicators of Health Outcomes for Nutrient Adequacy AHRQ (Ottawa and Indicator Tufts) Cancer/neoplasms • All cancers ✓ • Breast cancer ✓ • Colorectal cancer/colon polyps ✓ • Prostate cancer ✓ Cardiovascular diseases and hypertension ✓ Diabetes (type 2) and metabolic syndrome (obesity) ✓ Falls ✓ Immune response ✓ —a • Asthma • Autoimmune disease ✓ Diabetes (type 1) ✓ Inflammatory bowel and Crohn’s disease ✓ Multiple sclerosis ✓ Rheumatoid arthritis ✓ —a Systemic lupus erythematosus • Infectious diseases ✓ —a Tuberculosis —a Influenza/upper respiratory infections —b Neuropsychological functioning —b • Autism —b • Cognitive function —b • Depression Physical performancec ✓ Preeclampsia, pregnancy-induced hypertension, and other non-skeletal ✓ reproductive outcomes Skeletal health (commonly bone health) • Serum 25OHD, as intermediate ✓ • Parathyroid hormone, as intermediate ✓ • Calcium absorption ✓ • Calcium balance ✓ • Bone mineral content/bone mineral density ✓ • Fracture risk ✓ • Rickets/osteomalacia ✓ aSpecific condition not reviewed as a health outcome in AHRQ. bOutcome category not considered in AHRQ. cIn the discussions within this chapter, physical performance is considered together with falls to avoid redundancy.

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130 DIETARY REFERENCE INTAKES FOR CALCIUM AND VITAMIN D followed, in ascending order, by case reports, case series, case–control studies, cohort studies, and, finally, the highest form of evidence, the randomized, controlled, double-blind trial (Croswell and Kramer, 2009). Only the RCT can show a causal relationship between an intervention and an outcome. Observational evidence can show only associative links, not causality. The highest level of observational evidence is the cohort study—a large, population-based, prospective investigation to compare an exposed group with an unexposed group. However, the cohort study does not reach the level of evidence of an RCT, because the intervention is not a random or chance event; rather it is the choice of the investigator (Croswell and Kramer, 2009). Nested case–control studies are a type of cohort study and were considered at that level of evidence; in some literature, populations from RCTs were evaluated as a cohort (adjusting for treatment assignment or limiting the analysis to the control group) and thus are at the same level of evidence as other observational research. A summary of the strengths and weaknesses of the various types of observational studies and RCT studies is shown in Table 4-2. Flaws, biases, and confounding effects are an inevitable aspect of any study design, and the strength of a study therefore depends on the ability of the investigator to control such methodological obstacles. In addition, even well-designed studies can be weakened by complications such as loss to follow-up, missing outcomes, subject non-compliance, and a biased selection process (Baker and Kramer, 2008). The Process In addition to its consideration of the AHRQ analyses, the committee conducted searches of several online bibliographical databases, including Medline, Science Direct, and WorldCat/First Search. Evidence searches were carried out to identify relevant RCTs in support of a causal relation- ship between vitamin D and/or calcium and the health outcome under consideration, and these were weighted as the strongest type of evidence for development of a DRI. The second tier of evidence considered was observational to support associative relationships between vitamin D and/ or calcium and a health outcome. Further examination was carried out to determine the quality of the observational evidence and whether the results were in agreement with RCT outcomes for a specific indicator. Potential confounders were also taken into account. Figure 4-1 shows the committee’s ranking of evidence by the strength of the study design. In the figure, RCTs prevail over observational and ecological studies as the stron- gest evidential support and were therefore necessary for a health outcome indicator to be further considered for DRI development. When the total- ity of evidence, including causal evidence, was supported by concordance

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131 POTENTIAL INDICATORS OF ADEQUACY AND SELECTION OF INDICATORS TABLE 4-2 Comparison of the Strengths and Weaknesses of Observational Study Designs and Randomized Controlled Trials for Use in DRI Development Study Type/ Quality Ranking For Definition Strengths Weaknesses DRI Development Ecological • Provides an • Outcome Low exploratory measures are not An observational overview or predictable at the study in which the indication for individual level units of analysis are a potential populations or groups association with of people, rather than outcome of individuals interest Cross–sectional • Allows for study • Possible selection Low moderate of either a whole bias An observational study population or a • Susceptible to in which a statistically representative mis-classification significant sample sample • Poor design of a population is • Provides estimates for uncommon used to estimate the of prevalence diseases or relationship between of all factors conditions an outcome of interest measured • Simultaneous and population • Facilitates greater data collection variables as they exist generalizability obscures the at one particular time order of effects Case–control • Good design • Does not provide Moderate for uncommon an estimate of An observational diseases or incidence or epidemiological study conditions prevalence of the of persons with the • Time and disease, unless outcome variable of resource efficient data about the interest and a suitable population size control group of are available persons without the • Possible selection variable of interest bias • Susceptible to mis-classification • Simultaneous data collection obscures the order of effects continued

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132 DIETARY REFERENCE INTAKES FOR CALCIUM AND VITAMIN D TABLE 4-2 Continued Study Type/ Quality Ranking For Definition Strengths Weaknesses DRI Development Cohort • Good design for • Can be High moderate common diseases expensive and A method of or conditions time-consuming epidemiological study • Relative timing • Possible selection in which subsets of a of exposure bias from loss to defined population can and disease is follow-up be identified as exposed less confusing • Statistically to a factor hypothesized than with other inefficient to influence the observational probability of study designs occurrence of an outcome Randomized • More similar to • Expensive and High controlled trial experimental time-consuming study design than • Subjects may not An experimental to observational be representative study design in which design of all who might exposure is randomly • Provides strongest receive treatment assigned and in evidence for which the frequency causality of the outcome of • Fulfills the basic interest is compared assumption between one or more of statistical groups receiving an hypothesis tests experimental treatment and a group receiving a placebo or the current standard of care SOURCE: Gordis (2009). between RCTs and high-quality observational evidence and had strong bio- logical plausibility, the committee gave further consideration to a potential indicator for development of a DRI. When observational evidence failed to support the findings of RCTs, the indicator’s validity for consideration was reevaluated, and a decision to give further consideration was made on the balance of the totality of evidence. For each potential indicator discussed in this chapter, the review of evidence included consideration of the analytical approach, study popula- tion, and research protocol design and the overall quality of the evidence for each study reviewed. The introductory statement for each indicator includes ecological studies. Observations made from such studies require caution in their interpretation because the outcome measures are not known at the individual level, and inferring individual characteristics or

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133 POTENTIAL INDICATORS OF ADEQUACY AND SELECTION OF INDICATORS FIGURE 4-1 Ranking study designs: Ranking is shown in descending order of quality from top to bottom; the length of bars is arbitrary and indicates the relative strength of a study design. fig 4-1.eps relationships from group-level measures would be fallacious. Ecological bitmap studies, however, can contribute important information in more than an exploratory manner. Where it was relevant or needed in the absence of hu- man studies, evidence for biological plausibility was included in the review as gleaned from experimental animal and mechanistic studies. The ob- servational evidence reviewed included cross–sectional, case–control, and cohort (prospective and retrospective) studies. As pointed out previously, the strongest evidence among observational studies is from the cohort study. This study design offers an advantage over the case–control design in that it allows for observation of the incidence of a health outcome or the rate at which the health outcome develops in association with vitamin D or calcium intake or status in the population under study. In case–control studies, cases are included without identifying the entire “exposed” and “unexposed” populations from which they were derived, thus inferences drawn about a health outcome related to vitamin D or calcium intake or status are less reliable using this type of design. As a tool to aid in the review process, the committee developed evi- dence “maps” for each indicator to provide an overarching view of the balance of relevant evidence from ecological and biological plausibility studies, observational studies, systematic reviews, and RCTs (including trials where the indicator was a primary outcome as well as other evidence from trials where the indicator was a secondary or non-pre-specified outcome). These served largely as an organizing tool and are included in Appendix

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134 DIETARY REFERENCE INTAKES FOR CALCIUM AND VITAMIN D F. The organizational construct of the maps did not allow distinctions be- tween studies relative to the quality of the study design; however, this was considered by the committee in the overall evaluation of data. The nature of the data surrounding each potential indicator is de- scribed below, beginning with a brief statement about the condition under consideration, followed by a summary of the evidence for ecological and biological plausibility studies, observational studies, systematic reviews from the two AHRQ reports, and additional evidence not covered in the AHRQ reviews. Each indicator is then evaluated in a summary discussion of the utility of the evidence for DRI development. REVIEW OF POTENTIAL INDICATORS Owing to the importance of a variety of acute and chronic diseases as public health concerns and the accumulating data focused on the hypoth- esis that vitamin D and/or calcium may have an impact on disease risk, it was crucial that this committee consider a wide spectrum of indicators for DRI development. After reviewing the available data, including recent systematic reviews from AHRQ and other literature, the committee chose to focus on areas where the research database is most compelling and the indicator is of public health concern within the context of DRI develop- ment. The following discussions review the roles of vitamin D and calcium in the reduction of risk for the health indicators identified in Table 4-1. The entirety of evidence for each indicator that was reviewed by the committee cannot be presented in detail here, and the following discus- sions are a summary of relevant evidence. In drawing its conclusions about an indicator, the committee evaluated the strengths and weaknesses of the studies considered for each indicator, including an examination of the methods used for measuring an indicator, its relevance to total intake and functional or physiological outcomes, and the strength of the study design. This approach is summarized in Box 4-2. Cancer/Neoplasms As the second leading cause of death in the United States, cancer is a major public health concern. Cancer encompasses a wide range of malig- nancies with many variations in etiology and pathogenesis. Thus, the com- mittee considered not only total cancer, but also specific malignancies in which vitamin D and/or calcium have been examined for an interaction thought to play a role. Cancer is a disease in which genetically damaged cells within a tissue experience uncontrolled growth and invasion with subsequent spread to other host organs. The metastatic spread leads to dysfunction of vital or- gans causing significant morbidity and culminating in death. An expanding

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135 POTENTIAL INDICATORS OF ADEQUACY AND SELECTION OF INDICATORS BOX 4-2 Evaluation of Evidence for DRI Development In its review of evidence, the committee used a qualitative approach to determine its confidence in interpreting positive or negative relationships between vitamin D and/or calcium and indicators of disease outcomes for DRI development. In analyzing and weighing the data, the committee considered the following factors: • Preliminary evidence in support of a relationship between vitamin D and/or calcium and a disease outcome is not always complete or well substantiated. • Evidence for the effect of vitamin D and/or calcium on disease outcomes is heterogeneous and may not provide strong support for a consistent and predictable outcome. • Clinical trials have the greatest influence in moderating confidence in a relationship between vitamin D and/or calcium and a disease outcome. The committee’s findings and conclusions were derived from its weighing of the totality of evidence and its ranking of evidence based on examina- tion of study methods, relevance to dietary intake, effect of vitamin D and/or calcium on disease outcome, and overall strength of the study design. array of experimental studies examining cells in culture and rodent models of cancer are providing evidence that vitamin D may have an impact on carcinogenesis at several organ sites (Deeb et al., 2007; Welsh, 2007; Davis, 2008). In parallel, epidemiological investigations of diverse approaches are examining the role of vitamin D in human cancer (WCRF/AICR, 2007; Yetley et al., 2009). In contrast, very few randomized and controlled pro- spective intervention trials with vitamin D targeting cancer as the primary outcome have been undertaken, leaving major gaps in understanding of causal relationships. Although more challenging to study in vitro, studies of dietary calcium in rodent models have also suggested a potential role in cancer risk; there are, as discussed below, experimental and clinical studies providing evidence in support of calcium as a modulator of carcinogenesis, particularly in the colon and rectal mucosa. All Cancers Cancer represents hundreds of different histopathologically distinct types of malignancy derived from virtually all organs and tissues. Investi-

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334 DIETARY REFERENCE INTAKES FOR CALCIUM AND VITAMIN D Riggs, B. L., W. M. O’Fallon, J. Muhs, M. K. O’Connor, R. Kumar and L. J. Melton, 3rd. 1998. Long-term effects of calcium supplementation on serum parathyroid hormone level, bone turnover, and bone loss in elderly women. Journal of Bone and Mineral Research 13(2): 168-74. Riggs, B. L., L. J. Melton, R. A. Robb, J. J. Camp, E. J. Atkinson, L. McDaniel, S. Amin, P. A. Rouleau and S. Khosla. 2008. A population-based assessment of rates of bone loss at mul- tiple skeletal sites: evidence for substantial trabecular bone loss in young adult women and men. Journal of Bone and Mineral Research 23(2): 205-14. Riis, B., K. Thomsen and C. Christiansen. 1987. Does calcium supplementation prevent post- menopausal bone loss? A double-blind, controlled clinical study. New England Journal of Medicine 316(4): 173-7. Ritchie, L. D., E. B. Fung, B. P. Halloran, J. R. Turnlund, M. D. Van Loan, C. E. Cann and J. C. King. 1998. A longitudinal study of calcium homeostasis during human pregnancy and lactation and after resumption of menses. American Journal of Clinical Nutrition 67(4): 693-701. Rohan, T. E., A. Negassa, R. T. Chlebowski, C. D. Ceria-Ulep, B. B. Cochrane, D. S. Lane, M. Ginsberg, S. Wassertheil-Smoller and D. L. Page. 2009. A randomized controlled trial of calcium plus vitamin D supplementation and risk of benign proliferative breast disease. Breast Cancer Research and Treatment 116(2): 339-50. Ron, M., M. Levitz, J. Chuba and J. Dancis. 1984. Transfer of 25-hydroxyvitamin D3 and 1,25-dihydroxyvitamin D3 across the perfused human placenta. American Journal of Obstetrics and Gynecology 148(4): 370-4. Rosen, C. J., A. Morrison, H. Zhou, D. Storm, S. J. Hunter, K. Musgrave, T. Chen, W. Wei and M. F. Holick. 1994. Elderly women in northern New England exhibit seasonal changes in bone mineral density and calciotropic hormones. Bone and Mineral 25(2): 83-92. Rossi, M., J. K. McLaughlin, P. Lagiou, C. Bosetti, R. Talamini, L. Lipworth, A. Giacosa, M. Montella, S. Franceschi, E. Negri and C. La Vecchia. 2009. Vitamin D intake and breast cancer risk: a case–control study in Italy. Annals of Oncology 20(2): 374-8. Rothberg, A. D., J. M. Pettifor, D. F. Cohen, E. W. Sonnendecker and F. P. Ross. 1982. Maternal-infant vitamin D relationships during breast-feeding. Journal of Pediatrics 101(4): 500-3. Rowling, M. J., C. Gliniak, J. Welsh and J. C. Fleet. 2007. High dietary vitamin D prevents hy- pocalcemia and osteomalacia in CYP27B1 knockout mice. Journal of Nutrition 137(12): 2608-15. Rucker, D., J. A. Allan, G. H. Fick and D. A. Hanley. 2002. Vitamin D insufficiency in a popu- lation of healthy western Canadians. Canadian Medical Association Journal 166(12): 1517-24. Ruiz-Irastorza, G., M. V. Egurbide, N. Olivares, A. Martinez-Berriotxoa and C. Aguirre. 2008. Vitamin D deficiency in systemic lupus erythematosus: prevalence, predictors and clinical consequences. Rheumatology 47(6): 920-3. Rummens, K., R. van Bree, E. Van Herck, Z. Zaman, R. Bouillon, F. A. Van Assche and J. Verhaeghe. 2002. Vitamin D deficiency in guinea pigs: exacerbation of bone phenotype during pregnancy and disturbed fetal mineralization, with recovery by 1,25(OH)2D3 infusion or dietary calcium-phosphate supplementation. Calcified Tissue International 71(4): 364-75. Russell, R., M. Chung, E. M. Balk, S. Atkinson, E. L. Giovannucci, S. Ip, A. H. Lichtenstein, S. T. Mayne, G. Raman, A. C. Ross, T. A. Trikalinos, K. P. West, Jr. and J. Lau. 2009. Opportunities and challenges in conducting systematic reviews to support the develop- ment of nutrient reference values: vitamin A as an example. American Journal of Clinical Nutrition 89(3): 728-33.

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