• 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 specification 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 studies, 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 summarized 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 workshop 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).

Within the scientific and clinical literature, there is a general hierarchy of study design. The lowest form of evidence is the idea or opinion,