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Japanese recommendations without RDA: Vitamin D about 200 IU, Vitamin K about 60 ug– May 2013

Dietary Reference Intakes for Japanese 2010: Fat-Soluble Vitamins

/Nutr Sci Vitaminol, 59, S57-S66, 2013
Kiyoshi Tanaka1, Junji TfeRAO2, Yoshihiro Shidoji3, Hiroshi Tamai4, Eri Imai5 and Toshio Okano6
1 Department of Food and Nutrition, Kyoto Women's University, Kyoto 605-8501, Japan tanakak at kyoto-wu.ac.jp
2 Department of Food Science, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima 770-8503, Japan
3 Department of Nutrition and Health Science, Graduate School of Human Health Science, University of Nagasaki, Nagasaki 851-2195, Japan 4Department of Pediatrics, Osaka Medical College, Osaka 569-8686, Japan 5 Section of the Dietary Reference Intakes, Department of Nutritional Epidemiology, National Institute of Health and Nutrition, Tokyo 162-8636, Japan 6Department of Hygienic Sciences, Kobe Pharmaceutical University, Kobe, 658-8558, Japan
(Received October 26, 2012)

Summary We have determined the Dietary Reference Intakes for fat-soluble vitamins (vitamin A, vitamin D, vitamin E, and vitamin K) for the Japanese. Regarding vitamin A, the estimated average requirement (EAR) and the recommended dietary allowance (RDA) were defined for those aged 1 y old and over. For vitamin D, vitamin E, and vitamin K, the EAR or RDA was not adopted, because of the insufficient data available. Thus, the adequate intake (AI) was determined for those vitamins based on the food surveillance data and biomarkers for each vitamin. The AI for vitamin D was decided as the median intake of vitamin D in the population with a circulating 25-hydroxy vitamin D level which was high enough for bone health. The basis for the AI for vitamin E was the median intake of a-tocopherol in the healthy population considering the lack of unfavorable health consequences attributable to its deficiency. The AI for vitamin K was determined as the vitamin K intake, required to avoid blood coagulation abnormalities. The tolerable upper intake level (UL) was determined for vitamin A, vitamin D and vitamin E, but not for vitamin K, since no adverse effects have been reported even with its high dosage.

{Note: have only extracted the details on Vitamin D and Vitamin K PDF is attached at the bottom of this page}

Vitamin D

Background information

Vitamin D2 and vitamin D3 are naturally occurring compounds with potent vitamin D activity. The indices for the DRI of vitamin D is based on the summation of the values of these 2 compounds. The human body obtains vitamin D from 2 sources. One is exposure to ultraviolet irradiation, which converts pro-vitamin D3 (7-dehydrocholesterol) in the skin to pre-vitamin D3, which in turn is converted into vitamin D3 by thermal isomerization. The other is dietary intake of vitamin D2 and vitamin D3 from such sources as mushrooms and fish; good sources for vitamin D2 and vitamin D3, respectively. The current DRIs do not discriminate between vitamin D2 and D3 intake because the compounds have similar characteristics and a similar molecular weight and exert an almost equal level of biological activity.
Vitamin D is first metabolized to 25-hydroxy vitamin D (250HD) before being metabolized to la,25-dihydroxy vitamin D (la,25(0H)2D), its active form. Major actions of vitamin D include enhancing the absorption of calcium and phosphate in the intestine and kidneys and stimulating bone formation and growth. Circulating 250HD level is the best index of vitamin D status. As vitamin D deficiency and resultant hypocalcemia cause elevated levels of serum parathyroid hormone (PTH), serum concentration of PTH can also be a good index of vitamin D deficiency (30).

Adequate intake Evidence for determining AI

Vitamin D deficiency impairs calcium absorption from the intestine and kidney, thus decreases calcium availability, resulting in rickets in children and osteomalacia in adults. In adults, especially the elderly, even so-called "vitamin D insufficiency," which is milder than vitamin D deficiency, can result in increased secretion of PTH, increased bone resorption, and decreased bone mineral density. Therefore, the basis for determining the vitamin D requirement is maintenance of a serum 250HD level sufficiently high to maintain normal calcium availability and avoid elevation of serum PTH level. Due to limitations on the data available, AI was determined as the median intake of vitamin D in a population in which the required circulating 250HD level is maintained.

AI for adults

In a study conducted in the northern United States, an area in which residents receive limited sunshine exposure, serum PTH level after vitamin D administration decreased in those with a serum 250HD level below 50 nmol/L but not in those with a level above 50 nmol/L (31). In a study in Niigata, those with a 250HD level less than 50 nmol/L had higher serum PTH levels and a higher prevalence of low bone mineral density (32). Based on consideration of these results, maintenance of a circulating 250HD level of at least 50 nmol/L is considered necessary to avoid elevation of serum PTH level and decrease in bone mineral density. In the study conducted in the northern United States, serum PTH level exhibited seasonal variation, reaching a nadir between August and October and a peak between March and May. However, this variation was not observed in those taking 5.5 mg/d or more of vitamin D (33), leading to the conclusion that taking at least 5.5 mg/d of vitamin D can prevent elevation of PTH in those living in areas in which they have limited sunshine exposure.
In 7 studies that examined Japanese women (34-39) aged 50 to 69 y, the average 250HD level was found to exceed 50 nmol/L. In contrast, in several studies that examined women aged 18 to 29 y (32, 34) and women aged 30 to 49 y (34), the average level was found to be below 50 nmol/L. Based on these findings and the findings from US studies, the median vitamin D intake of adults aged 50 to 69 y was determined to be an appropriate basis for determining the adult AI. As the 2005 and 2006 National Health and Nutritional Survey (NHNS) (40, 41) found that the median intake of vitamin D in adults aged 50 to 69 y was 5.5 mg/d, the AI was set as 5.5 mg/d. Due to lack of data for those aged 18 to 29 y, 30 to 49 y, and above 70 y, as well as lack of data for males, AI for both males and females in these age groups was also set at 5.5 mg/d.

AI for children

As the findings regarding the relationship between vitamin D intake and plasma 250HD concentration in children have been inconsistent, they were considered unsuitable as the basis for determining the vitamin D AI for children. Thus, the median vitamin D intake, as reported in the 2005 and 2006 NHNS (40, 41), was used as the basis for determining the AI.

AI for infants

In an epidemiological study conducted in Kyoto, 22% of neonates were found to have craniotabes, a mineralization defect of bone, likely due to vitamin D deficiency (42). The incidence of craniotabes exhibited seasonal variation, with a peak and nadir between January and May and between July and November, respectively. Circulating 250HD level was found to be below 25 nmol/L in 37% of all neonates diagnosed with craniotabes at l mo after birth. In breast milk-fed neonates, serum concentration of 250HD was found to be less than 25 nmol/L in 5 7% of subjects and below 12.5 nmol/L in 17%. In contrast, none of the formula or mixed-fed infants were found to have an inadequate serum 250HD level. It should be noted that neonates born in a vitamin D-deficient state may not recover to a vitamin D-sufficient state within a short period, and that the serum 250HD level of breast milk-fed infants was found to decrease further during the winter months (43), indicating that the vitamin D delivered from breast milk may have been unsatisfactory. The vitamin D AI for infants was determined to be 2.5 mg/d by multiplying 0.78 L/d (15, 16), the average daily milk intake, by 3.05 mg/L (44), the vitamin D concentration in breast milk as reported in the Standard Tables of Food Composition in Japan, 5th Revised and Enlarged Edition.
However, this AI value is appropriate only for infants with adequate sun exposure, defined as 2 h/wk to the face or 30 min/wk to the face and extremities. Breast-milk-fed infants with little sun exposure are at higher risk of developing rickets. Considering that previous research found that no infants developed rickets after supplementation with 2.5 mg/d of vitamin D for 6 mo and assuming that infants receive an average of 2.38 mg/d of vitamin D from breast milk, it follows that a daily intake of 4.88 mg/d of vitamin D is satisfactory for avoiding rickets. Based on these data, the AI of vitamin D for infants aged 0 to 5 mo with limited sun exposure was determined to be 5 mg/d. Recently, however, a
Table 2. DRIs for vitamin D (/mg/d).
1 Adequate intakes for an infant who is exposed to appropriate sunlight.
The value in parentheses is adequate intakes for those with less sunlight exposure.
study using a novel, highly accurate procedure found the average vitamin D concentration in breast milk to be only 0.6 mg/L (14). If this value is employed, the average vitamin D intake of breast-milk-fed infants would be only 0.47 mg/d. Such discrepancies indicate the need for further research into this value (45, 46).

AI for infants aged 6 to 11 mo

The AI of vitamin D for infants aged 6 to 11 mo with adequate sun exposure was determined to be 5 mg/d. This value was also applied to infants aged 6 to 11 mo with limited sun exposure due to lack of evidence for determining the AI.

Additional amount during pregnancy

In a study of pregnant women with limited sun exposure, an inadequate serum 25OHD concentration was observed in those with an average vitamin D intake of less than 5.3 mg/d but not in those an average (47) vitamin D intake higher than 7 mg/d (48). As these findings indicate that pregnant women require at least 7 mg/d of vitamin D, the additional amount of vitamin D required for pregnant women was determined to be 1.5 mg/d.

Additional amount during lactation

Based on the findings described above, the additional amount of vitamin D required for lactating women was determined to be 2.5 mg/d.

Tolerable upper untake level

Basic considerations

Prolonged intake of excessive quantities of vitamin D can lead to unfavorable outcomes, such as hypercalcemia, renal dysfunction, soft tissue calcification, and growth retardation. As an increased serum 25OHD level itself does not directly cause health problems, the presence of hypercalcemia rather than of a high serum 25OHD level is considered an appropriate indicator for determining the UL.

UL for adults

In an intervention study administering doses of vitamin D for 3 mo, serum calcium concentration was found to exceed the reference value in some subjects receiving 95 mg/d of vitamin D but not in those receiving 60 mg/d of vitamin D (49). Thus, the lowest observed adverse effect level (LOAEL) and NOAEL were determined to be 95 mg/d and 60 mg/d, respectively. The latter value was divided by an uncertainty factor of 1.2 yielding a UL for adults of 50 mg/d. Since neither administration of 45 mg/d of vitamin D to elderly subjects for 3 mo (50) nor administration of 50 mg/d to pregnant and lactating subjects (51 ) was found to be associated with hypercalcemia, stratification by sex or age group was not performed, and a UL of 50 mg/d was applied to all adult groups.

UL for infants

Based on a study that observed no growth retardation in infants administered an average of 44 mg/d of vitamin D for 6 mo, the NOAEL for infants was determined to be 44 mg/d (52), which, assuming an uncertainty factor of 1.8, yielded a UL of 25 mg/d. UL for children
As data were unavailable for this age group, the UL for children was determined by extrapolating the UL values for adults (50 mg/d) and infants (25 mg/d) based on the reference body weight. Sex differences were not considered.
DRI values for vitamin D are listed in Table 2.

Vitamin K

Basic considerations

Naturally occurring vitamin K consists of phylloquinones (PKs; vitamin K1) and menaquinones (MKs; vitamin K2). Menaquinones are further subdivided into 11 analogues depending on the number of isoprene units (4-14) in the prenyl side chain. Among the menaquinones, of nutritional importance are menaquinone-4 (MK-4), which is ubiquitously present in animal foods, and menaquinone-7 (MK-7), which is abundantly present in natto, a traditional Japanese food made from soybeans fermented with Bacillus subtilis. At present, data are scarce for determining the relative biological activity of these analogues, and no corrections have been made for PK and MK-4 with similar molecular weights. MK-7, which has a much larger molecular weight, can be converted into its MK-4 equivalent using the following formula:
MK-4 equivalent (mg)=MK-7 (mg)X444.7/649.
The sum of the quantity of PK, MK-4, and MK-7 as corrected above was employed in determining the DRI for vitamin K. Although long-chain MKs are produced by intestinal bacteria and MK-4 is also produced by enzymatic conversion from PK, their contribution was not considered sufficiently large to contribute to fulfilling this requirement. Although antibiotic treatment can impair vitamin K status by decreasing the production of MKs by intestinal flora and decreasing vitamin K utilization by inhibiting the enzymatic activity of vitamin K epoxide reductase (66), antibiotic treatment itself does not cause vitamin K deficiency if average vitamin K intake is maintained (67).
The principal biological action of vitamin K is activation of prothrombin and other serum coagulation factors, thereby enhancing blood coagulation. Other actions include the modulation of bone formation by activation of osteocalcin, a bone matrix protein, and inhibition of arterial calcification by activation of matrix gla protein (MGP), another vitamin-K-dependent matrix protein.

Determining DRI Evidence for determining AI

Since delayed blood coagulation is the only clinically manifested abnormality attributable to vitamin K deficiency, the intake necessary to maintain normal serum coagulation was considered an appropriate basis for determining the AI for vitamin K. In Japan, however, coagulation abnormalities due to vitamin K deficiency are rarely observed in healthy subjects. An intervention study of young vitamin K-deficient male volunteers weighing 72 kg found that administration of 40 and 32 mg/d of vitamin resulted in a decrease in serum PK level and an elevation in undercarboxylated prothrombin, a serum marker for vitamin K deficiency, respectively, but that administration of 82 mg/d of vitamin K returned these levels to normal values (68). Based on these findings, the vitamin K requirement for healthy adults was determined to be approximately 1 mg/kg-d.
Recent studies have suggested that skeletal vitamin K deficiency is a risk factor for fracture (69, 70), indicating that a much higher vitamin K intake is necessary for skeletal action. Although a recent metaanalysis found that vitamin K administration significantly reduced fracture incidence, it employed a high dosage (45 mg/d) of MK-4, which is considered to be pharmacological rather than nutritional (71). Based on the findings of previous research, a vitamin K intake of approximately 1.0 mg/kg'd was determined to be satisfactory to avoid even mild deficiency, and thus set as the AI for vitamin K.

AI for adults

As described above, a vitamin K intake of 82 mg/d in those weighing 72 kg was found sufficient to avoid deficiency (68). Extrapolation of this value by the 0.75th power of the BW ratio was used as the basis for determining the adult AI. Although the elderly may be more susceptible to vitamin K deficiency due to various fac-tors such as impaired intestinal absorption of vitamin K, at present, the data are scarce, and thus the AI for the elderly was the same as that for those aged 50 to 69 y.

AI for children

The AI for children was determined by extrapolating the AI for adults by the 0.75th power of the BW ratio.

AI for infants aged 0 to 5 mo

Neonates are susceptible to vitamin K deficiency for various reasons, such as poor transplacental vitamin K transport (72), low vitamin K content in the breast milk (14, 73), or low production of vitamin K in the intestinal flora (74). As neonatal vitamin K deficiency is known to cause neonatal melena, a form of gastrointestinal bleeding, and intracranial bleeding, vitamin K is orally administered just after birth for their prevention. The AI of 4.0 mg/d for this age group was determined by multiplying the average milk intake (0.78 L/d) by the average vitamin K content of milk (5.17 mg/L) and assuming oral administration of vitamin K just after birth in the clinical setting.
AI for infants aged 6 to 11 mo
The AI was determined to be 7 mg/d by considering the amount of vitamin K received from sources other than breast milk.

Additional amount during pregnancy

Increased requirements for vitamin K or alterations in circulating vitamin K levels in pregnant women have not been reported. Because of poor transplacental transport, vitamin K intake in pregnant women is unlikely to affect vitamin K status in the fetuses or neonates. Thus, no additional amount required for pregnant women was determined.

Additional amount during lactation

Since lactating women have not been reported to be at higher risk for vitamin K deficiency, no additional amount required for lactating women was determined.

Tolerable upper intake level

Although menadione, a vitamin K metabolite, can cause toxicity, no toxicity has been reported regarding
PKs and MKs. As 45 mg/d of MK-4 is clinically adminstered to many patients in Japan with osteoporosis with no reports of serious adverse events, the UL for vitamin K was not determined.

Other remarks

Due to the abundant vitamin K content of natto, its intake is contraindicated in patients treated with warfarin. In contrast, patients undergoing long-term antibiotic treatment or experiencing chronic obstruction of the biliary tract or impaired fat absorption are at higher risk of vitamin K deficiency.
DRI values for vitamin K are listed in Table 4.


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