Changes in body composition and bone of female collegiate soccer players through the competitive season and off-season.

OBJECTIVES: To assess body composition and bone changes pre- to post-season (pre-post) and post- to off-season (post-off) in female soccer athletes (SC). METHODS: Outcomes were assessed using DXA and pQCT in 23 SC and 17 controls at three times throughout season. RESULTS: SC, non-starters in particular, lost lean mass pre-post (-0.9±0.2 kg, p<0.01; not different from controls, p=0.2) and gained fat mass post-off (1.4±0.3 kg, p<0.01; differed from controls, p=0.01). Baseline femoral neck and hip aBMD were higher in SC than controls (both,p<0.04), but increased in controls more than SC in pre-post and decreased post-off. SC cortical bone mineral content (BMC), cortical area and periosteal circumference increased pre-post (all, p<0.01; differed from controls, p<0.05) and trabecular vBMD decreased post-off (-3.0±1.3 mg/cm3; p=0.02; not different from controls, p=0.4). Both SC and controls increased cortical BMC, cortical area, and thickness post-off (all, p<0.01). CONCLUSION: Soccer players lost lean mass over the competitive season that was not recovered during off-season. Bone size increased pre- to post-season. Female soccer athletes experience body composition and bone geometry changes that differ depending on the time of season and on athlete's playing status. Evaluations of athletes at key times across the training season are necessary to understand changes that occur.

The negative effect of sitting time on bone is mediated by lean mass in pubertal children.

OBJECTIVE: Effects of time in moderate to vigorous physical activity (MVPA) and sitting (SIT) on bone were tested, hypothesizing that high MVPA would be positively associated with bone size and strength, offset effects of high SIT, and be mediated by lean mass. METHODS: 155 children (79 male, 58 pubertal), 6-20 years (10.2±3.5 yr) were measured by dual-energy x-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT). MVPA and SIT were measured by 7-day activity recall. Regression analyses tested effects of MVPA and SIT on bone. Mediation analysis was conducted to determine if lean mass mediated the effect of activity on bone. RESULTS: In pubertal boys, SIT was negatively associated with tibial endosteal and periosteal circumference as well as bone strength (ß= -0.19, -0.14, and -5.68, respectively; all p<0.05). Effects of SIT on bone circumferences and strength were mediated by lean mass. MVPA did not offset the effects of SIT. In pubertal girls, MVPA was positively associated with cortical thickness (ß=0.01, p<0.05) and the association was not mediated by lean mass. CONCLUSIONS: Current health communications that encourage increased physical activity should include additional messaging to decrease time spent sitting, especially in pubertal boys.

Variation in cortical density within the cortical shell of individuals across a range in densities and ages.

OBJECTIVES: The purpose of this study was to determine variability in cortical volumetric bone density (vBMD) from a single slice tibia image over a range of vBMD readings and ages. METHODS: Males and females (N=80; aged 6-80) were randomly selected from a previous study. Cortical vBMD at the anterior, posterior, medial, and lateral regions as well as the endocortical, mid-cortical, and pericortical regions of the cortical shell were determined using pQCT. RESULTS: Mean anterior ROI cortical vBMD (1111±11 mg/cm(3)) was lower than the posterior and lateral ROIs (1169±7 mg/cm(3) and 1151±9 mg/cm(3), respectively), (p<0.05). Individuals with lower overall cortical vBMD and younger individuals had greater vBMD variability within the shell (r=0.37, p=0.004). Difference between anterior and posterior regions was inversely associated with cortical vBMD and jump power (r=0.46, p=0.001). Endocortical vBMD (1080±6 mg/cm) was lower than the mid-cortical and pericortical regions (1152±5 mg/cm(3) and 1147±5 mg/cm, respectively). CONCLUSIONS: Variability in cortical vBMD was higher among young individuals and those with lower overall cortical vBMD, while lowest in older individuals and men. The anterior ROI had lower mean cortical vBMD than posterior or lateral regions, and endocortical vBMD was lower than the mid- and pericortical regions.

Effect of level of farm mechanization early in life on bone later in life.

OBJECTIVE: To determine whether an active rural lifestyle during childhood and adolescence, defined as low farm mechanization, was associated with bone measures later in life. METHODS: DXA bone data from total body, hip and spine, and pQCT data from 4% and 20% distal radius were obtained on 330 individuals (157 women) aged 20-66 years who farmed at least 75% of their lives. Primary bone outcomes included areal bone mineral density (aBMD), aBMD Z-scores, cortical and trabecular volumetric BMD, cortical thickness and periosteal circumference. Relationship between bone and recall of level of farm mechanization as a child was determined after stratifying by sex and controlling for covariates. RESULTS: Controlling for covariates, females from low mechanized farms had higher femoral neck (FN) bone area (p=0.03) than those on high or moderate mechanized farms. No group differences in pQCT ulna measurements or z-scores were found in either gender. CONCLUSION: A low farm mechanization level (high physical activity) prior to 20 years of age is associated with greater FN bone area in females. Future research that includes type and amount of physical activity performed will contribute to growing knowledge of how and when regular physical activity during childhood and adolescence affects adult bone health.

Effect of different collegiate sports on cortical bone in the tibia.

OBJECTIVES: The purpose of this study was to determine the effect of sports participation on cortical bone in the tibia. METHODS: 53 female collegiate athletes (25 cross-country, 16 soccer, and 12 volleyball) and 20 inactive controls had the left distal 20% tibia scanned by pQCT. Cortical volumetric BMD (vBMD) was measured within the cortical shell at the anterior, posterior, medial, and lateral regions and standard deviations were calculated. RESULTS: Total vBMD was greater in the control group (1161±5 mg/mm(3)) than each of the sports (p<0.05). Soccer players (1147±5 mg/mm(3)) had greater vBMD than volleyball players (1136±7 mg/mm(3)) (p<0.05), but similar to cross-country runners (1145±5 mg/mm(3)). Cortical thickness was greatest in soccer players (4.1±0.1 mm), while cross-country and control subjects (3.8±0.1 mm) had greater thickness than volleyball players (3.4±0.1 mm)(p<0.05). Periosteal circumference was greater in volleyball players (71±1.4 mm) than soccer, cross-country, and control subjects (68±0.9, 69±0.8, and 66±1 mm, respectively; all, p<0.05). vBMD variation within the cortical shell was greater among control subjects (70±6 mg/cm(3)) than each of the athlete groups, with soccer players having lower variation than cross country runners (within-in person SD 36±6 mg/cm(3) and 54±5 mg/cm(3) respectively; p<0.05). CONCLUSION: These results indicate bone geometry and distribution within the cortical shell of the tibia varies depending upon sporting activities of young women.

Muscle-bone relationships in the lower leg of healthy pre-pubertal females and males.

Muscle-bone relationships in healthy pre-pubertal children were investigated using four muscle measures as predictors of tibial strength: 66% tibia cross-sectional muscle area (CSMA) by pQCT; leg lean mass (LLM) by DXA; and muscle power (Power) and force (Force) measured during a two-footed jump. Polar strength strain index (pSSI), a calculated surrogate for bone strength at the 20% distal tibia, was obtained on 105 (54 male) self-assessed pre-pubertal children. The amount of muscle (CSMA, LLM) may influence bone strength more than muscle strength (Power, Force) during periods of rapid growth. Correlations and multiple regression partial-R values from models controlling for age, sex, height and weight were obtained for each muscle predictor. CSMA, LLM, Power and Force were positively correlated with pSSI (R=0.84, 0.92, 0.85; 0.66, respectively, all p<0.01). Partial-R values were highest for LLM (partial-R=0.21), similar for CSMA and Power (0.14, 0.15, respectively) and lowest for Force (0.04) in predicting pSSI. Muscle predictors were associated with total and cortical area (R=0.59 to 0.90; p<0.01 for all), but not cortical vBMD at the 20% distal tibia site. These data support relationships between muscle predictors and bone parameters measured by pQCT in healthy pre-pubertal children.

Influence of rapid growth on skeletal adaptation to exercise.

During rapid growth, increased body weight and muscle strength result in increased loads on bone. Bone adapts to these increased strains by increasing bone modeling and remodeling. As the growth rate decreases, bone that was formed as a result of these adaptations continues to mineralize and "catch up", and bone modeling and remodeling decreases. Bone benefits of exercise in childhood are reported in some studies, although we observed less BMC gain at trabecular-rich sites during the peri-pubertal period in children who jumped than those who did not. Data from 13 existing pediatric exercise studies were compiled to determine whether similar patterns of age-related bone changes could be identified, and whether the bone benefit of exercise differed depending upon pubertal stage. The benefit of exercise on total body BMC gains occurred across all ages, whereas greater exercise-induced gains at the spine and hip were observed in younger children compared to older children. The majority of studies found a positive effect of exercise on bone, but typically this involved limiting the analysis to specific sub-populations (i.e., higher calcium intake, lower baseline activity levels, smaller body size). Limitations of the studies published to date are discussed.

Effect of truncal adiposity on plasma lipid and lipoprotein concentrations.

OBJECTIVE: The purpose of this study was to determine the effect of body fat distribution on plasma lipid and lipoprotein concentrations in healthy individuals. METHODS: Subjects were 290 women and 223 men aged 20-66 years old. Lipid panels were obtained and truncal adiposity measurements were determined by total body dual energy x-ray absorptiometry (DXA). Physical activity was measured using a modification of the Seven Day Physical Activity Recall Questionnaire and dietary intake was collected by 24-hour recall. General linear models were used with covariates included. RESULTS: Percent of total body fat in the trunk had the strongest correlation to the android/gynoid regional fat mass ratio determined by regional DXA analyses in both women (r2=0.97, p < 0.001) and men (r2=0.93, p < 0.001). Total cholesterol (r=0.134, p < 0.05), LDL (r=0.140, p < 0.05), HDL (r= -0.181, p < 0.001), total cholesterol to HDL ratio (r=0.240, p < 0.001) and triglyceride (r=0.300, p < 0.001) concentrations had the strongest correlation to percent of total body fat in the trunk in women. Total cholesterol (r= 0.151, p < 0.05), total cholesterol to HDL ratio (r=0.216, p < 0.001), and triglyceride (r=0.227, p < 0.001) concentrations had the strongest correlation to percent of total body fat located in the trunk among men. CONCLUSION: Lipid profiles, consistent with increased cardiovascular risk, were associated with percent of total body fat in the trunk independent of lifestyle factors.

Bioavailability of vitamin D from fortified process cheese and effects on vitamin D status in the elderly.

We conducted 2 studies to determine the effect of vitamin D-fortified cheese on vitamin D status and the bioavailability of vitamin D in cheese. The first study was designed to determine the effect of 2 mo of daily consumption of vitamin D3-fortified (600 IU/d) process cheese on serum 25-hydroxyvitamin D (25-OHD), parathyroid hormone (PTH), and osteocalcin (OC) concentrations among 100 older (> or =60 yr) men and women. Participants were randomized to receive vitamin D-fortified cheese, nonfortified cheese, or no cheese. Serum levels of 25-OHD, PTH, and OC were measured at the beginning and end of the study. There were no differences in 25-OHD, PTH, or OC after 2 mo of fortified cheese intake. The vitamin D-fortified cheese group had a greater decrease in 25-OHD than other groups, due to higher baseline 25-OHD. A second study was conducted to determine whether the bioavailability of vitamin D2 in cheese (delivering 5880 IU of vitamin D2/56.7-g serving) and water (delivering 32,750 IU/250 mL) is similar and whether absorption differs between younger and older adults. The second study was a crossover trial involving 2 groups of 4 participants each (younger and older group) that received single acute feedings of either vitamin D2-fortified cheese or water. Serial blood measurements were taken over 24 h following the acute feeding. Peak serum vitamin D and area under the curve were similar between younger (23 to 50 yr) and older (72 to 84 yr) adults, and vitamin D2 was absorbed more efficiently from cheese than from water. These studies demonstrated that vitamin D in fortified process cheese is bioavailable, and that young and older adults have similar absorption. Among older individuals, consuming 600 IU of vitamin D3 daily from cheese for 2 mo was insufficient to increase serum 25-OHD during limited sunlight exposure.

Evidence for an interaction between calcium intake and physical activity on changes in bone mineral density.

Results of trials on the effects of physical activity on bone mineral density (BMD) are conflicting. The current hypothesis was that calcium intake modifies the bone response to physical activity. Published trials on physical activity and bone density were reviewed, and the results of 17 trials are summarized. Physical activity has beneficial effects on BMD at high calcium intakes, with no effect at mean calcium intakes less than a mean of 1000 mg/day. The modifying effect of calcium intake on BMD among exercise groups is more pronounced in the lumbar spine than in the radius. This analysis may explain conflicting results of trials on physical activity and calcium effects on bone. Controlled trials designed to test adequately this hypothesis are needed.

Longitudinal study of calcium intake, physical activity, and bone mineral content in infants 6-18 months of age.

Although increased physical activity early in life is recommended for optimizing bone health, no controlled trials on the effect of activity on bone mass accretion during periods of rapid growth have been reported. The purpose of this study was to determine whether infants randomized to a 1 year gross motor activity program had a greater bone mass accretion than infants randomized to a fine motor activity program. The gross motor program included activities that focused on loading the skeleton and were performed for 15-20 minutes/day, 5 days/week by study personnel. Infants (n = 72) were enrolled at 6 months of age, and total body bone mineral content (BMC), 3-day diet records, and activity levels were obtained at 6, 9, 12, 15, and 18 months. BMC was associated with weight, length, and bone area at all ages and correlated with earlier calcium intakes. Calcium intake appeared to modify the effect of gross motor activity on bone mass accretion; infants in both groups had similar bone accretion at moderately high calcium intakes, but at low calcium intakes infants in the gross motor program had less bone accretion than infants in the fine motor program. Compliant infants in the gross motor group had lower BMC at 18 months compared with noncompliant infants. These results indicate that BMC in infants is related to calcium intake, and we speculate that participation in a gross motor program during rapid bone growth may lead to reduced bone accretion in the presence of a moderate to moderately low calcium intake.

Carboxy-terminal propeptide of human type I collagen and pyridinium cross-links as markers of bone growth in infants 1 to 18 months of age.

Serum carboxy-terminal propeptide of human type I collagen (PICP) concentrations, as a marker for bone formation, and urinary pyridinium (Pyd) cross-link concentrations, as a marker of bone resorption, were determined in 66 healthy infants aged 1-18 months who are being studied longitudinally. We hypothesized that there would be a positive correlation of growth velocity, increase in bone area, and bone mass accretion rates with PICP and Pyd cross-link concentrations. Since osteocalcin is currently used as a marker of bone formation, serum osteocalcin concentrations were also measured. Mean serum PICP and urinary Pyd cross-link concentrations were significantly greater than adult concentrations. Future growth velocity, increase in bone area, and bone mass accretion rates were not associated with PICP, Pyd cross-link, or osteocalcin concentrations. Growth velocity during the 3 months preceding sample collection correlated with serum PICP, Pyd/kg, and osteocalcin concentrations (r = 0.474, p < 0.001; r = 0.379, p < 0.001; and r = 0.516, p < 0.001, respectively). Previous increase in bone area correlated with serum PICP concentrations (r = 0.359, p = 0.01). The relationship between the infant's previous bone mass accretion rate and PICP was of borderline significance (r = 0.281, p = 0.055). In summary, normative data for PICP, Pyd cross-link concentrations, and parameters of bone growth are provided for infants 1-18 months of age and indicate that these markers reflect past and current bone metabolism and may be helpful in monitoring bone disorders in infants.

Total body bone mineral content and tibial cortical bone measures in preschool children.

This study was undertaken to identify factors that influence total body bone area (TBBA), total body bone mineral content (TBBMC), and tibial cortical bone measures in 239 children aged 3-5 years. We obtained information on demographic and anthropometric characteristics and measurements of diet, physical activity, and strength. In multiple regression analysis, TBBA correlated with height (p < 0.001), weight (p < 0.001), percent body fat (p < 0.001), and calcium intake (p = 0.02). TBBMC correlated with TBBA (p < 0.001), age (p = 0.001), and weight (p = 0.02) and inversely correlated with height (p < 0.001) and percent body fat (p < 0.001). Children born preterm had lower TBBMC compared with children born at term (p = 0.02). Both periosteal and endosteal circumferences were correlated with weight (both,p < 0.001) and inversely correlated with age (p = 0.006 and p = 0.003, respectively) and percent body fat (p = 0.002 and p = 0.005 respectively). Endosteal circumference was greater and cortical bone area was lower in children born preterm compared with those born at term (both, p = 0.04). Findings of higher TBBA and lower TBBMC in children with high percent body fat indicate undermineralization of bone and suggest that obesity in preschool children may have detrimental effects on total body bone mass accretion. A smaller tibial periosteal circumference and thus cross-sectional area in children with the same weight but higher percent body fat also would lead to a biomechanical disadvantage in these children. Findings of low TBBMC and cortical bone area among children born preterm need to be confirmed in other populations. We speculate that differences in these measurements between children born preterm and at term may be caused by differences in activity.

High bone mass in a female Hutterite population.

We examined a Hutterite population (n = 243) to determine if their agriculturally diverse, self-sufficient communal lifestyle promotes optimal bone mass attainment because of adequate calcium intake and high physical activity levels during growth and young adulthood. We measured total body (TB) and lumbar bone mineral content (BMC) and bone mineral density (BMD) in 39 school-age (younger) females and 204 working (older) females. Forty-five percent of older females and 79% of younger females currently consumed > or = 3 servings (svg) of dairy per day. Older females had lumbar (0.6 +/- 1.3) and TB (1.1 +/- 1.1) BMD Z scores greater than 0 (both, p < 0.001). The lumbar BMD Z score of younger females was not different from 0 (-0.1 +/- 1.0; p = 0.5). Both lumbar (r = 0.46; p < 0.001) and TB (r = 0.20; p = 0.02) BMD Z scores increased with increasing age. In multiple regression analyses for older females, lumbar bone area (p < 0.001), weight (p < 0.001), current hours on feet per day (p = 0.01), colony workload (p < 0.01), and estrogen status (p = 0.06) predicted lumbar BMC. TB bone area (p < 0.001), current hours on feet per day (p < 0.001), and colony workload (p < 0.01) predicted TB BMC. For younger females, lumbar bone area (p < 0.001), weight (p < 0.01), years in present colony (p = 0.02), and menses (p < 0.001) predicted lumbar BMC. TB bone area (p < 0.001), height (p < 0.01), years in present colony (p = 0.03), and menses (p < 0.01) predicted TB BMC. The effect of colony workload could not be separated from other factors different by colony. A heritability estimate of 0.66 was calculated for lumbar BMD using mother and daughter Z scores. Adequate calcium intake during growth, high physical activity early in life, and genetic factors may be contributing to above normal BMD levels in adult female Hutterites.

Developmental changes in calcium kinetics in children assessed using stable isotopes.

Total exchangeable calcium pool size (TEP) and bone calcium accretion rate (Vo+) were measured using stable isotopes in healthy children and young adults. 42Ca or 46Ca was given intravenously to 10 children aged 10 months to 14 years and 3 women aged 23-33 years. Calcium kinetic parameters were determined using a two- or three-exponential curve of the resultant serum and urine tracer excesses. These data were compared with previously reported (radiotracer) kinetic studies of 21 children and 5 adults without known bone disease. Current results are comparable to those previously obtained, and the data from all studies were analyzed together. Total Vo+ was significantly greater in children aged 3-16 years than in adults (2.8 +/- 1.6 versus 0.7 +/- 0.2 g/day, p less than 0.01). Both TEP and Vo+ were significantly correlated to age independently of variations in body weight (p less than 0.01 for each). The ratio ko+ = Vo+/TEP was greater in children than adults (0.36 +/- 0.15 versus 0.12 +/- 0.03 day-1, p less than 0.001). These data demonstrate increased bone flow of calcium associated with increases in exchangeable calcium pools in children compared to adults. Vo+ and TEP may be maximum in early adolescence, associated with peak rates of net calcium accretion. The use of stable isotopes permits the safe evaluation of calcium kinetics in patients of all ages.

Effects of calcium supplementation on calcium homeostasis and bone turnover in lactating women.

Lactation is a time of calcium flux, because women secrete approximately 210 mg calcium/day in breast milk, and they experience a transient bone loss. The objectives of this study were to determine the effect of calcium supplementation on adaptive responses in calcium homeostasis during lactation and after weaning. Two cohorts of women participated in a 6-month randomized calcium supplementation trial. Lactation cohort women (97 lactating, 99 nonlactating) were studied during the first 6 months post partum, and weaning cohort women (95 lactating, 92 nonlactating) were studied during the second 6 months post partum. Lactating women in the weaning cohort weaned approximately 1.5 months after enrollment. PTH was 18-30% lower in lactating than in nonlactating women (P < 0.01). Serum 1,25-dihydroxyvitamin D was 11-16% higher in lactating than in nonlactating women and remained elevated for approximately 1.5 months after weaning (P = 0.06). Calcium supplementation decreased serum PTH and 1,25-dihydroxyvitamin D in lactating and nonlactating women similarly. At 6 months, the calciuric response to calcium supplementation was less in lactating (compared with nonlactating) women (P = 0.06). Biomarkers of bone turnover were higher in lactating than in nonlactating women during lactation and after weaning but were not effected by calcium supplementation. Calcium supplementation has little effect on lactation-induced changes in the calcium economy.

Do North American women need supplemental vitamin D during pregnancy or lactation?

Studies in European and other countries have shown that vitamin D deficiency during pregnancy may adversely affect fetal growth, bone ossification, tooth enamel formation, and neonatal calcium homeostasis. Whether effects of vitamin D deficiency on pregnant or lactating mothers differ from effects observed in nonpregnant or nonlactating women is not clear. Poor maternal vitamin D status during lactation results in low breast-milk vitamin D. However, human milk usually contains small vitamin D amounts and, under normal circumstances, the sunshine exposure of human-milk--fed infants is the major factor affecting their vitamin D status. Mothers at risk of vitamin D deficiency are those who avoid dairy products, which are routinely vitamin D fortified, and live in more northern latitudes. Dark-skinned women also are theoretically at risk of vitamin D deficiency. Sunshine exposure is a major vitamin D source, and given adequate exposure, supplemental vitamin D is not necessary. However, defining adequate sunshine exposure is difficult.

Nutritional concerns of lactating women consuming vegetarian diets.

Nutritional inadequacies during lactation may affect the well-being of the mother, infant, or both. Vitamin D and calcium status in vegetarian women may be low, resulting in maternal bone demineralization. Vitamin B-12 deficiency resulting in neurologic damage has been reported in infants of vegetarian women. A review of several studies completed on women in the northeastern United States who were consuming a macrobiotic diet is presented. Supplemental vitamin D does not appear to be necessary given sufficient sun exposure. Calcium intake in vegetarian mothers was low and differences in calcium-regulating hormones were apparent. However, it is not clear whether these hormonal changes resulted in adequate adaptation whether these hormonal changes resulted in adequate adaptation and prevented bone demineralization. The low calcium intake in the vegetarian women did not result in lower milk calcium concentrations. Elevated methylmalonic acid excretion, which is often seen in vitamin B-12 deficiency, was noted in the vegetarian mothers and their infants. Infants with high methylmalonic acid excretion were consuming milk low in vitamin B-12.

Urinary methylmalonic acid excretion in infants fed formula or human milk.

Serum vitamin B-12 and urinary methylmalonic acid (MMA) concentrations were determined in 62 healthy infants aged 1-6 mo. Urinary MMA was inversely correlated with serum vitamin B-12 concentrations (r = -0.550, p less than 0.001); serum vitamin B-12 was higher (p less than 0.001) and urinary MMA concentrations were lower (p less than 0.001) in formula-fed infants than in infants fed human milk (from the breast). Human-milk-fed infants who had received supplemental formula had higher serum vitamin B-12 concentrations than did infants exclusively fed human milk. It is not clear whether the serum vitamin B-12 and urinary MMA concentrations in infants fed human milk reflect biochemical deficiency of vitamin B-12, and the clinical significance of these findings needs to be investigated.

Vitamin B-12: low milk concentrations are related to low serum concentrations in vegetarian women and to methylmalonic aciduria in their infants.

In a group of 13 strict vegetarian and 6 omnivorous lactating women, relationships were studied among maternal milk and serum vitamin B-12, and milk vitamin B-12 and infant urinary methylmalonic acid (MMA) excretion. Milk vitamin B-12 concentrations were lower in women consuming a strict vegetarian diet compared with an omnivorous diet. Milk vitamin B-12 was inversely related to length of time on a vegetarian diet and positively correlated with maternal serum vitamin B-12 concentrations. Infant urinary MMA excretion was inversely related to milk vitamin B-12 concentrations less than 362 pmol/L. The 1989 recommended dietary allowance for vitamin B-12 of 221 pmol/d for infants is close to the intake below which infant urinary MMA excretion is increased. We conclude that the current RDA for infants provides little margin of safety.