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Two Unanswered Letters

The following letters received no reply or acknowledgment.

October 15, 1997

Dr. Bruce Alberts, President

National Academy of Sciences

2101 Constitution Avenue, NW

Washington, DC 20418

Dear Dr. Alberts:

As you may be aware, the Dietary Reference Intakes report on calcium, magnesium, phosphorus, vitamin D, and fluoride prepared by the Institute of Medicine of the National Academy of Sciences and scheduled for publication this month, contains a number of recommendations concerning fluoride that are cause for grave concern over their validity for setting public health policy.

This concern has been heightened by statements made by speakers and panel members and their responses to queries at the recent September 23rd workshop on the report held at the National Academy of Sciences. We, the undersigned, regard the problem as so serious that we are requesting you to take immediate steps to delete the fluoride section of the report and to have it re-addressed by a panel that includes members of the scientific community who are not committed to promoting or supporting fluoride use. What follows is a brief summary of the basis for our concern.

At the heart of the matter is whether fluorine, as fluoride (F¯), should be ranked with Ca, Mg, P, and vitamin D as an essential nutrient. In fact, there is no known essential biochemical role for fluoride in any animal, including humans. The formation of sound, decay-resistant and caries-free teeth as well as strong, sturdy bones, whether in animal or human populations, does not require fluoride, or at least not in more than minuscule, trace amounts. As acknowledged by sources cited in the report, even when a mother's fluoride intake is elevated, her milk is extremely low in fluoride, but owing to prenatal accumulation, her baby excretes more fluoride than it ingests from her milk. This fact clearly indicates that any natural physiological need for fluoride, if indeed any exists, must be exceedingly small and certainly far below that being recommended in the report.

At the September 23rd workshop, as recorded on videotape, fluoride was repeatedly regarded by speakers and panel members as an essential nutrient. But, toward the end, when challenged on this key issue, Dr. Vernon R. Young, Chair of the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, bluntly stated that fluoride should not be considered as an "essential" component of the diet. Instead, without clarifying the distinction, he insisted that it should be viewed as only a "beneficial element."

The fact that fluoride is incorporated into the mineral matrix of bones and teeth does not make it an essential nutrient. Other elements hardly considered essential, such as lead and cadmium, also accumulate in bones and teeth, and they are not regarded as beneficial. Obviously, if fluoride is not essential in human nutrition, any consideration of it in terms of an "adequate intake" is clearly not appropriate and should not be part of a "dietary reference intakes" report.

An association of fluoride with reduction in dental caries is cited as the basis for recommending the various intakes of fluoride. At the same time, the report acknowledges that most of the anti-caries effect attributed to fluoride occurs by topical exposure, not through systemic ingestion.

Moreover, large, whole-population studies not cited in the report (e.g., in New Zealand) show that declines in tooth decay over the last 40-50 years have been occurring independently of fluoride exposure and use, thereby further challenging current arguments for significant benefit from fluoride. Without question, however, ingestion of even milligram amounts of fluoride during infancy and early childhood can produce the unmistakable toxic effects of dental fluorosis. This disruption of normal enamel formation is stated in the report not to be of "public health significance" if the fluoride concentration in the drinking water is below 2 mg/liter (2 ppm). But reports of disfiguring dental fluorosis with staining and pitting of the enamel in areas with 1-2 ppm fluoride in the drinking water were evidently overlooked, despite the claim at the workshop that the literature review was comprehensive and thorough.

Of even greater concern, in relation to public health, is the proposal in the report that only the early stages of skeletal fluorosis are the appropriate criteria for fluoride intoxication. For this purpose a tolerable upper level ingestion limit of 10 milligrams of fluoride per day for 10 or more years in persons age 9 or older is proposed. But this level of intake is not tolerable, and, according to the sources cited in the report, it can and does lead to crippling skeletal fluorosis (Hodge, 1979). For young adults, assuming 50% retention of ingested fluoride in hard tissues, as stated on page 8-2 of the prepublication copy of the report, an absorbed intake of 10 mg/day amounts to a yearly accumulation of 1.8 grams or over 50 grams after 30 years. At this level debilitating skeletal fluorosis was observed by Raj Roholm in his classic studies of cryolite workers. But before this condition is reached, there are various pre-skeletal phases of fluoride intoxication with serious health implications that arise from much lower levels of intake, especially when calcium and magnesium are marginal, an aspect not considered in the report. Among these manifestations are increased hip-fracture among the elderly from deterioration in bone strength and quality (in agreement with long-term laboratory animal studies), increased osteosarcoma in young males (also demonstrated in male rats), chronic gastrointestinal irritation (reversible with decreased exposure to fluoride), and various neuromuscular disorders whose connection with fluoride has been well confirmed in peer-reviewed publications without convincing refutation. Recent studies showing decreased IQ scores correlating with dental fluorosis (again backed up by laboratory animal research) were also omitted from consideration.

When questioned at the workshop about these omissions, the speakers and the members of the panel became defensive and were unwilling or unable to explain why such findings had been excluded in setting the upper tolerance level of fluoride at 10 mg/day. From the record of some of the committee members' past promotion or support of fluoride use, including slow-release fluoride for treatment of osteoporosis (known to produce abnormal bone of inferior strength), these responses, although disappointing, are perhaps not too surprising. But, in such an important matter, should not at least some balance of viewpoint have been represented? As seen in the videotape (a copy of which has been sent to the Academy) the attitude of some of the presenters and panelists toward those who cited contrary data and questioned why such findings were not discussed can only be described as condescending and demeaning. Today, with so many additional sources of fluoride present in processed foods, commercial beverages, and dental care products that were not there when water fluoridation began, the total intake of fluoride, even among children, has increased to as much as 2-5 milligrams or more per day, well above the initially proposed optimum of 1 mg/day (from one liter of 1-ppm fluoridated water). With these higher levels of fluoride intake, dental fluorosis and other toxic effects noted above have also increased. We are sure that you would agree that it is immensely important to both the national interest and the world of science that the publications of the National Academy of Sciences maintain the highest standards of competence, objectivity, and integrity. In our view, unless the section on fluoride is withdrawn from this report on essential nutrients it could seriously threaten those standards. Therefore, we urge you to remove this section, and further request that should the fluoride issue be revisited by the Academy at some time in the future, that you should ensure that the investigating panel includes independent scientists who are fully conversant with the literature on the full range of fluoride's harmful effects.

Sincerely yours,

ALBERT W. BURGSTAHLER, Ph.D.

(Organic Chemistry and Environmental Fluoride), Professor of Chemistry, The University of Kansas*, Department of Chemistry, 4035 Malott Hall, Lawrence, Kansas 66045.

ROBERT J. CARTON, Ph.D. (Environmental Sciences and Risk Assessment), Former Risk Assessment Manager for the Office of Toxic Substances, U.S. Environmental Protection Agency. Mailing address: 2455 Ballenger Creek Pike, Adamstown, MD 21710.

PAUL CONNETT, Ph.D. (Environmental Chemistry and Toxicology), Professor of Chemistry, St. Lawrence University*, Department of Chemistry, Canton, New York 13617.

RICHARD FOULKES, B.A.,M.D. (Physician). Former Consultant to the Minister of Health, Province of British Columbia, Canada. PO Box 278, Abbotsford, B.C., Canada V2S 4N9.

J. WILLIAM HIRZY, Ph.D., (Chemistry and Risk Assessment). Senior Vice President, National Federation of Federal Employees*, Local 2050, P.O. Box 76082, Washington D.C. 20013.

ROBERT L. ISAACSON, Ph.D., (Neurobehavioral Science). Distinguished Professor, Department of Psychology, Binghamton University*, Binghamton, NY 13902-6000.

DAVID C. KENNEDY, D.D.S., (Dentist). Past President of the International Academy of Oral Medicine and Toxicology*, 3243 Madrid Street, San Diego, CA 92110.

HAROLD D. KLETSCHKA, M.D., F.A.C.S., (Cardiovascular Surgeon). Past military consultant in thoracic and cardiovascular surgery to the U.S. Air Force Surgeon General and the Surgeon of Headquarters Command, Washington, D.C. Founder and first Chief of the USAF Cardiovascular Research Center (Parks Air Force Base, CA). Former Chairman, President and CEO of Bio-Medicus, Inc. Mailing address: 1925 Noble Drive, Minneapolis, MN 55422-4158.

LENNART KROOK, D.V.M., Ph.D., (Pathology). Cornell University*, Emeritus Professor of Pathology, New York State College of Veterinary Medicine, Ithaca, N.Y. 14853-6401.

RICHARD A. KUNIN, M.D., President, Society for Orthomolecular Health Medicine, 2698 Pacific, San Francisco, CA 94115 JOHN R. LEE, M.D. (Physician), 9620 Bodega Highway, Sebastopol, CA 95472.

WILLIAM MARCUS, Ph.D., (Toxicology).

GENE W. MILLER, Ph.D., (Biochemistry and Toxicology). Former Head of Biology, Associate Dean of Science and Dean of Environmental Science, Utah State University*, Emeritus, College of Science, Department of Biology, Logan, Utah 84322-5305.

PHYLLIS MULLENIX, Ph.D. (Pharmacology and Neurotoxicology). Former Head of the Department of Toxicology, Forsyth Dental Center*, Boston. Research Associate, Department of Psychiatry, Children's Hospital*, Boston. Mailing address: P.O. Box 753, Andover, MA 01810.

ALBERT SCHATZ, Ph.D. (Microbiology). Former Professor of Science Education, Temple University*, Philadelphia, PA.

* These affiliations are listed for identification purposes only and do not imply endorsement of this letter by the institutions involved.

Sixteen weeks later the following letter was sent, also receiving no reply or acknowledgment:

February 4, 1998

Kenneth I. Shine, M.D.

President, Institute of Medicine

National Academy of Sciences

2101 Constitution Ave. NW

Washington, DC 20418

Dear Dr. Shine:

Last October my co-signers and I sent to Dr. Bruce Alberts the enclosed joint letter concerning the fluoride recommendations in the impending publication by the National Academy Press of the report on Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Although we do not understand why we have not received a reply, we trust that our letter was brought to the attention of the Food and Nutrition Board of the Institute of Medicine for appropriate action.

When we submitted our letter we were under the impression that the position of the Food and Nutrition Board on the questions we raised was not yet settled. We have since learned, however, through the publication of the full text of the Summary of the report in the September/October 1997 issue of Nutrition Today, pp. 182-188, that the upper level intake and other recommendations for fluoride had already been officially submitted for general distribution, even at the time the September 23rd workshop on the report was held at the Academy.

Does the appearance of the pre-publication version of the report Summary in that issue of Nutrition Today (which only reached our science library here on November 13) mean that the Food and Nutrition Board still considers an intake of 10 milligrams of fluoride per day (Table S-6) to be a tolerable upper level for persons over age 9 without significant risk of serious adverse health effects?

What is especially troublesome about the Board's position on this matter is that it explicitly and emphatically contradicts the recently published views of the most distinguished and long-time fluoride expert member of the Panel on Calcium and Related Nutrients - Professor Gary M. Whitford of the Medical College of Georgia. In the second, revised edition of his widely-cited monograph on The Metabolism and Toxicity of Fluoride (Karger, Basel, 1996), he states on page 138 (copy enclosed):

"Most estimates indicate that crippling skeletal fluorosis occurs when 10-20 mg of fluoride have been ingested on a daily basis for at least 10 years." With this clinical condition, he notes, ". . . bone ash fluoride concentrations generally exceed 9,000 ppm. Calcification of ligaments often precludes joint mobility and numerous exostoses may be present. These effects may be associated with muscle wasting and neurological complications due to spinal cord compression."

Why do the recommendations of the Food and Nutrition Board on this critical matter contradict these well-considered views of the leading fluoride expert on the Board's Panel on Calcium and Related Nutrients? Clearly, a fluoride intake level that produces "crippling skeletal fluorosis" can hardly be regarded as tolerable and certainly should not remain uncorrected. Although it is widely believed that". . . crippling skeletal fluorosis has not been and is not a public health problem in the USA" (Whitford, op. cit., page 137), the same cannot be said of the situation in other parts of the world, e.g., in China, India, the Middle East, and Africa, where crippling skeletal fluorosis is still a serious endemic health problem-even at less than 10 mg/day fluoride intake. Moreover, in the absence of sufficient numbers of contemporary biopsy and necropsy bone fluoride analyses, it is very unwise to assume that little or none of the extensive middle and old-age osteoarthritis that plagues so many people in the United States is not an undiagnosed manifestation of various stages of skeletal fluorosis. In this connection it is important to note that otherwise unexplained intermittent episodes of gastric pain and muscular weakness have been clinically linked in areas of endemic dental and skeletal fluorosis to fluoride intakes as low as 2 to 5 mg/day (ref. 1). These peer-reviewed reports fully validate earlier clinical findings of the occurrence of these very same and related effects in fluoridated communities in the United States and other countries which have been discounted or ignored without scientific refutation (ref. 2).

Today, when many officials at all levels in our government seem to have difficulty in being forthright and admitting what is true, it ill behooves us as scientists not to tell the public what is known to be true, whether or not it agrees with what is generally accepted as true. "For truth is truth, though never so old, and time cannot