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T.
RENCE INTAKES
Applications
In
Dietary
Planning
Subcommittee on Interpretation and Uses of
Dietary Reference Intakes
and the
Stancling Committee on the Scientific Evaluation of
Dietary Reference Intakes
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
OCR for page R2
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board
of the National Research Council, whose members are drawn from the councils of the
National Academy of Sciences, the National Academy of Engineering, and the Institute of
Medicine. The members of the committee responsible for the report were chosen for their
special competences and with regard for appropriate balance.
Support for this project was provided by the U.S. Department of Agriculture, Economic
Research Service, Contract No. 43-3AEM-1-80053; Health Canada; U.S. Department of Health
and Human Services, Office of Disease Prevention and Health Promotion, Contract No. 282-
96-0033; Dannon Institute; and the Dietary Reference Intakes Corporate Donors' Fund.
Contributors to the Fund include Roche Vitamins Inc., Mead Johnson Nutritionals, and
M&M/Mars. The opinions or conclusions expressed herein are those of the Subcommittee
on Interpretation and Uses of Dietary Reference Intakes and are not necessarily those of the
~ .. . .
lunching organ~zahons.
Library of Congress Cataloging-in-Publication Data
Dietary reference intakes: applications in dietary planning /
Subcommittee on Interpretation and Uses of Dietary Reference Intakes and
the Standing Committee on the Scientific Evaluation of Dietary Reference
Intakes.
p.; cm.
Includes bibliographical references and index.
ISBN 0-309-08714-7 (hardcover: elk. paper) - ISBN 0-309-08853-4
(pbk.: elk. paper)
1. Nutrition. 2. Reference values (Medicine)
[DNLM: 1. Nutrition Assessment. 2. Energy Intake. 3. Nutrition
Policy. 4. Nutritional Requirements. 5. Reference Standards. QU 146
D5658 2003] I. Institute of Medicine (U.S.). Subcommittee on
Interpretation and Uses of Dietary Reference Intakes. II. Institute of
Medicine (U.S.). Standing Committee on the Scientific Evaluation of
Dietary Reference Intakes.
QP141.D527 2003
613.2-dc21
2003006783
ISBN 0-309-51882-2 (PDF)
This report is available from the National Academies Press, 500 Fifth Street, N.W., Lockbox
285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metro-
politan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at:
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Copyright 2003 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America.
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures
and religions since the beginning of recorded history. The serpent adopted as a logotype by
the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche
Museen in Berlin.
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"I(nowin,g is not enough; we mast apply.
Willing is not enough; we must dfo. "
Goethe
...........
..... ..................................
.... .... . : . .
.............. .
............ .......
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Shaping the Future for Health
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THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society
of distinguished scholars engaged in scientific and engineering research, dedicat-
ed to the furtherance of science and technology and to their use for the general
welfare. Upon the authority of the charter granted to it by the Congress in 1863,
the Academy has a mandate that requires it to advise the federal government on
scientific and technical matters. Dr. Bruce M. Alberts is president of the National
Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter
of the National Academy of Sciences, as a parallel organization of outstanding
engineers. It is autonomous in its administration and in the selection of its mem-
bers, sharing with the National Academy of Sciences the responsibility for advising
the federal government. The National Academy of Engineering also sponsors
engineering programs aimed at meeting national needs, encourages education
and research, and recognizes the superior achievements of engineers. Dr. Wm. A.
Wulf is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of
Sciences to secure the services of eminent members of appropriate professions in
the examination of policy matters pertaining to the health of the public. The
Institute acts under the responsibility given to the National Academy of Sciences
by its congressional charter to be an adviser to the federal government and, upon
its own initiative, to identify issues of medical care, research, and education. Dr.
Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Scienc-
es in 1916 to associate the broad community of science and technology with the
Academy's purposes of furthering knowledge and advising the federal government.
Functioning in accordance with general policies determined by the Academy, the
Council has become the principal operating agency of both the National Academy
of Sciences and the National Academy of Engineering in providing services to the
government, the public, and the scientific and engineering communities. The
Council is administered jointly by both Academies and the Institute of Medicine.
Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of
the National Research Council.
www. nationa l-academies.org
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SUBCOMMITTEE ON INTERPRETATION AND USES OF
DIETARY REFERENCE INTAKES
SUSAN I. BARR (chair), Food, Nutrition and Health, University of
British Columbia, Vancouver
TANYA D. AGURS-COLLINS, Howard University Cancer Center,
Washington, D.C.
ALICIA CARR]QUIRY, Department of Statistics, Iowa State
University, Ames
ANN M. COULSTON, Hattner/Coulston Nutrition Associates,
Palo Alto, California
BARBARA L. DEVANEY, Mathematica Policy Research, Princeton,
New Jersey
JOHANNA T. DWYER, Frances Stern Nutrition Center, New
England Medical Center and Tufts University, Boston
Massachusetts ~ through May 2001)
JANET R. HUNT, U.S. Department of Agriculture Grand Forks
Human Nutrition Research Center, Grand Forks, North Dakota
SUZANNE P. MURPHY, Cancer Research Center of Hawaii,
University of Hawaii, Honolulu
VALERIE TARASUK' Department of Nutritional Sciences and Public
Health Sciences, University of Toronto, Ontario
DR! Committee Liaison
WILLIAM M. RAND, Department of Family Medicine and
Community Health, Tufts University School of Medicine,
Boston, Massachusetts
Staff
MARY POOS, Study Director
ALICE VOROSMARTI, Research Associate ~ through October 2001)
LESLIE VOGELSANG, Research Assistant
SHELLEY GOLDBERG, Senior Project Assistant ~ through fune 2001)
HARLEEN SETHI, Senior Project Assistant
v
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STANDING COMMITTEE ON THE SCIENTIFIC
EVALUATION OF DIETARY REFERENCE INTAKES
JOHN W. ERDMAN, Jr. ~ chair), Department of Food Science and
Human Nutrition, University of Illinois at Urbana-Champaign
LINDSAY H. ALLEN, Department of Nutrition, University of
California, Davis
STEPHANIE A. ATKINSON, Department of Pediatrics, Faculty of
Health Sciences, McMaster University, Hamilton, Ontario
SUSAN I. BARR, Food, Nutrition and Health, University of British
Columbia, Vancouver
BENJAMIN CABALLERO, Center for Human Nutrition, Johns
Hopkins Bloomberg School of Public Health, Baltimore,
Maryland
SANFORD A. MILLER, Center for Food and Nutrition Policy,
Virginia Polytechnic Institute and State University, Alexandria
WILLIAM M. RAND, Department of Family Medicine and
Community Health, Tufts University School of Medicine,
Boston, Massachusetts
JOSEPH V. RODRICKS, ENVIRON International Corporation,
Arlington, Virginia
ROBERT M. RUSSELL, U.S. Department of Agriculture Jean
Mayer Human Nutrition Research Center on Aging, Tufts
University, Boston, Massachusetts
Consultants
GEORGE H. BEATON, GHB Consulting, Ontario
VERNON R. YOUNG, Laboratory of Human Nutrition, School of
Science, Massachusetts Institute of Technology, Cambridge
U.S. Government Liaison
KATHRYN Y. McMURRY, Office of Disease Prevention and
Health Promotion, U.S. Department of Health and Human
Services, Washington, D.C.
Canadian Government Liaison
PETER W.F. FISCHER, Nutrition Research Division, Health
Protection Branch, Health Canada, Ottawa, Ontario
V1
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Staff
ALLISON A. YATES, Stucly Director
MARY POOS, Senior Program Officer
PAULA TRUMBO, Senior Program Officer
GAIL E. SPEARS, Staff Editor
SANDRA AMAMOO-KAKRA, Senior Project Assistant
· ~
V11
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FOOD AND NUTRITION BOARD
ROBERT M. RUSSELL (vice chair), U.S. Department of
Agriculture Jean Mayer Human Nutrition Research Center on
Aging, Tufts University, Boston, Massachusetts
LARRY R. BEUCHAT, Center for Food Safety, University of
Georgia, Griffin
BENJAMIN CABALLERO, Center for Human Nutrition, Johns
Hopkins Bloomberg School of Public Health, Baltimore,
Maryland
SHIRIKI KUMANYIKA, Center for Clinical Epidemiology and
Biostatistics, University of Pennsylvania School of Medicine
Philadelphia
LYNN PARKER, Child Nutrition Programs and Nutrition Policy,
Food Research and Action Center, Washington, D.C.
A. CATHARINE ROSS, Nutrition Department, Pennsylvania State
University, University Park
BARBARA O. SCHNEEMAN, Department of Nutrition, University
of California, Davis
STEVE L. TAYLOR, Department of Food Science and Technology
and Food Processing Center, University of Nebraska-Lincoln
CATHERINE E. WOTEKI, Department of Food Science and
Human Nutrition, Iowa State University, Ames
BARRY L. ZOUMAS, Department of Agricultural Economics and
Rural Sociology, Pennsylvania State University, University Park
Staff
ALLISON A. YATES, Director
LINDA D. MEYERS, Deputy Director
GERALDINE KENNEDO, Administrative Assistant
GAIL E. SPEARS, Staff Editor
GARY WALKER, Financial Associate
V111
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Preface
This report is the second of a series intencleci to provide guidance
in using Dietary Reference Intakes (DRIs). Its focus is the applica-
tions of DRIs in clietary planning. This report, and the previous
report in this series on applicaiton of DRIs in clietary assessment, is
from the Subcommittee on Interpretation and Uses of Dietary Ref-
erence Intakes (Uses Subcommittee) of the Stancling Committee
on the Scientific Evaluation of Dietary Reference Intakes (DRI Com-
mittee) .
The Food and Nutrition Board anticipated that substantive guici-
ance would be neecleci by U.S. and Canaclian health professionals in
the transition to the new DRIs clevelopeci jointly by Canaclian and
American scientists. These new values represent a significant clepar-
ture from the former Recommencleci Dietary Allowances (RDAs)
for the United States and Recommencleci Nutrient Intakes (RNIs)
for Canada.
In the past, RDAs and RNIs were the primary values available to
U.S. and Canaclian health professionals for planning and assessing
the cliets of inclivicluals and groups. The new DRIs represent a more
complete set of values. They were clevelopeci in recognition of the
growing and diverse uses of quantitative reference values and the
availability of more sophisticated approaches for clietary planning and
assessment purposes. The Uses Subcommittee approached its work
in two phases; this report examines the appropriate use of each
type of available DRI value in planning nutrient intakes of groups
and inclivicluals. The earlier report presented information on the
appropriate uses of specific DRI values in assessing cliets for groups
1X
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PREFACE
and inclivicluals. Each report reviews the statistical underpinnings
for the various uses of the DRI values, illustrates these uses through
sample applications, and provides guidelines to help professionals
determine when specific uses are appropriate or inappropriate.
The Uses Subcommittee was charged to review the scientific liter-
ature regarding the uses of clietary reference stanciarcis and their
applications, and to (1) provide guidance for the appropriate appli-
cations of DRIs for specific purposes, (2) identify inappropriate
applications of these values, (3) evaluate various assumptions
regarding intake and requirement distributions, (4) review acljust-
ments neecleci to minimize potential errors in clietary intake ciata,
and (~) give special consideration, as appropriate, to the uses of
DRI values of specific nutrients. A brief description of the overall
DRI project is given in Appendix A.
This report has been reviewoci in ciraft form by inclivicluals
chosen for their diverse perspectives and technical expertise, in
accordance with procedures approved by the NRC's Report Review
Committee. The purpose of this inclepenclent review is to provide
canclici and critical comments that will assist the institution in mak-
ing its published report as sound as possible and to ensure that the
report meets institutional stanciarcis for objectivity, evidence, and
responsiveness to the study charge. The review comments and ciraft
manuscript remain confidential to protect the integrity of the cle-
liberative process. We wish to thank the following inclivicluals for
their review of this report:
Mikel Aickin, Kaiser Permanente Northwest Division; Phyllis E.
Bowen, University of Illinois at Chicago; Helen H. Jensen, Iowa State
University; Susan Krebs-Smith, National Cancer Institute; Mary J.
Kretsch, University of California, Davis; George McCabe, Purdue
University; Grace Ostenso, Washington, D.C.; Beatrice L. Rogers,
Tufts University; and Christopher Sempos, SUNY Buffalo.
Although the reviewers listed above have provicleci many construc-
tive comments and suggestions, they were not askoci to endorse the
conclusions or recommendations nor clici they see the final ciraft of
the report before its release. The review of this report was overseen
by Eileen Kennedy, International Life Sciences Institute, and Enriqueta
Bond, Burroughs Wellcome Funci. Appointed by the National
Research Council and the Institute of Medicine, they were responsi-
ble for making certain that an inclepenclent examination of this
report was carried out in accordance with institutional procedures
and that all review comments were carefully consiclereci. Responsi-
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PREFACE
bility for the final content of this report rests entirely with the
authoring committee and the institution.
The support of the government of Canada in establishing the
Uses Subcommittee represents an important component of a
pioneering first step in the stanciarclization of nutrient reference
intakes in North America. The Canaclian government's support of
these activities and the participation of Canaclian scientists as full
partners in this effort are gratefully acknowlecigeci.
The DRI Committee wishes to acknowledge, in particular, the
commitment and cleclication shown by Susan I. Barr who assumed
the chairmanship of the Uses Subcommittee following completion
of the first report on clietary assessment. Dr. Barr has steered this
project through some very controversial issues to provide health
professionals specific guidance on the appropriate use of these new
clietary reference intake values for cliet planning.
Sincere thanks are also extencleci to George H. Beaton, technical
consultant to the DRI Committee, for his willingness to critically
review this report cluring many phases of development. His thought-
ful comments and constructive assistance provicleci an important
impetus to move the conceptual framework forward cluring the
project's developmental and subsequent stages. Not all issues have
been resolved, but the foundation for aciciressing them has been
strengthened significantly. We also extend special thanks to the staff
of the Food and Nutrition Board and especially to Mary Poos, study
director for the Uses Subcommittee, for her contributions to the
synthesis of the report. We recognize that significant efforts were
required by the Subcommittee and Food and Nutrition Board staff
to complete the report. Thus on behalf of the DRI Committee and
the Food and Nutrition Board, we wish to thank Allison A. Yates,
Director of the Food and Nutrition Board and study director for
the DRI activity, for her continued oversight, and also recognize,
with appreciation, the contributions of Shelley Goldberg, Sybil Boggis,
Harleen Sethi, Alice Vorosmarti, Leslie Vogelsang, and Paula Trumbo.
We wish also to thank Gail Spears for editing the manuscript.
Cutberto Garza
Chair, Food and Nutrition Board
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Contents
SUMMARY
1 INTRODUCTION TO DIETARY PLANNING
Background, 20
What Are Dietary Reference Intakes?, 22
Implementation of Dietary Planning for Inclivicluals and
Groups, 26
Caveats Regarding the Use of Dietary Reference Intakes
in Dietary Planning and Assessment, 27
2 USING DIETARY REFERENCE INTAKES IN
PLANNING DIETS FOR INDIVIDUALS
Summary, 35
Introduction, 36
Setting Appropriate Nutrient Goals, 37
Planning for Energy Intakes of Inclivicluals, 41
Developing Dietary Plans, 43
3 USING DIETARY REFERENCE INTAKES IN
PLANNING DIETS FOR GROUPS
Summary, 55
General Considerations, 56
Overview of Planning for Nutrient Intakes of Groups, 58
Considerations in Planning for a Target Usual Nutrient
Intake Distribution, 63
x~
1
19
35
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XIV
CONTENTS
Planning for Energy and Macronutrient Intakes of Groups, 76
Planning Menus to Achieve Target Usual Nutrient Intake
Distributions, 80
Planning Interventions to Change the Shape of the Intake
Distribution, 87
4 A THEORETICAL APPROACH USING NUTRIENT
DENSITY TO PLAN DIETS FOR GROUPS
Summary, 89
Introduction, 90
Planning for Heterogeneous Groups Using a Comparison
of Target Meclian Nutrient Intake to Mean Energy
Intake (or Expenditure, 93
Planning for Heterogeneous Groups Using the Distribution
of Nutrient Intakes Expressed as a Density, 96
Technical Considerations of the Nutrient Density
Distribution Approach, 103
5 EXAMPLES OF PLANNING FOR GROUPS
Summary, 107
Introduction, 108
Planning Diets in an Assisteci-Living Facility for Senior
Citizens, 108
Planning Menus for a School Nutrition Program, 113
Planning Diets for a Heterogeneous Group Using a
Nutrient Density Approach, 116
Interventions That May Change the Shape of the Intake
Distribution: Nutrient Supplementation, 123
Food Fortification, 126
6 SPECIAL CONSIDERATIONS AND ADJUSTMENTS
Summary, 133
Introduction, 133
Influence of the Nutrient Sources, 134
Individual Characteristics That Influence Dietary
Requirements, 139
Lifestyle Factors That Affect Requirements, 144
Dietary Planning for People Who Are Ill, 144
7 IMPLICATIONS AND RECOMMENDATIONS
Dietary Planning for Groups, 147
Research to Improve the Quality of Dietary Intake Data, 150
89
107
133
147
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CONTENTS
XV
Guidance for Dietary Planning, 152
Research to Improve Estimates of Nutrient Requirements, 153
8 REFERENCES
APPENDIXES
A Origin and Framework of the Development of Dietary
Reference Intakes
B Food Guidance in the United States and Canada
C The Target Nutrient Density of a Single Food
D Voluntary Nutrient Fortification
E Adjustment of Observed Intake Data to Estimate the
Distribution of Usual Intakes in a Group
F Biographical Sketches of Subcommittee Members
INDEX
156
163
171
183
192
196
209
213
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2E.RENCE INTAKES
Applications
m
Dietary
Planning
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