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OCR for page 35
Using Dietary Reference
Intakes in Planning Diets
for Inclivicluals
SUMMARY
The goal of planning a cliet for an incliviclual is to achieve a low
probability of inadequacy while not exceeding the Tolerable Upper
Intake Level (UL) for each nutrient. The Recommencleci Dietary
Allowance (RDA) or Acloquate Intake (AI) is used as the target
nutrient intake for inclivicluals, and planners should realize that
there is no recognized benefit of usual intakes in excess of these
levels. Fooci-baseci nutrition education tools are regularly used to
help an incliviclual plan a healthy cliet. However, as a result of the
evaluation of new ciata regarding nutrient requirements presented
in the Dietary Reference Intake reports, some nutrition education
tools (e.g., the U.S. Food Guicle Pyramid and Canacia's Food Guicle
to Healthy Eating) may require revision to remain current. The
DRIs are one of several criteria that should be consiclereci when
upciating such tools.
Assuming that current nutrition education tools have been evalu-
ateci to determine if they are consistent with the new reference
intakes for nutrients, inclivicluals who wish to plan nutritionally acle-
quate cliets for themselves can review their usual intakes with one of
the food guides. Food labels can be used to help choose foods that
will make up a healthful cliet. Inclivicluals can further plan their
intakes to be consistent with clietary guidelines (e.g., Dietary G~'ide-
lines for Americans tUSDA/HHS, 2000], Canada's Guidelines for
Healthy Eating Health Canada, 1990a] ). Gaps or excesses identified
can then be remeclieci by planning to alter the type or amount of
35
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36
DIETARY REFERENCE INTAKES
foocis selected from the various food groups, by using fortified
foocis, or if necessary, by using nutrient supplements.
INTRODUCTION
The Dietary Reference Intakes (DRIB) are used to establish goals
in planning cliets for inclivicluals. This may include: (1) providing
guidance to healthy inclivicluals who are concerned about meeting
their nutrient neecis, (2) counseling those with special lifestyle
considerations (e.g., athletes and vegetarians) or those requiring
therapeutic cliets, (3) formulating cliets for research purposes, and
(4) developing fooci-baseci clieta~y guidance for inclivicluals. This
chapter focuses on planning cliets for normal healthy inclivicluals.
Other situations, including planning therapeutic cliets, are aciciresseci
in Chapter 6.
Planning cliets for inclivicluals involves two steps. First, nutrient
goals must be set that are appropriate, taking into account various
factors that may have an impact upon nutrient neecis. Figure 2-1
provides an algorithm for this process. In this chapter the goal for
incliviclual planning is to ensure that the cliet as eaten has an accept-
ably low probability of nutrient inacloquacy while simultaneously
minimizing the risk of nutrient excess. This goal is achieved with
| Individual |
Are there "special considerations"?
No
Plan so that the RDA or Al for
age/sex is met
Remain below the UL
Other Tutrients
Yes
e.g., smoker (vitamin C)
athlete (iron)
vegetarian (iron, zinc)
ill person (nutrients
affected by illness)
Plan for appropriate intakes of
specific nutrients of concern
based on special
considerations
FIGURE 2-1 Schematic decision tree for planning diets for individuals.
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USING DRIs IN PLANNING DIETS FOR INDIVIDUALS 37
cliets that meet the recommencleci intakes (Recommencleci Dietary
Allowance or Acloquate Intake) without exceeding the Tolerable
Upper Intake Level. Observed intakes may have a high probability
of being inacloquate or excessive on any given clay, but a low proba-
bility over time.
When comparing observed intakes to nutrient goals, planners
neeci to be conscious of the errors associated with brief assessments
of clietary intake. It is very difficult to obtain accurate estimates of
inclivicluals' usual nutrient intakes because intakes typically vary so
much from one clay to the next. Dietary intakes assessed by multiple
Manhour recalls, clietary records, or quantitative cliet histories provide
the strongest bases for quantitative assessments of nutrient acloquacy,
but no method is without error. A full discussion of the uncertainty
associated with estimates of an incliviclual's usual intake cleriveci
from these methods can be found in the DRI report on clietary
assessment (IOM, 2000a). Food frequency questionnaires are not
recommencleci for use in assessments of nutrient acloquacy because
they have not been found to yield sufficiently accurate estimates of
inclivicluals' usual intakes of specific nutrients.
The second step in planning a cliet for an incliviclual is to develop
a clietary plan that the incliviclual will consume. While the art of
crafting appropriate clietary patterns and counseling inclivicluals to
achieve them is beyond the scope of this report, information is pro-
vicleci on how to use the DRIs to accomplish these tasks.
SETTING APPROPRIATE NUTRIENT GOALS
. .
As explained in Chapter 1, Dietary Reference Intakes (DRIB) con-
sist of four types of reference intakes that are used to assess and
plan diets of individuals and groups: the Estimated Average Require-
ment (EAR), the Recommencleci Dietary Allowance (RDA), the Acle-
quate Intake (AI), and the Tolerable Upper Intake Level (UL). The
EAR is not used as a goal in planning individual diets. By definition, a
cliet planned to provide the EAR of a nutrient would have a 50 percent
likelihood of not meeting an incliviclual's requirement, and this is
an unacceptable degree of risk for the incliviclual. What follows is an
examination of the RDA, AI, and UL as the three reference intakes
related to planning diets for individuals.
Recommended Dietary Allowance
A major goal of clietary planning for inclivicluals is to achieve an
acceptably low probability of nutrient inacloquacy for a given incli-
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38
DIETARY REFERENCE INTAKES
victual. At the same time, the planner must consider whether increas-
ing an incliviclual's intake beyond its customary level will result in
any recognizable benefit. At low levels of intake, the probability of
benefit associated with an increase in intake levels is high, but as
intake levels rise above the EAR, the probability of benefit of an
increased intake diminishes. Planning a cliet for an incliviclual that
is likely to meet his or her requirement for a nutrient is complicated
by the fact that the incliviclual's requirement is almost never known.
Most inclivicluals have requirements close to the average require-
ment for inclivicluals of their sex and age, and the best estimate of
an incliviclual's requirement is thus the EAR. However, again by
definition, half the inclivicluals in a group have requirements that
exceed the EAR. Accordingly, an intake at the level of the EAR
would be associated with an unacceptably high risk (50 percent) of
not meeting an incliviclual's requirement and would not be suitable
as a goal for planning. As intake increases above the EAR, the risk
of inacloquacy decreases from 50 percent and reaches 2 to 3 per-
cent at the RDA. Thus, the probability of inacloquacy is very low for
inclivicluals with intakes at the RDA. However, the probability that a
given incliviclual will benefit from an increase in intake also decreases
to the same extent, and is near zero (less than 2 to 3 percent) when
intake increases above the RDA.
The new RDAs may be used as the targets for planning nutrient
intakes that result in acceptably low probability of inacloquacy for
the incliviclual. The RDA is intencleci to encompass the normal bio-
logical variation in the nutrient requirements of inclivicluals. It is set
at a level that meets or exceeds the actual nutrient requirements of
97 to 98 percent of individuals in a given life stage and gender
group. This level of intake, at which there is a 2 to 3 percent proba-
bility of the incliviclual not meeting his or her requirement, has
traditionally been aclopteci as the appropriate reference when plan-
ning for inclivicluals. It should be noted that selecting this intake
level was, and continues to be, judgmental.
When counseling an individual, it is important to consider whether
any recognizable benefit will be achieved if the incliviclual's current
intake level is increased. The likelihood of recognizable benefit
must be weighed against the costs (monetary and otherwise) likely
to be incurred in increasing this intake. An intake level could be
chosen at which the risk to the incliviclual is either higher or lower
than the 2 to 3 percent level of risk that is inherent in the definition
of the RDA.
When other levels are chosen they should be explicitly justified.
For example, for a woman between the ages of 19 and 30 years, the
. .
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USING DRIs IN PLANNING DIETS FOR INDIVIDUALS 39
RDA for iron is 18 ma, and is set to cover the neecis of women with
the highest menstrual blood losses. A particular woman might feel
that her menstrual losses were light. Accordingly, she may be willing
to accept a 10 percent risk of not meeting her requirements, and
thus would have as her goal consumption of only 13 mg of iron/clay
(see Appendix I in the DRI micronutrient report tIOM, 20014~.
Adequate Intake
An AI is set when scientific evidence is not sufficient to establish
an EAR and RDA. Uncler these circumstances the AI is the target
that is used for planning incliviclual cliets. Although greater uncer-
tainty exists in determining the probability of inacloquacy for a
nutrient with an AI than for a nutrient with an RDA, the AI pro-
vicles a useful basis for planning. However, the probability of inacle-
quacy associated with a failure to achieve the AI is unknown. Unlike
a nutrient with an EAR and an RDA, it is not possible to select a
level of intake relative to the AI with a known probability of inacle-
quacy.
AIs are set in a variety of ways, as clescribeci elsewhere (i.e., IOM,
1997, 1998a, 2000b, 2001, 2002a). But in general they are the
observed mean or meclian nutrient intakes by groups of presumably
healthy inclivicluals, or they are baseci on a review of ciata cleriveci
from both clietary and experimental approaches (e.g., the AIs for
calcium and vitamin D tIOM, 1997] ~ . Regardless of how an AI was
established, intake at the level of the AI is likely to meet or exceed
an incliviclual's requirement, although the possibility that it could
fail to meet the requirements of some inclivicluals cannot be clis-
counteci.
To11erab11e Upper Intake I~eve11
A UL also is provicleci for many nutrients. The UL is the highest
level of chronic ciaily nutrient intake that is likely to pose no risk of
adverse health effects to almost all inclivicluals in the specified life
stage and gentler group. In general, intakes from food, supple-
ments, and other sources (such as water) should be planned so that
the UL is not exceeded. The UL is not a recommended level of
intake, but an amount that can be tolerated biologically, with no
apparent risk of adverse effects, by almost everyone. Risk to the
individual is minimized by diets and practices that provide levels of
nutrients below the UL, and thus when planning incliviclual cliets,
the UL should not be exceeded.
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40
DIETARY REFERENCE INTAKES
For most nutrients, intakes at or above the UL would rarely be
attained from unfortified food alone. For example, the intake of a
31-year-olci woman who consumed 3.0 mg of vitamin B6 was at the
99th percentile of the intakes from food sources reported in the
1994-1996 Continuing Survey of Food Intakes by Inclivicluals (CSFII)
in the United States (IOM, 1998a). Her RDA is 1.3 mg/ciay, and the
UL is 100 mg/ciay. If this same woman clecreaseci her intake to 1.43
mg/ciay, it would be similar to the bOth percentile of intakes in the
CSFII. In either case, her intake would be above the RDA and well
below the UL. Even if she acicleci a serving of a highly fortified
cereal that contained 2.0 mg of vitamin B6 per serving to her intake
each clay, her usual intake would still be well below the UL.
As reported in the CSFII, few inclivicluals haci intakes from foocis
that exceecleci the UL. However, since these ciata were collected,
fortification of foocis in the United States has increased. In acicli-
tion, these ciata clici not capture supplement usage. Therefore, it is
probable that current intake levels of vitamin B6 and other nutri-
ents from food sources alone might be higher than those reported
in the CSFII.
Close attention to intake from highly concentrated sources of
nutrients, such as highly fortified foocis or supplements (particularly
high-close single nutrient supplements or high-potency multiple-
nutrient supplements) may be warranted for some inclivicluals. For
some nutrients, total intake may exceed the UL, especially if a per-
son consumes large amounts from supplements and also has a high
intake from food sources. For example, if the same 31-year-olci
woman, in aciclition to her cliet (the 99th percentile of B6 intake of
3.0 mg/day), consumed a high-potency single supplement capsule
of vitamin B6 that provicleci 80 mg/ciay, her total intake would be 83
mg/ciay. This amount greatly exceeds the RDA of 1.3 mg/ciay and
approaches the UL of 100 mg/ciay. If she consumed two supple-
ment capsules per clay, her intake would exceed the UL and she
would be at potential risk of sensory neuropathy, the adverse effect
used to set the UL for vitamin B6.
Suppose that the same woman consumed a high-potency single
supplement of zinc that provicleci 25 mg/ciay in aciclition to her
ciaily clietary intake of 10 ma. Her total zinc intake would be 35 ma/
clay, which exceeds the RDA of 8 mg/ciay and approaches the UL of
40 mg/ciay. If she also consumed a fortified cereal with 100 percent
of the Daily Value for zinc (15 mg), the UL would be exceecleci.
Careful attention must be given when planning diets for individuals
consuming high-close supplements or multiple sources of fortified
foocis so that total intake floes not exceed the UL. There is no
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USING DRIs IN PLANNING DIETS FOR INDIVIDUALS 41
clocumenteci advantage to intakes that exceed the RDA or AI for
healthy persons.
PLANNING FOR ENERGY INTAKES OF INDIVIDUALS
The underlying objective of planning for energy is similar to plan-
ning for nutrients to attain an acceptably low risk of inacloquacy
and of excess. The approach to planning for energy, however, clickers
substantially from planning for other nutrients. When planning for
inclivicluals for nutrients such as vitamins, minerals, and protein,
one plans for a low probability of inacloquacy by meeting the Recom-
mencleci Dietary Allowance (RDA) or Acloquate Intake (AI), and a
low probability of excess by remaining below the Tolerable Upper
Intake Level (UL). Even though intakes at or above the RDA or AI
are almost certainly above an incliviclual's requirement, and thus
would have little or no likelihood of benefit, there are no adverse
effects to the incliviclual of consuming an intake above his or her
requirement, provicleci intake remains below the UL.
The situation for energy is quite different. The best way to assess
and plan for energy intake of inclivicluals is to consider the health-
fulness of their body weights (or body mass inclex tBMI] ~ because
with energy there is an obvious adverse effect to inclivicluals who
consume intakes above their requirements over time, weight gain
occurs. This difference is reflected in the fact that there is no RDA
for energy, as it would be inappropriate to recommenci an intake
that exceecleci the requirement (anci would leaci to weight gain) of
97 to 98 percent of inclivicluals. Instead, equations have been clevel-
opeci that reflect the total energy expenditure (TEE) as estimated
from doubly labeled water ciata and associated with an incliviclual's
sex, age, height, weight, and physical activity level. The product of
these equations is termed an estimated energy requirement (EER)
(IOM, 2002a).
Although different equations were clevelopeci for normal-weight
and overweight inclivicluals, because they are quite similar, it is rec-
ommencleci that the equations for normal-weight inclivicluals be
used for all inclivicluals (IOM, 2002a). All equations predict total
energy expenditure and, by definition, the intake required to main-
tain an individual's current weight and activity level. They were not
clesigneci, for example, to leaci to weight loss in overweight inclivicluals.
However, just as is the case with other nutrients, energy neecis vary
from one incliviclual to another, even though their characteristics
may be similar. This variability is reflected in the standard deviation
(SD) of the requirement estimate, which allows for estimating the
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42
DIETARY REFERENCE INTAKES
range within which the incliviclual's requirements could vary. Note
that this floes not imply that an incliviclual would maintain energy
balance at any intake within this range; it simply indicates how vari-
able requirements could be among those with similar characteristics.
For example, the equation for the EER (IOM, 2002a) for normal-
weight women 19 to 50 years of age is:
EER (kcal) = 354.1 - (6.91 x age ty1) + physical activity
coefficient x (9.36 x weight ~kg] + 726 x height tm] ~
This equation can be applied to a 33-year-olci woman, 1.63 m in
height and weighing 55 kg (BMI = 20.8 kg/m2), whose activity is
equivalent to walking about 2 mi/ciay (this level of activity would be
categorized as "low active," and the physical activity coefficient for
this activity level is 1.12~. Her estimated energy requirement would
be calculated as:
EER (kcal) = 354.1 - (6.91 x 33) + 1.12 x
(9.36 x 55 + 726 x 1.63) = 2,028
This value of 2,028 kcal represents the average energy require-
ment of women with her specified characteristics (age, height, weight,
and activity level). The SD of the EER is estimated as 70 percent of
the stanciarci error of the fit of the regression equation (IOM,
2002a). In this example, the SD of the EER would be 160 kcal. The
range within which a given woman's energy requirement likely falls
(e.g., the 95 percent confidence interval) would be 2,028 + (2 x 160
kcal), or between 1,708 and 2,348 kcal/day.
It should be emphasized that usual energy intakes are highly cor-
relateci with energy expenditure. This means that most people who
have access to enough food will consume an amount of energy very
close to what they expend, and as a result, maintain their weight
within relatively narrow limits over reasonable periods of time. Any
changes in weight that do occur usually reflect small imbalances in
intake over expenditure accumulated over a long period of time.
For normal inclivicluals who are weight-stable, at a healthy weight,
and performing at least the minimal recommencleci amount of total
activity, their energy expenditure (anci recommencleci intake) is
their usual energy intake. This also applies to maintaining current
weight and activity level in overweight individuals. Thus, if one knew
an incliviclual's usual energy intake, one would plan to maintain it
rather than calculate the EER to obtain an estimate. In most situa-
c,
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USING DRIs IN PLANNING DIETS FOR INDIVIDUALS 43
lions, however, the usual energy intakes of inclivicluals are not
known, so the equations for TEE are useful planning tools.
Using the Estimated Energy Requirement to Maintain Body Weight
in an Individual
When the planning goal is to maintain body weight in an inclivici-
ual with specified characteristics (age, height, weight, and activity
level), an initial planning estimate for energy intake is provicleci by
the equation for TEE of an incliviclual with those characteristics. By
definition the estimate would be expected to underestimate the
true energy expenditure 50 percent of the time, and to overestimate
it 50 percent of the time, leacling to corresponding changes in body
weight. This indicates that monitoring body weight would be
required when using the equations to estimate incliviclual energy
expenditure. For example, if one was enrolling subjects in a study
in which it was important to maintain body weight with a specified
activity level, one might begin by fouling each incliviclual the
amount of energy estimated using the equation for their EER. Body
weight would be closely monitored over time, and the amount of
energy provicleci to each incliviclual would be acljusteci up or clown
from the EER as required to maintain body weight.
Planning for Macronutr~ent Distribution
In addition to planning a diet that meets an individual's energy
requirements and has a low probability of nutrient inacloquacy and
potential risk of excess, an individual's intake of macronutrients
(e.g., carbohydrate, fat, and protein) should be planned so that
carbohydrate, total fat, n-6 and n-3 polyunsaturated fatty acids, and
protein are within their respective acceptable ranges (IOM, 2002a).
For example, consider the 33-year-olci, low-active woman cliscusseci
previously, who had an EER of approximately 2,000 kcal. The ranges
within which her macronutrient intakes should fall are shown in
Table 2-1.
DEVELOPING DIETARY PLANS
Once appropriate nutrient intake goals have been iclentifieci for
the incliviclual, these must be translated into a clietary plan that is
acceptable to the incliviclual. This is most frequently accomplished
using nutrient-baseci food guidance systems.
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DIETARY REFERENCE INTAKES
TABLE 2-1 Distribution of Macronutrient Intake Using the
Acceptable Macronutrient Distribution Range for a 33-Year-
Olci, Low-Active Woman
Acceptable Range of Macronutrient
Macronutrient Intake for Energy
Distribution Range Requirement of
Macronutrient ( % of energy) a ~2000 kcal (g)
Carbohydrate 45-65 225-325
Protein 10-35 50-175
Total fat 20-35 44-78
n-6 Polyunsaturated fatty acids 5-10 11-22
n-3 Polyunsaturated fatty acids 0.6-1.2 1.3-2.7
Added sugars < 25 < 500 kcal
a Source: IOM (2002a).
Nutr~ent-Based Food Guidance Systems in the United States
and Canada
Dietary reference stanciarcis (e.g., the former Recommencleci Dietary
Allowances tRDAs] in the United States and the Recommencleci
Nutrient Intakes tRNIs] in Canacia) have been used to provide fooci-
baseci clietary guidance in many ways, including through clevelop-
ment of national food guides and clietary guidelines for healthy
populations and as a basis for information on food and supplement
labels. Dietary guidance systems and food composition tables are
the most universally accessible sources of nutrition information
available to practitioners and laypersons. Practitioners may also use
many other sources of nutrition information for incliviclual plan-
ning (such as new information in the scientific literature or infor-
mation on disease prevention from professional associations).
In practice, guidance about food choices, such as the U.S. Food
Guide Pyramid or Canada's Food Guide to Healthy Eating, are
widely used. These guides recommenci that users select the appro-
priate amount of food for their age, sex, physiological status, body
size, and physical activity level from among a range of servings from
several different food groups. The intent is that over a period of
clays to weeks, varied choices within each group allow recommencleci
intakes of nutrients to be attained. The former RDAs and RNIs were
two of the major elements from which these food guidance systems
were clevelopeci; future revisions will uncloubtecily consider the new
Dietary Reference Intakes (DRIs). Thus, reference stanciarcis for
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USING DRIs IN PLANNING DIETS FOR INDIVIDUALS 45
nutrients are implicitly used in planning incliviclual cliets when food
guides are used.
The following sections present a brief summary of the ways that
nutrient recommendations have been used in food guides and food
labels. Appendix B provides a more cletaileci description.
Food Guides in the United States and Canada
Both the Food Guide Pyramid (Figure 2-2) and the Food Guide
to Healthy Eating (Figure 2-3) are guides for healthy persons to
achieve acloquate total nutrient intakes from food sources. Acljust-
ments in intakes clue to varying requirements (e.g., age, sex, physio-
logical status) are accomplished with these tools by mollifying the
number of servings consumed. In these systems, foocis within a
group are assumed to have particular and fairly similar nutrient
profiles, and the specified serving sizes are baseci in part on an
amount that would provide comparable levels of key nutrients from
Fats, Oils, & Sweets
USE SPARINGLY
Milk, Yogurt,
& Cheese
Group
2-3 SERVINGS
Vegetable
Group
3-5 SERVINGS
FIGURE 2-2 U.S. Food Guide Pyramid.
SOURCE: USDA (1992~.
Meat, Poultry, Fish,
Dry Beans, Eggs,
& Nuts Group
2-3 SERVINGS
Fruit
Group
2-4 SERVINGS
Bread, Cereal,
Ring ~ Pacts
Group
6-11
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46
DIETARY REFERENCE INTAKES
· ~— Health Sante
· ~ ~ Canada Canada
~— ~
{Ed _ ~
TO HEALTHY EATING
FOR PEOPLE FOUR YEARS
AND OVER
Enjoy a variety
Of foods from each
OrouD every dav
Choose ioweF
fat foods
more often.
Hot Cereal
175 mL
3/4 cup
1 Bagel, Pita or Bun
Pasta or
Rirn
250 mL
1 cup
1 Serving
Fresh, Fmzen or
Canned Vegetables
or Fruit
125 mL
1 Medium Size Vegetable or Fruit 1/2 cup
rig
3'X1"x155 2 Slices
50q 50g
Beans
19R pan ml
113-213 Can
50-100 g
Meat, Poultry or Fish
50-100 g
1-2 Eggs
100g
1/3 cup
FIGURE 2-3 Canada's Food Guide to Healthy Eating.
SOURCE: Health Canada ( 1991~ .
Other
Foods
Taste and enjoy-
ment can also
come from other
foods and bever-
ages that are not
part of the 4 food
groups. Some of
these foods are
higher in fat or
Calories, so use
these foods in
moderation.
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USING DRIs IN PLANNING DIETS FOR INDIVIDUALS 47
foocis within the group. For example, each serving in the "meat and
alternatives" group is a good source of protein. One serving of any
of the alternatives in this group would have approximately the same
amount of protein. As inclicateci earlier, the design of food guidance
systems is that, over a period of time (clays or weeks), inclivicluals
who consume the recommencleci number of servings from each
food group, and who choose a variety of foocis within each group,
will obtain the recommencleci intakes for all nutrients.
As an example, consider an active 22-year-olci pregnant woman
who receives clietary counseling. Using the Food Guide Pyramid as
a guide to achieve the recommencleci intakes of nutrients, her meal
pattern would include a minimum of three servings (7 oz) of
protein-rich foocis, three servings of dairy products, two servings of
fruits, and three servings of vegetables (focusing on foocis rich in
folate, vitamin C, and ,3-carotene), and seven servings from the
breaci, cereal, rice, and pasta group. Aciclitional servings of foocis
from these groups and from the tip of the pyramid would be acicleci
if neecleci to meet energy requirements. From this the nutritionist
would develop a menu plan and an example of food choices baseci
on the above clietary pattern.
Table 2-2 is an example of planning a clay's menu using the Food
Guide Pyramid. Table 2-3 compares its nutrient content to the cur-
rent RDAs or Acloquate Intakes (AIs) for nutrients. It can be seen
that the sample clay's menu exceeds intake recommendations for
all nutrients, even though it is for only one clay. It is important to
emphasize that food choices within this menu pattern would vary,
and the intake from the one sample clay will not accurately reflect
the average intake over several clays. For example, the average intake
of nutrients provicleci by the sample clay's menu in amounts sub-
stantially above the RDA could decrease (e.g., the sample menu
provides vitamin A in amounts well above the RDA because carrots,
a concentrated source of the provitamin A carotenoici, ,3-carotene,
were inclucleci). It is expected that varied food choices within the
menu pattern would allow average intake to meet recommencia-
tions for most nutrients and energy neecis.
Those who use food guides to plan menus for inclivicluals must
recognize that when new reference intakes for nutrients are devel-
opeci, there is an unavoidable time lag before the guides can be
assessed to determine whether they support the new nutrient refer-
ence stanciarcis. When new reference intakes have changed consici-
erably from previous standards, a food guide may not be appropri-
ate. For example, the new RDAs for vitamin A (IOM, 2001), while
somewhat lower than the previous stanciarcis, specify the use of
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48
DIETARY REFERENCE INTAKES
TABLE 2-2 Sample Planning Menu for a Prenatal Client Aged
22 Years Baseci on the Food Guicle Pyramid
Mid-Afternoon
Breakfast Lunch Snack Dinner Evening Snack
3/4 cup 2 oz tuna fish 5 wheat 1 cup skim 1 cup yogurt
orange juice (PRO) crackers milk (DG) (nonfat)
(FG) 1 tsp (BCG) 4 oz roasted (DG)
1 cup fortified mayonnaise 2 tbsp peanut chicken 1/2 cup fresh
wheat cereal (FSG) butter breast blueberries
with raisins 2 slices whole (PRO) (PRO) (FG)
(BCG) wheat bread 1 apple (FG) 1 cup cooked 1/4 cup dry
1 slice mixed (BCG) (with 1 cup skim long grain roasted
grain toast lettuce and milk (DG) rice (BCG) almonds
(BCG) tomato) 1/2 cup (PRO)
1 tsp 1/2 cup cooked
margarine cooked spinach
(FSG) carrots (VG)
1 tbsp jelly (VG) 1 cup tossed
(FSG) 1 glass salad (VG)
1 cup skim sweetened 2 tbsp low-fat
milk (DG) iced tea French
dressing
(FSG)
NOTE: Nutrient analysis was performed using Nutritionist Five, First DataBank, Inc.
2000. FG = fruit group, BCG = bread and cereal group (bread, cereal, rice, and pasta),
FSG = fat and sweet group (fats, oils, and sweets), DG = dairy group (milk, yogurt, and
cheese), PRO= protein-rich group (meat, poultry, fish, dry beans, eggs, nuts), VG =
vegetable group.
retinal activity equivalents (RAE) rather than retinal equivalents
(RE) when calculating or reporting the amount of total vitamin A
in mixed or plant foocis. An RAE gives the ,3-carotene:retinol equiv-
alency ratio as 12:1, versus the former equivalency of 6:1 (NRC,
1989~. The increased ratio means that a larger amount of ,3-carotene
is neecleci to meet the vitamin A requirement for inclivicluals who
rely on plant sources of this vitamin in their cliet. Therefore, newer
food guides may neeci to reflect an increase in the amount of darkly
colored, carotene-rich fruits and vegetables needed to provide vita-
min A in the cliet.
Consideration should be given to the new DRIs when food guides
are upciateci. In the interim, dietetic practitioners who plan cliets
should familiarize themselves with the nutrient intake recommen-
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USING DRIs IN PLANNING DIETS FOR INDIVIDUALS 49
TABLE 2-3 Comparison of Nutrient Intake with Current
Recommencleci Intake, Baseci on a Sample Planning Menu
(Table 2-2)
Planned RDA or AI Planned Intake as
Nutrient Intake for Pregnancya % of RDA or AI
Energy (kcal) 2,363 2,365 EERb
Protein (g) 131 71 c 185
Carbohydrate (g) 320 175 183
Vitamin A (,ug RAE)d 2,253 770 ,ug RAE 293
Vitamin C (mg) 140 85 165
Vitamin E (ma oc-tocopherol)e 15 15 100
Thiamin (mg) 1.9 1.4 135
Riboflavin (mg) 3.5 1.4 250
Niacin (mg) 44 18 244
Vitamin B6 (mg) 3.0 1.9 158
Folate (,ug) 606 600 ,ug DFEf 101
Vitamin B12 (pa) 8.2 2.6 315
Calcium (mg) 1,841 1,000 184
Copper (mg) 1.9 1.0 190
Iron (mg) 41 27 152
Magnesium (mg) 649 350 185
Phosphorus (mg) 2,505 700 358
Zinc (mg) 14 11 127
a RDA = Recommended Dietary Allowance, AI = Adequate Intake.
b Estimated Energy Requirement (EER) = 354.1 - (6.91 x 22) + 1.27 x (9.36 x 54 + 726 x
1.65) + 0 (pregnancy energy deposition for first trimester) = 2,365 kcal.
c Protein = 46 g/day + 25 g/day of additional protein during pregnancy.
d Database values for vitamin A in retinal equivalents (RE) were converted to retinal
activity equivalents (RAE). For retinal, 1 RE = 1 RAE. For carotenoids, 1 RE = 0.5 RAE.
e Nineteen oc-tocopherol equivalents (oc-TE) x 0.8 mg = 15.2 mg oc-tocopherol, where 0.8
is the ratio of oc-tocopherol to oc-TE.
f 1 ,ug dietary folate equivalent (DFE) = 1 ,ug food folate.
cations that have changed substantially, examine existing tools, and
mollify methods as necessary to ensure that these targets are met.
For tif ed Foods
Fortified and enriched foocis have the advantage of providing
aciclitional sources of certain nutrients that might otherwise be
present only in low amounts in some food sources. Therefore, they
are helpful in planning diets to reduce the probability of inadequacy
of specific nutrients. In addition, they may afford the opportunity
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so
DIETARY REFERENCE INTAKES
to acici nutrients in highly bioavailable forms, as is the case with
folate- and vitamin B~2-fortifieci foocis.
The fortification of foocis is undertaken for public health reasons.
For example, in the United States and Canada, ioclizeci salt; cereal
grains fortified with thiamin, riboflavin, niacin, iron, and folate;
and vitamin D-fortifieci milk were intencleci to recluce the risk of
inacloquate intakes of those nutrients. Fortification provides a fooci-
baseci means for increasing intakes of particular nutrients and in
some cases can be especially targeted to specific groups at risk of
shortfalls in specific nutrients (e.g., infant formulas and infant cereals
fortified with iron are useful to meet the high iron neecis of older
infants and young children.
In aciclition to fortification initiated by government authorities for
public health reasons, inclepenclent voluntary fortification uncler-
taken by private industry is also allowoci in the United States. Often
the amount of a nutrient acicleci cluring such voluntary fortification
may be baseci on commercial appeal, rather than public health
analysis of desirable clietary aciclitions. It is necessary to use highly
fortified foocis selectively when planning cliets so that they contrib-
ute to nutrient acloquacy without causing excess intakes. Canaclian
regulations are different and do not permit independent voluntary
fortification. (For aciclitional information, see Appendix D.)
Nutrient Supplements
Nutrient supplements provide an aciclitional means of consuming
specific nutrients that otherwise might be in short supply. Depenci-
ing on their formulation, they may consist of single nutrients or a
combination of many different vitamins, elements, or other nutri-
ent and nonnutrient ingredients. Doses vary from levels close to the
RDA or AI to several times these levels. Supplements are useful
when they fill a specific identified nutrient gap that cannot or is not
otherwise being met by the individual's food-based dietary intake.
For example, it is recommencleci that women who might become
pregnant obtain 400 ,ug of folic acid from the use of fortified foocis
or supplements, in addition to obtaining folate from a varied diet.
For pregnant women, iron supplements may be suggested to meet
needs for this nutrient that are unlikely to be achieved from food
sources alone (IOM, 1992~. However, there can be clisacivantages
associated with supplement use. For example, inclivicluals at risk
may not adhere to the supplement regimen. In other cases, those
who are already consuming the RDA or AI for most nutrients from
food sources may use supplements, but they will not achieve any
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USING DRIs IN PLANNING DIETS FOR INDIVIDUALS 51
recognized health benefit from consuming more of these nutrients
as supplements and may be at risk of excessive intake.
Food and Supplement Labels in the United States and Canada
In the United States, the percent of Daily Values stated on food
and supplement labels for vitamins and elements is baseci on the
Reference Daily Intakes (RDI) established by the Food and Drug
Administration. In the early l990s, the term RDI replaced the term
"US RDA" for vitamins and elements on food labeling. The current
RDI values are the same as the US RDAs that were provicleci on food
labels in the past, which are baseci on the highest RDA across the
various age and gentler categories (with the exception of pregnancy
and lactation) from the 1968 RDAs (NRC, 1968~. Aciclitional RDI
values have been acicleci for nutrients for which there were no RDAs
in 1968 (e.g., folate). Table 2-4 compares the current RDA or AI to
the US RDI. An example of a U.S. food label is shown in Figure 2-4.
In Canada the food and supplement labels are baseci on the high-
est RNI for any age and gentler group over age 2 from the 1983
Canaclian RNIs (Consumer and Corporate Affairs Canada, 1988~.
Table 2-4 also compares the values used for the food label in Canada
with the current RDAs or AIs. Canaclian nutrition labeling has
recently been revised, and the new label closely resembles the U.S
nutrition label. An example of the new Canaclian label format is
shown in Figure 2-~.
Similar to the previously cliscusseci situation with food guides, food
labels also may not reflect the most current nutrient reference stan-
ciarcis. Consumers neeci to be aware of the discrepancies that exist
when using the food label information to plan their cliets.
Dietary Guidelines in the United States and Canada
The U.S. Dietary Guidelines and Canacia's Guidelines for Healthy
Eating are designed to provide advice about dietary patterns that
promote health and prevent chronic disease in a healthy popula-
tion (see Appendix B). The clietary guidelines describe food choices
that will help inclivicluals meet their recommencleci intake of nutri-
ents. Like the DRIB, the guidelines apply to cliets consumed over
several days not a single day or single meal. Nutrient reference
stanciarcis are not the primary focus of clietary guidelines, but when
selecting healthy food choices baseci on the guidelines, inclivicluals
are more likely to meet recommencleci intakes of nutrients and to
have macronutrient intakes that fall within the acceptable macro-
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DIETARY REFERENCE INTAKES
TABLE 2-4 Comparison of the Recommencleci Dietary
Allowances (RDA) and Acloquate Intakes (AI) with Daily
Values (DV) for Vitamins and Minerals Used on Food Labels
in the United States and Canada
U.S. Reference
Daily Intake
Nutrient RDA or AIa (Dv)b Canadian DVC
Vitamin A (,ug)
Vitamin C (mg)
Vitamin D (,ug)
Vitamin E (ma oc-tocopherol)
Thiamin (mg)
Riboflavin (mg)
Niacin (mg)
Vitamin B6 (mg)
Folate (,ug)
Vitamin B12 (pa)
Pantothenic acid (mg) 5
Biotin (,ug)
Choline (mg)
Calcium (mg)
Chromium (,ug)
Copper (mg)
Fluoride (mg)
900 RAE
90
15
15
1.2
1.3
16
1.7
400
2.4
30
550
1,300
35
0.9
4
5,000 IU
60
10
30 IU
1.5
1.7
20
2.0
400
10
300
1,000 RE
60
5
10
1.3
1.6
23 NE
1.8
220
2
7
1,000 1,100
120
Iodine (,ug) 150 150 160
Iron (mg) 18 18 14
Magnesium (mg) 420 400 250
Phosphorus (mg) 1,250 1,000 1,100
Selenium (,ug) 55
Zinc (mg) 11 15 9
a Highest values for any age/sex category except pregnant/lactating. RAE = retinal
activity equivalents.
b The U.S. DVs are higher than the recently recommended intakes (RDAs or AIs) for
thiamin, riboflavin, niacin, vitamin Be, vitamin B12, pantothenic acid, biotin, chromium,
copper, and zinc. The DVs are lower for vitamin C, vitamin D, calcium, magnesium, and
phosphorus. It is not possible to directly compare vitamin A, vitamin E, and folate
because the DV is in International Units (IU) while the RDA is in mg or ,ug and differ-
ent bioavailability factors are incorporated into the values. There are three nutrients
with an RDA or AI but no DV (choline, fluoride, and selenium).
c The Canadian DVs are higher than the RDAs or AIs for thiamin, riboflavin, niacin,
vitamin Be, pantothenic acid, and iodine. The DVs are lower for vitamin C, vitamin D,
vitamin E, folate, vitamin B12, calcium, iron, magnesium, and phosphorus. There are
six nutrients with an RDA or AI but no RDI (biotin, choline, chromium, copper, fluo-
ride, and selenium). RE = retinal equivalents, NE = niacin equivalents.
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USING DRIs IN PLANNING DIETS FOR INDIVIDUALS 53
Sugars 59
C)alories from Fat 11
Your Daily Values may be higher or lower depending on
your calorie needs:
Calories:
Total Fat Less than
Sat Fat Less than
Cholesterol Less than
Sodium Less than
Total Carbohydrate
FIGURE 2-4 U.S. food label.
SOURCE: FDA (2000~.
65g
20g
300mg
2,500
nutrient distribution ranges. For example, the U.S. guideline "Let
the Pyramid Guide Your Food Choices" promotes dietary nutrient
acloquacy. The Canaclian guideline "Enjoy a Variety of Foods" is
baseci on the principle that foocis contain combinations of nutrients
and other substances that are neecleci for good health. Thus, an
incliviclual is more likely to meet nutrient neecis by eating a variety
of foocis. The U.S. guidelines also emphasize choosing a variety of
grains, especially whole grains, and consuming adequate servings of
fruits and vegetables, which provide important nutrients that may
be low among some population subgroups (e.g., pregnant women
OCR for page 54
~4
FIGURE 2-5 Canadian food label.
SOURCE: Health Canada (2002~.
DIETARY REFERENCE INTAKES
716~
and the elclerly). The guidelines state that fruits and vegetables are
excellent sources of folate and antioxidant nutrients such as vita-
min C, vitamin E, and carotenoicis, and thus help to prevent nutri-
ent inacloquacy. In aciclition, high intakes of fruits and vegetables
are associated with recluceci disease risk and are good sources of
phytochemicals. The guidelines also serve to promote the impor-
tance of moderation and avoiding excess salt, fat, sugar, and alco-
holic beverages. The guidelines, if followoci, also ensure moclera-
tion in intakes of foocis that provicle energy but few nutrients.
Representative terms from entire chapter:
dietary reference
