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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

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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: www.iom.edu. 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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