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3
Methods for Examining Food and Nutrient Intakes

The committee examined the dietary intakes of food groups, food subgroups, and nutrients by infants, children, and adults to identify food and nutrient intakes needing improvement for each of the identified age groups of Child and Adult Care Food Program (CACFP) participants. This chapter briefly covers the data sources used along with their strengths and limitations, the standards against which intakes were measured, and the methods used to examine food and nutrient intakes.

FOOD AND NUTRIENT DATA SOURCES

Brief Description

The primary source of data on food and nutrient intake was the What We Eat in America component of the National Health and Nutrition Examination Survey (NHANES) 2003–2004. These specific survey years were selected as the most complete source of data on the nutrients and food groups of interest. NHANES is conducted by the National Center for Health Statistics and is designed to provide national estimates of the health and nutrition status of the civilian, noninstitutionalized population in the 50 states. The data used included dietary intake data on individuals of all ages; demographic information including age, gender, and physiological status (e.g., whether a woman was pregnant or lactating); and measures of stature and weight by age. Data on supplement use were not included in the analyses. All analyses used the appropriate statistical weights to adjust for the NHANES sample design. For the estimation of variances of



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3 Methods for Examining Food and Nutrient Intakes The committee examined the dietary intakes of food groups, food sub- groups, and nutrients by infants, children, and adults to identify food and nutrient intakes needing improvement for each of the identified age groups of Child and Adult Care Food Program (CACFP) participants. This chapter briefly covers the data sources used along with their strengths and limita- tions, the standards against which intakes were measured, and the methods used to examine food and nutrient intakes. FOOD AND NUTRIENT DATA SOURCES Brief Description The primary source of data on food and nutrient intake was the What We Eat in America component of the National Health and Nutrition Examination Survey (NHANES) 2003–2004. These specific survey years were selected as the most complete source of data on the nutrients and food groups of interest. NHANES is conducted by the National Center for Health Statistics and is designed to provide national estimates of the health and nutrition status of the civilian, noninstitutionalized population in the 50 states. The data used included dietary intake data on individuals of all ages; demographic information including age, gender, and physiological status (e.g., whether a woman was pregnant or lactating); and measures of stature and weight by age. Data on supplement use were not included in the analyses. All analyses used the appropriate statistical weights to adjust for the NHANES sample design. For the estimation of variances of 45

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46 CHILD AND ADULT CARE FOOD PROGRAM quantities of interest, the committee used the method of balanced repeated replication and constructed the replicated weight sets as described by Fuller (2009).The main data source for food group intake was the MyPyramid Equivalents Database, 2.0 (MPED 2.0), for U.S. Department of Agriculture (USDA) Survey Foods, 2003–2004. This database translates the amounts of foods reported in the dietary recalls from the What We Eat in America survey (USDA/ARS, 2004) into the number of equivalents for each of the 32 major food groups and subgroups in MyPyramid. The MPED 2.0 includes variables for discretionary solid fat (including some oils), added sugars, and alcoholic beverages. Data on vitamin D were obtained from What We Eat in America, NHANES 2007–2008 (USDA/ARS, 2010a, Table 1). Limited food intake data were also available from the first Feeding Infants and Toddlers Study (FITS) (Ziegler et al., 2006). The FITS survey population included a large, representative, cross-sectional sample of parents or caregivers that pro- vided information on the diet and eating habits of infants, toddlers, and preschoolers living in the United States. Its primary objective was to obtain information on nutrient intakes and gaps, and consumption patterns within this population. The first FITS was conducted in 2002, and the second FITS was initiated in 2008 and completed in 2009. The second survey included an expanded sample size and age range of 0 to 48 months (Nestlé Nutri- tion Institute, 2009), but data from the second survey were not available to the committee. Strengths and Limitations Strengths of the NHANES 2003–2004 data sets relate to the survey de- sign, quality control, large sample size, and availability of data on nutrients of interest to the committee. Limitations relate to the lack of reliable data on supplement intake (mentioned above); the accuracy of the self-reported dietary intakes (diet recalls); and, for the purposes of this report, the rela- tively small number of low-income infants, children, and adults. Self-Reported Dietary Data The under-reporting of food intakes appears to be more common than over-reporting at all age levels including children and adolescents, and es- pecially among persons who are overweight or obese (Braam et al., 1998; Bratteby et al., 1998; Fisher et al., 2000; Little et al., 1999). There is fur- ther evidence that psychological factors contribute to under-reporting, and these may be more prevalent among obese women (Kretsch et al., 1999; Scagliusi et al., 2003). The accuracy of dietary reporting, particularly that

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47 EXAMINING FOOD AND NUTRIENT INTAKES related to children, however, is highly dependent on the survey instrument (Livingstone and Robson, 2000). The NHANES dietary data used by the committee were obtained using the Automated Multiple-Pass Method, which limits the under-reporting of food intakes (Johnson et al., 2008) and improves the accuracy of estimated energy intakes in normal-weight adults (Moshfegh et al., 2008). Even using this method, however, Moshfegh and colleagues (2008) found that individu- als who were overweight or obese under-reported their intakes. Although the under-reporting of energy is reasonably well documented, the extent to which nutrients are underestimated is unclear. Results obtained in the Observing Protein and Energy Nutrition study conducted by the National Cancer Insti- tute (Subar et al., 2003) suggest that individuals who under-report do so for all food groups, but the degree of under-reporting can vary between foods. The implication of the under-reporting of food intakes is an overestimation of the prevalence of inadequacy; that is, more of the individuals may have ad- equate intakes than the analysis indicates. The over-reporting of food intake may be most likely for young children (up to about age 8 years) (Basch et al., 1990; Lytle et al., 1993). The major implication of the over-reporting of food intake is that the prevalence of nutrient inadequacy may be underestimated. Number of Low-Income Subjects Because the sample sizes for low-income individuals were small and would not provide reliable data about intakes at the tails of the intake dis- tribution, the committee considered the extent of the difference by income. Using weighted 1-day dietary intake data from What We Eat in America, NHANES 2003–2004, for individuals ages 2 years and over (USDA/ARS, 2010b, Table 7), the committee compared mean intakes of calories and selected nutrients for those with incomes below 185 percent of the federal poverty level and those with higher incomes. Calorie intakes were similar (2,183 vs. 2,204 kcal/d for those with lower vs. higher incomes). Looking specifically at children ages 2 through 5 years, nutrient intakes tended to be somewhat higher for the lower-income children (for example, iron intakes were 13.9 mg/d vs. 11.3 mg/d for the higher-income children). Thus, nutri- ents of concern for the full sample would encompass those of concern for the low-income sample. Based on these findings, the committee considered it appropriate to use the data spanning the entire income range in order to increase the reliability of the intake estimates. Despite the limitations addressed above, the dietary intake data were an important source of information for examining food and nutrient intakes. These data enabled the committee to identify nutrients likely to be either under- or overconsumed by the age groups examined.

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48 CHILD AND ADULT CARE FOOD PROGRAM STANDARDS USED TO REVIEW FOOD INTAKES Infants and Children Younger Than 2 Years of Age Because the Dietary Guidelines for Americans (HHS/USDA, 2005) ex- cludes children under the age of 2 years, published statements of the Ameri- can Academy of Pediatrics (AAP) were used as the source of dietary guidance for this age group (see Table 3-1). Nutrient intakes were examined using Dietary Reference Intakes (see later section “Nutrient Intake Evaluation”). The AAP acknowledges that there is little evidence for order of first foods and states that its preferred first foods are iron-fortified cereal and pu- reed meat (AAP, 2009). However because iron and zinc are better absorbed from meat than grains, they may be a preferred first food, particularly for breastfed infants (Krebs et al., 2006). Children Over 2 Years of Age and Adults The standard used to review food intakes of persons over 2 years of age was the MyPyramid food guidance system.1 MyPyramid provides specific food-based dietary guidance that are consistent with the recommendations in the 2005 Dietary Guidelines for Americans (HHS/USDA, 2005) for all individuals over the age of 2 years. That is, MyPyramid uses food patterns to translate the 2005 Dietary Guidelines into recommendations about the types and amounts of food that will promote health and healthy weight (Marcoe et al., 2006). Extensive information about MyPyramid is available online at www.mypyramid.gov. A key aspect of MyPyramid concerns the forms of foods used to develop the food patterns. In particular, the foods included in each of the MyPyramid food groups are the lowest in fat (e.g., lean meat and fat-free milk), and they are free of added sugars (e.g., water- packed canned fruit). THE DETERMINATION OF AGE GROUPS, BODY WEIGHTS AND HEIGHTS, AND ESTIMATED CALORIE REQUIREMENTS Before dietary intakes could be assessed, it was necessary to establish appropriate age groups for CACFP, determine body weights and heights by 1 The DASH diet eating plan (NHLBI, 2010; http://www.nhlbi.nih.gov/hbp/prevent/h_ eating/h_eating.htm), which is very similar to the MyPyramid food guide, has been docu- mented to lower blood pressure among adults (Appel et al., 2006; Ard et al., 2004; Sacks et al., 2001); however the committee found that its use for review of food intakes and planning meals for CACFP would present logistical problems. For example, it would not match satis- factorily with the MyPyramid Equivalents Database, 2.0, for USDA Survey Foods, 2003–2004 (MPED 2.0).

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49 EXAMINING FOOD AND NUTRIENT INTAKES TABLE 3-1 Dietary Guidance for Infants and Children Under the Age of 2 Years Dietary Guidance Source Breastfeeding Breastfeeding is the preferred method of infant feeding AAP, 2005, 2009 because of the nutritional value and health benefits of human milk. Encourage breastfeeding with exclusion of other foods AAP, 2005, 2009; WHO, 2002, until infants are around 6 months of age. 2003 Continue breastfeeding for first year after birth. AAP, 2005, 2009 Continue breastfeeding into second year after birth if AAP, 2001a, 2005, 2009; mutually desired by the mother and child. Kleinman, 2000 Formula Feeding For infants who are not currently breastfeeding, use AAP, 2001a, 2005, 2009; infant formula throughout the first year after birth. Kleinman, 2000 Infant formula used during the first year after birth AAP, 1999, 2001a, 2005, 2009 should be iron-fortified. Feeding Other Foods to Infants and Young Children Introduce semisolid complementary foods gradually AAP, 2005, 2009; Kleinman, beginning around 6 months of age. 2000; WHO, 2002, 2003 Introduce single-ingredient complementary foods, one AAP, 2009 at a time for a several-day trial. Introduce a variety of semisolid complementary foods AAP, 2009; WHO, 2003 throughout ages 6–12 months. Encourage consumption of iron-rich complementary AAP, 2001b, 2005, 2009 foods during ages 6–12 months. Avoid introducing fruit juice before 6 months of age. AAP, 2001b, 2009; Kleinman, 2000 Limit intake of fruit juice to 4–6 fluid ounces/day for AAP, 2001b, 2009 children ages 1–6 years. Encourage children to eat whole fruits to meet their AAP, 2001b, 2009 recommended daily fruit intake. Delay the introduction of cow’s milk until the second AAP, 2005, 2009 year after birth. Cow’s milk fed during the second year after birth AAP, 2009 (age 1 year) should be whole milk. Developing Healthy Eating Patterns Provide children with repeated exposure to new foods AAP, 2009; ADA, 2004 to optimize acceptance and encourage development of eating habits that promote selection of a varied diet. Prepare complementary foods without added sugars or AAP, 2009 salt (i.e., sodium). Promote healthy eating early in life. ADA, 2004 Promoting Food Safety Avoid feeding hard, small, particulate foods up to age AAP, 2009 4 years to reduce risk of choking.

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50 CHILD AND ADULT CARE FOOD PROGRAM age group, and estimate calorie requirements by age group. These topics are addressed below. Establishing Age Groups Throughout the report, the committee uses the notation X–Y to mean X through Y months or years (e.g., 2–4 years means ages 2 through 4 years and 11 months). One of the first steps in the committee’s approach was to establish age groups to use to examine food and nutrient intakes. Current CACFP regulations specify requirements for infants, three groups of children (1–2, 3–5, and 6–12 years), and adults. However, the commit- tee selected different age ranges to evaluate children’s and adults’ intakes relative to current dietary guidance. Descriptive data on food group and nutrient intakes were initially calculated for the following age groups: • Infants ages 6–11 months; • Preschool children age 1 year; • Preschool children ages 2–4 years; • Schoolchildren ages 5–10 years; • Schoolchildren ages 11–13 years; • Youth ages 14–18 years; • Adults ages 19–59 years; • Older adults ages 60 years and older; and • Older adults ages 70 years and older. The age groups for children were chosen to conform with (1) the ages used by the Committee to Review the WIC Food Packages (IOM, 2006a) for preschool children and (2) those used by the Committee on Nutrition Standards for the National School Lunch and Breakfast Program (IOM, 2010) for schoolchildren and adolescents. For infants, analyses were not performed for those under 6 months of age because intakes from breast milk could not be quantified. However, because breast milk is a poor source of iron and zinc after 6 months of age, intakes of these two nutrients were examined by breastfeeding status for infants 6–11 months of age. Separate analyses were performed for younger adults (ages 19–59 years) and adults 60 years of age and older because of differences in their calorie requirements. Initial analyses compared the intakes of adults ages 60 years and older with those of adults ages 70 years and older. The differences were not large, however, and only the broader age group (60 years and older) was used for further analyses. The relatively few pregnant and lactating women were not excluded from the analyses, nor were their intakes examined separately. Because very

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51 EXAMINING FOOD AND NUTRIENT INTAKES few pregnant and lactating women are likely to participate in the adult care portion of CACFP, their requirements were not considered separately. Their nutrient needs would be somewhat higher than those for most women. Determination of Body Weights and Heights Body weight is used to estimate both calorie requirements and protein requirements, and height (length for infants and young children) is also needed to estimate calorie requirements. Therefore, the mean and median body weights and heights were calculated for each age group using anthro- pometric measures from NHANES 2003–2004. Table 3-2 shows the results by gender and age group. Estimation of Calorie Requirements To compare food group intakes with those recommended by MyPyra- mid, it was necessary to select an appropriate MyPyramid pattern for each age group. Because the patterns are determined by calorie requirements, an estimation of calorie needs was made for each CACFP age group, based on TABLE 3-2 Calculated Mean and Median Body Weights and Heights by Age Group Based on NHANES 2003–2004 Age and Gender Mean Body Median Body Mean Height Median Height Group Weight (kg) Weight (kg) (cm) (cm) 82.2a 81.8a 1 year 11.6 11.5 2–4 years 16.1 15.9 99.2 99.1 5–10 years Males 30.6 28.5 129.1 129.1 Females 31.2 27.9 129.5 128.9 11–13 years Males 54.3 51.8 157.5 156.7 Females 53.6 51.4 155.7 155.6 14–18 years Males 73.0 69.7 174.7 175.2 Females 63.2 59.5 161.9 161.9 19–59 years Males 88.0 85.7 177.0 177.3 Females 75.3 70.7 163.1 163.1 $ 60 years Males 87.3 85.5 174.7 174.8 Females 73.0 70.3 160.4 160.1 NOTE: kg 5 kilogram; NA 5 not applicable; NHANES 5 National Health and Nutrition Examination Survey. aRecumbent lengths are given for children 1 year old. SOURCE: NHANES 2003–2004.

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52 CHILD AND ADULT CARE FOOD PROGRAM the age- and gender-specific Estimated Energy Requirement (EER) equa- tions in Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (IOM, 2002/2005). In ad- dition, for children 2 years and older and adults, the committee specified a physical activity level (PAL). The values selected are either low-active or active for the children and sedentary for the adults, as summarized below: • For children ages 1 year and 2–4 years, the committee adopted the approach used by the Committee to Review the WIC Food Packages (IOM, 2006a). This included the use of median heights and weights described in the Dietary Reference Intakes report that includes the EER equations (IOM, 2002/2005) and, for children 2–4 years, a low-active PAL. • For children ages 5–10, 11–13, and 14–18 years, the committee adopted the approach used by the Committee on Nutrition Stan- dards for the National School Lunch and Breakfast Program (IOM, 2010). This included the use of median heights and weights from the Centers for Disease Control and Prevention (CDC) growth charts (Kuczmarski et al., 2000), an active PAL for children 5–10 years, and a low-active PAL for children and adolescents 11–18 years. • For adults 19 years and older, the committee used heights and selected weights from NHANES 2003–2004 and a sedentary PAL. Because a large portion of the adult NHANES population is over- weight, actual weights were not used. Instead, for adults ages 19–59 years, actual weights were replaced with weights that would be consistent with a body mass index (BMI) of 22 (as a midpoint within the range of recommended BMI) for actual heights. For adults ages 60 years and older, the weights used were consistent with a BMI of 25 for actual heights. The use of the higher BMI for this age group was based on evidence that a proportion of the disabled population requiring day care may be at greater risk of low energy intake (Bartali et al., 2003; Sharkey, 2008). Estimated EERs are shown in Table 3-3 by age group and gender and by age group for males and females combined. FOOD INTAKE EVALUATION The evaluation of food intake tends to be complex because many foods are consumed episodically rather than regularly. As described in Appendix G, only one of two possible approaches to use was considered feasible. The Iowa State University Foods method (Nusser et al., 1996) was tested

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53 EXAMINING FOOD AND NUTRIENT INTAKES TABLE 3-3 Median and Mean Estimated Energy Requirements (EERs) and Rounded Calorie Levels by Age Group Median or Meana Calorie Level Average of Rounded Calorie Age Group Males Levels for Males (years) Males Females and Females and Females 1 NA NA 935 950 2–4 NA NA 1,285 1,300 5–10 1,894 1,765 1,830 1,800 11–13 2,125 1,905 2,015 2,000 14–18 2,686 2,044 2,365 2,400 19–29a 2,725 2,078 2,401 2,400 30–39a 2,636 2,046 2,341 2,300 40–49a 2,567 1,997 2,282 2,300 50–59a 2,489 1,920 2,204 2,200 $ 6 0a 2,209 1,687 1,948 1,900 NOTE: NA 5 not applicable. aCalorie levels for adults $ 19 years are mean EERs. SOURCES: EERs for 1 and 2–4 years were calculated based on data from the Continuing Survey of Food Intakes by Individuals (USDA/ARS, 2000) using the median heights method described in the Dietary Reference Intake report (IOM, 2002/2005), as shown in IOM (2006a, p. 51). EERs for 5–10, 11–13, and 14–18 years were calculated using median height and weight from CDC growth charts (Kuczmarski et al., 2000), as shown in IOM (2010, p. 70). EERs for adults over age 19 were calculated using data from NHANES 2003–2004. and found appropriate to use to estimate usual food intakes. Mean calorie intakes from discretionary solid fat and added sugars were estimated using the values 9 calories per gram of fat and 4 calories per gram of sugar. To evaluate how well children’s and adult’s usual food group intakes aligned with Dietary Guidelines for Americans, the committee compared the mean food group intakes for one day with the MyPyramid food patterns (USDA, 2009) for the selected age groups and calorie levels. Calories from solid fat and added sugars were compared with MyPyramid’s allowance for calories from these sources. Tables of the comparisons appear in Chapter 4 (Table 4-1) and Chapter 5 (Table 5-1). NUTRIENT INTAKE EVALUATION A primary focus of the committee’s assessment of nutrients was to examine the apparent prevalence of inadequate or excessive intakes of nutrients. To carry out the intake assessments, the committee estimated usual nutrient intakes and used methods recommended and described by the Institute of Medicine (IOM) for the assessment of energy and nutrient intakes (IOM, 2000). These methods make use of the Estimated Average

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54 CHILD AND ADULT CARE FOOD PROGRAM Requirement (EAR), Adequate Intake (AI), and Tolerable Upper Intake Level (UL), but not the Recommended Dietary Allowance (RDA). The methods used in estimating usual intakes and applying the different types of reference values are described below and in Appendix G. Estimating Usual Nutrient Intakes The usual intake of a nutrient is an individual’s long-term average in- take of that nutrient (NRC, 1986). Usual intake must be estimated; it can- not be observed, because day-to-day intakes vary considerably. The Iowa State University method (Nusser et al., 1996) is the commonly used and accepted approach for estimating the usual intakes by population groups. This method estimates the distribution of usual intakes by using a single 24-hour recall for all members of the group and a second 24-hour recall for some proportion of the group. For NHANES 2003–2004, a second 24-hour recall was collected for all persons in the sample. The personal computer version of the Software for Intake Distribution Estimation (PC-SIDE; ISU, 1997) was used to estimate (1) usual nutrient intake distributions and (2) the proportion of children and adults with usual intakes above or below the defined cutoff values. Applying the Dietary Reference Intakes: Institute of Medicine Methodology The Dietary Reference Intakes (DRIs) released by the IOM replaced the previously used RDAs (NRC, 1989) as authoritative reference values. The DRIs provide several types of reference values for use in the assessment and planning of diets of groups, including the EAR, the AI for nutrients without an EAR, the UL, and the Acceptable Macronutrient Distribution Range (AMDR). Definitions of these DRIs are given in Box 3-1. Contrary to earlier practice, all DRIs except the RDAs are useful for the assessment of nutrient intakes. The RDAs are inappropriate for the assess- ment of the nutrient intakes of groups because the percentage of individu- als with usual intakes below the RDA does not estimate the percentage of individuals with inadequate intakes. The prevalence of inadequate intakes can be estimated by comparing usual intakes in the group to the entire distribution of requirements in the same group. This approach is known as the full probability approach and was proposed by the National Research Council (1986). The EAR cut-point method, a shortcut of the full probabil- ity approach, may also be used to obtain such an estimate (Beaton, 1994; Carriquiry, 1999; IOM, 2000). Estimation of the prevalence of nutrient inadequacy in a group by determining the proportion of individuals with

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55 EXAMINING FOOD AND NUTRIENT INTAKES BOX 3-1 Definitions of Dietary Reference Intakes Used to Plan and Assess Group Intakes Estimated Average Requirement (EAR) An EAR is the usual daily intake level that is estimated to meet the nutrient requirements of half of the healthy individuals in a life-stage and gender group. Adequate Intake (AI) When the evidence was insufficient to determine an EAR for a nutrient, the Institute of Medicine set AI values instead. The AI is defined as a recommended average daily nutrient intake level and is based on observed or experimentally derived intake levels or approximations of the mean nutrient intake level by a group (or groups) of apparently healthy people that are assumed to be adequate (IOM, 2006b). Tolerable Upper Intake Level (UL) A UL is the highest daily intake level that likely poses no risk of adverse health effects. As the usual daily intake increases above the UL, the risk of adverse effects increases. The ULs for most nutrients are based on intakes from supplements as well as intakes from foods and beverages. Acceptable Macronutrient Distribution Range (AMDR) The AMDRs are de- fined for energy-providing macronutrients. AMDRs define the range of usual daily intakes that is associated with a reduced risk of chronic disease while providing adequate amounts of essential nutrients. intakes below the RDAs would lead to overestimation of the true preva- lence of nutrient inadequacy (IOM, 2000). DRIs are defined for 12 different life-stage and gender groups. For schoolchildren, the groups are 5–8 years (both genders), males ages 9–13 years, females ages 9–13 years, males ages 14–18 years, and females ages 14–18 years. Evaluating Adequacy for Nutrients with an EAR The proportion of a group with usual daily intakes below the EAR is an estimate of the prevalence of nutrient inadequacy in that population group. With the exception of iron for female adolescents, the method of choice for assessment of the prevalence of nutrient inadequacy is the EAR cut-point method (IOM, 2000, 2003). The EAR cut-point method involves estimation of the proportion of individuals in a group whose usual nutrient intakes are less than the EAR. It has been shown that, under certain assumptions, the proportion with usual intakes less than the EAR is an estimate of the propor-

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56 CHILD AND ADULT CARE FOOD PROGRAM tion of a group whose usual intakes do not meet the requirements (Beaton, 1994; Carriquiry, 1999; IOM, 2000). This approach was used to estimate the prevalence of inadequate intakes within each of the CACFP age groups for protein, carbohydrates, nine vitamins (A, B6, B12, C, E, thiamin, riboflavin, niacin, and folate), and three minerals (phosphorus, magnesium, and zinc). Some of the CACFP age groups contain more than one DRI age group; for example, the age group for children 5 to 10 years contains two: DRI age groups 4–8 years and 9–13 years. The CACFP group for females (or males) ages 19–59 years contains three DRI groups: 19–30, 31–50, and 51–60 years. When mixed CACFP age groups occurred, the committee first esti- mated usual nutrient intake distributions and the proportion of individuals with usual intakes below the EAR using the DRI groups. The committee then computed the weighted average of the DRI group-specific prevalence of inadequacies, where the weights were given by the proportion of persons that belonged to each DRI group in the mixed CACFP group. For female adolescents and for women ages 19–59 years, the probabil- ity approach (NRC, 1986) was used to assess iron intake, as recommended by the IOM (2000). This more complex approach accounts for both the distribution of iron requirements (which is skewed for these age-gender groups; see IOM, 2000) and the distribution of usual intakes. Moreover, the committee increased the EAR value used for females ages 11–13 years from 5.7 mg of iron per day to 7.5 mg per day, as explained in the School Meals report (IOM, 2010, pp. 65–66). Dietary Reference Intakes: Applications in Dietary Assessment (IOM, 2000) provides more detailed information about the EAR cut-point and probability methods. Evaluating Adequacy for Nutrients with an AI Groups with mean intakes at or above the AI can generally be assumed to have a low prevalence of inadequacy for the criterion of adequate nutri- tional status used for that nutrient. Assumptions about the inadequacy of intakes cannot be made when the mean intake is below the AI. As described by the IOM (2000), the inherent limitations of the AI affect the inferences that can be made about the prevalence of inadequacy for nutrients with an AI (IOM, 2000). Data were evaluated by comparing the estimated mean in- takes with the AI. For the mixed DRI age groups, the committee proceeded as described above and computed the weighted average of the mean intakes divided by the age-appropriate AIs. Evaluating the Risk of Excessive Intake The proportion of a group with intakes above the UL is an estimate of the prevalence of intakes at risk of being excessive. The data from NHANES

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57 EXAMINING FOOD AND NUTRIENT INTAKES 2003–2004 do not include contributions from dietary supplements. For this reason, the committee’s assessment of usual nutrient intakes relative to ULs focused primarily on intakes of sodium. Usual intakes of saturated fat and cholesterol were compared with the recommendations in the 2005 Dietary Guidelines for Americans (HHS/ USDA, 2005) to determine the percentage of individuals in each age group with intakes that exceeded the recommendations. Evaluating Ranges of Energy Intake from Macronutrients AMDRs are expressed as a percentage of the total energy intake. For example, the AMDR for fat for children ages 4 through 18 years is 25 to 35 percent of the total energy intake. For these nutrients, the proportion of an age group that fell within defined AMDRs, as well as proportions with usual intakes that either exceeded or fell below the AMDRs, was examined. SUMMARY NHANES 2003–2004, plus the MPED 2.0, were the primary sources of dietary data used by the committee. The standards against which intakes were measured included AAP recommendations for those younger than 2 years, the 2005 Dietary Guidelines for Americans (HHS/USDA, 2005) for those 2 years and older, and the DRIs for persons across the entire age span. Mean food intakes for those ages 2 years and older were evaluated by comparison with MyPyramid food pattern recommendations for selected calorie levels. Nutrient intakes were evaluated using the IOM methodology. Results of these evaluations appear in the next two chapters. REFERENCES AAP (American Academy of Pediatrics). 1999. Iron fortification of infant formulas. Pediatrics 104(1 I):119–123. AAP. 2001a. WIC program. Pediatrics 108(5):1216–1217. AAP. 2001b. American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics. Pediatrics 107(5):1210–1213. AAP. 2005. Breastfeeding and the use of human milk. Pediatrics 115(2):496–506. AAP. 2009. Pediatric Nutrition Handbook, 6th ed. Elk Grove Village, IL: AAP. ADA (American Dietetic Association). 2004. Position of the American Dietetic Association: Dietary guidance for healthy children ages 2 to 11 years. Journal of the American Dietetic Association 104(4):660–677. Ard, J. D., C. J. Coffman, P. H. Lin, and L. P. Svetkey. 2004. One-year follow-up study of blood pressure and dietary patterns in Dietary Approaches to Stop Hypertension (DASH)-Sodium participants. American Journal of Hypertension 17(12):1156–1162. Appel, L. J., M. W. Brands, S. R. Daniels, N. Karanja, P. J. Elmer, and F. M. Sacks. 2006. Dietary approaches to prevent and treat hypertension: A scientific statement from the American Heart Association. Hypertension 47(2):296–308.

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