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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 Health Canada; U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion, Contract No. 282-96-0033; the Dietary Reference Intakes Private Foundation Fund, including the Dannon Institute and the International Life Sciences Institute; and the Dietary Reference Intakes Corporate Donors' Fund. Contributors to the Fund to date include Daiichi Fine Chemicals, Inc.; Kemin Foods, L.C.; M&M/Mars; Mead Johnson Nutritionals; Nabisco Foods Group; Natural Source Vitamin E Association; Roche Vitamins Inc.; U.S. Borax; and Weider Nutritional Group. The opinions or conclusions expressed herein are those of the committee and do not necessarily reflect those of the funders.
Library of Congress Cataloging-in-Publication Data
Dietary reference intakes. Applications in dietary assessment : a report of the Subcommittees on Interpretation and Uses of Dietary Reference Intakes and Upper Reference Levels of Nutrients, and the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-309-07311-1 (hardcover) — ISBN 0-309-07183-6 (pbk.)
1. Nutrition. 2. Reference values (Medicine) 3. Nutrition—Evaluation. I. Title: Applications in dietary assessment. II. Institute of Medicine (U.S.). Subcommittee on Interpretation and Uses of Dietary Reference Intakes. III. Institute of Medicine (U.S.). Subcommittee on Upper Reference Levels of Nutrients. IV. Institute of Medicine (U.S.). Standing Committee on the Scientific Evaluation of Dietary Reference Intakes.
[DNLM: 1. Nutrition Assessment. 2. Dietetics. 3. Nutrition Policy. 4. Nutritional Requirements. QU 146 D5656 2001]
QP141 D525 2001
613.2—dc21
00-069187
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Institute of Medicine
National Research Council
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SUBCOMMITTEE ON INTERPRETATION AND USES OF DIETARY REFERENCE INTAKES
SUZANNE P. MURPHY (Chair),
Cancer Research Center of Hawaii, University of Hawaii, Honolulu
LENORE ARAB,
Department of Epidemiology, University of North Carolina School of Public Health, Chapel Hill
SUSAN I. BARR, Faculty of Agricultural Sciences,
University of British Columbia, Vancouver
SUSAN T. BORRA,
International Food Information Council, Washington, D.C.
ALICIA L. CARRIQUIRY,
Department of Statistics, Iowa State University, Ames
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
JEAN-PIERRE HABICHT,
Division of Nutritional Sciences, Cornell University, Ithaca, New York
JANET C. KING,*
USDA Western Human Nutrition Research Center, University of California, Davis
HARRIET V. KUHNLEIN,
Centre for Indigenous Peoples' Nutrition and Environment, McGill University, Ste. Anne de Bellevue, Quebec
Consultant
GEORGE BEATON,
GHB Consulting, Willowdale, Ontario
Staff
Mary Poos, Study Director
Alice L. Vorosmarti, Research Associate
Michele Ramsey, Senior Project Assistant
Karah Nazor, Project Assistant
* |
Term of Service February 17, 1998, to June 30, 1999 |
SUBCOMMITTEE ON UPPER REFERENCE LEVELS OF NUTRIENTS
IAN C. MUNRO (Chair),
CanTox, Inc., Mississauga, Ontario
GEORGE C. BECKING,
Phoenix OHC, Kingston, Ontario
RENATE D. KIMBROUGH,
Institute for Evaluating Health Risks, Washington, D.C.
RITA B. MESSING,
Division of Environmental Health, Minnesota Department of Health, St. Paul
SANFORD A. MILLER,
Graduate School of Biomedical Sciences, University of Texas Health Sciences Center, San Antonio
HARRIS PASTIDES,
School of Public Health, University of South Carolina, Columbia
JOSEPH V. RODRICKS,
The Life Sciences Consultancy LLC, Washington, D.C.
IRWIN H. ROSENBERG,
Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
STEVE L. TAYLOR,
Food Processing Center, University of Nebraska-Lincoln
JOHN A. THOMAS, Professor Emeritus,
University of Texas Health Science Center at San Antonio
GARY M. WILLIAMS,
Department of Pathology, New York Medical College, Valhalla, New York
Staff
Sandra Schlicker, Study Director
Michele Ramsey, Senior Project Assistant
STANDING COMMITTEE ON THE SCIENTIFIC EVALUATION OF DIETARY REFERENCE INTAKES
VERNON R. YOUNG (Chair),
Laboratory of Human Nutrition, School of Science, Massachusetts Institute of Technology, Cambridge
JOHN W. ERDMAN, JR. (Vice-Chair),
Division of Nutritional Sciences, College of Agricultural, Consumer and Environmental Sciences, 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
ROBERT J. COUSINS,
Center for Nutritional Sciences, University of Florida, Gainesville
JOHANNA T. DWYER,
Frances Stern Nutrition Center, New England Medical Center and Tufts University, Boston, Massachusetts
JOHN D. FERNSTROM,
UPMC Health System Weight Management Center, University of Pittsburgh School of Medicine, Pennsylvania
SCOTT M. GRUNDY,
Center for Human Nutrition, University of Texas Southwestern Medical Center at Dallas
JANET C. KING,*
USDA Western Human Nutrition Research Center, University of California, Davis
SANFORD A. MILLER,
Graduate School of Biomedical Sciences, University of Texas Health Sciences Center, San Antonio
WILLIAM M. RAND,
Department of Family Medicine and Community Health, Tufts University School of Medicine, Boston, Massachusetts
U.S. Government Liaison
ELIZABETH CASTRO,
Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, Washington, D.C.
* |
Term of Service December 12, 1997, to June 30, 1999 |
Canadian Government Liaison
PETER W.F. FISCHER,
Nutrition Research Division, Health Protection Branch, Health Canada, Ottawa, Ontario
Staff
Allison A. Yates, Study Director
Gail E. Spears, Administrative Assistant
Mary Poos, Senior Program Officer
Sandra Schlicker, Senior Program Officer
Paula Trumbo, Senior Program Officer
Alice L. Vorosmarti, Research Associate
Kimberly Freitag, Research Assistant
Michele Ramsey, Senior Project Assistant
FOOD AND NUTRITION BOARD
CUTBERTO GARZA (Chair),
Division of Nutritional Science, Cornell University, Ithaca, New York
ALFRED H. MERRILL, JR. (Vice Chair),
Center for Nutrition and Health Sciences, Emory University, Atlanta, Georgia
ROBERT M. RUSSELL (Vice Chair),
Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
VIRGINIA A. STALLINGS (Vice Chair),
Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, Pennsylvania
LARRY R. BEUCHAT,
Center for Food Safety and Quality Enhancement, University of Georgia, Griffin
BENJAMIN CABALLERO,
Center for Human Nutrition, Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland
FERGUS M. CLYDESDALE,
Department of Food Science, University of Massachusetts at Amherst
ROBERT J. COUSINS,
Center for Nutritional Sciences, University of Florida, Gainesville
SCOTT M. GRUNDY,
Center for Human Nutrition, University of Texas Southwestern Medical Center at Dallas
LYNN PARKER,
Child Nutrition Programs and Nutrition Policy, Food Research and Action Center, Washington, D.C.
ROSS L. PRENTICE,
Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
A. CATHARINE ROSS,
Department of Nutrition, The Pennsylvania State University, University Park
ROBERT E. SMITH,
R.E. Smith Consulting, Inc., Newport, Vermont
STEVE L. TAYLOR,
Food Processing Center, University of Nebraska-Lincoln
Staff
Allison A. Yates, Director
Gail E. Spears, Administrative Assistant
Gary Walker, Financial Associate
Preface
This report is one of a series that relates to the development of Dietary Reference Intakes. This report focuses on applications of Dietary Reference Intakes (DRIs) in dietary assessment from the Subcommittee on Interpretation and Uses of Dietary Reference Intakes (Uses Subcommittee) of the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes (DRI Committee). A forthcoming report from this Subcommittee will address applications of DRIs in dietary planning.
The Food and Nutrition Board anticipated that considerable guidance would be needed to assist American and Canadian health professionals in the transition from using the former Recommended Dietary Allowances (RDAs) for the United States and Recommended Nutrient Intakes (RNIs) for Canada to using the new DRIs, and thus charged the DRI Committee and the Uses Subcommittee to develop advice on the appropriate uses of these new references.
In the past, RDAs and RNIs were the primary values that were available to health professionals for planning and assessing the diets of individuals and groups. However, the former RDAs and RNIs were not ideally suited for many of these applications. The new DRIs represent a more complete set of values that were developed anticipating diverse uses for planning and/or assessment and thus allow more robust approaches. To assist health professionals in their use of the new DRIs, the Uses Subcommittee divided its work into two parts: the current report examines the appropriate use of each of the available DRI values in assessing nutrient intakes of groups and of individuals and a second report will present informa-
tion on the appropriate use of specific DRI values in the planning of diets for groups and for individuals. Each report will present the statistical underpinnings for the various uses of the DRI values, present sample applications, and provide guidelines to help professionals determine when specific uses are inappropriate.
A probability approach to assessing prevalence of nutrient inadequacy in groups was developed and presented—with extensive statistical validation and identification of sources of error—in the National Research Council Report, Nutrient Adequacy (NRC, 1986). The availability of Estimated Average Requirements (EARs), one of the categories of DRIs, makes the use of the probability approach possible. A modified approach, using the Estimated Average Requirement (EAR) as a cutpoint for assessing the prevalence of nutrient inadequacy in groups, is presented in this report. The cut-point method, however, is not a new independent approach; it is a modification of the probability approach. The statistical validation of the EAR cutpoint method to assess prevalence of inadequacy in groups is presented in this report.
When the initial plan to revise the former RDAs was published (IOM, 1994), the Food and Nutrition Board envisioned the simultaneous establishment of the DRI Committee and two standing subcommittees, the Subcommittee on Upper Reference Intake Levels of Nutrients and the Uses Subcommittee. However, circumstances precluded the early convening of the Uses Subcommittee. It was not established until early 1998, after the release of the first two nutrient reports (IOM, 1997, 1998b).
The Uses Subcommittee, with expertise in nutrition, dietetics, statistics, nutritional epidemiology, public health, economics, and consumer perspectives, was charged to review the scientific literature regarding the uses of dietary reference standards and their applications, and to provide guidance for (1) the appropriate application of DRIs for specific purposes and identification of inappropriate applications, (2) appropriate assumptions regarding intake and requirement distributions, (3) adjustments needed to minimize potential errors in dietary intake data, and (4) appropriate use of DRI values of specific nutrients. Starting with the report of the Panel on Dietary Antioxidants and Related Compounds, this specific guidance will be found in the nutrient reports.
This report reflects the work of the Food and Nutrition Board's DRI Committee, the Uses Subcommittee, and the Subcommittee on Upper Reference Levels of Nutrients. The support of the government of Canada and Canadian scientists in establishing the Uses Subcommittee represents a pioneering first step in the standardiza-
tion of nutrient reference intakes in North America. A brief description of the overall DRI project is given in Appendix A.
This report has been reviewed by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review was to provide candid and critical comments to assist the authors and the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The contents of the review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We wish to thank the following individuals for their participation in the review of this report: Cynthia M. Beall, Ph.D., Case Western Reserve University; William H. Danforth, M.D., Washington University; Mary J. Kretsch, Ph.D., RD, U.S. Department of Agriculture; George P. McCabe, Ph.D., Purdue University; Grace L. Ostenso, Ph.D., Washington, D.C.; Eric B. Rimm, Sc.D., Harvard School of Public Health; Christopher P. Sempos. Ph.D., State University of New York; Helen Smiciklas-Wright, Ph.D., RD, Pennsylvania State University; Paul D. Stolley, M.D., MPH, University of Maryland at Baltimore; and Valerie Tarasuk, Ph.D., University of Toronto.
Although the individuals listed above provided many constructive comments and suggestions, responsibility for the final content of this report rests solely with the authoring committee and the Institute of Medicine.
The DRI Committee wishes to acknowledge, in particular, the commitment and dedication shown by Suzanne P. Murphy, chair of the Uses Subcommittee. Dr. Murphy's expertise and direction were key to the resolution of controversial issues and to the presentation of technically complex information and its statistical basis in a clear and readily understandable manner. Sincere thanks are also extended to George H. Beaton for his willingness to participate as a technical consultant to the Uses Subcommittee. His provocative comments and assistance provided an important impetus to move the conceptual framework, while still in development and far from complete, forward. Not all issues have been resolved, but the foundation has been initiated. 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 many contributions to the synthesis of the report. We recognize the significant efforts of the Subcommittee and the Food and Nutrition Board staff that were required to achieve the completion of this report. It is, of course,
the Food and Nutrition Board staff who get much of the work completed, so on behalf of the DRI Committee and the Board, we wish to thank Allison 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 Michele Ramsey, Alice Vorosmarti, Karah Nazor, Sandra Schlicker, and Gail Spears. We wish also to thank Carol Suitor for scientific and organizational review, Judith Dickson for editing the manuscript, and Mike Edington and Claudia Carl for assistance with its publication.
Vernon Young
Chair, Standing Committee on the Scientific Evaluation of Dietary Reference Intakes
Cutberto Garza
Chair, Food and Nutrition Board