Guiding Principles for Developing Dietary Reference Intakes Based on Chronic Disease (2017) / Chapter Skim
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2 The Current Process to Establish Dietary Reference Intakes
2 The Current Process to Establish Dietary Reference Intakes
Pages 39-72
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From page 39... ...
) as well as potential risk of excess nutrient intake (Tolerable Upper Intake Level [UL]
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and a UL. If adequate data are available, the DRI may have incorporated considerations for BOX 2-1 Dietary Reference Intakes The Dietary Reference Intakes (DRIs)
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The current DRI process was initiated in the early 1990s, in recognition of the expanded uses of dietary reference values and newer insights into the role of nutrients. With sponsorship primarily from U.S.
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If such data are available, an EAR is identified and used to establish an RDA (an intake level that meets the needs of nearly all members of a sex and life-stage group, i.e., two standard deviations above the
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The DRI process also considers risks of adverse effects from excessive intakes. Thus, many nutrients that have an EAR and RDA or AI also have a UL, which represents a maximal daily intake level that is unlikely to lead to adverse health effects when consumed habitually.
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However, as intake increases above the UL, risk of adverse effects may increase. It should be noted that much less is known about the "shape" of the risk curve for the adverse effects EAR 1.0 RDA UL 1.0 Risk of Adverse Effects Risk of Inadequacy 0.5 0.5 0.0 0.0 Observed Level of Intake FIGURE 2-1 Relationship between Dietary Reference Intakes (DRIs)
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However, because of their importance to health, establishing reference values for adequacy for essential nutrients has been considered necessary, regardless of the certainty in the evidence. In the past, therefore, the basis for nutrient adequacy has varied for each nutrient depending, in part, on the availability of data that allowed estimation of an EAR.
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NOTES: Numbering and arrows reference hierarchical proximity to the clinical outcome of interest. Blood pressure is a surrogate for cardiovascular disease and bone density is a sur rogate for fracture risk.
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Step 3: Intake Assessment The reference values determined in Step 2 are then compared to current levels of intake. A variety of different national survey data are used for this com parison, including the National Health and Nutrition Examination Survey, the Continuing Survey of Food Intake by Individuals, and the Canadian Community Health Survey.
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Federal Assess the nutrient adequacy USDA child nutrition EAR, AI, UL supplemental of specific population programs (USDA, food program groups to determine what 2016) planning supplemental foods should be provided Research Design and evaluate data Planning diets EAR, AI, RDA, UL from human studies; analyze for intervention dietary intake data studies (individual level application)
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nutrient intake NOTES: AI = adequate intake; AMDR = acceptable macronutrient distribution range; CCHS = Canadian Community Health Survey; DRI = Dietary Reference Intake; EAR = Estimated Average Requirement; NHANES = National Health and Nutrition Examination Survey; NTD = neural tube defect; RDA = Recommended Dietary Allowance; UL = Tolerable Upper Intake Level; USDA = U.S. Department of Agriculture.
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. In the case of saturated fatty acids, monounsaturated fatty acids, trans fatty acids, cholesterol, beta carotene, and other carotenoids, DRI committees have concluded that no EAR or AI values could be determined because of insufficient evidence that these food components are considered essential to human health (IOM, 2000b, 2002/2005)
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. DRI committees have also taken into account potential reductions or increases in chronic disease outcomes.
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Nutrient Adequacy Endpoints Calcium EAR Bone healthc Serum calcium Parathyroid Calcium balancec hormone Calcium Bone mineral absorption content/bone mineral densityc Hypertension
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D in some biologically Diabetes (type 2) and different ways, most metabolic syndrome notably among those Falls of African American Fracture risk ancestry.
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D levels consistent with desirable changes in bone density and fracture risk)
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to calcium and vitamin Cardiovascular diseases D in some biologically Diabetes (type 2) and different ways, most metabolic syndrome notably among those Falls of African American Fracture riskc ancestry; however, the Immune responses (asthma, available data were too autoimmune disease)
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56 PRINCIPLES FOR DEVELOPING DRIs BASED ON CHRONIC DISEASE TABLE 2-3 Continued Indicator Selected as the Basis for Indicators Considered, But Not Selected Establishment of Chronic Disease Reference Related DRI (AI, Biomarkers of Surrogate Nutrient Value EAR, UL) Nutrient Adequacy Endpoints ULd Hypercalcemia and related toxicity Emerging evidence for all-cause mortality, some cancers, cardiovascular risk, falls and fractures Sodium AIe Replenish losses of Sodium balance Blood pressure sodium needs Chloride balance Plasma renin of moderately Serum activity active, apparently concentration Blood lipids healthy concentration individuals Insulin resistance Based on ensuring adequate intake of other nutrients
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Falls and fractures All-cause mortality Balance studies AI for 0-12 months was RCTs with feeding or based on mean sodium behavioral interventions intake. Observational studies For 1-18 years, AI is extrapolated down based on energy intake.
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is a point on the continuous relationship with blood pressure that corresponds with the next level above the AI that was tested in dose-response trials. Total fiber AIe Intake level found Fiber intake, Blood pressure to protect against satiety and Hyperlipidemia coronary heart weight Glucose tolerance disease.
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intake. Colon cancer Breast cancer Evidence was insufficient to Other cancers (endometrial, set levels for: ovarian)
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60 PRINCIPLES FOR DEVELOPING DRIs BASED ON CHRONIC DISEASE TABLE 2-3 Continued Indicator Selected as the Basis for Indicators Considered, But Not Selected Establishment of Chronic Disease Reference Related DRI (AI, Biomarkers of Surrogate Nutrient Value EAR, UL) Nutrient Adequacy Endpoints Fluoride AIe Prevention of Fluoride balance Bone mineral dental caries content UL UL for infants and Enamel fluorosis children ages 0-8 years is based on risk of enamel fluorosis (two studies from 1937 and 1942)
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THE CURRENT PROCESS TO ESTABLISH DIETARY REFERENCE INTAKES 61 Considerations for Chronic Disease Types of Studiesa Other Populationsb Dental caries Epidemiological studies AI for 0-12 months was (observational) based on mean fluoride intake.
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NOTES: AI = adequate intake; CVD = cardiovascular disease; DRI = Dietary Reference Intake; EAR = Estimated Average Requirement; LOAEL = lowest-observed-adverse-effect level; RCT = randomized controlled trial; UL = Tolerable Upper Intake Level. Systematic reviews, conducted by an outside contractor, were used by the DRI committee to establish DRIs for calcium and vitamin D (IOM, 2011)
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Intervention studies AI for children age 1-18 years is extrapolated from adult AI based on median energy intakes. Evidence was insufficient to set levels for: - sex - race/ethnicity - pregnancy - those on a high protein diet -individuals on diuretic therapies -individuals with predisposition to hyperkalemia -individuals older than 50 years of age b Criteria for nutrition adequacy might differ for different ages and justification is described; it is not basal or normative, as in other reports.
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DRIs based on indirect measurement of chronic disease outcomes using intermediate outcomes were established for sodium, vitamin D, calcium, and potassium. The UL for sodium was based on risk of increased blood pressure and cardiovascular outcomes, particularly cardiovascular disease and stroke.
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Types of Study Designs Used to Develop DRIs The scientific data used to establish DRIs have been drawn from observational and experimental studies done in humans. For the most part, experimental studies have been used to establish EARs and RDAs, while AIs and ULs have been based more often on evidence from observational studies.
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Standards for children are extrapolated from adult data based on a body weight or a metabolic factor and then adjusted for growth or tissue deposition needs. An estimate for tissue deposition is also required for estimating nutrient requirements of pregnant women.
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Zinc The zinc requirement may be as much as 50 percent higher, especially for strict vegetarians who consume grains and legumes as the major food staples. Vitamin A Individuals who do not consume animal-based foods must meet their requirement by consuming sufficient provitamin A carotenoids or fortified foods.
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Individuals unaccustomed to Sodium Due to the excessive loss of prolonged physical activity in sodium, the AI might not a hot environment that engage apply to individuals in these in intense exercise under such situations. environment Recommendation according Protein Recommendation for adults is to reference body weight 0.8 g/kg/day.
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Table 2-4 lists the appropriate adjustments for several common considerations. As the previous DRI committees began to introduce the idea of chronic disease outcomes as a basis for nutrient adequacy or toxicity, they began to
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1998a. Dietary Reference Intakes: A risk assessment model for establishing upper intake levels for nutrients.
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2006b. Dietary Reference Intakes: The essential guide to nutrient requirements.
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