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DRI DIETARY REFERENCE INTAKES FOR Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids Panel on Macronutrients, Panel on the Definition of Dietary Fiber, Subcommittee on Upper Reference Levels of Nutrients, Subcommittee on Interpretation and Uses of Dietary Reference Intakes, and the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes Food and Nutrition Board

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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 Na- tional Academy of Sciences, the National Academy of Engineering, and the Institute of Medi- cine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This project was funded by the U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion, Contract No. 282-96-0033, TO #4; Health Canada; the U.S. Food and Drug Administration; the National Institutes of Health; the Centers for Disease Control and Prevention; the U.S. Department of Agriculture; the Department of Defense; the Institute of Medicine; the Dietary Reference Intakes Private Foundation Fund, including the Dannon Institute and the International Life Sciences Institute, North America; and the Dietary Reference Intakes Corporate Donors’ Fund. Contributors to the Fund in- clude Roche Vitamins Inc, Mead Johnson Nutrition Group, and M&M Mars. The views pre- sented in this report are those of the Institute of Medicine Standing Committee on the Scientific Evaluation of Dietary Reference Intakes and its panels and subcommittes and are not necessarily those of the funding agencies. Library of Congress Cataloging-in-Publication Data Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids / Panel on Macronutrients, Panel on the Definition of Dietary Fiber, Subcommittee on Upper Reference Levels of Nutrients, Subcommittee on Interpretation and Uses of Dietary Reference Intakes, and the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board. p. ; cm. Includes bibliographical references and index. ISBN 0-309-08525-X (pbk.) — ISBN 0-309-08537-3 (hardcover) 1. Nutrition. 2. Reference values (Medicine) [DNLM: 1. Nutrition. 2. Diet. 3. Reference Values. ] I. Institute of Medicine (U.S.). Panel on Macronutrients. II. Institute of Medicine (U.S.). Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. QP141.D529 2005 613.2—dc22 2004031026 Additional copies of this report are 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 metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2002/2005 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 cul- tures and religions since the beginning of recorded history. The serpent adopted as a logo- type by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated 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. Ralph J. Cicerone 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 engi- neering 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 Sciences 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. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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PANEL ON DIETARY REFERENCE INTAKES FOR MACRONUTRIENTS JOANNE R. LUPTON (Chair), Faculty of Nutrition, Texas A&M University, College Station GEORGE A. BROOKS, Department of Integrative Biology, University of California, Berkeley NANCY F. BUTTE, Department of Pediatrics, U.S. Department of Agriculture/Agriculture Research Service Children’s Nutrition Research Center, Baylor College of Medicine, Houston, Texas BENJAMIN CABALLERO, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland JEAN PIERRE FLATT, Department of Biochemistry and Molecular Biology, University of Massachusetts Medical Center, Worcester SUSAN K. FRIED, Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey PETER J. GARLICK, Department of Surgery, State University of New York at Stony Brook SCOTT M. GRUNDY, Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas SHEILA M. INNIS, BC Research Institute for Children’s and Women’s Health, University of British Columbia, Vancouver DAVID J.A. JENKINS, Department of Nutritional Sciences, University of Toronto, Ontario RACHEL K. JOHNSON, Department of Nutrition and Food Sciences, University of Vermont, Burlington RONALD M. KRAUSS, Department of Molecular Medicine, Lawrence Berkeley National Laboratory, University of California, Berkeley PENNY KRIS-ETHERTON, Department of Nutrition, Pennsylvania State University, University Park ALICE H. LICHTENSTEIN, Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts FRANK Q. NUTTALL, Department of Medicine, University of Minnesota School of Medicine, Minneapolis PAUL B. PENCHARZ, Departments of Pediatrics and Nutritional Sciences, University of Toronto, Ontario F. XAVIER PI-SUNYER, Department of Medicine, Columbia University, New York WILLIAM M. RAND, Department of Family Medicine and Community Health, Tufts University School of Medicine, Boston, Massachusetts PETER J. REEDS (deceased), Department of Animal Sciences, University of Illinois at Urbana-Champaign ERIC B. RIMM, Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts SUSAN B. ROBERTS, Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts v

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Staff PAULA R. TRUMBO, Study Director SANDRA SCHLICKER, Senior Program Officer ALICE L. VOROSMARTI, Research Associate KIMBERLY STITZEL, Research Assistant (until January 2001) CARRIE L. HOLLOWAY, Research Assistant GAIL E. SPEARS, Staff Editor SANDRA AMAMOO-KAKRA, Senior Project Assistant MICHELE RAMSEY, Senior Project Assistant (until June 2001) vi

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PANEL ON THE DEFINITION OF DIETARY FIBER JOANNE R. LUPTON (Chair), Faculty of Nutrition, Texas A&M University, College Station GEORGE C. FAHEY, Department of Animal Sciences, University of Illinois at Urbana-Champaign DAVID J.A. JENKINS, Department of Nutritional Sciences, University of Toronto, Ontario JUDITH A. MARLETT, Department of Nutritional Science, University of Wisconsin-Madison JOANNE L. SLAVIN, Department of Food Science and Nutrition, University of Minnesota, St. Paul JON A. STORY, Department of Foods and Nutrition, Purdue University, West Lafayette, Indiana CHRISTINE L. WILLIAMS, Department of Pediatrics, Columbia University, New York Consultants LEON PROSKY, Prosky Associates, Rockville, Maryland ALISON STEPHEN, CanTox, Inc., Mississauga, Ontario Staff PAULA R. TRUMBO, Study Director ALICE L. VOROSMARTI, Research Associate KIMBERLY STITZEL, Research Assistant (until January 2001) CARRIE L. HOLLOWAY, Research Assistant GAIL E. SPEARS, Staff Editor SANDRA AMAMOO-KAKRA, Senior Project Assistant MICHELE RAMSEY, Senior Project Assistant (until June 2001) vii

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SUBCOMMITTEE ON UPPER REFERENCE LEVELS OF NUTRIENTS IAN C. MUNRO (Chair through December 2001), CanTox, Inc., Mississauga, Ontario, Canada JOSEPH V. RODRICKS (Chair beginning January 2002), ENVIRON International Corporation, Arlington, Virginia G. HARVEY ANDERSON, Department of Nutritional Sciences, University of Toronto, Ontario GEORGE C. BECKING, Phoenix OHC, Kingston, Ontario ELAINE FAUSTMAN, Department of Environmental Health, University of Washington, Seattle SUZANNE HENDRICH, Department of Food Science and Human Nutrition, Iowa State University, Ames SANFORD A. MILLER, Center for Food and Nutrition Policy, Virginia Polytechnic Institute and State University, Alexandria HARRIS PASTIDES, School of Public Health, University of South Carolina, Columbia JOHN A. THOMAS, San Antonio, Texas GARY M. WILLIAMS, Department of Environmental Pathology and Toxicology, New York Medical College, Valhalla, New York Staff SANDRA SCHLICKER, Study Director SANDRA AMAMOO-KAKRA, Senior Project Assistant viii

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SUBCOMMITTEE ON INTERPRETATION AND USES OF DIETARY REFERENCE INTAKES SUSAN I. BARR (Chair), Department of Food, Nutrition, and Health, University of British Columbia, Vancouver TANYA D. AGURS-COLLINS, Department of Oncology, Howard University Cancer Center, Washington, D.C. ALICIA CARRIQUIRY, Department of Statistics, Iowa State University, Ames ANN M. COULSTON, Hattner/Coulston Nutrition Associates, LLC., Palo Alto, California BARBARA L. DEVANEY, Mathematica Policy Research, Princeton, New Jersey JANET HUNT, U.S. Department of Agriculture/Agriculture Research Service, Grand Forks Human Nutrition Research Center, Grand Forks, North Dakota SUZANNE MURPHY, Cancer Research Center of Hawaii, University of Hawaii, Honolulu VALERIE TARASUK, Department of Nutritional Sciences, University of Toronto, Ontario Staff MARY POOS, Study Director ALICE L. VOROSMARTI, Research Associate HARLEEN SETHI, Project Assistant ix

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STANDING COMMITTEE ON THE SCIENTIFIC EVALUATION OF DIETARY REFERENCE INTAKES VERNON R. YOUNG (Chair through April 2002), Laboratory of Human Nutrition, School of Science, Massachusetts Institute of Technology, Cambridge JOHN W. ERDMAN, JR. (Vice-Chair), Department of Food Science and Human Nutrition, 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 JOHN D. FERNSTROM, UMPC 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 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 ROBERT M. RUSSELL, Jean Mayer U.S. Department of Agriculture Research Center on Aging, Tufts University, Boston, Massachusetts Technical Advisor to the DRI Projects GEORGE BEATON, GHB Consulting, Willowdale, Ontario 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 x

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Staff ALLISON A. YATES, Study Director MARY POOS, Senior Program Officer SANDRA SCHLICKER, Senior Program Officer PAULA R. TRUMBO, Senior Program Officer ALICE L. VOROSMARTI, Research Associate CARRIE L. HOLLOWAY, Research Assistant GAIL E. SPEARS, Staff Editor SANDRA AMAMOO-KAKRA, Senior Project Assistant xi

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xvi PREFACE ing various questions confronted by the panel and subcommittees. Thus, although governed by scientific rationales, informed judgments were often required in setting reference values. The reasoning used for each nutrient is described in Chapters 5 through 11. Chapter 13 addresses major con- ceptual issues related to the uses of the DRIs that were included in the early stages of the DRI process and have been developed further by the Uses Subcommittee. The quality and quantity of information on overt deficiency diseases for protein, amino acids, and essential fatty acids available to the com- mittee were substantial. Unfortunately, information regarding other nutri- ents for which their primary dietary importance relates to their roles as energy sources was limited most often to alterations in chronic disease biomarkers that follow dietary manipulations of energy sources. Given the uniqueness of the nutrients considered in this report (i.e., they or their precursors serve as energy sources and, for this purpose, can substitute for each other in the diet), the inability to determine an Esti- mated Average Requirement (EAR) or a Tolerable Upper Intake Level (UL) in many cases is not surprising. Also, for most of the nutrients in this report (with a notable exception of protein and some amino acids), there is no direct information that permits estimating the amounts required by children, adolescents, the elderly, or pregnant and lactating women. Simi- larly, data were exceptionally sparse for setting ULs for the macronutrients. Dose–response studies were either not available or were suggestive of very low intake levels that could result in inadequate intakes of other nutrients. These information gaps and inconsistencies often precluded setting reli- able estimates of upper intake levels that can be ingested safely. The report’s attention to energy would be incomplete without its substantial review of the role of daily physical activity in achieving and sustaining fitness and optimal health (Chapter 12). The report provides recommended levels of energy expenditure that are considered most com- patible with minimizing risks of several chronic diseases and provides guid- ance for achieving recommended levels of energy expenditure. Inclusion of these recommendations avoids the tacit false assumption that light sedentary activity is the expected norm in the United States and Canada. Readers are urged to recognize that the Dietary Reference Intakes (DRI) process is iterative in character. The Food and Nutrition Board and the DRI Committee and its subcommittees and panels fully expect that the DRI conceptual framework will evolve and be improved as novel informa- tion becomes available and is applied to an expanding list of nutrients and other food components. Thus, because the DRI activity is ongoing, com- ments were solicited widely and received on the published reports of this series. Refinements that resulted from this iterative process were included in the general information regarding approaches used (Chapters 1

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xvii P REFACE through 4) and in the discussion of uses of DRIs (Chapter 13). With more experience, the proposed models for establishing reference intakes of nutrients and other food components that play significant roles in pro- moting and sustaining health and optimal functioning will be refined. Also, as new information or new methods of analysis are adopted, these reference values undoubtedly will be reassessed. Many of the questions that were raised about requirements and recommended intakes could not be answered satisfactorily for the reasons given above. Thus, among the panel’s major tasks was to outline a research agenda addressing information gaps uncovered in its review (Chapter 14). The research agenda is anticipated to help future policy decisions related to these and future recommendations. This agenda and the critical, com- prehensive analyses of available information are intended to assist the private sector, foundations, universities, governmental and international agencies and laboratories, and other institutions in the development of their respective research priorities for the next decade. This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with pro- cedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its 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 review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Arne Astrup, The Royal Veterinary and Agricultural University; George Blackburn, Beth Israel Deaconess Medical Center; Elsworth Buskirk, Pennsylvania State University; William Connor, Oregon Health and Science University; John Hathcock, Council for Responsible Nutrition; Satish Kalhan, Case Western Reserve University School of Medicine; Martijn Katan, Wageningen Agricultural University; David Kritchevsky, The Wistar Institute; Shiriki Kumanyika, University of Pennsylvania School of Medicine; William Lands, National Institutes of Health; Geoffrey Livesey, Independent Nutrition Logic; Ross Prentice, Fred Hutchinson Cancer Research Center; Barbara Schneeman, University of California, Davis; Christopher Sempos, State University of New York, Buffalo; Virginia Stallings, Children’s Hospital of Philadelphia; Steve Taylor, University of Nebraska; Daniel Tomé, Institut National Agronomique Paris-Grinon; and Walter Willett, Harvard School of Public Health.

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xviii PREFACE Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclu- sions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Catherine Ross, Pennsylvania State University and Irwin Rosenberg, Tufts University, appointed by the Institute of Medicine, who were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. The Food and Nutrition Board gratefully acknowledges the Canadian government’s support and Canadian scientists’ participation in this initia- tive. This close collaboration represents a pioneering first step in the har- monization of nutrient reference intakes in North America. A description of the overall DRI project and of the panel’s task is given in Appendix B. The Food and Nutrition Board joins the DRI Committee, the Panel on Macronutrients, the Panel on the Definition of Dietary Fiber, the UL Sub- committee, and the Uses Subcommittee in extending sincere appreciation to the many experts who assisted with this report by giving presentations to the various groups charged with its development, providing written materials, participating in the groups’ open discussions, analyzing data, and other means. Many, but far from all, of these individuals are named in Appendix C. Special gratitude is extended to the staff at ENVIRON Inter- national Corporation for providing national survey data. The respective chairs and members of the Panel on Macronutrients and subcommittees performed their work under great time pressures. Their dedication made the report’s timely completion possible. All gave their time and hard work willingly and without financial reward; the public and the science and practice of nutrition are among the major beneficiaries of their dedication. The Food and Nutrition Board thanks these indi- viduals, and especially the staff responsible for its development—in par- ticular, Paula Trumbo for coordinating this complex report, and Sandra Schlicker, who served as a program officer for the study. The intellectual and managerial contributions made by these individuals to the report’s comprehensiveness and scientific base were critical to fulfilling the project’s mandate. Sincere thanks also go to other FNB staff, including Alice Vorosmarti, Kimberly Stitzel, Carrie Holloway, Gail Spears, Sandra Amamoo-Kakra, and Michele Ramsey, all of whom labored over nearly three years of work to complete this document. And last, but certainly not least, the Food and Nutrition Board wishes to extend special thanks to Sandy Miller, who initially served as chair of the Panel on Macronutrients; Joanne Lupton, who subsequently assumed the role of chair of the panel and continued in that role through the

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xix P REFACE study’s completion; and Vernon Young, who served as chair of the DRI Committee since the inception of the overall DRI activity. Professor Young’s dedication to this and earlier DRI activities and his uncompromis- ing standards for scientific rigor are most gratefully acknowledged. Cutberto Garza Chair, Food and Nutrition Board

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Contents SUMMARY 1 1 INTRODUCTION TO DIETARY REFERENCE INTAKES 21 What Are Dietary Reference Intakes? 21 Categories of Dietary Reference Intakes, 22 Determination of Adequacy, 28 Parameters for Dietary Reference Intakes, 29 Summary, 36 References, 36 2 METHODS AND APPROACHES USED 38 Overview, 38 Types of Data Used, 39 Methods to Determine the Adequate Intake for Infants, 44 Methods to Determine the Dietary Requirements for Children and Adults, 46 Estimates of Nutrient Intake, 48 Dietary Intakes in the United States and Canada, 49 Summary, 50 References, 50 3 RELATIONSHIP OF MACRONUTRIENTS AND PHYSICAL ACTIVITY TO CHRONIC DISEASE 53 Overview, 53 Cancer, 53 Heart Disease, 57 xxi

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xxii CONTENTS Dental Caries, 61 Type 2 Diabetes Mellitus, 62 Obesity, 64 Skeletal Health, 66 Summary, 66 References, 66 4 A MODEL FOR THE DEVELOPMENT OF TOLERABLE UPPER INTAKE LEVELS 84 Background, 84 A Model for the Derivation of Tolerable Upper Intake Levels, 85 Risk Assessment and Food Safety, 86 Application of the Risk Assessment Model to Nutrients, 91 Steps in the Development of the Tolerable Upper Intake Level, 94 Intake Assessment, 104 Risk Characterization, 104 References, 105 5 ENERGY 107 Summary, 107 Background Information, 108 Selection of Indicators for Estimating the Requirement for Energy, 117 Factors Affecting Energy Expenditure and Requirements, 131 Approach Used to Determine Total Energy Expenditure, 151 Findings by Life Stage and Gender Group, 164 Adverse Effects of Overconsumption of Energy, 223 Research Recommendations, 225 References, 240 6 DIETARY CARBOHYDRATES: SUGARS AND STARCHES 265 Summary, 265 Background Information, 265 Evidence Considered for Estimating the Average Requirement for Carbohydrate, 277 Findings by Life Stage and Gender Group, 280 Intake of Carbohydrates, 294 Adverse Effects of Overconsumption, 295 Research Recommendations, 323 References, 324

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xxiii C ONTENTS 7 DIETARY, FUNCTIONAL, AND TOTAL FIBER 339 Summary, 339 Background Information, 340 Evidence Considered for Estimating the Requirement for Dietary Fiber and Functional Fiber, 362 Findings by Life Stage and Gender Group, 384 Intake of Dietary Fiber, 390 Adverse Effects of Overconsumption, 391 Research Recommendations, 399 References, 400 8 DIETARY FATS: TOTAL FAT AND FATTY ACIDS 422 Summary, 422 Background Information, 424 Evidence Considered for Estimating the Requirements for Total Fat and Fatty Acids, 440 Factors Affecting the Requirements, 447 Findings by Life Stage and Gender Group, 456 Intakes of Total Fat and Fatty Acids, 473 Adverse Effects of Overconsumption, 481 Research Recommendations, 505 References, 515 9 CHOLESTEROL 542 Summary, 542 Background Information, 543 Findings by Life Stage and Gender Group, 546 Intake of Cholesterol, 549 Adverse Effects of Overconsumption, 549 Risk Characterization, 573 Research Recommendations, 574 References, 578 10 PROTEIN AND AMINO ACIDS 589 Summary, 589 Background Information, 590 Selection of Indicators for Estimating the Requirement for Protein (Nitrogen), 610 Selection of Indicators for Estimating the Requirement for Individual Amino Acids, 613 Findings by Life Stage and Gender Group for Total Protein, 619 Findings by Life Stage and Gender Group for Indispensable Amino Acids, 662

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xxiv CONTENTS Intake of Total Protein and Amino Acids, 682 Tolerable Upper Intake Levels for Protein, 692 Tolerable Upper Intake Levels for Individual Amino Acids, 695 Research Recommendations, 737 References, 738 11 MACRONUTRIENTS AND HEALTHFUL DIETS 769 Summary, 769 Introduction, 770 Dietary Fat and Carbohydrate, 772 n-9 Monounsaturated Fatty Acids, 816 n-6 Polyunsaturated Fatty Acids, 820 n-3 Polyunsaturated Fatty Acids, 826 Saturated Fatty Acids, Trans Fatty Acids, and Cholesterol, 835 Conjugated Linoleic Acid, 836 Dietary Fiber and Functional Fiber, 838 Dietary Protein, 839 References, 845 12 PHYSICAL ACTIVITY 880 Summary, 880 Background Information, 881 Physical Activity Level and Energy Balance, 884 Evidence for Healthful Effects of Physical Activity, 912 Balance of Carbohydrate and Lipid Oxidation During Exercise and Recovery, 917 Physical Fitness, 923 Adverse Effects of Excessive Physical Activity, 926 Research Recommendations, 929 References, 929 13 APPLICATIONS OF DIETARY REFERENCE INTAKES FOR MACRONUTRIENTS 936 Overview, 936 Assessing Nutrient Intakes of Individuals, 937 Assessing Nutrient Intakes of Groups, 941 Planning Nutrient Intakes of Individuals, 946 Planning Nutrient Intakes of Groups, 947 Nutrient-Specific Considerations, 949 Integrated Example, 963 Summary, 964 References, 965

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xxv C ONTENTS 14 A RESEARCH AGENDA 968 Approach, 968 Major Knowledge Gaps, 969 The Research Agenda, 971 APPENDIXES A Glossary and Acronyms 973 B Origin and Framework of the Development of Dietary Reference Intake 978 C Acknowledgments 985 D Dietary Intake Data from the Third National Health and Nutrition Examination Survey (NHANES III), 1988–1994 988 E Dietary Intake Data from the Continuing Survey of Food Intakes by Individuals (CSFII), 1994–1996, 1998 1028 F Canadian Dietary Intake Data, 1990–1997 1066 G Special Analyses for Dietary Fats 1076 H Body Composition Data Based on the Third National Health and Nutrition Examination Survey (NHANES III), 1988–1994 1078 I Doubly Labeled Water Data Used to Predict Energy Expenditure 1104 J Association of Added Sugars Intake and Intake of Other Nutrients, 1203 K Data Comparing Carbohydrate Intake to Intake of Other Nutrients from the Continuing Survey of Food Intakes by Individuals (CSFII), 1994–1996, 1998 1226 L Options for Dealing with Uncertainties 1244 M Nitrogen Balance Studies Used to Estimate the Protein Requirements in Adults 1250 BIOGRAPHICAL SKETCHES OF PANEL AND 1259 SUBCOMMITTEE MEMBERS 1275 INDEX 1319 SUMMARY TABLES, DIETARY REFERENCE INTAKES

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