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DIETARY REFERENCE INTAKES FOR Water, Potassium, Sodium, Chloride, and Sulfate

Panel on Dietary Reference Intakes for Electrolytes and Water

Standing Committee on the Scientific Evaluation of Dietary Reference Intakes

Food and Nutrition Board

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu



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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate DIETARY REFERENCE INTAKES FOR Water, Potassium, Sodium, Chloride, and Sulfate Panel on Dietary Reference Intakes for Electrolytes and Water Standing Committee on the Scientific Evaluation of Dietary Reference Intakes Food and Nutrition Board INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate 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. This study was supported by a contract between the National Academy of Sciences and the U.S. Department of Health and Human Services’ Office of Disease Prevention and Health Promotion, Contract No. 282-96-0033, T03; the National Heart, Lung, and Blood Institute of the National Institutes of Health; the U.S. Environmental Protection Agency; the U.S. Department of Agriculture; Health Canada; the Institute of Medicine; the Dietary Reference Intakes Private Foundation Fund—International Life Sciences Institute-North America and the Dannon Institute; and the Dietary Reference Intakes Corporate Donors’ Fund. Contributors to the Fund have included Roche Vitamins, M&M/Mars, Mead Johnson Nutritionals, and the Nabisco Foods Group. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Panel on Dietary Reference Intakes for Electrolytes and Water. Dietary reference intakes for water, potassium, sodium, chloride, and sulfate / Panel on Dietary Reference Intakes for Electrolytes and Water, Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board. p. ; cm. Includes bibliographical references and index. ISBN 0-309-09158-6 (hardcover)—ISBN 0-309-09169-1 (pbk.)—ISBN 0-309-53049-0 (PDF) 1. Diet. 2. Nutrition. [DNLM: 1. Nutritional Requirements—Canada. 2. Nutritional Requirements—United States. 3. Electrolytes—Canada. 4. Electrolytes—United States. 5. Reference Values—Canada. 6. Reference Values—United States. 7. Water—Canada. 8. Water—United States.] I. Title. TX551.I59 2004 613.2—dc22 2004028191 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 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 cultures 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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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Adviser to the Nation to Improve Health

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate 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, 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. 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 members, 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 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. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate PANEL ON DIETARY REFERENCE INTAKES FOR ELECTROLYTES AND WATER LAWRENCE J. APPEL (Chair), Departments of Medicine, Epidemiology, and International Health (Human Nutrition), Johns Hopkins University, Baltimore, Maryland DAVID H. BAKER, Department of Animal Sciences, and Division of Nutritional Sciences, University of Illinois, Urbana ODED BAR-OR, Department of Pediatrics, McMaster University, Hamilton, Ontario KENNETH L. MINAKER, Geriatric Medicine Unit, Massachusetts General Hospital, Division on Aging, Department of Medicine, Harvard Medical School, Boston, Massachusetts R. CURTIS MORRIS, JR., Departments of Medicine, Pediatrics, and Radiology, University of California, San Francisco *LAWRENCE M. RESNICK, Division of Hypertension, New York Presbyterian Hospital, Cornell Medical Center, Cornell University Medical College, New York MICHAEL N. SAWKA, Thermal and Mountain Medicine Division, U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts STELLA L. VOLPE, School of Nursing, University of Pennsylvania, Philadelphia MYRON H. WEINBERGER, Indiana University School of Medicine, Indianapolis PAUL K. WHELTON, Tulane University Health Sciences Center, New Orleans, Louisiana Consultant MARSHALL LINDHEIMER, University of Chicago Hospitals and Clinics, Chicago, Illinois Staff PAULA R. TRUMBO, Study Director (through May 2003) ALLISON A. YATES, Study Director (starting June 2003) CARRIE L. HOLLOWAY, Research Assistant (through August 2002) CRYSTAL RASNAKE, Research Assistant (starting September 2002) SANDRA AMAMOO-KAKRA, Senior Project Assistant *   Active member through May 2003.

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate STANDING COMMITTEE ON THE SCIENTIFIC EVALUATION OF DIETARY REFERENCE INTAKES JOHN W. ERDMAN, JR. (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, Canada SUSAN I. BARR, Department of Food, Nutrition, and Health, University of British Columbia, Vancouver, Canada BENJAMIN CABALLERO, Center for Human Nutrition, Johns Hopkins University 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, Jean Mayer U.S. Department of Agriculture Research Center on Aging, Tufts University, Boston, Massachusetts Technical Advisor to the DRI Projects VERNON YOUNG, School of Laboratory Sciences, 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, DC Canadian Government Liaison PETER W.F. FISCHER, Nutrition Research Division, Health Protection Branch, Health Canada, Ottawa, Ontario, Canada Staff ALLISON A. YATES, Study Director MARY POOS, Senior Program Officer (through November 2003) PAULA TRUMBO, Senior Program Officer (through May 2003) CRYSTAL RASNAKE, Research Assistant GAIL E. SPEARS, Staff Editor SANDRA AMAMOO-KAKRA, Senior Project Assistant

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate FOOD AND NUTRITION BOARD CATHERINE E. WOTEKI (Chair), Iowa Agriculture and Human Economics Experiment Station, Iowa State University, Ames ROBERT M. RUSSELL (Vice Chair), Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts LARRY R. BEUCHAT, Center for Food Safety and Quality Enhancement, University of Georgia, Griffin BENJAMIN CABALLERO, Center for Human Nutrition, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland SUSAN A. FERENC, SAF*RISK LC, Madison, Wisconsin NANCY F. KREBS, School of Medicine, University of Colorado, Denver SHIRIKI K. KUMANYIKA, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia REYNALDO MARTORELL, Rollins School of Public Health. Emory University, Atlanta LYNN PARKER, Child Nutrition Programs and Nutrition Policy, Food Research and Action Center, Washington, DC NICHOLAS J. SCHORK, Department of Psychiatry, University of California, San Diego JOHN W. SUTTIE, Department of Biochemistry, University of Wisconsin-Madison STEVE L. TAYLOR, Department of Food Science and Technology and Food Processing Center, University of Nebraska, Lincoln BARRY L. ZOUMAS, Department of Agricultural Economics and Rural Sociology, Pennsylvania State University, University Park Staff LINDA MEYERS, Director (Deputy Director through September 2003) ALLISON A. YATES, Director through September 2003 GAIL E. SPEARS, Administrative Assistant GERALDINE KENNEDO, Administrative Assistant ELISABETH RIMAUD, Financial Associate

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate Preface This report is one in a series that presents a comprehensive set of reference values for nutrient intakes for healthy U.S. and Canadian individuals and populations. It is a product of the Food and Nutrition Board (FNB) of the Institute of Medicine, working in cooperation with Canadian scientists. The report establishes a set of reference values for dietary electrolytes and water to expand and replace previously published Recommended Dietary Allowances (RDAs) and Recommended Nutrient Intakes (RNIs) for the United States and Canada, respectively. Close attention was given to the evidence relating electrolyte intake to the risk of high blood pressure and hypertension, as well as other diseases, and the amounts of water from beverages and foods needed to maintain hydration. In addition, since requirements for sulfur can be met by inorganic sulfate in the diets of animals, a review of the role in inorganic sulfur in the form of sulfate is included. The group responsible for developing this report, the Panel on Dietary Reference Intakes for Electrolytes and Water, under the oversight and assistance of the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes (the DRI Committee), has analyzed the evidence on risks and beneficial effects of nutrients included in this review. Although all reference values are based on data, available data were often sparse or drawn from studies with significant limitations in addressing various questions confronted by the panel. Thus, although governed by scientific rationales, informed judgments were often required in setting these reference values. The reasoning used

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate in evaluating each nutrient is described in Chapters 4 through 7. Chapter 3 outlines the risk assessment approach used to establish the reference values for upper intake levels as developed and further modified by the DRI Subcommittee on Upper Reference Levels. Chapter 8 addresses major conceptual issues related to the uses of the DRIs that were included in the early stages of the DRI process and have been developed further as described in reports from the Subcommittee on Interpretation and Uses of Dietary Reference Intakes. While the quantity of research reports relating sodium and potassium intake to blood pressure is quite large, the quality of the research useful to the panel for setting requirements of sodium and potassium was limited. In particular, there was a dearth of large, dose-response studies with clinically relevant biological outcomes carried out in normal, apparently healthy individuals. Given the ability of many humans to adapt to varying amounts of electrolyte intake and the impact of temperature and activity level on needs of electrolytes and water, it was not possible to determine Estimated Average Requirements (EAR) for these nutrients. Instead, Adequate Intakes (AIs) were set for sodium, potassium, and water. No AI was set for sulfate as there is sufficient sulfur in the human diet from foods (derived from sulfur amino acids) and water to meet the needs of healthy individuals. No specific Tolerable Upper Intake Levels (ULs) were set for water, potassium, or sulfate as healthy persons can adapt to higher intakes from foods and beverages. In contrast, a UL was set for sodium based upon the increased risk of cardiovascular outcomes, particularly cardiovascular disease and stroke. Readers are urged to recognize that the DRI process is iterative in character. The FNB and the DRI Committee and its subcommittees and panels fully expect that the DRI conceptual framework will evolve and be improved as novel information becomes available and is applied to an expanding list of nutrients and other food components. Thus because the DRI activity is ongoing, comments have been 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 and 2 and in the discussion of uses of DRIs in Chapter 8). With more experience, the proposed models for establishing reference intakes of nutrients and other food components that play significant roles in promoting and sustaining health and optimal functioning will be refined. Also, as new information or new meth-

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate ods 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 9). The research agenda is anticipated to help future policy decisions related to these and future recommendations. This agenda and the critical, comprehensive 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 procedures approved by the National Research Council’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: Michael Alderman, Albert Einstein College of Medicine; John R. Claybaugh, Tripler Army Medical Center; David Cole, University of Toronto; Gary Curhan, Harvard University; Johanna T. Dwyer, Tufts New England Medical Center; Shiriki K. Kumanyika, University of Pennsylvania; Gary W. Mack, Yale University; Melinda Manore, Oregon State University; Timothy Noakes, Sports Science Institute of South Africa; Suzanne Oparil, University of Alabama at Birmingham; Frank Sacks, Harvard University; Judith Stern, University of California at Davis. Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by John W. Suttie, University of Wisconsin, appointed by the Institute of Medicine, who was 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

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate content of this report rests entirely with the authoring panel and the institution. The support of the Canadian government and Canadian scientists’ participation in this initiative are gratefully acknowledged. This close collaboration represents a pioneering first step in the harmonization 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 DRI Committee and the Panel on DRIs for Electrolytes and Water extend sincere appreciation to the many experts who assisted with this report by giving presentations to the panel, providing written materials, participating in the groups’ open discussions, analyzing data, reviewing the report, and other means. Many, but far from all, of these individuals are named in Appendix L. Special gratitude is extended to the staff at ENVIRON International Corporation for providing national survey data. The Panel on DRIs for Electrolytes and Water performed their work under great time pressure. Their dedication made the report’s 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. Special thanks go to DRI Committee members Robert Russell, Joseph Rodricks, and Susan Barr for assisting the Panel in its review. In addition, the DRI Committee thanks the staff responsible for its development—in particular Paula Trumbo who served as a program officer for the study through June 2003, Allison A. Yates, who stepped in as Paula’s replacement, and Crystal Rasnake, research assistant on the project in the later phases of its completion and key to organizing the many references and tables. 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 Carrie Holloway, Mary Poos, Gail Spears, and Sandra Amamoo-Kakra, who also contributed their efforts over the years to complete this document. And last, but certainly not least, the DRI Committee wishes to extend special thanks to panel chair Larry Appel, who oversaw the entire report development process, to Vernon Young, past chair of the DRI Committee, and to Cutberto Garza, former Chair of the Food and Nutrition Board, under whom this study was initiated. John Erdman Chair, DRI Committee

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate Postscript: Following release of the report in pre-publication copy form, the Panel and DRI Committee were saddened to learn of two untimely events: the deaths of both Lawrence M. Resnick, M.D., a member of the Panel who was steadfast in his views while congenial in his search for approaches that were scientifically supportable; and Vernon R. Young, Ph.D., who, as the first chair of the DRI Committee, led the pursuit of integrating good science into nutrient-based reference values while challenging all those involved to think past old axioms as the term “nutrient” was redefined; he was a true scholar.

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate Contents     SUMMARY   1 1   INTRODUCTION TO DIETARY REFERENCE INTAKES   21      What Are Dietary Reference Intakes?,   21      Categories of Dietary Reference Intakes,   22      Parameters for Dietary Reference Intakes,   29      Summary,   35      References,   35 2   OVERVIEW AND METHODS   37      Summary,   37      Background,   37      Methodological Considerations,   38      Estimates of Nutrient Intake,   46      Dietary Intakes in the United States and Canada,   47      References,   48 3   A MODEL FOR THE DEVELOPMENT OF TOLERABLE UPPER INTAKE LEVELS   50      Background,   50      A Model for the Derivation of Tolerable Upper Intake Levels,   52      Risk Assessment and Food Safety,   52      Application of the Risk Assessment Model to Nutrients,   57

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate      Steps in the Development of the Tolerable Upper Intake Level,   61      Intake Assessment,   70      Risk Characterization,   70      References,   72 4   WATER   73      Summary,   73      Background Information,   74      Body Water,   75      Methods for Estimating Water Requirements,   86      Methods for Estimating Hydration Status,   90      Factors Affecting Water Requirements,   127      Findings by Life Stage and Gender Group,   140      Intake of Water,   157      Adverse Effects of Overconsumption,   161      Research Recommendations,   165      References,   166 5   POTASSIUM   186      Summary,   186      Background Information,   188      Indicators Considered for Estimating the Requirement for Potassium,   190      Factors Affecting Potassium Requirements,   225      Findings by Life Stage and Gender Group,   231      Intake of Potassium,   242      Adverse Effects of Overconsumption,   247      Research Recommendations,   254      References,   255 6   SODIUM AND CHLORIDE   269      Summary,   269      Background Information,   272      Indicators Considered for Estimating the Requirements for Sodium and Chloride,   275      Factors Affecting Sodium and Chloride Requirements,   293      Findings by Life Stage and Gender Group,   301      Intake of Sodium,   318      Adverse Effects of Overconsumption,   323      Research Recommendations,   395      References,   397

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate 7   SULFATE   424      Summary,   424      Background Information,   425      Indicators Considered for Estimating the Requirement for Sulfate,   429      Factors Affecting Sulfate Requirements,   429      Findings by Life Stage and Gender Group,   430      Intake of Sulfate,   430      Adverse Effects of Overconsumption,   433      Research Recommendations,   443      References,   443 8   APPLICATIONS OF DIETARY REFERENCE INTAKES FOR ELECTROLYTES AND WATER   449      Overview,   449      Assessing Nutrient Intakes of Individuals,   450      Assessing Nutrient Intakes of Groups,   453      Planning Nutrient Intakes of Individuals,   455      Planning Nutrient Intakes of Groups,   456      Nutrient-Specific Considerations,   456      Summary,   461      References,   462 9   A RESEARCH AGENDA   465      Approach,   465      Major Knowledge Gaps,   466      The Research Agenda,   468     APPENDIXES     A   Glossary and Acronyms   471 B   Origin and Framework of the Development of Dietary Reference Intakes   477 C   Predictions of Daily Water and Sodium Requirements   485 D   U.S. Dietary Intake Data from the Third National Health and Nutrition Examination Survey, 1988–1994   494 E   U.S. Dietary Intake Data for Water and Weaning Foods from the Continuing Survey of Food Intakes by Individuals, 1994–1996, 1998   518 F   Canadian Dietary Intake Data for Adults from Ten Provinces, 1990–1997   527 G   U.S. Water Intake and Serum Osmolality Data from the Third National Health and Nutrition Examination Survey, 1988–1994   534

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate H   U.S. Total Water Intake Data by Frequency of Leisure Time Activity from the Third National Health and Nutrition Examination Survey, 1988–1994   537 I   Dose-Response Effects of Sodium Intake on Blood Pressure   546 J   U.S. Serum Electrolyte Concentration Data from the Third National Health and Nutrition Examination Survey, 1988–1994   558 K   Options for Dealing with Uncertainties   564 L   Acknowledgments   569 M   Biographical Sketches of Panel Members   572     INDEX   577     SUMMARY TABLES, DIETARY REFERENCE INTAKES          Recommended Intakes for Individuals, Vitamins   606      Recommended Intakes for Individuals, Elements   608      Recommended Intakes for Individuals, Total Water and Macronutrients   610      Acceptable Macronutrient Distribution Ranges   611      Additional Macronutrient Recommendations   611      Tolerable Upper Intake Levels (UL), Vitamins   612      Tolerable Upper Intake Levels (UL), Elements   614      Estimated Average Requirements for Groups   616

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Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate DIETARY REFERENCE INTAKES FOR Water, Potassium, Sodium, Chloride, and Sulfate

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