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Weight Gain During Pregnancy: Reexaming the Guidelines
APPENDIX B
Supplementary Information on Nutritional Intake
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Weight Gain During Pregnancy: Reexaming the Guidelines
DIETARY REFERENCE INTAKES FOR PREGNANCY
TABLE B-1A Equations to Estimate Energy Requirement for Pregnant Women by Trimester
Estimated Energy Requirement (kcal/day) = Nonpregnant EER + Pregnancy Energy Deposition
1st trimester
EER = Nonpregnant (adolescent or adult) EER + 0
2nd trimester
EER = Nonpregnant (adolescent or adult) EER + 340
3rd trimester
EER = Nonpregnant (adolescent or adult) EER + 452
NOTE: EER = Estimated Energy Requirement. Use equations in Table B-1B to calculate non-pregnant EER. EER for adult women should be used for ages 19-50 years; EER for adolescent girls should be used for ages 9-18 years
SOURCE: IOM, 2006.
TABLE B-1B Equations to Calculate Estimated Energy Requirement (EER) for Nonpregnant Adolescents or Adult Women
14-18 Years of Age
Estimated Energy Requirement (kcal/day) = Total Energy Expenditure + Energy Deposition
EER = 135.3 − (30.8 × age [y]) + PA × [(10.0 × weight [kg]) + (934 × height [m])] + 25
19 Years and Older
Estimated Energy Requirement (kcal/day) = Total Energy Expenditure
EER = 354 − (6.91 × age [y]) + PA × [(9.36 × weight [kg]) + (726 v height [m])]
NOTE: PA = Physical Activity Coefficient. Use equations in Table B-1C to calculate PA.
SOURCE: IOM, 2006.
TABLE B-1C Physical Activity Coefficients (PA values) for Use in EER Equations for Adolescents or Adult Women
Sedentarya (PAL 1.0-1.39)
Low Activeb (PAL 1.4-1.59)
Activec (PAL 1.6-1.89)
Very Actived (PAL 1.9-2.5)
14-18 Years of Age
1.0
1.16
1.31
1.56
19 Years and Older
1.0
1.12
1.27
1.45
NOTE: PAL = Physical Activity Level.
aE.g., typical daily living activities (e.g., household tasks, walking to the bus).
bE.g., typical daily living activities PLUS 30-60 minutes of daily moderate activity (e.g., walking at 5-7 km/h).
cE.g., typical daily living activities PLUS at least 60 minutes of daily moderate activity.
dE.g., typical daily living activities PLUS at least 60 minutes of daily moderate activity PLUS an additional 60 minutes of vigorous activity or 120 minutes of moderate activity.
SOURCE: IOM, 2006.
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TABLE B-2 Dietary Reference Intakes for Pregnant Women: Vitamins, Elements, Total Water, and Macronutrients in Alphabetical Order
Nutrient
EARa
RDAb/AIc
ULd
Biotin
14-18 y
—
30 μg/day
—
19-30 y
—
30 μg/day
—
31-50 y
—
30 μg/day
—
Boron
14-18 y
—
—
17 mg/day
19-30 y
—
—
20 mg/day
31-50 y
—
—
20 mg/day
Calcium
14-18 y
—
1,300 mg/day
2.5 g/day
19-30 y
—
1,000 mg/day
2.5 g/day
31-50 y
—
1,000 mg/day
2.5 g/day
Carbohydrate
14-18 y
135 g/day
175 g/day
—
19-30 y
135 g/day
175 g/day
—
31-50 y
135 g/day
175 g/day
—
Chloride
14-18 y
—
2.3 g/day
3.6 g/day
19-30 y
—
2.3 g/day
3.6 g/day
31-50 y
—
2.3 g/day
3.6 g/day
Choline
14-18 y
—
450 mg/day
3.0 g/day
19-30 y
—
450 mg/day
3.5 g/day
31-50 y
—
450 mg/day
3.5 g/day
Chromium
14-18 y
—
29 μg/day
—
19-30 y
—
30 μg/day
—
31-50 y
—
30 μg/day
—
Copper
14-18 y
785 μg/day
1,000 μg/day
8,000 μg/day
19-30 y
800 μg/day
1,000 μg/day
10,000 μg/day
31-50 y
800 μg/day
1,000 μg/day
10,000 μg/day
Fiber (Total)
14-18 y
—
28 g/day
—
19-30 y
—
28 g/day
—
31-50 y
—
28 g/day
—
Flouride
14-18 y
—
3.0 mg/day
10 mg/day
19-30 y
—
3.0 mg/day
10 mg/day
31-50 y
—
3.0 mg/day
10 mg/day
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Nutrient
EARa
RDAb/AIc
ULd
Folatee
14-18 y
520 µg/day
600 µg/day
800 µg/day
19-30 y
520 µg/day
600 µg/day
1,000 µg/day
31-50 y
520 µg/day
600 µg/day
1,000 µg/day
Iodine
14-18 y
160 µg/day
220 µg/day
900 µg/day
19-30 y
160 µg/day
220 µg/day
1,100 µg/day
31-50 y
160 µg/day
220 µg/day
1,100 µg/day
Iron
14-18 y
23 mg/day
27 mg/day
45 mg/day
19-30 y
22 mg/day
27 mg/day
45 mg/day
31-50 y
22 mg/day
27 mg/day
45 mg/day
Linoleic acid
14-18 y
—
13 g/day
—
19-30 y
—
13 g/day
—
31-50 y
—
13 g/day
—
α-Linolenic Acid
14-18 y
—
1.4 g/day
—
19-30 y
—
1.4 g/day
—
31-50 y
—
1.4 g/day
—
Magnesiumf
14-18 y
335 mg/day
400 mg/day
350 mg/day
19-30 y
290 mg/day
350 mg/day
350 mg/day
31-50 y
300 mg/day
360 mg/day
350 mg/day
Manganese
14-18 y
—
2.0 mg/day
9 mg/day
19-30 y
—
2.0 mg/day
11 mg/day
31-50 y
—
2.0 mg/day
11 mg/day
Molybdenum
14-18 y
40 µg/day
50 µg/day
1,700 µg/day
19-30 y
40 µg/day
50 µg/day
2,000 µg/day
31-50 y
40 µg/day
50 µg/day
2,000 ug/day
Niacing
14-18 y
14 mg/day
18 mg/day
30 mg/day
19-30 y
14 mg/day
18 mg/day
35 mg/day
31-50 y
14 mg/day
18 mg/day
35 mg/day
Nickel
14-18 y
—
—
1.0 mg/day
19-30 y
—
—
1.0 mg/day
31-50 y
—
—
1.0 mg/day
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Nutrient
EARa
RDAb/AIc
ULd
Pantothenic Acid
14-18 y
—
6.0 mg/day
—
19-30 y
—
6.0 mg/day
—
31-50 y
—
6.0 mg/day
—
Phosphorus
14-18 y
1,055 mg/day
1,250 mg/day
3.5 g/day
19-30 y
580 mg/day
700 mg/day
3.5 g/day
31-50 y
580 mg/day
700 mg/day
3.5 g/day
Potassium
14-18 y
—
4.7 g/day
—
19-30 y
—
4.7 g/day
—
31-50 y
—
4.7 g/day
—
Proteinh
14-18 y
0.88 g/kg/day
71 g/day
—
19-30 y
0.88 g/kg/day
71 g/day
—
31-50 y
0.88 g/kg/day
71 g/day
—
Riboflavin
14-18 y
1.2 mg/day
1.4 mg/day
—
19-30 y
1.2 mg/day
1.4 mg/day
—
31-50 y
1.2 mg/day
1.4 mg/day
—
Selenium
14-18 y
49 µg/day
60 µg/day
400 µg/day
19-30 y
49 µg/day
60 µg/day
400 µg/day
31-50 y
49 µg/day
60 µg/day
400 µg/day
Sodium
14-18 y
—
1.5 g/day
2.3 g/day
19-30 y
—
1.5 g/day
2.3 g/day
31-50 y
—
1.5 g/day
2.3 g/day
Thiamin
14-18 y
1.2 mg/day
1.4 mg/day
—
19-30 y
1.2 mg/day
1.4 mg/day
—
31-50 y
1.2 mg/day
1.4 mg/day
—
Vitamin Ai
14-18 y
530 µg RAE/day
750 µg RAE/day
2,800 µg/day
19-30 y
550 µg RAE/day
770 µg RAE/day
3,000 µg/day
31-50 y
550 µg RAE/day
770 µg RAE/day
3,000 µg/day
Vitamin B6
14-18 y
1.6 mg/day
1.9 mg/day
80 mg/day
19-30 y
1.6 mg/day
1.9 mg/day
100 mg/day
31-50 y
1.6 mg/day
1.9 mg/day
100 mg/day
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Nutrient
EARa
RDAb/AIc
ULd
Vitamin B12
14-18 y
2.2 μg/day
2.6 μg/day
—
19-30 y
2.2 μg/day
2.6 μg/day
—
31-50 y
2.2 μg/day
2.6 μg/day
—
Vitamin C
14-18 y
66 mg/day
80 mg/day
1,800 mg/day
19-30 y
70 mg/day
85 mg/day
2,000 mg/day
31-50 y
70 mg/day
85 mg/day
2,000 mg/day
Vitamin D
14-18 y
—
5.0 μg/dayj
50 μg/day
19-30 y
—
5.0 μg/dayj
50 μg/day
31-50 y
—
5.0 μg/dayj
50 μg/day
Vitamin Ek
14-18 y
12 mg/day
15 mg/day
8,00 mg/day
19-30 y
12 mg/day
15 mg/day
1,000 mg/day
31-50 y
12 mg/day
15 mg/day
1,000 mg/day
Vitamin K
14-18 y
—
75 μg/day
—
19-30 y
—
90 μg/day
—
31-50 y
—
90 μg/day
—
Water (Total)l
14-18 y
—
3.0 L/day
—
19-30 y
—
3.0 L/day
—
31-50 y
—
3.0 L/day
—
Zinc
14-18 y
10.5 mg/day
12 mg/day
34 mg/day
19-30 y
9.5 mg/day
11 mg/day
40 mg/day
31-50 y
9.5 mg/day
11 mg/day
40 mg/day
NOTE: This table (taken from the DRI reports; see www.nap.edu) presents Recommended Dietary Allowances (RDA) in bold type or Adequate Intakes (AI) in ordinary type in Column 3.
aEAR = Estimated Average Requirement. An EAR is the average daily nutrient intake level estimated to meet the requirements of half of the healthy individuals in a group.
bRDA = Recommended Dietary Allowance. An RDA is the average daily dietary intake level sufficient to meet the nutrient requirements of nearly all (97-98 percent) healthy individuals in a group. It is calculated from an EAR.
cAI = Adequate Intake. If sufficient scientific evidence is not available to establish an EAR, and thus calculate and RDA, an AI is usually developed. The AI for breast-fed infants is the mean intake. The AI for other life-stage groups and gender groups (except healthy breast-fed infants) is believed to cover the needs of all healthy individuals in the group, but a lack of data or uncertainty in the data prevents being able to specify with confidence the percentage of individuals covered by this intake. In the absence of a UL, extra caution may be warranted in consuming levels above recommended intakes. Members of the general population should be advised not to routinely exceed the UL. The UL is not meant to apply to individuals who
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are treated with the nutrient under medical supervision or to individuals with predisposing conditions that modify their sensitivity to the nutrient
dUL = Tolerable Upper Intake Level. The UL is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individual in the general population. Unless otherwise specified, the UL represents total intake from food, water, and supplements.
eAs dietary folate equivalents (DFEs). 1 DFE = 1 μg food folate = 0.6 μg of folic acid from fortified food or as a supplement consumed with food = 0.5 μg of folic acid from a supplement taken on an empty stomach. In view of evidence linking folate intake with neural tube defects in the fetus, it is recommended that all women capable of becoming pregnancy consume 400 μg from supplements or fortified foods in addition to intake of food folate from a varied diet. It is assumed that women will continue consuming 400 μg from supplements or fortified food until their pregnancy is confirmed and they enter prenatal care, which ordinarily occurs after the end of the periconceptional period—the critical time for formation of the neural tube. The UL for folate applies to synthetic forms obtained from supplements, fortified foods, or a combination of the two.
fThe ULs for magnesium represent intake from pharmacological agents only and do not include intake from food and water.
gFor EAR and RDA: as niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan. The UL for niacin applies to synthetic forms obtained from supplements, fortified foods, or a combination of the two.
hBased on g protein per kg of body weight for the reference body weight, e.g., for adults 0.8 g/kg body weight for the reference body weight.
iRAE = Retinol activity equivalent. 1 μg RAE = 1 μg retinol, 12 μg β-carotene, and 24 μg α-carotene or β-cryptoxanthin. The RAE for dietary provitamin A carotenoids in foods is twofold greater than retinol equivalents (RE), whereas the RAE for preformed vitamin A in foods is the same as RE. The UL for vitamin A is for preformed vitamin A only.
jIn the absence of adequate exposure to sunlight, and as cholecalciferol. 1 μg cholecalciferol = 40 IU vitamin D.
kAs α-tocopherol. For EAR and RDA: α-tocopherol includes RRR-α-tocopherol, the only form of α-tocopherol that occurs naturally in foods, and the 2R-stereoisomeric forms of α-tocopherol (RRR-, RSR-, RRS-, and RSS-α-tocopherol) that occur in fortified foods and supplements. This does not include the 2S-stereoisomeric forms of α-tocopherol (SRR-, SSR-, SRS-, and SSS-α-tocopherol), also found in fortified foods and supplements. The 2S-stereoisomers are not stored in the body. For UL: applies to any form of supplemental α-tocopherol.
lTotal water includes all water contained in food, beverages, and drinking water.
SOURCE: IOM, 2006.
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TABLE B-3 Acceptable Macronutrient Distribution Ranges
Macronutrient
Range (percent of energy)
4-18 y
Adults
Fat
25-35
20-35
n-6 Polyunsaturated fatty acids* (linoleic acid)
5-10
5-10
n-3 Polyunsaturated fatty acids* (α-linolenic acid)
0.6-1.2
0.6-1.2
Carbohydrate
46-65
46-65
Protein
10-30
10-35
*Approximately 10 percent of the total can come from longer-chain n-3 or n-6 fatty acids.
SOURCE: IOM, 2006.
TABLE B-4 Additional Macronutrient Recommendations
Macronutrient
Recommendation
Dietary cholesterol
As low as possible while consuming a nutritionally adequate diet
Trans fatty acids
As low as possible while consuming a nutritionally adequate diet
Saturated fatty acids
As low as possible while consuming a nutritionally adequate diet
Added sugars*
Limit to no more than 25% of total energy
*Not a recommended intake. A daily intake of added sugars that individuals should aim for to achieve a healthful diet was not set.
SOURCE: IOM, 2006.
TABLE B-5 Estimated Healthy Eating Index-2005 Component and Total Scores, United States (1994-1996 and 2001-2002)
Component (maximum score)
1994-1996 Score (95% CI)
2001-2002 Score (95% CI)
Total fruit (5)
3.1 (3.0, 3.3)
3.1 (2.9, 3.3)
Whole fruit (5)
4.5 (4.3, 4.7)
3.4 (3.2, 3.7)*
Total vegetables (5)
3.6 (3.6, 3.7)
3.2 (3.1, 3.4)*
Dark green and orange vegetables and legumes (5)
1.4 (1.4, 1.5)
1.4 (1.2, 1.5)
Total grains (5)
5.0 (5.0, 5.0)
5.0 (5.0, 5.0)
Whole grains (5)
1.2 (1.2, 1.2)
1.0 (1.0, 1.1)*
Milk (10)
5.9 (5.7, 6.2)
6.3 (6.0, 6.5)*
Meat and beans (10)
10.0 (9.9, 10.0)
10.0 (10.0, 10.0)
Oils (10)
6.0 (5.8, 6.2)
6.8 (6.5, 7.1)*
Sodium (10)
3.2 (3.1, 3.3)
4.1 (3.9, 4.2)*
Saturated fat (10)
6.5 (6.4, 6.7)
6.4 (6.1, 6.7)
Calories from solid fat, alcohol, and added sugar (20)
7.8 (7.5, 8.2)
7.5 (6.9, 8.1)
Total HEI-2005 score (100)
58.2 (57.2, 59.2)
58.2 (56.6, 59.9)
NOTES: Excludes children under 2 years of age and breast-fed children.
*Significantly different (p < 0.05).
SOURCE: Nutrition Insight 37, USDA, available online at http://www.cnpp.usda.gov/Publications/NutritionInsights/Insight37.pdf [accessed April 16, 2009].
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TRENDS IN ENERGY INTAKE AND MARKERS OF ENERGY DENSITY
As the prevalence of obesity rises among childbearing-aged women and women entering pregnancy, important shifts in diet and physical activity have also occurred. In a recent study, Nielsen and colleagues (2002) used nationally representative data from the 1977-1978 Nationwide Food Consumption Survey and the 1989-1991 and 1994-1996 Continuing Surveys of Food Intake by Individuals to investigate the trends in total energy intake and energy intake by meal pattern type (Figure B-1). Data were stratified by age but not sex. These investigators found that among U.S. adults aged 19-39 years, there was an 18 percent increase in total energy intake over the 20-year period (1856 to 2198 kcal/d). When separated into energy from meal pattern type, the major contributor to this overall increase in energy intake was a sharp 58 percent increase in energy from snacks (244-387 kcal/d). Additionally, the percent of total energy from key food groups, such as salty snacks, sweetened beverages, candy, pizza, French fries, cheeseburgers, and Mexican-style food, increased between survey years 1977-1978 and 1994-1996.
These authors further investigated trends in beverage intake using the aforementioned data sources plus the 1999-2001 nationally-representative NHANES. For all age groups, including adults aged 19 to 39 years, sweet-
FIGURE B-1 Trends in energy intake and meal pattern type, U.S. adults aged 19-39 years.
SOURCE: Nielsen et al., 2002.
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ened beverage intake increased and milk consumption decreased between survey years 1977-1978 and 1999-2001 (Figure B-2) (Nielsen and Popkin, 2004). Specifically, energy from soft drinks nearly tripled (2.8 to 7.0 percent [approximately 50 to 144 kcal per person per day]), energy from fruit drinks doubled (1.1 to 2.2 percent [from 20 to 45 kcal per person per day]), and energy from milk decreased (8.0 to 5.0 percent [from 143 to 99 kcal per person per day]).
Taken together, these findings illustrate an increase in consumption of foods of low nutrient density in the general population. This has special implications for pregnancy and lactation, which require modest increases in energy intake but proportionally greater increases in vitamin and mineral intake.
The U.S. Dietary Guidelines represent federal nutrition policy. The recommendations of the Dietary Guidelines are interpreted for use by healthy Americans over 2 years of age in MyPyramid (available online: http://www.MyPyramid.gov [accessed October 16, 2008]). The current MyPyramid recommends that females aged 14-18 years and 31-50 years consume 8 combined servings of fruits and vegetables, while 9 combined servings is recommended for females aged 19-30 years. MyPyramid also makes more specific recommendations about types of vegetables, including dark green and orange vegetables, and legumes to ensure consumption of the variety of nutrients available from these foods. When the Guenther et al. (2006) exam-
FIGURE B-2 Trends in U.S. beverage consumption 1977-2001: percent of total energy intake.
SOURCE: Nielsen and Popkin, 2004.
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ined sub-groups of vegetables, mean intakes for childbearing-aged women were below the recommended amounts for all subgroups except for starchy vegetables (Figure B-3). These data clearly illustrate that childbearing-aged women failed to meet recommendations for fruits and vegetables.
Another method of quantifying the overall quality of American’s diets is through the use of the Healthy Eating Index-2005 (HEI-2005), a tool designed to measure compliance of diets with the key, diet-related recommendations of the 2005 Dietary Guidelines for Americans (HHS/USDA, 2005). The HEI-2005 has 12 components, as seen in Table B-5 (Guenther et al., 2006). For most components, higher intakes result in higher scores. Note, however, that for three components, saturated fat, sodium, and calories from solid fats, alcoholic beverages, and added sugars (SoFAAS), lower intake levels result in higher scores because lower intakes are more desirable. Monitoring changes in the HEI-2005 scores can provide a method for nutrition surveillance in the population.
In a recent analysis, trends in the HEI-2005 scores and its components were published for all Americans two years of age and older (subgroups of the population were not studied). From 1994-1996 to 2001-2002, there was little change in either overall HEI-2005 score or its components. The average HEI-2005 score was 58.2 out of 100 possible points in both time periods. American’s diets consistently met recommendations for the groups “Total Grains” and “Meat and Beans,” but were far below the maximum
FIGURE B-3 Mean daily intakes of vegetables by subtype among U.S. females 19-30 years of age.
SOURCE: Guenther et al., 2006.
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score for the groups, “Dark Green and Orange Vegetables” and “Legumes” as well as whole grains. Intakes from SoFAAS were well below the recommendations, as reflected in low scores on these components. From 1994-1996 to 2001-2002 the HEI-2005 score declined for the groups “Whole Fruit,” “Total Vegetables,” and “Whole Grains” while the score for the groups “Milk,” “Oils,” and “Sodium” improved.
Some of these dietary pattern changes may be a result of the trend toward obtaining a greater proportion of food outside the home. Self-reported dietary data from national surveys was used to show that the percentage of total energy intake obtained from foods consumed at home decreased from 77 in 1977-1978 to 65 percent from 1994-1996 (Figure B-4) (Nielsen et al., 2002). The amount of energy obtained from foods consumed from restaurants, including fast food establishments, doubled from 9 to 21 percent during this same period.
The aforementioned analysis relied on dietary intake data obtained from surveys. There is no “gold standard” method of assessing dietary intakes in individuals, and all self-reported dietary intake data have inherent biases. Therefore food supply data, collected directly from food producers and distributors, are often used to examine trends in American dietary patterns. The estimates are adjusted for spoilage, cooking losses, plate waste, and other food losses accumulated throughout the marketing system and
FIGURE B-4 Trends in energy intake (percent energy) by location, Americans aged 2+ years.
SOURCE: Nielsen et al., 2002.
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the home. Analysis of trends in food supply data provide the same conclusions regarding trends in increasing energy intake and overall diet quality of Americans as self-reported survey data.
The most recent loss-adjusted annual per capita food supply data analyses by the USDA’s Economic Research Service suggests a 12 percent increase in total energy intake (~300 kcal per person per day) from 1985 to 2000 (USDA, 2002; available online: http://www.ers.usda.gov/publications/FoodReview/DEC2002/frvol25i3a.pdf [accessed April 16, 2009]) (Figure B-5). Of the 300-kcal increase, grains (mainly refined grains) accounted for 46 percent; added fats, 24 percent; added sugars, 23 percent; fruits and vegetables, 8 percent of the increase. At the same time, energy intake from the meat and dairy groups together declined by 1 percent. When the per capita food supply data in 2000 was compared with the 1992 Food Guide Pyramid recommendations as a marker of overall diet quality, intakes exceeded recommendations for grains, meats, added fats, and added sugars, and fell below recommendations for dairy, fruits, and non-starchy vegetables (USDA, 2002; available online: http://www.ers.usda.gov/publications/FoodReview/DEC2002/frvol25i3a.pdf [accessed April 16, 2009]).
FIGURE B-5 Energy from the U.S. per capita food supply (adjusted for losses).
1Rounded to the nearest hundred.
2Not calculated for years beyond 1970.
SOURCE: USDA, 2002; available online at http://www.ers.usda.gov/publications/FoodReview/DEC2002/frvol25i3a.pdf [accessed April 16, 2009].
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REFERENCES
Guenther P. M., K. W. Dodd, J. Reedy and S. M. Krebs-Smith. 2006. Most Americans eat much less than recommended amounts of fruits and vegetables. Journal of the American Dietetic Association 106(9): 1371-1379.
HHS/USDA (U.S. Department of Health and Human Services/United States Department of Agriculture). 2005. Dietary Guidelines for Americans, 2005. 6th Edition. Washington, DC: Government Printing Office.
IOM (Institute of Medicine). 2006. Dietary Reference Intakes: The Essential Guide to Nutrient Requirement. Washington, DC: The National Academies Press.
Nielsen S. J. and B. M. Popkin. 2004. Changes in beverage intake between 1977 and 2001. American Journal of Preventive Medicine 27(3): 205-210.
Nielsen S. J., A. M. Siega-Riz and B. M. Popkin. 2002. Trends in energy intake in U.S. between 1977 and 1996: similar shifts seen across age groups. Obesity Research 10(5): 370-378.
Websites:
http://www.MyPyramid.gov
http://www.cnpp.usda.gov/Publications/NutritionInsights/Insight37.pdf
http://www.ers.usda.gov/publications/FoodReview/DEC2002/frvol25i3a.pdf
