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DRI DIETARY REFERENCE INTAKES

Applications in Dietary Assessment

A Report of the

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

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.



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DRI DIETARY REFERENCE INTAKES: Applications in Dietary Assessment DRI DIETARY REFERENCE INTAKES Applications in Dietary Assessment A Report of the 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 INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C.

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DRI DIETARY REFERENCE INTAKES: Applications in Dietary Assessment NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 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 This report is available for sale from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, DC 20055; call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP's on-line bookstore at http://www.nap.edu. For more information about the Institute of Medicine or the Food and Nutrition Board, visit the IOM home page at http://www.iom.edu. Copyright 2000 by the National Academy of Sciences. All rights reserved. Printed in the United States of America

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DRI DIETARY REFERENCE INTAKES: Applications in Dietary Assessment “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE Shaping the Future for Health

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DRI DIETARY REFERENCE INTAKES: Applications in Dietary Assessment THE NATIONAL ACADEMIES National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council 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. William 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. Kenneth I. Shine 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. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.

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DRI DIETARY REFERENCE INTAKES: Applications in Dietary Assessment 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

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DRI DIETARY REFERENCE INTAKES: Applications in Dietary Assessment 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

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DRI DIETARY REFERENCE INTAKES: Applications in Dietary Assessment 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

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DRI DIETARY REFERENCE INTAKES: Applications in Dietary Assessment 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

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DRI DIETARY REFERENCE INTAKES: Applications in Dietary Assessment 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

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DRI DIETARY REFERENCE INTAKES: Applications in Dietary Assessment 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-

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DRI DIETARY REFERENCE INTAKES: Applications in Dietary Assessment 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-

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DRI DIETARY REFERENCE INTAKES: Applications in Dietary Assessment 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,

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DRI DIETARY REFERENCE INTAKES: Applications in Dietary Assessment 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