Dietary Reference Intakes

1
Dietary Reference Intakes Dietary Guidelines in
Older Americans Act Nutrition Programs

•  Summary ISSUE PANEL
• February 11, 2002

National Policy Resource Center on Nutrition
Aging Florida International University, Miami,
FL Conducted by Cogent Research
2
Overview

• Background, by Dr. Nancy Wellman
• DRIs, EAR, RDA, AI, UL
• Rules and Regulations, by Jean Lloyd
• AOA and OAA regulations
• Issue Panel Overview, by Dr. Nancy Wellman
• Implication and Implementation, by Jean Lloyd

3
What are the Dietary Reference Intakes (DRIs)?

• Quantifiable reference values of nutrients,
  primarily for professionals
• Basis for planning and assessing the diets of
  healthy people
• Basis for federal nutrition and food programs

4
What is the purpose of the DRIs?

• To maintain nutritional adequacy
• To promote health
• To reduce risk of disease
• To provide a measure of excess

5
Who establishes the DRIs?

• The Food and Nutrition Board of the Institute of
  Medicine of the National Academy of Sciences
• Panels of experts, chosen by the Academy,
  independently selected
• Funded by DHHS, USDA, Health Canada, and private
  industry
• http//www.iom.edu

6
What are the different DRI values?

• Estimated average requirement (EAR)
• Recommended Dietary Allowances (RDA)
• Adequate Intake (AI)
• Tolerable Upper Intake Level (UL)

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What is the EAR?

• Nutrient intake to meet the requirement of half
  the healthy people of an age and gender
• A requirement is the lowest continuing intake
  that will maintain a defined level of nutriture

8
What is the RDA?

• Nutrient intake to meet the requirement for
  nearly all (97-98) of people of an age and
  gender
• EAR, plus 2 standard deviations

9
What is the AI?

• Nutrient intake of healthy people assumed to be
  adequate
• Insufficient data to establish an EAR
• Based on observed intakes, experimental data, etc.

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What is the UL?

• Highest daily nutrient intake likely to pose no
  risk of adverse health effects to almost all of
  the general population
• Not a recommended level, no established benefits
  of higher level, and increased risks

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What are some of the characteristics of the DRIs?

• Apply to healthy individuals
• Refer to average daily nutrient intake
• May vary substantially from day to day without
  ill effect in most cases

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What are some of the characteristics of the DRIs?

• Separate values apply to men and women
• New values apply to 51 to 70
• New values apply to 70

13
What are the Dietary Guidelines for Americans,
2000?

• They are brief science-based statements and text
  published by the Federal government that provide
  advice for healthy Americans age 2 years and over
  about food choices and physical activity to
  promote health and prevent disease.

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The Dietary Guidelines are

• Mandated by law
• Published every 5 years
• Based on the preponderance of scientific evidence
• Cornerstone of Federal nutrition policy
• Basis for healthy nutrition choices
• Basis for nutrition education/promotion activities

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How are the Guidelines revised?

• Advisory Committee appointed to review Guidelines
  through open process
• Committee report presented to DHHS and USDA
• DHHS and USDA review report and public comments
• The Secretaries of each agency publish revised
  guidelines.

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Aim for Fitness

• Aim for a healthy weight
• Be physically active each day

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Build a Healthy Base

• Let the Pyramid guide your food choices
• Choose a variety of grains daily, especially
  whole grains
• Choose a variety of fruits and vegetables daily
• Keep food safe to eat

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Choose Sensibly

• Choose a diet that is low in saturated fat and
  cholesterol and moderate in total fat
• Choose beverages and foods to moderate your
  intake of sugars
• Choose and prepare foods with less salt
• If you drink alcoholic beverages, do so in
  moderation

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The Food Guide Pyramid
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OAA Requirements

• SEC. 339 (2)(A)(i) State shall ensure that
  project provides meals that comply with the
  Dietary Guidelines for Americans.
• SEC. 339 (2)(A)(ii) State shall ensure that
  project provides meals that provide a minimum
  of 33 1/3 of the daily RDA if one meal per day
  66 2/3 RDA if 2 meals per day, and 100 RDA
  for 3 meals per day.
•  
• State Documents
• 1998 SUA Policies and Procedures Collection
• 34 (77) had guidelines for meal patterns.
• 35 (79) had guidelines for compliance with
  Dietary Guidelines.
• 40 (91) had guidelines that meals must comply
  with 33 of the RDA.

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OAA Requirements

• SEC. 339 (2)(A)(iii) ensure that the project
  provide(s) meals that to the maximum extent
  practical, are adjusted to meet any special
  dietary needs of program participants.
• SEC. 339 (2)(B) provides flexibility to local
  nutrition providers in designing meals that are
  appealing to program participants.
• State Documents
• 1998 SUA Policies and Procedures Collection (7)
• 21 (48) had guidelines for sodium and fat
  content of meals.
• 37 (84) had guidelines for special diets for
  health, religious or ethnic reasons.
• Some standard meal patterns requires foods high
  in vitamin C daily and vitamin A 3 times a week.

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OAA Requirements

• SEC. 339 (2)(A)(i) State shall ensure that
  project provides meals that comply with the
  Dietary Guidelines for Americans.
• SEC. 339 (2)(A)(ii) State shall ensure that
  project provides meals that provide a minimum
  of
• 33 1/3 of the daily RDA if one meal per day
• 66 2/3 RDA if 2 meals per day, and
• 100 RDA for 3 meals per day.

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OAA Requirements

• SEC. 339 (2)(A)(iii) State shall ensure that
  the project to the maximum extent practicable are
  adjusted to meet any special dietary needs of
  program participants.
• SEC. 339 (1) State shall solicit the advise of
  a dietitian or individual with comparable
  expertise in the planning of nutrition services.
• SEC. 339 (2)(G) State ensure that the project
  ensures that meal providers carry out such
  project with the advice of dietitians
•  
• State Documents
• 37 (84) had guidelines for special diets for
  health, religious or ethnic reasons.
•  

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OAA Requirements

• SEC. 339 (1) State shall solicit the advise of
  a dietitian or individual with comparable
  expertise in the planning of nutrition services.
• SEC. 339 (2)(G) State ensure that the project
  ensures that meal providers carry out such
  project with the advice of dietitians
• State Documents
• 1998 SUA Policies and Procedures (7)
• 10 (23) had no mention of utilizing the services
  of a dietitian at any level.
• 20 (45) had guidelines for the services of a
  registered and/or licensed dietitian or
  individual with comparable nutrition expertise at
  the AAA or local nutrition service provider
  level.
• 35 (77) had guidelines for dietitian at any
  level.
• 16 (36) had guidelines for the use of
  standardized recipes.
• 23 (52) had guidelines for use of computer
  assisted menu analysis.
• 34 (77) had guidelines for meal patterns..

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OAA Requirements

• SEC 102 (12) (b, c, d) Routine health screening
  nutrition counseling and education services
  health promotion programs.
• SEC. 331 (3) State plans establishment and
  operation of nutrition projects which may include
  nutrition education services and other
  appropriate nutrition services for older
  individuals.
• SEC. 339 (2) (J) State shall ensure that
  projects provide for nutrition screening and,
  where appropriate, for nutrition education and
  counseling.
•  
• State Documents
• 19 (43) had guidelines for health promotion and
  disease prevention activities
• 41 (93) had guidelines for nutrition education.

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OAA Requirements

•   SEC 206 (a) The Secretary shall measure and
  evaluate the impact of all programs
•   SEC 206 (d) The Secretary shall annually
  publish summaries and analyses of the results of
  evaluative research including health and
  nutrition education demonstration projects
•   SEC 401 (2) to design, test, and promote the
  use of innovative ideas and best practices in
  programs and services for older individuals.
• State Policies and Procedures
• 1998 SUA Policies and Procedures Collection
• 12 (27) had guidelines on how to collect
  required data.
• 13 (30) had guidelines for outcomes of
  monitoring and assessment.
• 17 (39) had guidelines on what data sources to
  use for needs assessment.

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Summary ISSUE PANEL February 11, 2002
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Cogent Research

• A strategic marketing research firm
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• Cambridge, MA

http//www.cogentresearch.com
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Panelists University

• YVONNE BRONNER, ScD, RD, Director, Public Health
  Program, Morgan State University, Baltimore, MD
• NOEL CHAVEZ, PhD, RD, Associate Professor, School
  of Public Health, University of Illinois,
  Chicago. IL
• EDWARD FRONGILLO, JR., PhD, Associate Professor,
  Cornell University, Ithaca, NY
• GORDON JENSEN, MD, PhD, Director, Vanderbilt
  Center for Human Nutrition, Nashville, TN
• MARY ANN JOHNSON, PhD, Professor, University of
  Georgia, Athens, GA
• ROBERT RUSSELL, MD, Director and Senior
  Scientist, Jean Mayer USDA Human Nutrition
  Research Center on Aging, Tufts University,
  Boston, MA
• JOE SHARKEY, MPH, RD, Nutritionist and Doctoral
  Candidate, University of North Carolina, Chapel
  Hill, NC

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Panelists Government

• JOSEPH CARLIN, MS, RD, FADA, Regional AoA
  Nutritionist, Boston, MA
• JOHANNA DWYER, DSc, RD, Assistant Administrator,
  Human Nutrition, USDA, Agricultural Research
  Service, Washington, DC
• NANCY GASTON, MA, RD, Senior Nutritionist, USDA,
  Center for Nutrition Policy Promotion,
  Alexandria, VA
• YVONNE JACKSON, PhD, RD, Director, Office of
  American Indian, Alaskan Native and Native
  Hawaiian Programs, AoA, Washington, DC
• FLORISTENE JOHNSON, MS, RD, Senior Aging
  Prg.Specialist, AoA, Dallas,TX
• JEAN LLOYD, MS, RD, Nutritionist, AoA, Washington
  DC
• BRIAN LUTZ, Acting Director, Office for
  Community-Based Services, AoA, Washington, DC
• KATHRYN MCMURRY, MS, Nutrition Food Science
  Advisor, ODPHP, USDHHS, Washington, DC
• DEBRA NICHOLS, MD, MPH, PH Advisor, ODPHP,
  USDHHS, Washington, DC
• JO ANN PEGUES, MPA, RD, Regional AoA
  Nutritionist, Denver, CO

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Panelists Aging Network

• DOUGLAS BUCK, PhD, FACN, State Nutritionist, CT
  Dept. Social Elderly Services, Hartford
• JENNIFER DRZIK, MS, RS, LD, State Nutritionist,
  MD Dept. of Aging, Baltimore
• JULIE HODGES, PhD, RD, FADA, Director, Health
  Care Services, Zartic Foods, Rome, GA
• BERTHA HURD, BS, Nutritionist, Dept. of Aging,
  City of Los Angeles, CA
• GORDON JENSEN, MD, PhD, Director, Vanderbilt
  Center for Human Nutrition, Nashville
• LINDA LAVINE, RD, LD/N, Corporate Dietitian, GA
  Food Service, Inc., St. Petersburg, FL
• LINDA MEYERS, PhD, Deputy Director, Food
  Nutrition Board, IOM, Washington, DC
• LINDA NETTERVILLE, MA, RD, Nutrition Prog. Mgr,
  Johnson County AAA, Olathe, KS
• MARTHA PEPPONES, MS, RD, Nutr Dir, Senior
  Services Snohomish County, Mukilteo, WA
• SUE ZEVAN, RD, State Nutritionist, Aging Adult
  Administration, Dept. Economic Security, Phoenix,
  AZ

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Panelists National Policy Resource Center
on Nutrition Aging

• Lester Rosenzweig, MS, RD, Associate Director
• Peggy Schafer, RD, Graduate Assistant
• Heidi Silver, PhD, RD, CNSD, Associate Director
  of Research
• Dian Weddle, PhD, RD, FADA, Associate Professor
  Co-Director
• Nancy Wellman, PhD, RD, FADA, Professor
  Director

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Discussion Topics

• Why must Older Americans Act Nutrition Program
  meals meet the most current Recommended Dietary
  Allowances and Adequate Intakes (as components of
  the Dietary Reference Intakes), and the 2000
  Dietary Guidelines for Americans?
• Must each Older Americans Act Nutrition Program
  meal individually meet these requirements?
• Assuming that all Older Americans Act Nutrition
  Program meals are culturally appropriate, what
  nutrients should be targeted?

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Discussion Topics

• How can Older Americans Act Nutrition Program
  meals be evaluated for meeting the Recommended
  Dietary Allowances, Adequate Intakes, and 2000
  Dietary Guidelines?
• How can Older Americans Act Nutrition Program
  meals be adjusted to meet special dietary needs?
• How can nutrition services, including nutrition
  screening, education, and counseling, incorporate
  the Dietary Reference Intakes, 2000 Dietary
  Guidelines, and targeted nutrients
  recommendations?
• What nutrition-related issues need attention at
  future Issue Panels and/or in outcomes research?

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Discussion Topic 1

Why must Nutrition Program meals meet the most
current RDA AIs, 2000 DGs?

• Reflect most recent scientific evidence
• Best-known guidance to meet nutritional needs
  of most older adults in America.

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Discussion Topic 2

• Must each Nutrition Program meal individually
  meet these requirements?

• Each meal should be reasonably nutritionally
  well-balanced and reflect 2000 DGs
• Meals provide a positive nutrition education
  model for participants
• NPs that serve 1 meal/d should ensure each meal
  ? 33 1/3 RDAs/AIs
• Prgs that offer 2 meals/day should ensure the
  sum of meals ? 66 2/3 RDAs/AIs lt but each
  meal itself does not have to be 33 1/3 gt
• Prgs serving 3 meals/day should ensure the sum
  of meals 100 RDAs/AIs.

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Discussion Topic 3

• Assuming all Nutrition Program meals are
  culturally appropriate, what nutrients should be
  targeted?

• Nutrition Program should emphasize foods high in
  fiber, ca, and protein.
• Prgs should continue to target vitamins A and C
• Vit A from vegetable-derived (carotenoid)
  sources.
• Future Issue Panel should target more specific
  recs
• Targeting specific nutrients ? permission to
  ignore other nutrients.

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Discussion Topic 4

• How can Nutrition Program meals be evaluated for
  meeting RDA, AI, 2000 DGs?

• Nutrition Program should plan evaluate meals
  for meeting the 2000 DGs 1/3 RDA/AI
  standards by computer-assisted analysis.
• RDs (or individuals with comparable expertise )
  should be available at state, area, local
  provider level to assure nutrient adequacy of
  meals.
• Meal patterns should be based on food servings
  delineated in Food Guide Pyramid
• combined meet 1/3 RDAs/AIs and 2000 DGs
• Be tested for meeting requirements, and include
  increased servings of fruits, vegetables, and
  whole grains.

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Use of Meal Patterns

• OAA does not specify compliance with a meal
  pattern.
• meal pattern is menu planning tool
• ensure inclusion of food component groups
• inclusion of foods high in specific nutrients
• Do state agencies use or require AAAs to use meal
  patterns?
• 34 (77) had guidelines for meal patterns.
• Source SUA Best Practices Toolkit Survey,
  NPRCNA, 8/2000

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Sample Meal Pattern

• 3 starches
• 2 vegetables
• 1 fruit
• 1 milk/alternative
• 1 meat/alternative
• 1 fat
• Dessert optional

42
Use of Standardized Recipes

• OAA does not specify use of standardized recipes.
  
• standardized recipes ensures consistency in
  preparation of food items and nutrient content
• Do state agencies use or require AAAs to use
  standardized recipes?
• 16 (36) had guidelines for use of standardized
  recipes.
• Source SUA Best Practices Toolkit Survey,
  NPRCNA, 8/2000

43
Use of Menu Analysis

• OAA does not specify use of menu analysis to
  ensure compliance with nutrient requirements.
• menu analysis ensures menus meet requirements
• Do state agencies use or require AAAs to use menu
  analysis with specific software and data sources?
• Half the states did not have guidelines.
• 23 (52) had guidelines for use of menu
  analysis.
• Source SUA Best Practices Toolkit Survey,
  NPRCNA, 8/2000

44
Use of Menu Analysis

• OAA does not specify different requirements when
  providing more than one meal a day.
• menu analysis is method to ensure two or three
  meals, combined, provides 2/3rd or 100 RDA
• some states establish different meal patterns for
  different meals of the day each meal provides
  all items on meal pattern.

45
Discussion Topic 5

• How can Nutrition Program meals be adjusted to
  meet special dietary needs?

• Nutrition Programs should accommodate specific
  dietary needs
• RDs (or individuals with comparable expertise )
  should be available.
• could also conduct needs assessments of the
  populations their programs serve.

46
Discussion Topic 6

• How can nutrition services, incl. Nutr.
  screening, edu., and counseling, incorporate
  DRIs, 2000 DGs, and targeted nutrients
  recommendations?

• New or existing nutrition screening, education,
  counseling tools and services should reflect
  standards established by DRIs and 2000 DGs.

47
Nutrition Education

• Nutrition education may be defined as any set of
  learning experiences designed to facilitate the
  voluntary adoption of eating and other
  nutrition-related behaviors conducive to health
  and well-being

Contento I, Balch GI, Bronner YL, Lytle LA,
Maloney SK, Olson CM, Swadener SS. The
effectiveness of nutrition education and
implications for nutrition education policy,
programs, and research a review of research. J
Nutr Educ. 199527(6)277-422.
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Nutrition Counseling

• Nutrition counseling is an individualized process
  that can help to manage personal nutrition care
  effectively. It is an essential service,
  particularly for children at risk. Counseling may
  be used to obtain more information, to review and
  strengthen acquired knowledge or desirable
  habits, or to help the child or adolescent set
  personal goals and make individualized decisions.

Position of the American Dietetic Association.
Child and adolescent food and nutrition programs.
J Am Diet Assoc. 199696913-917.
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Discussion Topic 7

• What nutrition-related issues need attention at
  future Issue Panels and/or in outcomes research?

• Nutrients to be targeted in Older Americans Act
  Nutrition Programs
• Outcomes-based research and demonstration
  projects
• Creating a balance between national uniformity
  and local autonomy
• Resource development

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Implications Implementations
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How will the DRIs/RDAs and Dietary Guidelines
affect the OAA Nutrition Programs?

• DRIs/RDAs and Dietary Guidelines
• Provide the basis for nutrition services, which
  is more than meal provision
• Provide the standards for meal service
• Provide the basis for nutrition screening
• Provide a basis for service interventions

52
How will the DRIs/RDAs and Dietary Guidelines
affect the OAA Nutrition Programs?

• DRIs/RDAs and Dietary Guidelines
• Provide the basis for nutrition education
• Provide the basis for nutrition counseling
• Provide the basis for assisting participants in
  modifying lifestyles and reducing health and
  functionality risks
• Provide the basis for outcome measurement

53
What does the AoA recommend for the aging network?

• AoA recommends that SUAs, AAAs, and local
  nutrition service providers begin to revise
• Policies, procedures, guidelines
• Program guidance
• Quality assurance standards
• Monitoring, assessment, and evaluation tools

54
What does the AoA recommend for the aging network?

• AoA recommends that SUAs, AAAs, and local
  nutrition service providers begin to revise
• Outcome measurement tools
• Program planning
• Program operations such as menu planning, menu
  costing, nutrition screening, nutrition
  education, nutrition counseling

55
What does the AoA recommend for the aging network?

• AoA recommends that SUAs, AAAs, and local
  nutrition service providers begin to revise
• Consumer education materials
• Health promotion/disease prevention programs and
  materials
• Provision of meals to meet special dietary needs

56
What does the AoA recommend for the aging network?

• AoA recommends that SUAs, AAAs, and local
  nutrition service providers begin to revise
• Food service catering/vending contracts
• Training and technical assistance