Section 1: Aiming To Meet Nutrient Intake Recommendation

Table D1-7b. Food sources of magnesium as consumed by Americans.² (Percent of total consumption, CSFII, 1994-1996)

¹ Source: Agricultural Research Service Nutrient Database for Standard Reference, Release 16-1. Mixed dishes and multiple preparations of the same food item have been omitted.

² Source: Cotton et al. 2004. Data are for persons aged 19 years and older, Day 1 intakes.

³ Food groups (n=12) contributing at least 1% in descending order: bananas, rice/cooked grains, fish/shellfish (excluding canned tuna), tea, ice cream/sherbet/frozen yogurt, hot breakfast cereal, soft drinks/soda, tortillas/tacos, meal replacements/protein supplements, candy, flour/baking ingredients, and spinach/greens.

The U.S. Department of Agriculture (USDA) (Fed. Reg. Notice, 2003) proposed a food intake pattern with the goal of meeting recommended intakes for all nutrients. The basic food groups used in this pattern and mentioned below are fruits, vegetables, grains, meat and beans, and milk. The proposed pattern has since been revised by USDA in collaboration with the Committee, to take into account the newly released IOM recommendations for potassium and sodium (IOM, 2004). Methods used in developing these patterns are summarized in Part C of this report. The revised food intake pattern meets nutritional recommendations for almost all nutrients, including most of the nutrients considered shortfall nutrients. Exceptions are vitamin E and potassium, as described below.

Vitamin E. As shown in Tables D1-2 and D1-4, and reported by Maras et al. (2004), vitamin E is a shortfall nutrient for nearly the entire population of U.S. adults and children. Although these data suggest widespread deficiency, there is no evidence of overt deficiency symptoms, i.e., sensory neuropathy and erythrocyte fragility, in the American population. Current intake levels likely are underestimated because of the underreporting of food intake on dietary surveys, especially related to the intake of fats and oils, and the limitations of nutrient databases with regard to the vitamin E content of foods (IOM, 2000a; Maras et al., 2004).

Most Americans do not typically consume foods that are especially rich in vitamin E on a daily basis. Table D1-8a lists the best food sources of vitamin E per standard amount from the Agricultural Research Service nutrient database along with the number of calories for that amount. Table D1-8b lists the major sources of vitamin E from American food consumption data. Although salad dressings, mayonnaise, and oils provide the greatest amount of vitamin E in American diets overall, the oil most commonly used in these products—soybean oil—is not an especially rich source of vitamin E. Oils containing higher amounts of vitamin E—sunflower, cottonseed, and safflower oils—are less commonly consumed. The same is true for nuts—almonds and hazelnuts are relatively rich in vitamin E; but peanuts and peanut butter, with lower levels of vitamin E, represent the majority of all nut consumption in the United States.

The revised USDA food intake pattern includes increases in vitamin E content over current consumption but still provides only 50 to 90 percent of the RDA for vitamin E. The food composites used in modeling the food pattern are relatively low in vitamin E content, reflecting Americans' relatively low use of foods rich in vitamin E. As the calorie level of the food pattern increases, the pattern comes closer to providing the recommended intake of vitamin E.

Table D1-8. Food Sources of Vitamin E.

Table D1-8a. Food sources of vitamin E ranked by milligrams of vitamin E per standard amount; also calories in the standard amount (All provide ≥10% of RDA for vitamin E for adults, which is 15 mg α–tocopherol (AT).)

Table D1-8b. Food sources of vitamin E as consumed by Americans² (Percent total consumption, CSFII, 1994-1996)

¹ Source: Agricultural Research Service Nutrient Database for Standard Reference, Release 16-1. Mixed dishes and multiple preparations of the same food item have been omitted.

² Source: Cotton et al. 2004. Data are for persons aged 19 years and older, Day 1 intakes.

³ Additional food groups (n=11) contributing at least 1% in descending order: pies/crisps/cobblers, broccoli, milk, cheese, biscuits, poultry, beef, crackers/pretzels, and tortillas/tacos.

^* Potato and corn chips

^** Shortening/animal fat

^*** Excl. canned tuna

Calcium. Milk and milk products are rich sources of calcium. Table D1-9a lists foods that provide at least 20 percent of the adult AI for calcium in standard amounts along with the number of calories provided by that serving size. Milk and milk products also are the major sources of calcium in U.S. diets (Table D1-9b), but calcium intake falls considerably short of the AI for most age groups beginning at age 9 years, especially for females. The revised USDA food pattern specifies 2 or 3 cups per day from the milk group, based on the calorie level of the pattern,² and meets the goals for calcium intake. The rationale for Question 4 below includes several tables that address ways to achieve recommended calcium intake. Part D, Section 5, "Selected Food Groups," addresses relationships of milk products with health.

Table D1-9. Food Sources of Calcium.

Table D1-9a. Food sources of calcium ranked by milligrams of calcium per standard amount; also calories in the standard amount. (All are ≥20% of AI for adults 19-50, which is 1000 mg.)

Table D1-9b. Food sources of calcium as consumed by Americans² (Percent of total consumption, CSFII, 1994-1996)

¹ Source: Agricultural Research Service Nutrient Database for Standard Reference, Release 16-1. Mixed dishes and multiple preparations of the same food item have been omitted.

² Source: Cotton et al. 2004. Data are for persons aged 19 years and older, Day 1 intakes.

³ Food groups (n=11) contributing at least 1% in descending order: yogurt, ready-to-eat cereal, soft drinks/soda, tortillas/tacos, eggs, dried beans/lentils, tomatoes, meal replacements/protein supplements, corn bread/corn muffins, hot breakfast cereal, and coffee.

Potassium. Potassium intake falls short of the AI for all age groups examined, but sources of potassium come from all the basic food groups. Table D1-10a lists the potassium content and calories for standard amounts of foods ranked by potassium content. For calorie levels at or above 1,600 kcal per day, the revised USDA food pattern provides more than 76 percent of the AI for potassium. For calorie levels less than 1,600 kcal per day, only 64 to 75 percent of the AIs would be met. As was the case for vitamin E, some of the food composites used in modeling the food pattern are relatively low in potassium content, reflecting Americans' relatively low use of some of the better potassium sources (see Table D1-10b for a list of major sources of potassium in American diets). The rationale for Question 2 below describes how this problem was addressed.

Table D1-10. Food Sources of Potassium.

Table D1-10a. Food sources of potassium ranked by milligrams of potassium per standard amount, also showing calories in the standard amount. (The AI for adults is 4700 mg. potassium)

Table D1-10b. Food sources of potassium as consumed by Americans² (Percent of total consumption, CSFII, 1994-1996)

¹ Source: ARS Nutrient Database for Standard Reference, Release 16-1. Mixed dishes and multiple preparations of the same food item have been omitted.

² Source: Cotton et al. 2004. Data are for persons aged 19 years and older, Day 1 intakes.

³ Additional food groups (n=11) contributing at least 1% in descending order: ice cream/sherbet/frozen yogurt, ready-to-eat cereal, fish/shellfish (excluding canned tuna). Cakes/cookies/quick breads/doughnuts, alcoholic beverages, cheese, pork (fresh/unprocessed), lettuce, ham, carrots, and onions.

Fiber. As for potassium, fiber intakes fall short of the AIs for all age groups examined. Table D1-11a lists the fiber content and calories for standard amounts of foods ranked by fiber content. As can be seen in Table D1-11b, the major source of fiber in the U.S. diet is yeast bread; however, white bread, which is the most common form of yeast bread, does not appear in the list of foods that are among the best fiber sources. The large amount of white yeast breads consumed (as bread, rolls, buns, and pizza crust) causes this food to be a major fiber contributor to American diets. However, legumes, many vegetables and fruits, and whole grains are far better dietary fiber sources for a standard amount.

Table D1-11. Food Sources of Dietary Fiber.

Table D1-11a. Food sources of dietary fiber ranked by grams of dietary fiber per standard amount; also calories in the standard amount (All are ≥10% of AI for adult women, which is 25 grams.)

Table D1-11b. Food sources of dietary fiber as consumed by Americans² (Percent of total consumption, CSFII, 1994-1996)

¹ Source: ARS Nutrient Database for Standard Reference, Release 16-1. Mixed dishes and multiple preparations of the same food item have been omitted.

² Source: Cotton et al. 2004. Data are for persons aged 19 years and older, Day 1 intakes.

³ Food groups (n=13) contributing at least 1% in descending order: tortillas/tacos, onions, lettuce, nuts/seeds, hot breakfast cereal, broccoli, green beans, corn, rice/cooked grains, crackers/pretzels, pies/crisps/cobblers, oranges/tangerines, spinach/greens.

Table D1-12 identifies the functions of the shortfall nutrients that are listed above. Increasing one's intake of each of these nutrients to achieve recommended nutrient intakes can help promote health.

Table D1-12. Functions of "Shortfall" Nutrients.

QUESTION 2: WHAT DIETARY PATTERNS ARE ASSOCIATED WITH ACHIEVING RECOMMENDED NUTRIENT INTAKES?

Conclusion

Two major aspects of the USDA dietary pattern contribute to meeting nutrient intake recommendations:

1. Consumption of foods from each of the basic food groups:
   • fruits
   • vegetables
   • grain
   • milk, yogurt, and cheese
   • meat, poultry, fish, dry beans, eggs, and nuts³
2. Consumption of a variety of food commodities within each of those food groups—since higher energy intake is strongly associated with greater variety and higher nutrient intake, attention also should be given to food group choices that maintain appropriate energy balance.

Rationale

This conclusion is supported by food pattern modeling conducted by USDA's Center for Nutrition Policy and Promotion (CNPP) and by one published study (Foote et al., 2004) that links survey data on food intake with data on nutrient intakes. It also is supported by information on nutrients provided by the basic food groups and their subgroups.

Food Pattern Modeling

The USDA method of food pattern modeling, which is described briefly in Part C, "Methodology," and in detail in "Notice of Availability of Proposed Food Guide Pyramid Daily Food Intake Patterns and Technical Support Data" (Fed. Reg. Notice, 2003), is a well-documented approach for developing food patterns (Welsh et al., 1993). The method is intended to develop the food pattern that meets the DRIs and that is as realistic and practical as possible (Fed. Reg. Notice, 2003). Food intake patterns were first developed using this method in the 1980s, and became the scientific basis for the Food Guide Pyramid. In 2003, a new pattern (developed using this same method) was proposed and submitted for public comment by USDA. Since then, USDA has slightly revised the proposed pattern to account for recent recommendations for potassium and sodium (IOM, 2004) and provided the Committee with the revised pattern. USDA states that it will use this report of the 2005 Dietary Guidelines Advisory Committee to finalize a new food intake pattern and will then develop graphic and educational materials for the public based on these patterns.

In developing the new daily food pattern, the nutrient content of preliminary patterns was compared to the new nutritional goals. If the goals were not met at a given calorie level, amounts from food groups or subgroups that were higher in the nutrients in question were increased, and corresponding changes were made in other groups to maintain total calories at the goal level. The adjustments were made in an iterative manner, to bring the pattern closer to its nutritional goals.

Most of the nutritional goals for the USDA food intake pattern, as identified in the Federal Register Notice, were met by making relatively modest changes from the pattern used in the original Pyramid (Welsh et al., 1993) (see Appendix G-2 for a table of food patterns from the original Pyramid.) Changes included:

• Increasing the number of calorie levels from 3 (1,600; 2,200; 2,800) to 12 (every 200 calories from 1,000 to 3,200).
• Separation of discretionary fats into solid fats and oils and soft margarines, and a shift in the proportions recommended to 40 percent solid fats, 60 percent oils—The original Pyramid patterns did not distinguish among types of fats, and the proportions were therefore the estimated intake proportions of 58 percent solid fats, 42 percent oils.
• Increasing the amounts of vegetables for some calorie levels—To meet nutritional goals, the overall amounts of vegetables recommended were increased for several calorie levels.
• Change in the relative amounts of vegetable subgroups—The nutrient profiles of dark green vegetables and legumes were relatively high in the nutrients needed to meet unmet nutrient goals. Therefore, amounts of these vegetables were preferentially increased and amounts of the remaining vegetable subgroups (starchy, orange, and other vegetables) were held constant or decreased.
• Increase in the amount of whole grains, to one-half of the total amount in every pattern—Enriched grains were proportionately decreased. At least 3 oz of whole grains are provided for the calorie levels equal to and above 1600 kcal per day.

The Committee examined these data and noted the concern identified by USDA that the pattern provides only 50 to 75 percent of the RDA for vitamin E at all except the highest calorie levels. In contrast, the pattern provides well over 100 percent of the RDA for many of the nutrients.

The Committee also noted that the nutrient profiles use the lowest fat forms of each food in the food group and/or a form free of added sugars. Thus, the foods that make up the composite could be described as a nutrient dense version of the foods. Examples include nonfat milk, chicken without the skin, and ground beef with no more than 5 percent fat. Although this approach allows food pattern recommendations to provide individuals a way to meet their nutrient needs while avoiding the overconsumption of calories and of food components such as saturated fats, the Committee recognized that this key aspect of the nutrient profiles could be overlooked easily and merits emphasis in nutrition education efforts.

In February 2004, the IOM released the report Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (IOM, 2004). This report included new AIs for potassium—values that were more than two times as high as the potassium goals used in developing the food pattern published in the Federal Register Notice. Consequently, at the Committee's request, USDA made adjustments in the food intake pattern so that it would provide higher percentages of the AI for potassium. The adjustments required increasing milk or other milk products to 3 cups or the equivalent, increasing vegetables by 0.5 cups and increasing fruits by 0.5 cups, per day. To compensate for the calories provided by the increases in these three groups, the amounts of grains in the pattern were decreased by about 1 ounce equivalent, and added sugars and solid fats were decreased for some age and/or sex groups.

Tables D1-13 and D1-14 show the revised USDA food pattern that incorporates the new standards for potassium.⁴ The nutritional goals for this pattern, shown in Table D1-1, were based on the current Dietary Reference Intakes (IOM, 1997, 1998, 2000a, 2001a, 2002, 2004). The nutrient content that was assigned to a standard amount of food from each food group and subgroup appears in Table D1-15. The values in Table D1-15 were used in combination with the daily intake amount for each food group or subgroup to estimate the amounts of nutrients provided by the food intake pattern (Table D1-16).

Table D1-13. Revised USDA Food Intake Patterns for Meeting Recommended Nutrient Intakes

This table shows the suggested amounts of food to consume from the basic food groups, subgroups, and oils to meet recommended nutrient intakes at 12 different calorie levels. Nutrient and energy contributions from each group are calculated based on nutrient dense forms of foods in each group (e.g., lean meats, fat-free milk). The table also shows the amount of discretionary calories that can be accommodated within each calorie level in addition to the suggested amounts of nutrient dense forms of foods in each group.

Notes for Table D1-13:

1. Food items included in each group and subgroup:

2. Quantity equivalents for each food group:

3. Explanation of vegetable subgroup amounts:
Vegetable subgroup amounts are shown in this table as weekly amounts, because it would be difficult for consumers to select foods from each subgroup daily. A daily amount that is one-seventh of the weekly amount listed is used in calculations of nutrient and energy levels in each pattern.

4. Explanation of grain subgroup amounts:
The whole grain subgroup amounts shown in this table represent at least 3 one-ounce servings, and one-half of the total amount as whole grains for all calorie levels of 1600 and above. This is the minimum suggested amount of whole grains to consume as part of the food patterns. More whole grains up to all of the grains recommended may be selected, with offsetting decreases in the amounts of other (enriched) grains. In patterns designed for younger children (1,000, 1,200, and 1,400 calories), one-half of the total amount of grains is shown as whole grains.

5. Explanation of oils:
Oils (including trans-free soft margarine) shown in this table represent the amounts that are added to foods during processing, cooking, or at the table. Oils and soft margarines include vegetable oils and soft vegetable oil table spreads that are trans-free. The amounts of oils listed in this table are not considered to be part of discretionary calories because they are a major source of the vitamin E and polyunsaturated fatty acids, including the essential fatty acids, in the food pattern. In contrast, solid fats are listed separately in the discretionary calorie table (Table D1-14) because, compared with oils, they are higher in saturated fatty acids and lower in vitamin E and mono- and polyunsaturated fatty acids, including essential fatty acids. The amounts of each type of fat in the food intake pattern were based on 60% oils and/or trans-free soft margarines and 40% solid fat. The amounts in typical American diets are about 42% oils or soft margarines and about 58% solid fats.

6. Discretionary calories are the remaining amount of calories in each food pattern after selecting the specified number of nutrient dense forms of foods in each food group. The number of discretionary calories assumes that food items in each food group are selected in nutrient dense forms (that is, forms that are fat-free or low-fat and that contain no added sugars). Solid fat and sugar calories always need to be counted as discretionary calories, as in the following examples:

Total discretionary calories should be limited to the amounts shown in the table at each calorie level. Additional information about discretionary calories, including an example of the division of these calories between solid fats and added sugars, is provided in Table D1-14.

Table D1-14. Discretionary Calories in Revised USDA Food Intake Patterns.

Discretionary calories are the remaining amount of calories in each food pattern after nutrient dense forms of foods in each food group are selected. This table shows the number of discretionary calories remaining in each food intake pattern if nutrient dense foods are selected. Those trying to lose weight may choose not to use discretionary calories. For those wanting to maintain their weight, discretionary calories may be used to increase the amount of food selected from each food group; to consume foods that are not in the lowest fat form (such as 2% milk or medium fat meat) or that contain added sugars; to add oil, fat, or sugars to foods; or to consume alcohol. The table shows an example of how these calories may be divided between solid fats and added sugars.

1. Discretionary calories: In developing the food patterns, food items in nutrient dense forms (that is, forms that are fat-free or low-fat and that contain no added sugars) were used. The number of discretionary calories assumes that food items in each food group are selected in nutrient dense forms. Solid fat and sugar calories always need to be counted as discretionary calories, as in the following examples:

Total discretionary calories should be limited to the amounts shown in the table at each calorie level. The calories assigned to discretionary calories may be used to increase intake from the basic food groups; to select foods from these groups that are higher in fat or with added sugars; to add oils, solid fats or sugars to foods or beverages; or to consume alcohol. See note 2 on limits for solid fats.

2. Solid fats: Amounts of solid fats listed in the table represent about 7 to 8% of calories from saturated fat.
Foods in each food group are represented in their lowest fat forms, such as fat-free milk and skinless chicken. Solid fats shown in this table represent the amounts of fats that may be added in cooking or at the table, and fats consumed when higher fat items are selected from the food groups (e.g., whole milk instead of fat-free milk, chicken with skin, or cookies instead of bread), without exceeding the recommended limits on saturated fat intake. Solid fats include meat and poultry fats eaten either as part of the meat or poultry product or separately; milk fat such as that in whole milk, cheese, and butter; shortenings used in baked products; and hard margarines.

Solid fats and oils are separated because their fatty acid compositions differ. Solid fats are higher in saturated fatty acids, and commonly consumed oils and trans-free soft margarines are higher in vitamin E and mono- and polyunsaturated fatty acids, including essential fatty acids. Oils listed in Table D-1- 13, and are not considered to be part of discretionary calories because they are a major source of the essential fatty acids and vitamin E in the food patterns.

The gram weights for solid fats are the amounts of these products that can be included in the pattern, and are not identical to the amount of lipids in these items, since some products (margarines, butter) contain water or other ingredients in addition to lipids.

3. Added sugars:
Added sugars are the sugars and syrups added to foods and beverages in processing or preparation, not the naturally-occurring sugars in fruits or milk. The amounts of added suggested in the example are NOT specific recommendations for amounts of added sugars to consume, but rather represent the amounts that can be included in each food intake pattern without over-consuming calories. The suggested amounts of added sugars may be helpful as part of the food patterns to allow for some sweetened foods or beverages, without exceeding energy needs. This use of added sugars as a calorie balance requires two assumptions: (1) that selections are made from all food groups in accordance with the suggested amounts and (2) that additional fats are used in the amounts shown, which together with the fats in the core food groups represent about 30% of calories from fat.

TABLE D1-15. Nutrient Profiles¹ of USDA Food Intake Pattern Food Groups and Subgroups
P. 1, Vitamins

This table shows the nutrient composition of each food group and subgroup. The nutrients are listed for a standard amount from each group, and the values are weighted averages of the nutrients in all foods in each group, in their lowest fat and sugar form. Weights for these average values are based on the amounts of each food consumed by Americans according to national surveys. See the notes page for additional information.

TABLE D1-15, (cont’d.). Nutrient Profiles¹ of USDA Food Intake Pattern Food Groups and Subgroups
P. 2, Minerals

TABLE D1-15, (cont’d.). Nutrient Profiles¹ of USDA Food Intake Pattern Food Groups and Subgroups
P. 3, Macronutrients

Notes for Table D1-15:

1. A Nutrient Profile is the nutrient content of a standardized amount of food from each food group or subgroup. It is calculated based on a weighted average of all foods in the group or subgroup eaten by Americans, as reported in the 1999-2000 NHANES survey. Weights for the nutrient profiles are determined from the relative amounts reported to have been consumed of each food in a particular group or subgroup. Nutrient values for each food group or subgroup have been calculated using values from USDA Nutrient Data Base, SR16-1.

2. The Standard Amount is an amount used in calculating nutrient profiles. It is expressed in volume or weight-equivalent measures. For the major food groups, it represents the amount in one "Pyramid serving" of the food. Serving equivalents for common foods in each group are listed in Note 2 to Table D1-10.

3. Vitamin A is expressed in µg RAE, vitamin E in mg AT. These units are used in the recent Dietary Reference Intakes reports. When values for a food were not available in these units, existing units were converted to obtain an estimate. Vitamin A from carotenoid sources (fruits and vegetables) expressed in µg RE was divided by 2 to obtain an estimate of vitamin A in µg RAE. Vitamin E expressed in mg ATE was multiplied by 0.8 to obtain an estimate of vitamin E in mg AT.

4. The nutrient profiles for whole grains and other grains include some added nutrients from moderately fortified ready-to-eat cereals. Moderately fortified ready-to-eat cereals were included as part of the nutrient profiles because of their widespread use among Americans.

5. The nutrient profile for the Milk Group is based on the nutrients in fat-free fluid milk.

Table D1-16. Nutrients in USDA Revised Food Intake Patterns
Page 1, vitamin

Table D1-16, (cont’d.). Nutrients in Revised USDA Food Intake Patterns.
Page 2, minerals

Table D1-16, (cont’d.). Nutrients in Revised USDA Food Intake Patterns.
Page 3, macronutrients

Table D1-16, (cont’d.). Nutrients in Revised USDA Food Intake Patterns.
Page 4, macronutrients

The revised food intake pattern differs in important ways from food intake patterns that reflect usual food consumption by Americans. In particular, for many age groups and energy levels the pattern includes:

• more green vegetables, orange vegetables, legumes, fruits, whole grains, and milk
• less enriched grains, total fats (especially solid fats), and added sugars

As shown in Table D1-13, the food pattern includes suggested amounts to eat from each of the basic food groups: fruits, vegetables, grains, meat and beans (which includes meat, poultry, fish, dry beans, eggs, and nuts), and milk (which includes nonfat milk, yogurt, and cheese).

The food pattern also shows suggested amounts of oils to consume, because oils are major contributors of essential fatty acids and vitamin E. In addition, the pattern lists amounts of discretionary calories that can be accommodated within each calorie level. Table D1-14 provides more detail about discretionary calories and lists one way these calories can be split—between solid fats and added sugars. These solid fats and added sugars may be contained in selections made from the basic food groups. For example, the fats in low-fat or whole milk and in higher-fat meat products are counted as solid fats; and the sugars that are added in the processing of sweetened cereals, fruits canned in syrup, or cookies are counted as added sugars. Similarly, one needs to count solid fats (e.g., butter) or various sugars (e.g., syrup) that are added to foods. Discretionary calories may also be used to increase the amounts of nutrient-dense choices from any food group, such as increased amounts of fruits or vegetables. (See Section D-3, "Discretionary Calories," for further information.)

Clearly, examination of Table D1-16 reveals that following the proposed pattern for one's calorie level would promote reaching recommended intakes of almost all nutrients. The RDA or AI is reached or exceeded for nearly all nutrients at most calorie levels. Vitamin E remains the leading exception. By making careful selections from Table D1-8a, the vitamin E recommendations could be achieved while limiting total fat intake to 20 to 35 percent of energy. Potassium is another exception: at 2,000 calories or below, less than 90 percent of the AI for potassium is provided by the revised food pattern. Selecting fruits and vegetables that have relatively high potassium content helps to meet the AI for potassium. A number of these foods are listed in Table D1-10a.

Studies Linking Food Intake with Recommended Nutrient Intake

The only published study (Foote et al., 2004) that links food intake with current recommended nutrient intakes (IOM, IOM, 1997, 1998, 2000a, 2001a, 2002, 2004) used data on adults in the Continuing Survey of Food Intakes by Individuals (CSFII) 1994–1996. Foote and colleagues (2004) found high correlations among energy intake, intakes from the five food groups, and the variety of different food commodities consumed from the basic food groups. Food commodities represent different food types, such as beef, oranges, wheat, and milk. Different preparations of these foods would be counted as the same basic food commodity. For example, for variety within the grain group, rice, white bread, and oatmeal would count as different commodities, but white bread, pancakes, and English muffins would not be considered different commodities. The combination of energy, intakes from the five food groups, and dietary variety was a strong predictor of the mean probability of adequacy (R² = .73 for men and .70 for women). Dietary variety within the milk and grain groups was more strongly correlated with improved nutrient adequacy than was variety within the remaining food groups. However, this analysis does not include data on potassium or fiber intake.

A number of studies have been conducted to determine the extent to which Americans have followed the guidance provided by the Food Guide Pyramid and how this relates to their nutrient intake. For example, three studies compare food intakes from national surveys with the recommended number of servings of food from the original Pyramid food intake pattern (Cleveland et al., 2000; Krebs-Smith et al., 1997; Munoz et al., 1997). In most cases, the revised food intake pattern in Table D1-13 specifies more servings of fruits, vegetables, and whole grains than does the 1992 Pyramid food pattern.

Cleveland et al. (2000) analyzed food and nutrient intake by adults, using data from CSFII 1994–1996 that focused on whole grain intake. These investigators found that consumers of whole grains had significantly better vitamin and mineral profiles than nonconsumers. Whole grain consumers also were more likely to meet Pyramid recommendations for the grain, fruit, and milk groups. Only 17 percent of the population consumed at least 2 servings of whole grains per day.

Two early studies analyzed food and nutrient intake data from CSFII 1989–1991 using Pyramid recommendations based on energy. Krebs-Smith et al. (1997) reported that adults who met Pyramid recommendations for all food groups had mean vitamin and mineral intakes that exceeded 100 percent of the 1989 RDA (NRC, 1989) mean daily fiber intake of 22 g, and fat intake at the then recommended level of 30 percent of calories. In contrast, at least one nutrient intake shortfall was found for food group patterns that did not meet one or more of the Pyramid food group recommendations. Munoz et al. (1997) found comparable micronutrient results for children who met the Pyramid recommendations, and they reported a mean daily fiber intake of 19 g. The children's fat intake averaged 35 percent of calories. In both studies, fewer than 5 percent of the population met all Pyramid recommendations.

Nutrients Provided by the Basic Food Groups and Their Subgroups

Basic Food Groups in the USDA Food Intake Pattern.
Table D1-17 summarizes the nutrient contributions of each of the basic food groups and of subgroups for vegetables and grains. To prepare the table, the percent contribution from each food group to the total intake of a nutrient was calculated at each calorie level and then averaged across all calorie levels. The method used to develop this table appears in Appendix G-2 along with more detailed results. Since the amount of nutrients provided by each food group is estimated based on foods commonly consumed in the United States, the nutrient contributions of food groups to an individual's diet could differ somewhat, depending on the foods selected from each group. The "Major Contribution" column identifies any nutrient provided by the food group in an amount greater than that provided by any of the other food groups.

Table D1-17. Summary of the Nutrient Contributions of Each Food Group, Averaged Over Food Patterns at All Energy Levels.

¹ Major contribution means that the food group or subgroup provides more of the nutrient than any other single food group, averaged over all calorie levels. When two food groups or subgroups provide equal amounts, it is noted as a tie.

² A substantial contribution means that the food group or subgroup provides 10% or more of the total amount of the nutrient in the food patterns, averaged over all calorie levels.

Results of the analysis include the following:

• Each food group is the major contributor of at least one nutrient. In addition, each group makes substantial contributions of many other nutrients. Each vegetable subgroup provides at least one nutrient in an amount exceeding 10 percent of the total, even though the amount of food specified for each vegetable subgroup is relatively small.
• For a few nutrients, the food group that is the major contributor of a nutrient shifts from calorie level to calorie level within the USDA food pattern. For example, for potassium, the milk group is the major contributor at most calorie levels, but at higher calorie levels there are more fruit servings, thereby making the fruit group the major contributor of potassium.
• For a few nutrients, a single food group provides a majority of the overall amount in the food pattern. This is true for vitamin C, for which the fruit group provides about 67 percent of the total; calcium, for which the milk group provides about 67 percent; and linoleic and α-linolenic acids, for which oils and soft margarines provide about 59 percent and 53 percent, respectively. For all other nutrients, no single food group provides more than half of the total amount of the nutrient provided by the food pattern.
• Each food group provides a wide array of nutrients in substantial amounts, emphasizing the importance of including all food groups in the daily diet.

Health Effects of Dietary Patterns Similar to the USDA Food Intake Pattern

The revised USDA food intake pattern results from a modeling process that integrated nutrient recommendations from the IOM, as described above. Because the process did not include the preparation of actual menus, it is appropriate to confirm that Western style menus can be constructed that meet the new IOM's nutrient recommendations. It also is useful to document the health effects of dietary patterns similar to the revised USDA food intake pattern since one goal of using the pattern is to help reduce the risk of chronic disease. To this end, results from the Dietary Approaches to Stop Hypertension (DASH) trials (Appel et al., 1997; Sacks et al., 2001) are informative.

The first DASH trial was a randomized feeding study that tested the effects of three distinct dietary patterns on blood pressure. Participants were randomized to (1) a control diet, (2) a fruits and vegetables diet, or (3) a diet now termed the DASH diet. The control diet had a nutrient composition that is typical of that consumed by many Americans. Its potassium, magnesium, and calcium levels were relatively low, and its macronutrient profile and fiber content corresponded to average U.S. consumption. The fruits and vegetables diet was rich in potassium, magnesium, and fiber but otherwise similar to the control diet. The DASH diet emphasized fruits, vegetables, and low-fat dairy products; included whole grains, poultry, fish, and nuts; and was reduced in red meat, sweets, and beverages with added sugars. The DASH diet was rich in potassium, magnesium, calcium, and fiber, and was reduced in total fat, saturated fat, and cholesterol; it also was slightly increased in protein. A 7-day menu cycle at each of four kcal levels (1,600, 2,100, 2,600 and 3,100) was prepared using commonly available foods (Karanja et al., 1999). As displayed in Table D1-18, the nutrient profile of the DASH diet is nearly identical to that of USDA revised food pattern.

Table D1-18. Comparison of Selected Nutrients in the DASHa Diet, the Revised USDA Food Intake Patterns, and Nutrient Intake Recommended by the Institute of Medicine (IOM).

 

Nutrientb	DASH Dietc (2100 kcals)	USDA Food Intake Patterns (2000 & 2200 kcals)	IOM Recommendations RDA/AI/AMDRd
Protein, g	94.3	96-103	56
Protein, % kcal	18	19	10-35%
Carbohydrate, g	306	278-313	130
Carbohydrate, % kcal	58	56	45-65%
Total fat, g	63.1	60.8-67.1	-
Total fat, % kcal	27	27	20-35%
Saturated fat, g	14.4	16.4-17.8	-
Saturated fat, % kcal	6.2	7.4-7.2	ALAPe
Monounsaturate fat, g	25.9	22.1-24.4	-
Monounsaturated fat, % kcal	11	10	-
Polyunsaturate fat, g	18.1	18-20.1	18.6f
Polyunsaturated fat, % kcal	7.8	8.0	5.5-11%g
Cholesterol, mg	128	236-256	ALAPe
Total dietary fiber, g	30	31-35	29h
Potassium, mg	4538	4154-4525	4700
Sodium, mg	1150*	1900-2110	1500
Magnesium, mg	498	386-425	320
Calcium, mg	1260	1333-1376	1000
Zinc, mg	12.1	17.3-15.4	11.0
Thiamin, mg	1.7	2.1-2.3	1.2
Riboflavin, mg	2.1	2.8-2.9	1.3
Niacin, mg	24.1	22.8-26.0	16.0
Vitamin B6, mg	2.8	2.4-2.7	1.3
Vitamin B12, µg	3.8	7.9-8.4	2.4
Vitamin C, mg	300	174-181	90
Vitamin E, mg ATi	11.6i	9.0-9.7i	15i

Adapted from and reprinted with permission, from Craddick et al. (2003). Copyright (2003) by Current Science, Inc.
^aDASH= Dietary Approaches to Stop Hypertension.
^bOnly nutrients analyzed in the DASH studies are included. Nutrients not analyzed but for which RDAs or AIs have been established (IOM 1997; 1998; 2000b; 2001; 2002; 2004): chromium, copper, fluoride, iodine, iron, manganese, molybdenum, phosphorus, selenium, Vitamin A, Vitamin D, Vitamin K, folate, pantothenic acid, biotin, and choline.
^cIn the DASH-Sodium trial, the average sodium intake was 1.5 g (65 mmol)as estimated by mean urinary excretion. The sodium intake of each participant was indexed to calorie level (0.9 to 1.8 g/d corresponding to 1600 to 3600 kcal/d) (Svetkey et al, 1999a).
^dAverage of recommended intake for young adult men and women; RDA = Recommended Dietary Allowance; AI = Adequate Intake; AMDR=Acceptable Macronutrient Distribution Range.
^eAs low as possible while consuming a nutritionally adequate diet.
^fAI for men for n-3 fatty acids = 1.6 g; for n-6 fatty acids = 17 g; total = 18.6 g.
^gn-3 fatty acids = 0.5-1.0 % of kcal; n-6 fatty acids = 5-10% of kcal.
^hAmount listed is based on 14 g dietary fiber/1000 kcal.
ⁱVitamin E RDA is 15 mg d-α-tocopherol (AT); 1 mg ~ 1.2 mg d-α-tocopherol equivalents (ATE). DASH diet contains 14.0 mg ATE, converted here to mg AT for comparability with AI and USDA food patterns.
^*The DASH diet has been studied at several different sodium levels. The sodium level of 1150 mg corresponds to the target for the lowest level in the DASH Sodium trial. The actual level provided, based on 24-hour urinary excretion, was 1500 mg (65 mmol).v

Among all participants, the DASH diet significantly lowered mean systolic blood pressure by 5.5 mmHg and mean diastolic blood pressure by 3.0 mmHg (net of control). The fruits and vegetables diet also significantly reduced blood pressure but to a lesser extent: it had about half of the effect of the DASH diet. In subgroup analyses, the DASH diet significantly lowered blood pressure in all major subgroups (men, women, blacks, non-blacks, hypertensives and non-hypertensives). In blacks, blood pressure reductions (systolic blood pressure/diastolic blood pressure) from the DASH diet (6.9/3.7 mmHg) were significantly greater than corresponding reductions in white participants (3.3/2.4 mmHg). The reductions in hypertensive individuals (11.6/5.3 mmHg) were striking and have obvious clinical relevance. In non-hypertensive individuals, corresponding net blood pressure reductions were 3.5/2/2 mmHg. Such blood pressure reductions, while smaller in magnitude, nonetheless have substantial public health relevance. In the DASH-Sodium trial, the DASH diet also lowered blood pressure at each of three sodium levels. In addition to blood pressure reduction, the DASH diet had beneficial effects on blood lipids (Obarzanek et al., 2001; Harsha et al., 2004) and on several biomarkers, including homocysteine (Appel et al., 2000) and markers of oxidative stress (Miller et al., 1998) and bone turnover (Lin et al., 2003).

It has been estimated that a population-wide reduction in BP of the magnitude observed in DASH could reduce stroke incidence by 27 percent and coronary heart disease (CHD) by 15 percent (Appel et al. 1997). Further reduction in CHD risk might be anticipated from changes in lipids and perhaps homocysteine. In observational epidemiological studies, dietary patterns similar to the DASH diet have been associated with a reduced risk of ischemic heart disease in men (Hu et al., 2000) and women (Fung et al., 2001).

Part D, Section 6, "Selected Food Groups," addresses relationships of the following food groups to health: fruits, vegetables, whole grains, and milk products.

QUESTION 3: WHAT FACTORS RELATED TO DIET OR PHYSICAL ACTIVITY MAY HELP OR HINDER ACHIEVING RECOMMENDED NUTRIENT INTAKES?

Conclusion

A sedentary lifestyle limits the amount of calories needed to maintain one's weight. Careful food selection is needed to meet recommended nutrient intakes within this calorie limit. Diets that include foods with a high nutrient content relative to calories are helpful in achieving recommended nutrient intakes without excess calories. Diets that include a large proportion of foods or beverages that are high in calories but low in nutrients are unlikely to meet recommended intakes for micronutrients and fiber, especially for sedentary individuals.

Rationale

This conclusion is based on a review of data on the effects of physical activity on the total energy requirement from a combination of 26 clinical trials and review articles related to nutrient density and dietary diversity (see Appendix G-3), 12 of which are cited within the body of the text. It also is based on studies of the effects of intake of added sugars on nutrient intake, which are covered in detail under Question 4 in Section 5, "Carbohydrates".

Physical Activity

The higher one's physical activity level, the higher the energy requirement, and the easier it is to plan a food intake pattern that meets recommended nutrient intakes. This is apparent when one examines the percentages of recommended nutrient intakes (see Table D1-16) that are provided by the revised USDA food intake pattern. The food intake pattern at higher energy (calorie) levels results in intakes that are less likely to be below recommended nutrient intakes and more likely to exceed them. In addition, it allows more leeway for foods that contain added sugars and solid fats. As reported by Foote et al. (2004), energy intake is the strongest predictor of the mean probability of adequacy. Increasing one's physical activity level is a healthy way to increase one's energy requirement (see Section 2, "Energy," for additional information about physical activity).

Nutrient Density

Nutrient-dense foods are those that provide substantial amounts vitamins and minerals and relatively fewer calories. Foods that are low in nutrient density are foods that supply calories but relatively small amounts of micronutrients (sometimes none at all). In contrast, energy-dense, nutrient-poor foods supply relatively small amounts of vitamins and minerals with many calories. A number of epidemiological studies using data obtained from national surveys suggest that energy-dense, nutrient-poor foods may displace nutrient-dense foods, potentially reducing the consumption of foods from the five foods groups to lower levels than recommended and limiting one's ability to achieve recommended nutrient intakes (Kant, 2000, 2003; Kant and Schatzkin, 1994). Increased intake of energy-dense, nutrient-poor foods was reported to result in increased total daily energy intake and smaller proportions of the population meeting the RDA for various nutrients. Respondents consuming a high proportion of energy-dense, nutrient-poor foods were more likely to report either no servings or less than the recommended number of servings of foods from the major food groups (Kant and Schatzkin, 1994). The strongest independent negative predictor of the reported number of foods of low nutrient density was the amount of nutrient-dense foods from the five major food groups (Kant and Graubard, 2003).

Dietary diversity among and within food groups was not related to total energy, fat, sugar, sodium, or cholesterol intake (Krebs-Smith et al., 1987), but individuals who consumed the greatest variety of foods (among the food groups, not within the food groups) had the most adequate nutrient intake (Kant et al., 1991).

Individuals consumed more total food when offered several different foods than when variety was more limited (Bellisle and Magnen, 1981; Pliner et al., 1980; Rolls et al., 1981a, 1981b, 1982; Spiegel and Stellar, 1990). In contrast, increased amounts of low-energy vegetables, prompted by high variety, have resulted in decreased energy intake and body fatness (McCory et al., 1999). The long-term effects of dietary variety on food intake and body weight are unknown.

Choosing foods that are rich sources of nutrients in short supply can be an effective way to put the concept of nutrient density into action. Using the food pattern in Table D1-13 that is appropriate for one's energy needs is one way to achieve a diet that meets recommended nutrient intakes.

Effects of Added Sugars on Vitamin and Mineral Intake

Added sugars are defined as sugars and syrups that are eaten separately at the table or added to foods during processing or preparation. As presented in detail in Section 5, "Carbohydrates," 19 papers show a decreased intake of at least 1 micronutrient with higher levels of added sugar intake. That section also provides evidence that small amounts of added sugars may have a beneficial effect on intake of vitamins and minerals, probably by improving the palatability of foods and beverages that might otherwise not be consumed.

QUESTION 4: HOW CAN THE FLEXIBILITY OF FOOD PATTERNS BE INCREASED?

Conclusion

By careful planning that considers the relative nutrient content of different foods, substitutions can be made to a food intake pattern to achieve recommended nutrient intakes.

Rationale

The Committee used empirical methods to identify ways to build flexibility into its recommendations for food guidance. In particular, the Committee asked USDA to use food pattern modeling or other nutrient analysis methods to identify ways to increase the flexibility of the proposed USDA food pattern while continuing to meet the nutritional goals. See Appendix G-2 for information about these analyses. Specific requests included identifying substitutions for refined grain products, legumes, and milk and milk products; comparing the nutrient contributions of fruits with fruit juices; and developing a lacto-ovo-vegetarian food pattern that met nutrient goals.

Legumes and Refined Grains

For individuals who choose not to eat legumes or refined grains, USDA staff prepared short lists of specific amounts of foods that could be substituted without substantially changing the nutrients or calories provided by a food pattern. For example, specified amounts of whole grains, dark green vegetables, and other vegetables could be substituted for a serving of legumes. More information appears in Part E and in Appendix G-2.

Milk and Milk Products

The milk group provides more than 70 percent of the calcium consumed by Americans. Other choices of dietary calcium are available (see Table D1-9a and Table D1-19) for those who choose not to consume the recommended quantities of milk products. Both calcium content and bioavailability should be considered when selecting dietary sources of calcium. Some plant foods have calcium that is well absorbed, but the large quantity of plant foods that would be needed to provide as much calcium as in a glass of milk may be unachievable for many. Many other calcium-fortified foods are available, but the percentage of calcium that can be absorbed is unavailable for many of them.

Table D1-19. Comparison of Various Sources of Calcium, Considering Bioavailability.

¹ Based on 1/2 cup serving size (~ 85g for green leafy vegetables) except for milk and fruit punch (1 cup or 240 mL) and cheese (1.5 oz).
² Taken from Pennington (1989) and USDA (1989), averaged for beans and broccoli processed in different ways, except for the Chinese vegetables which were taken from Heaney, et al. (1993).
³ Adjusted for load using the equation for milk (fractional absorption =0.889-0.0964 ln load) (Heaney et al., 1990) then adjusting for the ratio of calcium absorption of the test food relative to milk tested at the same load, the absorptive index.

For individuals who avoid milk because of its lactose content, the most feasible way to obtain all the nutrients provided by dairy is to substitute lactose-reduced or low-lactose milk products (see Part E).

The inclusion of milk products in the proposed food pattern contributes important amounts of calcium, potassium, magnesium, and vitamin A (see Table D1-20). Moreover, low calcium intakes have been associated with low intakes of magnesium, riboflavin, vitamin B6, vitamin B12, and thiamin (Barger-Lux et al., 1992). Increased milk product intake was associated with increased intake of calcium, magnesium, potassium, zinc, iron, vitamin A, riboflavin, and folate by Americans over the age of two (Weinberg et al., 2004). Without milk products in the revised USDA food intake pattern, calcium intakes range from 321 to 965 mg per day less than recommended intakes (see Table D1-21). These calcium values are the amounts provided by 1.1 to 3.2 glasses of milk. To meet recommended nutrient intakes, the food intake pattern that excludes milk would need to include a much larger amount of calcium-containing green vegetables and legumes than typically consumed by Americans.

Nondairy alternatives for calcium such as calcium-fortified orange juice or calcium-fortified soy products are listed in Table D1-19. This table considers only calcium and not the other nutrients provided by milk.

Table D1-20 Nutrients^* Provided by 3 Cups of 1% Milk.

^*Nutrients Provided if Daily Recommended Amounts from Milk Group (3 cup equivalents) are Consumed as 3 Cups of 1% Milk

Table D1-21. Difference Between Recommended Calcium Intakes and Calcium Provided by the Food Patterns if Milk Products are Excluded.

Fruits

The Committee also asked USDA to examine appropriate partitioning of the fruit group into fruit and juices. The question being addressed was, "How would guidance on the proportion of juice supplied by fruit juice affect the meeting of nutritional goals?" This question stemmed from a recent recommendation of the American Academy of Pediatrics (AAP) to limit fruit juice to no more than 4 to 6 ounces per day for children age 1 to 6 years, and to no more than 8 to 12 ounces per day for children age 7 to 18 years (AAP, 2001). Based on the fruit group analysis, the recommendation is to consume no more than one-third of the total recommended fruit group intake amount from fruit juice and the remainder from whole fruit (fresh, frozen, canned, dried). Increasing the proportion of fruit that is eaten in the form of whole fruit rather than juice is desirable to increase fiber intake, but it calls for more attention to consuming foods that are high in potassium. The fruit juices most commonly consumed by older children and adults provide more vitamin C, folate, and potassium in portions usually consumed than do the commonly eaten fruits. The recommended intake of fruits and juices achieve an optimal balance.

The Lacto-Ovo Vegetarian Food Pattern

The Committee also asked USDA to examine how substituting nuts, seeds, and legumes for the meat, poultry, and fish in the food pattern would affect the nutrient profile of the food group. The amount of eggs in the pattern was held constant. Although the nutrient profile of the egg, nut, seed, and legume group differed in some ways from the original "meat and beans group," it still provided for a food pattern that met recommended nutrient intakes. The lacto-ovo-vegetarian pattern was higher in vitamin E, fiber, and folate than the original pattern. It was lower, although still at or above recommendations, in protein, many B vitamins, and zinc; and it was lower in cholesterol.

Nuts, Seeds, and Legumes in the Food Pattern

The Subcommittee considered the possibility of recommending that nuts, seeds, and legumes become a separate food group because they are rich sources of trace nutrients and rich in diverse phytochemicals. Some nuts are also rich in vitamin E, and nuts may promote satiety. However, the most commonly consumed types of nuts (i.e. peanuts) are not especially high in vitamin E, and the consumption of large amounts of nuts could lead to an excess intake of calories. Rather than creating a separate food group for nuts and seeds, the Committee decided to recommend selecting choices from a list of foods rich in vitamin E as a means to help individuals increase their intakes of that vitamin. It was suggested that modifying the USDA food model system to include a food group rich in vitamin E, such as nuts or seeds, could provide a food pattern that meets the RDA for vitamin E (King et al., 1978). The lacto-ovo vegetarian pattern developed by USDA includes what is essentially a nut/seed/legume group that includes eggs, to replace all meat, poultry, and fish servings. The vitamin E in this pattern is 70 percent RDA at 1,800 kcal and 84 percent at 2,200 kcal. It does not reach 100 percent RDA until 2,800 calories.

QUESTION 5: ARE SPECIAL NUTRIENT RECOMMENDATIONS NEEDED FOR CERTAIN SUBGROUPS?

Conclusion

Special nutrient recommendations are warranted for the following subgroups and nutrients:

• Adolescent females and women of childbearing age—iron and folic acid
• Persons over age 50—vitamin B₁₂
• The elderly, persons with dark skin and persons exposed to insufficient UVB radiation—vitamin D

A conclusion specific to each group and nutrient follows, along with the rationale.

Women and Iron Conclusion

Substantial numbers of adolescent females and women of childbearing age have laboratory evidence of iron deficiency. Efforts are warranted to increase the dietary intake of iron-rich foods and of enhancers of iron absorption by these groups.

Women and Iron Rationale

Laboratory data from the Third National Health and Nutrition Examination Survey (1988–1994) indicate that iron deficiency (defined as having an abnormal value for at least two of three laboratory tests of iron status) affects 7.8 million adolescent females and women of childbearing age (age 12 to 49 years) (Looker et al., 1997). That is, 9 to 11 percent of nonpregnant women of childbearing age were iron deficient, and 2 to 5 percent of the women had iron deficiency anemia. These findings suggest the need to encourage this age group to increase dietary intake of iron-rich foods and of enhancers of iron absorption (meat and vitamin C). A list of sources of iron is provided in Table D1-22a and D1-22b.

Women and Folic Acid Conclusion

Since folic acid reduces the risk of the neural tube defects (NTD), called spinal bifida and anencephaly, daily intake of 400 µg of synthetic folic acid (from supplements or fortified food) is recommended for women who are capable of becoming pregnant and those in the first trimester of pregnancy.

Women and Folic Acid Rationale

The folic acid conclusion is based on the extensive review conducted by the IOM (IOM, 1998) and review of the two available reports on effects of folic acid fortification of enriched grain products. Based on its review of 7 population-based studies, 1 controlled metabolic study plus 1 additional piece of evidence, the IOM concluded, "the recommendation for women capable of becoming pregnant is to take 400 µg of folate from fortified foods and/or a supplement as well as food folate from a varied diet. It is not known whether the same level of protection could be achieved by using food that is naturally rich in folate" (IOM, 1998, p 12).

Since the relatively new folic acid fortification program to reduce the risk of NTDs could influence the need for obtaining folic acid from supplements, the Committee reviewed the two available reports on the effects of the fortification program. Evans et al. (2004) report that, post fortification, the percentage of high maternal serum alpha-fetoprotein values obtained during midtrimester of pregnancy decreased by 32 percent. The Centers for Disease Control and Prevention (CDC, 2004b) report that the incidence of spinal bifida and anencephaly decreased by 26 percent between the pre- and post-fortification periods (1995–1996 and 1999–2000), suggesting that the fortification of enriched grains has helped reduce risk. They note that the observed decrease in NTD-affected pregnancies is less than the estimate that was based on data from research trials.

Table D1-22. Food Sources of Iron.

Table D1-22a. Food sources of iron ranked by milligrams of iron per standard amount; also calories in the standard amount. (All are ≥10% of RDA for teen and adult females, which is 18 mg.)

Table D1-22b. Food sources of iron as consumed by Americans² (Percent of total consumption, CSFII, 1994-1996)

¹ Source: ARS Nutrient Database for Standard Reference, Release 16-1. Mixed dishes and multiple preparations of the same food item have been omitted.
² Source: Cotton et al. 2004. Data are for persons aged 19 years and older, Day 1 intakes
³ Food groups (n=8) contributing at least 1% in descending order: eggs, crackers/pretzels, meal replacements/protein supplements, tortillas/tacos, potato chips/corn chips/popcorn, orange/grapefruit juice, pancakes/waffles/French toast, and coffee.

Persons Over Age 50 and Vitamin B₁₂ Conclusion

A substantial proportion of individuals over age 50 may have reduced ability to absorb naturally occurring vitamin B₁₂ but not the crystalline form. Thus, all individuals over the age of 50 should be encouraged to meet their RDA for vitamin B₁₂ by eating foods fortified with vitamin B₁₂ such as fortified cereals, or by taking the crystalline form of vitamin B₁₂ supplements.

Persons Over Age 50 and Vitamin B₁₂ Rationale

This conclusion was supported by evidence from a systematic review conducted for the IOM (IOM, 1998) and by recent laboratory studies to screen for functional vitamin B₁₂ status, as summarized below, resulting in 11 studies.

According to the National Health and Nutrition Examination Survey in 1999–2000 for the U.S. population, mean daily vitamin B12 intake was above the RDA for all ages and both sexes, and ranged from 2.9 to 5.1 µg (CDC, 2004a). For people age 40 to 59 and age 60 and above, the mean and standard deviation of vitamin B₁₂ intake were 5.1±0.37 and 4.5±0.25 µg/day, respectively. Data are not available regarding the amount of crystalline vitamin B₁₂ consumed from fortified foods and supplements by people over age 50.

Based on a systematic, extensive review of the literature, the IOM (1998) set the RDA for vitamin B₁₂ at 2.4 µg per day. However, since 10 to 30 percent of the older population may be unable to absorb naturally-occurring vitamin B₁₂, the IOM advised that persons age 50 and older should meet their RDA mainly by consuming foods fortified with vitamin B₁₂ or by taking vitamin B₁₂-containing supplements. This RDA was based on the amount needed to maintain the hematological status, as well as the normal serum vitamin B₁₂ level. Neurological manifestation of vitamin B₁₂ deficiency was not used to establish vitamin B₁₂ status since it occurs at a later depletion stage than does the hematological status. Furthermore, the progression of neurological manifestation is variable, generally gradual, and currently not amenable for easy quantification.

This conclusion was further supported by recent studies utilizing serum radioimmunoassays of vitamin B₁₂, combined with serum total homocysteine (tHcy) and methylmalonic acid (MMA) values, to screen for functional vitamin B₁₂ status. A low serum vitamin B₁₂ value (< 300 pg/mL), high serum MMA value (> 0.4 µmol/L), and tHcy greater than 15.0 µmol/L would suggest vitamin B₁₂ deficiency. Using results from these three laboratory tests, Clarke and colleagues (2004) reported the prevalence rate of vitamin B12 deficiency to be 1 in 20 among people age 65 to 74, and 1 in 10 among people age 75 and older. Additionally, various clinical trials (McKay et al., 2000), either among free-living or institutionalized elderly, demonstrated that either oral vitamin B₁₂ supplements alone or multivitamin/mineral supplements could improve vitamin B₁₂ status.

A screening procedure using serum radioimmunoassay of vitamin B₁₂ combined with serum tHcy and MMA has been recommended for all individuals over age 65 to detect vitamin B₁₂ deficiency (Dharmarajan et al., 2003; Klee, 2000).

Special Groups and Vitamin D Conclusion

The elderly, persons with dark skin, and persons exposed to insufficient UVB radiation are at risk of being unable to maintain vitamin D status. Persons in these high-risk groups may need substantially more than the 1997 AI for vitamin D from vitamin D-fortified foods and/or vitamin D supplements.

Vitamin D Rationale

The relationship of vitamin D to health was evaluated from a systematic review of the scientific literature, which produced 28 studies and 14 reviews—largely articles that were unavailable when the IOM conducted its review on which the AIs for vitamin D were based (IOM, 1997). Adequate vitamin D status, which depends on dietary intake and cutaneous synthesis, is important for optimal calcium absorption, and it can reduce the risk for bone loss.

The criterion used by the IOM for setting the AI was the normal concentration of serum 25-hydroxyvitamin D concentration, an indicator of vitamin D status. In the absence of consensus for optimal vitamin D status based on functional indicators, the IOM panel identified normal ranges for serum 25-hydroxyvitamin D. The normal range for various populations is broad with means of serum 25-hydroxyvitamin D ranging from 25 to 137.5 nmol/L. Newer information on the relationship of serum 25-hydroxyvitamin D to health, the relationship of vitamin D intake to serum 25-hydroxyvitamin D concentration, vitamin D status of the U.S. population, and safety of vitamin D intakes is summarized in a supplement of a National Institutes of Health conference held in October 2003 (NIH, 2004). Two functionally relevant measures indicate that optimal serum 25-hydroxyvitamin D may be as high as 80 nmol/L. Among postmenopausal women who lived in Omaha, Nebraska, and who were supplemented with vitamin D, calcium absorption efficiency increased with increasing serum 25-hydroxyvitamin D values up to 80 nmol/L (Heaney et al., 2003b). Serum parathyroid hormone, which stimulates bone resorption, decreases with increasing serum 25-hydroxyvitamin D values up to 80 nmol/L (Chapuy et al., 1997; Thomas et al., 1998). Serum 25-hydroxyvitamin D values are below 80 nmol/L for much of the population (Looker et al., 2002; see Table D1-23). The elderly and individuals with dark skin are at a greater risk of low serum 25-hydroxyvitamin D concentrations (Holick 1985; Holick et al., 1989; Looker et al., 2002). Also at risk are those exposed to insufficient UVB radiation for the cutaneous production of vitamin D, e.g., housebound individuals. Serum 25-hydroxyvitamin D values increase with increasing oral vitamin D intake in both young and older subjects (Vieth et al., 2003). Further data are needed to determine if a serum 25-hydroxyvitamin D concentration of 80 nmol/L is sufficient to increase the efficiency of calcium absorption or to reduce PTH levels in the populations at risk.

For individuals within the high-risk groups, substantially higher daily intakes of vitamin D, i.e., 25 µg or 1000 IU of vitamin D, have been recommended to reach and maintain serum 25-hydroxyvitamin D values at 80 nmol/L (Heaney and Weaver, 2003; Holick, 2004). Applying the slope (0.7 mmol/L/microgram vitamin D) from the regression between vitamin D intake and change in serum 25-hydroxyvitamin D derived from a dose response study in men (Heaney et al., 2003b) to the mean serum 25-hydroxyvitamin D concentrations in the U.S. population shown in Table D1-23, one can estimate the additional vitamin D intake required to achieve and maintain a target vitamin D status. For example, women over age 80 with mean serum 25-hydroxyvitamin D values of 59.6 nmol/L might need to increase their vitamin D intakes by 29 µg or 1166 IU per day to achieve serum values of 80 nmol/L. Mean current consumption of vitamin D in females over age 71 participating in NHANES III was only 4.5 µg or 180 IU of vitamin D (Moore et al., 2004), an amount considerably below the 1997 AI of 600 IU. Dark skinned subgroups have lower vitamin D status than comparable fair-skinned subgroups, but the optimal vitamin D status and the ability of vitamin D intakes to increase serum 25-hydroxyvitamin D concentrations in various subgroups are not known.

A recent estimate of the vitamin D intakes of Americans surveyed in either NHANES III, 1988–1994, or the Continuing Survey of Food Intakes by Individuals (CSFII) 1994–1996, 1998, showed that the average reported intakes from food and supplements by all age and gender groups were below the 1997 IOM AI for vitamin D (Moore et al., 2004). Less than 10 percent of older adults (age 51 to 70) and only about 2 percent of the elderly (older than age 70) met the AI from food sources alone. Less than a third of the adolescent and adult women met the AI.

Fatty fish is the primary natural food source of vitamin D. Other good sources are all foods that have been vitamin D fortified: milk and some brands of margarine, ready-to-eat breakfast cereal, enriched rice and pasta, and fruit juices and drinks. Different kinds of vitamin D-fortified foods differ in the amounts of vitamin D they contain (Table D1-24). Vitamin D intakes of approximately 1000 IU per day can be achieved by consuming 3 cups of vitamin D fortified milk per day (300 IU) plus a supplement containing vitamin D (600 IU) plus 1 cup of vitamin D fortified orange juice (100 IU). Although this level of vitamin D intake exceeds the AI of 600 IU per day for an elderly person, there is no evidence that consuming this amount will have a detrimental effect on health. No signs of hypercalcemia or hypercalicuria were observed with healthy men and women who were given 4000 IU of vitamin D per day for 2 to 5 months (Vieth et al., 2001). For evaluation of vitamin D status, at-risk individuals should consult their physician.

Table D1-23. Serum 25-hydroxyvitamin D Values by Seasonal Subpopulation in the Contiguous U.S.

CI = Confidence Interval

Source: Looker et al., 2002

Table D1-24. Food Sources of Vitamin D.

Source: Raiten DJ and MF Picciano (Co-chairs). Vitamin D and Health in the 21st Century: Bone and Beyond. A conference conducting by the National Institutes of Health in Bethesda, Maryland on October 9-10, 2003. Accessed at: http://www.nichd.nih.gov/prip/ on 2 August 2004.

SUMMARY

Meeting nutrient recommendations is a basic premise of dietary guidance for Americans, but controlling calorie intake also is important. Most Americans consume too little vitamin E, potassium, and fiber; and many consume too little vitamin A, vitamin C, calcium, and magnesium. To meet nutrient recommendations, the committee recommends that children and adults consume a variety of foods from each of the basic food groups (fruits; vegetables; grains; milk, yogurt, and cheese; and meat, poultry, fish, dry beans, eggs, and nuts). To meet nutrient recommendations while controlling calories, it helps to choose foods that are high in nutrient content but low to moderate in calories and to increase one's level of physical activity.

Additional nutrient recommendations are warranted for a few large subgroups of the population, as follows:

• Adolescents and females of childbearing age need extra iron and folic acid
• Persons over age 50 benefit from taking vitamin B₁₂ in its crystalline form from foods fortified with this vitamin or supplements that contain vitamin B₁₂
• The elderly, persons with dark skin, and persons exposed to insufficient UVB radiation need extra vitamin D from vitamin D-fortified foods and/or supplements that contain vitamin D.

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Nusser SM, Carriquiry AL, Dodd KW, Fuller WA. A semiparametric transformation approach to estimating usual daily intake distributions. Journal of the American Statistical Association 91:1440-1449, 1996.

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Spiegel TA, Stellar E. Effects of variety on food intake of underweight, normal-weight and overweight women. Appetite 15(1):47-61, 1990.

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Thomas MK, Lloyd-Jones DM, Thadhani RI, Shaw AC, Deraska DJ, Barrett TK, Vamvakas EC, Dick IM, Prince RL, Finkelstein JS. Hypovitaminosis D in medical inpatients. The New England Journal of Medicine 338:777-783, 1998.

Vieth R, Chan PC, MacFarlane GD. Efficacy and safety of vitamin D(3) intake exceeding the lowest observed adverse effect level. American Journal of Clinical Nutrition 73:288-294, 2001.

Vieth R, Ladak Y, Walfish PG. Age-related changes in the 25-hydroxyvitamin D versus parathyroid hormone relationship suggest a different reason why older adults require more vitamin D. The Journal of Clinical Endocrinology & Metabolism 88(1):185-191, 2003.

Weinberg LG, Berner LA, Groves JA. Nutrient contributions of dairy food in the United States, Continuing Survey of Food Intakes by Individuals, 1994–1996, 1998. Journal of American Dietetic Association 104:895-902, 2004.

Welsh SO, Davis C, Shaw A. USDA's Food Guide Background and Development. Miscellaneous Publication 1514:5-6, September 1993.

Kant AK. Consumption of energy-dense, nutrient-poor foods by adult Americans: nutritional and health implications. The Third National Health and Nutrition Examination Survey, 1988-1994. American Journal of Clinical Nutrition 72(4):929-936, 2000.

Kant AK, Graubard BI. Predictors of reported consumption of low-nutrient-density foods in a 24-h recall by 8-16 year old US children and adolescents. Appetite 41(2):175-180, 2003.

Kant AK, Schatzkin A. Consumption of energy-dense, nutrient-poor foods by the US population: effect on nutrient profiles. Journal of the American College of Nutrition 13(3):285-291, 1994.

Kant A, Schatzkin A, Block G, Ziegler R, Nestle M. Food group intake patterns and associated nutrient profiles of the U.S. population. Journal of the American Dietetic Association 91(12):1532-1537, 1991.

Karanja NM, Obarzanek E, Lin PH, McCullough ML, Phillips KM, Swain JF, Champagne CM, Hoben KP. Descriptive characteristics of the dietary patterns used in the Dietary Approaches to Stop Hypertension Trial. DASH Collaborative Research Group. Journal of the American Dietetic Association 99(8 Suppl):S19-27, 1999.

King JC, Cohenour SH, Corruccini CG, Schneeman P. Evolution and modification of the Basic Four Food Guide. Journal of Nutrition Education 10(1):27-29, 1978.

Klee GG. Cobalamin and folate evaluation: measurement of methylmalonic acid and homocysteine vs vitamin B12 and folate. Clinical Chemistry 46:8(B):1277-1283, 2000.

Krebs-Smith SM, Cleveland LE, Ballard-Barbash R, Cook DA, Kahle LL. Characterizing food intake patterns of American adults. American Journal of Clinical Nutrition 65(4 Suppl):1264S-1268S, 1997.

Krebs-Smith SM, Smiciklas-Wright H, Guthrie HA, Krebs-Smith J. The effects of variety in food choices on dietary quality. Journal of the American Dietetic Association 87(7):897-903, 1987.

Lin PH, Aickin M, Champagne C, Craddick S, Sacks F, McCarron P, Most-Windhauser M, Rukenbrod F, Haworth L. Food group sources of nutrients in the dietary patterns of the DASH-Sodium trial. Journal of the American Dietetic Association 103; 488-496, 2003.

Looker AC, Dallman PR, Carroll MD, Gunter EW, Johnson CL. Prevalence of iron deficiency in the United States. Journal of the American Dietetic Association 277:973-976, 1997.

Looker AC, Dawson-Hughes B, Calvo MS, Gunter EW, Sahyoun NR. Serum 25-hydroxyvitamin D status of adolescents and adults in two seasonal subpopulations from NHANES III. Bone 30(5):771-777, 2002.

Mannisto S, Smith-Warner SA, Spiegelman D, Albanes D, Anderson K, van den Brandt PA, Cerhan JR, Colditz G, Feskanich D, Freudenheim JL, Giovannucci E, Goldbohm RA, Graham S, Miller AB, Rohan TE, Virtamo J, Willett WC, Hunter DJ, Neuhouser ML, Patterson RE, Thornquist MD, Omenn GS, King IB, Goodman GE. Dietary carotenoids and risk of lung cancer in a pooled analysis of seven cohort studies, Cancer Epidemiol Biomarkers Prev.13(1):40-8, 2004.

Maras JE, Bermudez OI, Qiao M, Bakun PJ, Boody-Alter EL, Tucker KL. Intake of alpha-tocopherol is limited among US adults. Journal of the American Dietetic Association 104(4):567-575, 2004.

McCory MA, Fuss PJ, McCallum JE, Yao M, Vinken AG, Hays NP, Roberts SB. Dietary variety within food groups; association with energy intake and body fatness in men and women. American Journal of Clinical Nutrition 69(3):440-447, 1999.

McKay DL, Perrone G, Rasmussen H, Dallal G, Hartman W, Cao G, Prior R, Roubenoff R, Blumberg JB. The effects of a multivitamin/mineral supplement on micronutrient status, antioxidant capacity and cytokine production in healthy older adults consuming a fortified diet. Journal of the American College of Nutrition 19(5):613-621, 2000.

Miller ER 3rd, Appel LJ, Risby TH. Effect of dietary patterns on measures of lipid peroxidation: results from a randomized clinical trial. Circulation. 98:2390-5, 1998.

Moore C, Murphy MM, Keast DR, Holick MF. Vitmain D intake in the United States. Journal of the American Dietetic Association. 2004: 104:980-983.

Munoz KA, Kreb-Smith SM, Ballard-Barbash R, Cleveland LE. Food intakes of US children and adolescents compared with recommendations. Pediatrics 100(3 Pt 1):323-329, 1997. Erratum in: Pediatrics 101(5):952-953, 1998.

National Research Council (NRC). Recommended Dietary Allowances, 10th Ed. National Academy Press, Washington, DC, 1989.

National Research Council (NRC). Nutrient Adequacy. Assessment Using Food Consumption Surveys. National Academy Press, Washington, DC, 1986.

Neuhouser ML, Patterson RE, Thornquist MD, Omenn GS, King IB, Goodman GE. Fruits and vegetables are associated with lower lung cancer risk only in the placebo arm of the beta-carotene and retinal efficacy trial (CARET). Cancer Epidemiol Biomarkers Prev 12:350-8, 2003.

Nusser SM, Carriquiry AL, Dodd KW, Fuller WA. A semiparametric transformation approach to estimating usual daily intake distributions. Journal of the American Statistical Association 91:1440-1449, 1996.

Obarzanek E, Sacks FM, Vollmer WM, Bray GA, Miller ER 3rd, Lin PH, Karanja NM, Most-Windhauser MM, Moore TJ, Swain JF, Bales CW, Proschan MA; DASH Research Group. Effects on blood lipids of a blood pressure-lowering diet: the Dietary Approaches to Stop Hypertension (DASH) Trial. American Journal of Clinical Nutrition 74:80-9, 2001.

Pennington JAT. Bowes and Church's Food Values of Portions Commonly Used (15th edition). JB Lippincott Company, Philadelphia, 1989.

Pliner P, Polivy J, Herman CP, Zakalusn I. Short-term intake of overweight individuals and normal weight dieters and non-dieters with and without choice among a variety of foods. Appetite 1:203-213, 1980.

Rolls BJ, Rolls ET, Rowe EA, Sweeney K. Sensory specific satiety in man. Physiology & Behavior 27(1):137-142, 1981b.

Rolls BJ, Rowe EA, Rolls ET. How sensory properties of foods affect human feeding behavior. Physiology & Behavior 29(3):409-417, 1982.

Rolls BJ, Rowe EA, Rolls ET, Kingston B, Megson A, Gunary R. Variety in a meal enhances food intake in man. Physiology & Behavior 26(2):215-221, 1981a.

Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, Obarzanek E, Conlin PR, Miller ER 3rd, Simons-Morton DG, Karanja N, Lin PH. Effects of blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. The New England Journal of Medicine 344:3-10, 2001.

Shikany JM, Heimburger DC, Piyathilake CJ, Desmond RA, Greene PG. Effect of folic acid fortification of foods on folate intake in female smokers with cervical dysplasia. Journal of Nutrition 20(5):409-414, 2004.

Spiegel TA, Stellar E. Effects of variety on food intake of underweight, normal-weight and overweight women. Appetite 15(1):47-61, 1990.

Suitor CW, Gleason PM. Using Dietary Reference Intake-based methods to estimate the prevalence of inadequate nutrient intake among school-aged children. Journal of the American Dietetic Association 102:530-536, 2002.

Thomas MK, Lloyd-Jones DM, Thadhani RI, Shaw AC, Deraska DJ, Barrett TK, Vamvakas EC, Dick IM, Prince RL, Finkelstein JS. Hypovitaminosis D in medical inpatients. The New England Journal of Medicine 338:777-783, 1998.

U.S. Department of Agriculture and U.S. Department of Health and Human Services (USDA/HHS). Nutrition and Your Health: Dietary Guidelines for Americans. Home and Garden Bulletin No. 252. USDA, Washington, DC, 2000.

U.S. Department of Agriculture. Handbook No. 8, Composition of Foods, Human Nutrition Information Service, Science and Education Administration, 1989.

Vieth R, Chan PC, MacFarlane GD. Efficacy and safety of vitamin D(3) intake exceeding the lowest observed adverse effect level. American Journal of Clinical Nutrition 73:288-294, 2001.

Vieth R, Ladak Y, Walfish PG. Age-related changes in the 25-hydroxyvitamin D versus parathyroid hormone relationship suggest a different reason why older adults require more vitamin D. The Journal of Clinical Endocrinology & Metabolism 88(1):185-191, 2003.

Weinberg LG, Berner LA, Groves JA. Nutrient contributions of dairy food in the United States, Continuing Survey of Food Intakes by Individuals, 1994-1996, 1998. Journal of American Dietetic Association 104:895-902, 2004.

Welsh SO, Davis C, Shaw A. USDA's Food Guide Background and Development. Miscellaneous Publication 1514:5-6, September 1993.

¹While the probability of adequacy for folate was found to be low, the data used were collected prior to the mandatory fortification of enriched grains with folate. See further discussion later in this section.

²In the food pattern with 1,000; 1,200; and 1,400 calories, which are targeted to children under 9 years of age, 2 cups from the milk group are recommended. In the food pattern with 1,600 calories and above, 3 cups from the milk group are recommended.

³Some patterns designed to meet nutrient intake recommendations divide this group into two groups: (1) meat, poultry, and fish and (2) seeds, dry peas and beans, and nuts.

⁴USDA has informed the Dietary Guidelines Advisory Committee that the final nutritional goals and food intake patterns will take into account all nutritional recommendations from this Committee.