from the association
                Practice Paper of the American Dietetic Association:
                                                      Using the Dietary Reference Intakes
           ABSTRACT                                   gan to release the Dietary Reference        EAR
           The Dietary Reference Intakes, a set       Intakes (DRIs), a set of nutrient ref-      “The average daily nutrient intake
           of nutrient reference standards devel-     erence standards for use in the             that is estimated to meet the require-
           oped for the United States and Can-        United States and Canada (1). The           ment of half the healthy individuals
           ada by the Institute of Medicine, pro-     DRIs were developed using a para-           in a particular life stage and [sex]
           vide tools for dietary assessment and      digm that considers the distribution        group” (9). In this context, “require-
           planning for individuals and groups.       of nutrient requirements as well as         ment” refers to a specific indicator of
           Because a distribution of require-         the possibility of excess (accordingly,     adequacy for each nutrient. In many
           ments is provided for most nutrients,      for many nutrients several DRIs are         cases, the requirement is based on in-
           it is possible to estimate a probability   available, each with specific applica-       take needed for a desirable level of
           of nutrient inadequacy for an individ-     tions for dietary assessment [2] or         function rather than the amount
           ual’s usual intake, and the prevalence     planning [3]). DRIs for groups of re-       needed to prevent deficiency disease.
           of nutrient inadequacy among the in-       lated nutrients were released period-       For example, the requirement for vi-
           takes of a group of people. The avail-     ically between 1997 and 2004 (1,4-8)        tamin C is based on its role as an
           ability of a Tolerable Upper Intake        (a summary of the DRI reports was           antioxidant rather than prevention of
           Level for many nutrients also allows       released in 2006 [9]). In the future,       scurvy (5). The EAR is not a recom-
           an evaluation of the risk of excessive     updated DRIs will be issued on a nu-        mended intake; by definition, it is in-
           intakes. However, some of these new        trient-specific   basis as warranted         adequate for half the healthy individ-
           applications are complex, and their        based on advances in the science; for       uals in a life stage and sex group.
           implementation would be facilitated        example, revised DRIs for calcium           However,theEARisusedtocalculate
           by better training aids and improved       and vitamin D have recently been re-        the RDA for nutrients with require-
           computer software. These new tools         leased (10).                                ment distributions that are normally
           would help registered dietitians be-          The purpose of this Practice Paper       distributed (which is assumed to be
           come more familiar with the appro-                                                     trueformostnutrients).TheEARhas
           priate applications of the Dietary Ref-    is to provide guidance for use of DRIs      important applications in assessing
           erence Intakes in the Nutrition Care       by registered dietitians (RDs). First,      theprevalenceofnutrientinadequacy
           Process,andbetterrecognizeboththe          each of the DRIs are defined and             in groups, as described in the section
           benefits and challenges associated          briefly described. Methods for using         in this article on using DRIs with
           with their use. Ultimately, use of         DRIs with individuals are presented         groups of people.
           more comprehensive methods of as-          in the next section, followed by meth-
           sessing and planning nutrient in-          odsforusingDRIswithgroups.Infor-            RDA
           takes has the potential to further         mation is presented on interpreting         “The average daily dietary nutrient
           enhance recognition of registered di-      food package labels and claims, and         intake that is sufficient to meet the
           etitians’ essential roles in nutrition     the article concludes with recommen-        nutrient requirements of nearly all
           care.                                      dationsfortrainingandtoolsforRDs.           (97%to98%)healthyindividuals in a
           J Am Diet Assoc. 2011;111:762-770.                                                     particular life stage and [sex] group”
                                                      DEFINITIONS OF DRIs                         (9). Individuals with usual intakes at
              n the past the only nutrient refer-                                                 or above the RDA almost certainly
              ence standard available for use by      The DRIs include the Estimated Av-          have adequate intakes; however, be-
           Ifood and nutrition practitioners          erage Requirement (EAR), RDA, the           cause the RDA exceeds the require-
           was the Recommended Dietary Al-            Adequate Intake (AI), the Tolerable         mentofmostindividuals, it is not ap-
           lowance (RDA). RDAs were used for          Upper Intake Level (UL), the Esti-          propriate to infer that individuals
           dietary planning and assessment for        mated Energy Requirement (EER),             withintakesbelowtheRDAareinad-
           both individuals and groups, al-           and the Acceptable Macronutrient            equate. The RDA should not be used
           though in some cases use of RDAs for       Distribution Range (AMDR). Defini-           in assessment or planning intakes of
           these applications was inappropriate.      tions and brief comments about the          groups.Itsprimaryuseisasagoalfor
           In 1997 the Institute of Medicine be-      primary intended uses of each of            intake by individuals.
                                                      these DRIs are provided below (see
             0002-8223/$36.00                         reference 9 for more details). Figure 1     AI
             doi: 10.1016/j.jada.2011.03.022          shows the relationships among the           “The recommended average daily in-
                                                      EAR, RDA, AI, and UL.                       takelevelbasedonobservedorexper-
           762   Journal of the AMERICAN DIETETIC ASSOCIATION                             ©2011bytheAmerican Dietetic Association
                                                                                                             lished for carbohydrate, protein, total
                                                                                                             fat, and for n-3 and n-6 polyunsatu-
                                                                                                             rated fatty acids. Intake within the
                                                                                                             AMDR is a goal for both individuals
                                                                                                             and groups.
                                                                                                             KEY CONCEPTS ABOUT DRIs
                                                                                                             Several key concepts apply to the
                                                                                                             DRIs: they are intended for use with
                                                                                                             generally healthy people; unless oth-
                                                                                                             erwise specified they apply to all
                                                                                                             sources of a nutrient, including di-
                                                                                                             etary supplements; and they apply to
                                                                                                             usual intake, over time, rather than
                                                                                                             to intake on a given day. Each of
                                                                                                             these concepts is expanded on below.
             Figure 1. Relationship between Dietary Reference Intakes. This figure shows that the Estimated   DRIs Are Intended for Use with Generally
             Average Requirement (EAR) is the intake at which the risk of inadequacy is 0.5 (50%) to an      Healthy People
             individual. The Recommended Dietary Allowance (RDA) is the intake at which the risk of          DRIs do not consider the effects of
             inadequacy is very small—only 0.02 to 0.03 (2% to 3%). The Adequate Intake (AI) does not bear   diseaseprocessesonnutrientrequire-
             a consistent relationship to the EAR or the RDA because it is set without knowledge of the      mentsortoxicity,nordotheyconsider
             requirement. At intakes between the RDA and the Tolerable Upper Intake Level (UL), the risks of drug–nutrient interactions. They are
             inadequacy and of excess are both close to zero. At intakes above the UL, the risk of adverse   also based on the assumption that di-
             effects may increase. (Adapted and reprinted with permission from reference 9, ©2006 by the     ets consumed have nutrient bioavail-
             National Academy of Sciences, Courtesy of the National Academies Press, Washington, DC.)        ability similar to those typically con-
             imentally     determined       approxima-       EER                                             sumed in the United States and
             tions or estimates of nutrient intake           “The EER is the average dietary en-             Canada. For some nutrients, guid-
             by a group (or groups) of apparently            ergy intake that is predicted to main-          anceisprovidedfordietswithaltered
             healthypeoplethatareassumedtobe                 tain energy balance in healthy adults           bioavailability (eg, for those consum-
             adequate; used when an RDA cannot               of defined age, [sex], weight, height,           ing vegetarian diets higher iron in-
             bedetermined”(9).RDAscouldnotbe                 and level of physical activity consis-          takes are recommended [6]).
             determined for some nutrients be-               tentwithgoodhealth.Inchildrenand
             cause scientific evidence on the re-             pregnant and lactating women, the               In Most Cases, DRIs Apply to all Sources
             quirement distribution was consid-              EER is taken to include the needs               of A Nutrient, Including Food, Beverages,
             ered inadequate. Accordingly, uses of           associated with the deposition of tis-          and Dietary Supplements
             the AI in dietary assessment and                sues or the secretion of milk at rates          Nutrient supplements are consumed
             planning are limited. The primary               consistent with good health” (9). Al-           byapproximatelyhalf the US popula-
             use of the AI is as an intake goal for          though the EER provides a rough es-             tion (11), and contribute to both nu-
             individuals and groups.                         timate of an individual’s energy                trient adequacy and potential risk of
                                                             needs, by definition, energy needs of            excessive intakes (12). Thus, with a
             UL                                              half the individuals with defined                few exceptions, when assessing or
             “The highest average daily nutrient             characteristics will fall below the             planning nutrient intakes using the
             intake level that is likely to pose no          EER,whereastheotherhalfwillhave                 DRIs, intakes from all sources of the
             risk of adverse health effects to al-           needs that exceed the EER. The EER              nutrient must be considered. The ex-
             most all individuals in the general             may be used as a starting point to              ceptions include: the UL for magne-
             population. As intake increases above           plan appropriate energy intakes, but            sium applies only to intake from non-
             the UL, the risk of adverse effects             body weight, because it is a readily            food sources (1); the ULs for vitamin
             may increase” (9). Note that the UL             monitored index, may be a more use-             E, niacin, and folate apply only to in-
             does not apply to individuals being             ful method of assessing the adequacy            take from fortified foods or supple-
             treated for nutrient deficiency: thera-          of energy intake.                               ments(4,5); and the UL for vitamin A
             peutic doses of vitamins and minerals                                                           applies only to intake of preformed
             used to treat deficiency states often            AMDR                                            retinol, whether present in foods or
             exceed the UL, but it is assumed that           The AMDRrepresents “a range of in-              supplements (6).
             these individuals would be monitored            takes for a particular energy source
             for adverse effects, and that the high          that is associated with reduced risk of         DRIs Apply to Usual Intake, rather than to
             intake would not continue indefi-                chronic disease while providing ade-            Intake on Any Given Day
             nitely. In most cases, the UL repre-            quate intakes of essential nutrients”
             sents an intake that should not be              (8). AMDRs, expressed as a percent-             Although the duration of time that
             exceeded.                                       ageoftotalenergyintake,wereestab-               reflects usual intake is difficult to de-
                                                                                            May 2011 ● Journal of the AMERICAN DIETETIC ASSOCIATION    763
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