Livro DRI 2006 (Micronutrientes)

Livro DRI 2006 (Micronutrientes)


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Figure 10, it can be seen that there is more variability in the
intake distribution (it ranges from less than 2 mg/day to almost 10 mg/
day) than in the requirement distribution (which ranges from about 2
mg/day to about 6 mg/day).
Copyright © National Academy of Sciences. All rights reserved.
Dietary Reference Intakes: The Essential Guide to Nutrient Requirements
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62 DRIs: THE ESSENTIAL GUIDE TO NUTRIENT REQUIREMENTS
When the above conditions are met, the individuals in triangle 1 (with intakes
below the EAR but above their own requirements) are similar in number to the
individuals in triangle 2 (with intakes above the EAR and below their own
requirements). These two triangles cancel one another out, and the number of
individuals that do not meet their requirements (those found to the left of the
45o \u201cIntake = Requirement\u201d line) is thus mathematically similar to the number
with usual intakes below the EAR.
The EAR cut-point method can also be applied to the example of 650 men
described in the first case study, as the requirement distribution is symmetrical,
intakes and requirements are independent, and the usual intake distribution is
more variable than the requirement distribution. In this case, one would simply
determine the number of men with intakes at or below the EAR of 7 mg/day.
From Table 5, this would be 10 (2 mg/day) + 10 (3 mg/day) + 20 (4 mg/day) +
20 (5 mg/day) + 30 (6 mg/day) + 50 (7 mg/day), for a total of 140 men. Divid-
ing this by the total group size of 650 yields the estimated prevalence of inad-
equacy of 21.5 percent, which is very similar to the estimate of 20 percent
obtained using the full probability method.
In summary, the full probability method and a shortcut, known as the EAR
cut-point method, can be used to estimate the prevalence of nutrient inad-
equacy in a group. Both methods require knowledge of the distribution of usual
intakes for the group, and that intakes and requirements are independent. The
EAR cut-point method has two additional requirements; namely, that the re-
quirement distribution is symmetrical, and that the distribution of usual in-
takes is more variable than the distribution of requirements. If either of these
two additional requirements is not met, the full probability method can be used
instead, provided the requirement distribution is known.
Case Study Four: Planning Diets in an Assisted-Living
Facility for Senior Citizens
An example of planning diets for institutionalized groups is menu planning for
senior citizens who reside in an assisted-living facility. Menus planned for these
institutions usually assume that the residents have no other sources of foods or
nutrients, and thus the menus are designed to meet all nutrient needs of the
residents. The goal of menu planning is to provide meals that provide adequate
nutrients for a high proportion of the residents, or conversely, the prevalence of
inadequate intakes is acceptably low among the residents.
The planner is developing a menu for an assisted living facility in which
the residents are retired nuns aged 70 years and above. For this age group, the
EAR for vitamin B
6
 is 1.3 mg/day. Assume that no data can be located on the
distribution of usual intakes of this group or a similar group, and that resources
are not available to conduct a dietary survey in the institution. How could the
Copyright © National Academy of Sciences. All rights reserved.
Dietary Reference Intakes: The Essential Guide to Nutrient Requirements
http://www.nap.edu/catalog/11537.html
PART I: APPLYING THE DIETARY REFERENCE INTAKES 63
planner proceed to determine the target intake distribution of vitamin B
6
 needed
to attain an acceptable prevalence of inadequacy?
STEP 1. DETERMINE AN ACCEPTABLY LOW PREVALENCE OF INADEQUACY
For vitamin B
6
, the EAR was set at a level adequate to maintain plasma pyri-
doxal phosphate levels at 20 nmol/L. This plasma level is not accompanied by
observable health risks, and thus allows a moderate safety margin to protect
against the development of signs or symptoms of deficiency. This cut-off level
was selected recognizing that its use may overestimate the B
6
 requirement for
health maintenance of more than half the group. For this reason, assume that
the planner has determined that a 10 percent prevalence of inadequacy (i.e., 10
percent with intakes below the EAR) would be an acceptable planning goal.
STEP 2. DETERMINE THE TARGET USUAL NUTRIENT INTAKE DISTRIBUTION
Next, the planner needs to position the intake distribution so the nutrient in-
take goals are met. In this example, the planner decides that the prevalence of
inadequacy in the group will be set at 10 percent, and as a result the usual
intake distribution of the group should be positioned such that only 10 percent
of the group has usual intakes less than the EAR.
Because data on the usual nutrient intake distributions of the residents are
not available, other sources must be used to estimate the target usual nutrient
intake distribution. Data on the distribution of usual dietary intakes of vitamin
B
6
 are available from several national surveys and thus are used. The adjusted
percentiles for women are summarized in Table 7.
Assuming there are no changes in the shape of the distribution, the amount
of the shift can be calculated as the additional amount of the nutrient that must
be consumed to reduce the proportion of the group that is below the EAR. This
is accomplished by determining the difference between the EAR and the intake
at the acceptable prevalence of inadequacy (in this case, the 10th percentile of
the usual intake distribution).
TABLE 7 Selected Percentiles of the Distributions of Usual Intake of
Vitamin B6 from Foods in Older Women
Percentile of Usual Intake Distribution of Vitamin B6 (mg/day)
Study n 5th 10th 25th 50th 75th 90th 95th
Survey A 1,368 0.92 1.04 1.24 1.53 1.93 2.43 2.76
Survey B 221 0.76 0.88 1.11 1.41 1.76 2.12 2.35
Survey C 281 0.5 0.6 0.7 1.0 1.3 1.6 1.8
Copyright © National Academy of Sciences. All rights reserved.
Dietary Reference Intakes: The Essential Guide to Nutrient Requirements
http://www.nap.edu/catalog/11537.html
64 DRIs: THE ESSENTIAL GUIDE TO NUTRIENT REQUIREMENTS
Examination of the data from the three surveys shows that estimated usual
intakes of vitamin B
6
 vary by as much as 30 percent among the surveys. As a
result, the difference between the EAR of 1.3 mg and the intake at the 10th
percentile varies, depending on which data are used. Table 8 shows that for
Survey A the difference is 0.26 mg (1.3 mg \u2013 1.04 mg = 0.26 mg); for Survey B,
the difference is 0.42 mg (1.3 mg \u2013 0.88 mg = 0.42 mg); and for Survey C, the
difference is 0.7 mg (1.3 mg \u2013 0.6 mg = 0.7 mg). In this example, the planner
may have no reason to choose data from one particular survey as \u201cmore appli-
cable\u201d to the group than another, so he may estimate target usual nutrient in-
take distributions using all three data sets. Accordingly, the target intake distri-
butions shift up by 0.26 mg, by 0.42 mg, and by 0.7 mg. using Survey A, B, or
C. In each case the target usual nutrient intake distribution would lead to the
accepted prevalence of inadequacy. Rather than choosing one set of survey data
over another, the planner could simply average the summary measures described
in the next section.
STEP 3. SELECT A SUMMARY MEASURE OF THE TARGET USUAL NUTRIENT
INTAKE DISTRIBUTION TO USE IN PLANNING
After the planner has estimated a target usual intake distribution, then this
information needs to be operationalized into a menu. In order to do this, the
planner will first have to select a summary measure of the target usual nutrient
intake distribution to use as a tool in planning the menu. The median of the
target intake distribution is the most useful; it can be calculated