A review of dietary standards, guidelines and nutrition education resources for the oral health professional.

Introduction

Inadequate nutrient intakes are linked to many leading causes of death in the United States, including obesity, hypertension, cardiovascular disease, cancer and type 2 diabetes. The risks of developing nutrition-related diseases could be minimized with a combination of variety, moderation and balance; the basic components of a healthy diet. (1) However, achieving a nutritionally adequate diet can be a challenge, especially with the hectic lifestyle of the average American eating meals and snacks away from home. (2) Approximately 1/3 of total kilocalories consumed by Americans are eaten away from home. These meals contain more fat, saturated fat, cholesterol and sodium, and less fiber, calcium and iron than meals prepared at home. Unfortunately these are the nutrients that are most over-consumed and underconsumed, respectively, by Americans, adding more insult to injury. (3)

Health professional recommendations for the past 40 years have emphasized portion control, a focus on major food groups, and increased physical activity. Whole grains, fruits and vegetables have always been the foods to emphasize in healthy meal planning. (1) Practicing the ABCs of good nutrition--adequacy, balance and calorie control--along with moderation and variety, is sound nutrition advice.

Health professionals need to keep abreast of current dietary recommendations and guidelines for health promotion and disease prevention so they can educate consumers on nutritious choices for a healthy diet. Dental hygienists are in an excellent position to perform diet and nutrition risk assessment in relation to general and oral health, provide dietary counseling relative to oral disease management, and make referrals to a registered dietitian (RD) for comprehensive nutritional assessment and medical nutrition counseling. (2) This column reviews the dietary guidelines, standards, and food labeling for dietary adequacy and healthy meal planning as baseline nutrition references for oral health professionals.

History of Dietary and Nutrition Standards

In 1941, a group of 25 scientists formulated the first Food and Nutrition Board of the Institute of Medicine of the National Academy of Sciences. Dietary standards were established for evaluating the nutritional intakes of large populations and planning of agricultural production. The first Recommended Dietary Allowances (RDAs) were published in 1943, listing nutritional requirements for only seven nutrients and consisting of one value for nutrient needs for various age groups. These standards are reevaluated and issued every four years. The framework for the latest recommendations from the Food and Nutrition Board is the most detailed document to date. It has been renamed the Dietary Reference Intakes (DRIs), which have been released in stages over the last 10 years. Established DRIs for vitamins, minerals and trace elements provide guidelines for determining nutrient needs for healthy individuals. They also detail the amounts of nutrients recommended to reduce chronic disease risk and prevent nutrition deficiencies and toxicities. (2,4-6)

Under the umbrella term "DRIs," five sets of standards have been established. These are Estimated Average Requirements (EARs), Recommended Dietary Allowances (RDAs), Adequate Intakes (AIs), Estimated Energy Requirements (EERs) and Tolerable Upper Intake Levels or Upper Levels (ULs). (4-6)

The EARs define the nutrient intake value that is estimated to meet the requirement of 50% of the individuals in a specific age and gender group. When an EAR is established for a nutrient, any intake below that value is considered inadequate for an individual. (4-6)

The RDAs represent the recommended intake of a nutrient that is sufficient to meet the needs of almost all healthy individuals of the same age and gender. They are based on the average requirement for health with a margin of safety to meet the needs of a healthy population. The recommendations do not represent the minimum requirements; instead, they are the optimum intake in health promotion. (1,2)

The AIs are recommendations for nutrient intake when insufficient information is available to establish an RDA. They are based on experimentally determined intakes that appear to maintain a defined nutritional state in a specific population. Adequate Intakes have been set for essential fatty acids, fiber, some B-vitamins, vitamin D, calcium, fluoride, and choline. (1)

The EERs are a more conservative standard used to provide a rough estimate of energy needs based on one's height, weight, gender and physical activity pattern. (1)

The ULs, the newest category, were established secondary to evidence of detrimental effects of inappropriate intakes of some nutrients. It is the maximum chronic daily intake of a nutrient that is unlikely to cause adverse effects in almost all people in a population. The Upper Level is not a goal for intake, but the uppermost limit below which nutrient intake should remain. For most nutrients, the UL is based on the combination of food intake, water, supplements and fortified foods. (1,2)

The DRIs are intended for diet planning. A healthy diet plan should aim to meet any RDA set. However, if no RDA has been established for a nutrient, the Adequate Intakes should be used as a guide. The further removed one's dietary intake is from nutrient standards, the greater the chance of nutritional inadequacy and developing nutrient deficiency or toxicity. (1)

The nutrient standards associated with DRIs are not used for food labeling due to their age- and gender-specific nature. The United States Food and Drug Administration (U.S. FDA) has developed a set of standard nutrient-intake values known as the Daily Values. These values are a reference used to express the nutrient content of foods on the "Nutrition Facts" panel on food labels. The Daily Values include two sets of standards, the Reference Daily Intakes (RDIs) and the Daily Reference Values (DRVs). The RDIs and DRVs do not actually appear on food labels; instead, the combination of both standards appears as the "Daily Values" on food labels.

The RDIs are nutrient-intake standards based on the 1968 RDAs for various vitamins and minerals. The highest RDA value out of all categories is used as the RDI. They are set for four categories: infants, toddlers, individuals over four years of age, and pregnant and lactating women. The RDIs make up the majority of the Daily Values. (1)

The DRVs are nutrient-intake standards established for protein, carbohydrate, and other dietary components lacking an RDA or related standard, such as total fat, saturated fat and cholesterol intake. The DRVs for sodium and potassium are constant values, whereas those for the remaining nutrients increase as caloric intake increases. (1)

Food Labeling

The U.S. FDA labeling requirement also maintains strict guidelines over the use of health claims, and the definition of terms must meet specific content requirements. The Food Safety and Inspection Service (FSIS) regulates meat and poultry, while the FDA regulates labeling of food products and ingredients added to food. (2)

Nutrition labeling is a mandatory requirement on all processed food products. Foods exempt from nutrition labeling are plain coffee; tea; most spices; foods prepared in restaurants, supermarkets, dells and bakeries; and fast-food products. Food labels must include product name, net contents, name and address of manufacturer, and ingredients listed in descending order by weight. (2) Figure 1 illustrates the components of a sample label. For a comprehensive resource on the Nutrition Facts label, visit the U.S. FDA Center for Food Safety and Applied Nutrition Web site at http://www.cfsan.fda.gov/~dms/foodlab.html.

U.S. Dietary Guidelines

In response to health concerns regarding morbidity and mortality rates, since 1980, the USDA in conjunction with the United States Department of Health and Human Services (USDHHS) have published "Dietary Guidelines for Americans" to aid dietary planning. The guidelines provide authoritative advice for children over the age of two and all adults on good dietary habits to promote health and reduce risk of major chronic diseases. Federal law requires updating the guidelines every five years. Nutrition and medical experts outside the government agencies also contribute their expertise to the process. (7,8)

[FIGURE 1 OMITTED]

The 2005 Dietary Guidelines for Americans are the basis for federal nutrition policy offering Americans achievable goals for controlling weight; building stronger muscles and bones; and preventing heart disease, diabetes and some cancers. It emphasizes physical activity and calorie control more than any previous edition. Exercise recommendations are 30 minutes per day for adults; 60-90 minutes at least 5 days per week for weight reduction; and 60 minutes per day for children. The 80-page report identifies 41 key recommendations, 23 for the general public the other 18 for special populations such as children, women who may become pregnant, or Americans who are over the age of 50. General key recommendations are to take a personalized approach to dietary advice and weight management (one size does not fit everyone); eat a variety of foods from every group in balance, moderation and attention to calorie control; and achieve a balance between food intake and regular physical activity. (8,9)

MyPyramid Food Guidance System

MyPyramid is based on both the guidelines and the Dietary Reference Intakes from the National Academy of Sciences, while also taking into account current consumption patterns of Americans. It translates the guidelines into a total diet, meeting nutrient needs from food sources and moderating dietary components often consumed in excess. MyPyramid provides Web-based interactive and print materials for consumers as well as professionals. The materials include Food Intake Patterns identifying food intake amounts based on an individual's age, gender and activity level; an Education Framework explaining the what, how and why of changes needed in the American diet to promote good health; and a Glossary defining key terms used in the MyPyramid document. (8,10) The MyPyramid Education Framework provides specific recommendations for making food choices to improve the nutrition quality of the American diet. The interrelated recommendations would result in increased intake of vitamins, minerals, dietary fiber and other essential nutrients often lacking in the American diet; lowered intake of saturated fats, trans fats and cholesterol with increased intake of fruits, vegetables and whole grains to decrease the risk for chronic diseases; and calorie intake balanced with energy needs to prevent weight gain and/or promote a healthy weight. The educational framework has four overarching themes:

   Variety--eat foods from all food groups and subgroups;

   Proportionality--consume more fruits, vegetables, whole
      grains and fat-free or low-fat milk products and limit saturated
      or trans fats, added sugars, cholesterol, salt and alcohol;

   Moderation--make food choices that limit intake of saturated
      or trans fat, added sugars, cholesterol, salt and alcohol; and

   Activity--be physically active every day. (8,10)

The MyPyramid icon is a series of vertical color bands of varying widths. The emphasis is on the vegetables and fruits groups (green and red bands) occupying the majority of the space in the center of the pyramid, followed by the grains group (orange band) to the far left margin, with the next largest emphasis being the milk and meat and beans groups (blue and purple bands) on the far right margin, and the narrowest section (yellow band) in the direct center is oils. The stick figure on the left side of the pyramid emphasizes the inclusion of daily exercise. The icon also includes information at the bottom outlining recommendations for a daily 2000-calorie diet; physical activity; and limiting fats, sugars and salt. The interactive Food Guidance System at www.MyPyramid.gov offers a customized Food Intake Pattern for 12 different caloric levels. These patterns outline the suggested daily amounts of food from each basic food group. The "Discretionary Calorie Allowance" constitutes the remaining amount of calories in a food intake pattern utilizing fat-free or low-fat foods with no added sugars for snack options. MyPyramid also provides caloric recommendations based on gender, age and activity level ranging from toddler through adult. (10)

The MyPyramid Food Guidance System offers Americans instant nutrition advice with a more personalized approach in making food choices, balanced with daily exercise, in promoting a healthier lifestyle.

Diet, Nutrition and Oral Health Education

Within the scope of the dental hygiene process of care, behavior modification promoting general and oral health is paramount in providing comprehensive treatment to dental clients. As health educators, dental hygienists advocate proper diet and nutrition advice as it relates to the prevention of disease. Dental hygienists need to maintain current reference and resource materials in nutrition standards, dietary guidelines and diet adequacy in their recommendation of sound nutrition practices as it relates to diet and oral health.

The Internet provides quick, easy, and affordable resources. In addition to the MyPyramid Web site, there are other excellent Web sites for information on diet, health and nutrition, such as:

* www.eatright.org (American Dietetic Association)

* www.nal.usda.gov/fnic (USDA Food & Nutrition Information Center)

* www.nationaldairycouncil.org (National Dairy Council)

* www.usda.gov/cnpp (USDA Center for Nutrition Policy & Promotion)

* www.fda.gov (US Food and Drug Administration)

* www.americanheart.org (American Heart Association)

Diet and Oral Health Web addresses include the following:

* www.ada.org/public/topics/diet.asp (American Dental Association)

* www.nidcr.nih.gov (National Institute of Dental & Craniofacial Research)

Summary

Comprehensive dental hygiene care encompasses diet and nutrition risk assessment as it relates to general and oral health. Providing dietary counseling relative to the management of oral disease and making referrals to an RD for comprehensive nutritional assessment counseling is exemplary multidisciplinary health care. Diet counseling within dental hygiene care is certainly the first line of defense in health promotion and disease prevention. Please look for the next Nutrition column in March on implementing a nutritional counseling plan in practice.

References

(1.) Wardlaw GM, Hampl JS: Perspectives in nutrition, 7th ed. New York: McGraw-Hill, 2007.

(2.) Palmer CA: Diet and nutrition in oral health, 2nd ed. Upper Saddle River: Prentice Hall, 2007.

(3.) Lin B-H, Frazao E, Guthrie J: Food and Drug Administration, Away from home foods increasingly important to the quality of the American diet. Community Nutrition Institute. CNI report February 19, 1999; pp. 4-5.

(4.) Institute of Medicine Standing Committee on Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board: Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D, and fluoride. Washington, D.C.: National Academy Press, 1997.

(5.) International Food Information Council. Dietary reference intakes: an update, August 2002. Available at http://ific.org/publications/other/driupdateom.cfm. Accessed Sep. 29, 2007.

(6.) Institute of Medicine: Dietary reference intakes: the essential reference to nutrient requirements. Washington D.C.: National Academy Press, 2006.

(7.) Keenan DP, Abusabha R: The fifth edition of the dietary guidelines for Americans: lessons learned along the way. J Am Dietetic Assoc 2001; 101: 631-4.

(8.) Nappo-Dattoma L: 2005 USDA nutrition guidelines. Access 2005; 19(8): 29-35.

(9.) United States Department of Health and Human Services. Dietary guidelines for Americans 2005. Available at www. healthierus.gov/dietaryguidelines. Accessed Sep. 29, 2007.

(10.) United States Department of Agriculture. MyPyramid.gov. Available at www.MyPyramid.gov. Accessed Sep. 29, 2007.

By Luisa Nappo-Dattoma, RDH, RD, EdD

Luisa Nappo-Dattoma, RDH, RD, EdD, is a full-time assistant professor at Farmingdale State College in Farmingdale, N.Y.