Dietary Reference Intakes for Sodium and Potassium (2019) / Chapter Skim
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2 Applying the "Guiding Principles Report"
2 Applying the "Guiding Principles Report"
Pages 37-60
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From page 37... ...
Although the standardization of food fortification and enrichment along with dietary guidance to the public contributed to reducing the prevalence of nutrition deficiencies, there was a subsequent rise in the prevalence of obesity and related chronic diseases. As the public health burden in the 1 Throughout this report, DRIs based on chronic disease is used when broadly describing the category, such as when referring to the guidance in the Guiding Principles Report (NASEM, 2017a)
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From page 38... ...
, which expanded the DRI model to include a new DRI category based on chronic disease. THE COMMITTEE'S INTERPRETATION OF THE GUIDING PRINCIPLES REPORT The Guiding Principles Report provides recommendations on methodological approaches to establishing DRIs based on chronic disease (see Box 2-1)
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Recommendation 3: The committee recommends that DRI committees use Grad ing of Recommendations Assessment, Development and Evaluation (GRADE) in assessing the certainty of the evidence related to the causal association between nutrient or other food substances and chronic diseases.
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In addition, if increased intake of a substance has been shown to increase the risk of a chronic disease, such a relationship should be characterized as the range where a decreased intake is beneficial. If the increase in risk only occurs at intakes greater than the traditional UL, no chronic disease Dietary Reference Intake would be required, because avoiding intakes greater than the UL will avoid the chronic disease risk.
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From page 41... ...
SOURCE: NASEM, 2017a. Nomenclature and Conceptual Underpinnings Guidance from the Guiding Principles Report Nutrient deficiency diseases from inadequate intake and adverse effects from excess intake are well established for many essential nutrients.
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42 DIETARY REFERENCE INTAKES FOR SODIUM AND POTASSIUM FIGURE 2-1 Possible DRI ranges for a single chronic disease, depending on the shape of the intake–response relationship, as presented in the Guiding Principles Report.
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From page 43... ...
. Committee's Application of the Guiding Principles Report Although the scope of its work was limited to potassium and sodium, the committee was mindful that its application of the Guiding Principles Report might have implications for future DRI reviews, particularly in assessing nonessential nutrients and food substances.
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From page 44... ...
Because the DRIs comprise a set of different reference value categories, labeling the new category itself the chronic disease DRIs or DRI based on chronic disease had the potential of dividing the DRIs into "the adequacy and toxicity DRIs" and "the chronic disease DRIs." Such a distinction would appear to counter the Guiding Principles Report recommendation that a single DRI committee be convened to establish the adequacy, toxicity, and chronic disease reference values for a specific nutrient (see Box 2-1, Guiding Principles Report Recommendation 10)
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From page 45... ...
. Although its approach to reviewing the evidence to establish DRIs based on chronic disease and deriving the sodium CDRRs was conceptually aligned with the Guiding Principles Report, the committee further considered issues of implementation and clarity of communication in the expression of values.
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From page 46... ...
Similarly, if there is evidence of adverse effects from high levels of intake, a DRI committee uses its expert judgment and best available evidence to determine a level of intake after which risk increases to establish a UL. In contrast, the Guiding Principles Report described the new DRI category as being established only when the body of evidence on the relationship between a nutrient and chronic disease risk is sufficient and when an intake–response relationship can be characterized.
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From page 47... ...
. The Guiding Principles Report recommended a GRADE rating of at least moderate strength for both the causal relationship and the intake–response relationship for the DRI based on chronic disease to be established, although it was also noted that "when a food substance increases chronic disease risk, the level of certainty considered acceptable might be lower" (NASEM, 2017a, p.
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From page 48... ...
strength of evidence and integrating such an assessment into the decisionmaking process for the DRIs for adequacy and the DRIs for oxicity are not t yet standardized. Recommendations in the Guiding Principles Report introduce a more formal strength-of-evidence assessment to the DRI process, specifically for informing decision making related to DRIs based on chronic disease.
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From page 49... ...
evidence to the derivation of DRIs based on chronic disease compared to the other DRI categories. In its application of the Guiding Principles Report guidance, the committee explored the body of evidence provided in the Agency for Healthcare Research and Quality systematic review, Sodium and Potassium Intake: Effects on Chronic Disease Outcomes and Risks (AHRQ Systematic Review)
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. The AHRQ Systematic Review assessed risk of bias for all studies meeting the inclusion criteria.
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. For these reasons, the committee primarily relied on randomized controlled trials to inform its decision making regarding establishing DRIs based on chronic disease for potassium and sodium.
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Heterogeneity is actually expected and potential sources can be identified from the formulation of the population, intervention, comparison, and outcome (PICO) statements.
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The AHRQ Systematic Review performed meta-analyses for key questions and subquestions when randomized controlled trials were available, but it did not explore the potential sources of heterogeneity. Recognizing the importance of explaining the inconsistencies in order to have confi
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From page 54... ...
Use of strength-of-evidence rating Pursuant to the guidance provided in the Guiding Principles Report, the committee determined that it would establish a DRI based on chronic disease if there was at least moderate strength of evidence for both a causal and an intake–response relationship between potassium or sodium intake and chronic disease risk. In this approach, situations can arise in which there is moderate or high strength of evidence of a causal relationship between intake of a nutrient and a chronic disease indicator, but insufficient or low strength of evidence of an intake–response relationship.
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. Committee's Application of the Guiding Principles Report A 2010 Institute of Medicine report developed a conceptual framework for qualifying surrogate markers for specific uses (IOM, 2010)
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THE CHRONIC DISEASE RISK REDUCTION INTAKE IN CONTEXT OF THE OTHER DRI CATEGORIES In its review of the evidence and application of the guidance in the Guiding Principles Report, the committee considered the conceptual interrelationships among the DRI categories. The following sections briefly summarize how the committee applied its collective expert judgment to make the distinction between the CDRR and the other DRI categories for potassium and sodium.
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From page 57... ...
. The expanded DRI model allows for a more nuanced characterization of the relationship between nutrient intake and chronic disease risk reduction.
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From page 58... ...
For sodium, the CDRR reflects the lowest level of intake for which there was sufficient strength of evidence to characterize a chronic disease risk reduction. According to the Guiding Principles Report, if increases in chronic disease risk only occur at intakes greater than the UL, then no CDRR would be necessary.
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From page 59... ...
The committee interpreted the Guiding Principles Report as creating a new DRI category, termed in this report the Chronic Disease Risk Reduction Intake (CDRR) , which is distinct from the AI and UL.
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From page 60... ...
2017b. Guiding principles for developing Dietary Reference Intakes based on chronic disease -- Highlights from the consensus report.
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