Rethinking the Acceptable Macronutrient Distribution Range for the 21st Century: A Letter Report (2024)
Chapter: 4 Current Applications of the Acceptable Macronutrient Distribution Range
4
Current Applications of the Acceptable Macronutrient Distribution Range
CURRENT APPLICATIONS OF THE AMDR
The report Guiding Principles for Developing Dietary Reference Intakes Based on Chronic Disease (NASEM, 2017) acknowledged two common uses of the Acceptable Macronutrient Distribution Range (AMDR): a population level application, e.g., nutrition surveillance, and an individual level application, e.g., development of dietary guidance. Table 4-1 shows commonly used applications of the AMDR at the level of both individuals and groups.
Considerations in Support of Uses of the AMDR
As part of its evidence-gathering activities, in February 2024, the committee held a virtual workshop, Rethinking the AMDR for the 21st Century. The committee also conducted a narrative literature review (as described below). Box 4-1 shows a list of reported uses of the AMDR presented by speakers in the workshop and from the committee’s review of the literature.
The workshop included speakers from a variety of different organizations that plan and/or assess diets of individuals and/or groups (see Appendix B).1 Most, but not all, presenters reported using the AMDR. For
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1 The public workshop Rethinking the AMDR for the 21st Century was held on February 22, 2024. The agenda and recording of the workshop is available at https://www.nationalacademies.org/event/41682_02-2024_a-standing-committee-for-the-review-of-the-dietary-reference-intakes-framework-open-session (accessed June 3, 2024).
TABLE 4-1 Common Applications of Dietary Reference Intake (DRI) Values for Populations and for Individuals
| Application | Description | Example | DRI |
|---|---|---|---|
| Population Level Application: Nutrition surveillance | Assess the prevalence of nutrient inadequacy and potentially excessive intake in a population by sex/life-stage group | NHANES (United States), CCHS (Canada) | EAR, UL, AMDR |
| Individual Level Application: Development of dietary guidelines | Develop recommended food intake patterns to ensure that individuals meet recommendations for nutrient intake, with consideration of typical food intake patterns | The Dietary Guidelines for Americans (USDA and HHS, 2020); Canada’s Food Guide (Health Canada, 2024); Army Regulation 40-25 (U.S. Army, 2017) | EAR, AI, RDA, UL, AMDR |
NOTES: AI = Adequate Intake; AMDR = Acceptable Macronutrient Distribution Range; CCHS = Canadian Community Health Survey; DRI = Dietary Reference Intake; EAR = Estimated Average Requirement; NHANES = National Health and Nutrition Examination Survey; RDA = Recommended Dietary Allowance; UL = Tolerable Upper Intake Level.
SOURCE: NASEM, 2017.
each institution represented, the committee obtained information on the applications of the AMDRs with examples of specific applications within the stakeholder’s domain and the extent of their reliance on the AMDR to achieve their work. Specific applications included employing the AMDR as a qualitative check or as an assessment or planning tool. Some speakers reported that they were mandated to use the Dietary Reference Intakes (DRIs), but none had a legislative or regulatory requirement to use the AMDR specifically.
Overall, the AMDRs were reported as being used as a primary or secondary tool for assessment of diets or for dietary planning. For some users, the AMDR provided a check for overall dietary quality after using other DRI values to evaluate adequacy, safe upper levels of intake, and/or chronic disease risk reduction. A clear message conveyed in the workshop was the lack of consistency in either the way users applied the AMDRs or in their dependency on it.
Some users reported using the AMDR for public health applications because it enhanced flexibility in menu development. These users indicated that they would find it difficult to carry out their work if the AMDR was not retained. To illustrate, in an institution operating under national authority, the AMDRs were used in menu planning for groups of persons at multiple sites across the country. In such cases, the AMDR was used
BOX 4-1
Summary of Applications of the Acceptable Macronutrient Distribution Range (AMDR)
- Surveillance and monitoring macronutrient intakes of individuals and groups.
- Food labeling, including nutrition facts and health claims.
- Developing dietary guidance:
- Benchmarks—for a representative or single diet, and
- Ranges of energy nutrients in modeled diets.
- Evaluating individual diets, including in the clinical setting.
- Menu planning (group and individual):
- Weight loss diets,
- National and state agencies/institutions (e.g., correctional services, feeding programs, older populations),
- Military rations and diets,
- Documenting how menus meet regulatory and other standards/requirements and relevant nutrition policies,
- Providing flexibility in menu planning to accommodate varying food preferences of consumers,
- Providing flexibility to help in lowering food costs within limited budgets, and
- Technical assistance for menu approvals—provide easy substitutions.
- Providing rationale for public funding of dietary planning.
- Fostering partnerships between private sector (e.g., local restaurants) and public health agencies (government and nongovernmental organizations [NGOs]).
- Patient education; health promotion tool.
- Designing research projects on health effects of food products and nutrient intakes.
SOURCES: Presentations by speakers at the February 22, 2024, workshop on Rethinking the AMDR for the 21st Century (see Appendix B for workshop agenda) and literature summarized in Table 4-2 (see Appendix C for citations).
to develop a national 28-day cycle menu to help ensure that nutritional requirements were met for a broad range of individuals. This offered a rationale for keeping the AMDRs because they served as the foundation for dietary planning in a publicly funded setting. However, it became apparent from the presentations that there was variation in application of the AMDR and awareness of the strength of the evidence.
Other users reported that the AMDR was used for menu planning only and not as a primary assessment tool. In clinical practice, the AMDRs were reported as being used in planning diets for populations with metabolic disorders, which was not the original intent, as the DRIs are not therapeutic values. Some users noted that for dietary guidance, the AMDRs
could be used as benchmarks (e.g., for a representative or single diet with the aim of having mean macronutrient levels fall within the AMDR boundaries). Conversely, for a distribution of simulated diets, the aim was to have an acceptable proportion of diets with macronutrient content within the AMDR boundaries. Issues related to macronutrient quality were noted.
To identify additional evidence supporting the reported uses of the AMDR, the committee carried out a non-systematic narrative literature search in Embase and Medline using the search terms “AMDR” and “Acceptable Macronutrient Distribution Range.” The search included articles published through April 2024. Results of the literature search are presented in Table 4-2 and Appendix C. Although many of the users in the workshop reported using the AMDR as an assessment tool, a variety of other applications were found in the published literature. For example, the AMDR is used in dietary planning for clinical trials. Interestingly, the literature search revealed that researchers from many countries globally applied the AMDR to assess dietary intake in the local populations. Numerous articles reported applying the AMDR to assess populations with risk factors for chronic disease. Additionally, some applied the AMDR in weight loss regimens or for sports medicine, muscle, or endurance studies.
Two studies pointed out that the Recommended Dietary Allowance (RDA) for protein intake, based on grams per kilogram (kg) body weight
TABLE 4-2 Literature Search Results
| Topic | Number of articles |
|---|---|
| Assessing Intakes: Non-U.S./Non-Canadian populations | 35 |
| Assessing Intakes: U.S./Canadian populations | 32 |
| Using the AMDR to assess risk of chronic disease: U.S./Canadian populations | 13 |
| Use of the AMDR by the Dietary Guidelines Advisory Committee | 8 |
| Planning intakes: U.S./Canadian populations | 6 |
| Using the AMDR to assess risk of chronic disease: Non-U.S./Non-Canadian populations | 3 |
| Review papers on using the AMDR/DRIs | 3 |
| AMDR vs. RDA | 1 |
| Planning Intakes: Non-U.S./Non-Canadian populations | 1 |
NOTES: See Appendix C for the list of articles. AMDR = Acceptable Macronutrient Distribution Range; DRI = Dietary Reference Intake; RDA = Recommended Dietary Allowance.
per day, differed from that calculated from the protein AMDR range (10–35 percent of calories). The authors noted that the lowest level of protein intake suggested in the AMDR (10 percent of calories) was higher than would be achieved by consuming protein at the RDA level (0.8 grams per kg) (Wolfe, 2015; Wolfe et al., 2017). It was further noted that using the AMDR rather than the RDA for planning and assessing dietary patterns provided more flexibility in the amount of protein that could be consumed in the context of a complete diet, especially under differing physiologic conditions.
SUMMARY
Based on the information gathered from workshop presenters’ experiences with the AMDR, along with a narrative literature search, the committee considered rationales for retaining or not retaining the AMDRs. From both the workshop and their narrative review of the literature, the committee identified a range of both applications and awareness of the scientific underpinnings of the AMDR across users.
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