EURRECA – A Network of Excellence to align European micronutrient recommendations

Public Health Aspects in the Prevention and Control of Vitamin Deficiencies

Vitamin deficiencies remain major etiological factors in the global burden of disease, especially in low- and middle-income countries. The purpose of this state-of-the-art review was to update current information on deficiencies of vitamins and public health approaches to addressing them. Some stages of life present a higher risk of deficiency than others: risks are higher in pregnant women, children (from conception to young childhood), adolescents, the elderly, and all of the over 800 million people globally who are undernourished. At risk are approximately 125 million preschool children with vitamin A deficiency, as well as sub-populations at risk of deficiencies of folate, thiamin, vitamin B12, niacin, riboflavin, other B vitamins. and vitamin D. Addressing micronutrient deficiencies requires identifying those at risk and then working to prevent and manage that risk. Public health approaches include improved, diversified diets; supplementation; fortification and biofortification; and other supportive public health measures. Historically, as with pellagra and beriberi and, in the last 3 decades, with vitamin A and folic acid, there has been encouraging progress, but much remains to be done.

Reducing waste in nutritional epidemiology: review and perspectives

We discuss efforts in improving the value of nutrition research. We organised the paper in five research stages: Stage 1: research priority setting; Stage 2: research design, conduct and analysis; Stage 3: research regulation and management; Stage 4: research accessibility and Stage 5: research reporting and publishing. Along the stages of the research cycle, varied initiatives exist to improve the quality and added value of nutrition research. However, efforts are focused on single stages of the research cycle without vision of the research system as a whole. Although research on nutrition research has been limited, it has potential to improve the quality of nutrition research and develop new tools and instruments for this purpose. A comprehensive assessment of the magnitude of research waste in nutrition and consensus on priority actions is needed. The nutrition research community at large needs to have open discussions on the usefulness of these tools and lead suitable efforts to enhance nutrition research across the stages of the research cycle. Capacity building is essential and considerations of nutrition research quality are vital to be integrated in training efforts of nutrition researchers.

The genomics of micronutrient requirements

Healthy nutrition is accepted as a cornerstone of public health strategies for reducing the risk of noncommunicable conditions such as obesity, cardiovascular disease, and related morbidities. However, many research studies continue to focus on single or at most a few factors that may elicit a metabolic effect. These reductionist approaches resulted in: (1) exaggerated claims for nutrition as a cure or prevention of disease; (2) the wide use of empirically based dietary regimens, as if one fits all; and (3) frequent disappointment of consumers, patients, and healthcare providers about the real impact nutrition can make on medicine and health. Multiple factors including environment, host and microbiome genetics, social context, the chemical form of the nutrient, its (bio)availability, and chemical and metabolic interactions among nutrients all interact to result in nutrient requirement and in health outcomes. Advances in laboratory methodologies, especially in analytical and separation techniques, are making the chemical dissection of foods and their availability in physiological tissues possible in an unprecedented manner. These omics technologies have opened opportunities for extending knowledge of micronutrients and of their metabolic and endocrine roles. While these technologies are crucial, more holistic approaches to the analysis of physiology and environment, novel experimental designs, and more sophisticated computational methods are needed to advance our understanding of how nutrition influences health of individuals.

EURRECA-Framework for Aligning Micronutrient Recommendations

There is currently no standard approach for deriving micronutrient recommendations, and large variations exist across Europe, causing confusion among consumers, food producers, and policy makers. More aligned information could influence dietary behaviors and potentially lead to a healthier population. Funded by the European Commission, EURRECA (EURopean micronutrient RECommendations Aligned) has developed methods and applications to guide Nutrient Recommendation Setting Bodies through the process of setting micronutrient reference values. The EURRECA approach is crystallized into its framework that outlines a standard process for deriving and using dietary reference values for micronutrients in a transparent, systematic, and scientific way. The 9 activities of the framework can be clustered into four stages (i) defining the problem, (ii) monitoring and evaluating, (iii) deriving dietary reference values, and (iv) using dietary reference values in policy making. The EURRECA framework should not be interpreted as a prescriptive description of a linear process, but as a structured guide for checking that all issues essential for deriving requirements have at least been considered.

Explaining the variability in recommended intakes of folate, vitamin B12, iron and zinc for adults and elderly people

Objective

To signal key issues for harmonising approaches for establishing micronutrient recommendations by explaining observed variation in recommended intakes of folate, vitamin B12, Fe and Zn for adults and elderly people.

Design

We explored differences in recommended intakes of folate, vitamin B12, Fe and Zn for adults between nine reports on micronutrient recommendations. Approaches used for setting recommendations were compared as well as eminence-based decisions regarding the selection of health indicators indicating adequacy of intakes and the consulted evidence base.

Results

In nearly all reports, recommendations were based on the average nutrient requirement. Variation in recommended folate intakes (200–400 μg/d) was related to differences in the consulted evidence base, whereas variation in vitamin B12recommendations (1·4–3·0 μg/d) was due to the selection of different CV (10–20 %) and health indicators (maintenance of haematological status or basal losses). Variation in recommended Fe intakes (men 8–10 mg/d, premenopausal women 14·8–19·6 mg/d, postmenopausal women 7·5–10·0 mg/d) was explained by different assumed reference weights and bioavailability factors (10–18 %). Variation in Zn recommendations (men 7–14 mg/d, women 4·9–9·0 mg/d) was also explained by different bioavailability factors (24–48 %) as well as differences in the consulted evidence base.

Conclusions

For the harmonisation of approaches for setting recommended intakes of folate, vitamin B12, Fe and Zn across European countries, standardised methods are needed to (i) select health indicators and define adequate biomarker concentrations, (ii) make assumptions about inter-individual variation in requirements, (iii) derive bioavailability factors and (iv) collate, select, interpret and integrate evidence on requirements.

European micronutrient recommendations aligned: a general framework developed by EURRECA

BACKGROUND

In Europe, micronutrient recommendations have been established by (inter)national committees of experts and are used by public health-policy decision makers to monitor and assess the adequacy of the diets of population groups. Current micronutrient recommendations are, however, heterogeneous, whereas the scientific basis for this is not obvious. Alignment of setting micronutrient recommendations is necessary to improve the transparency of the process, the objectivity and reliability of recommendations that are derived by diverse regional and (inter)national bodies.

OBJECTIVE

This call for alignment of micronutrient recommendations is a direct result of the current sociopolitical climate in Europe and uncovers the need for an institutional architecture. There is a need for evidence-based policy making, transparent decision making, stakeholder involvement and alignment of policies across Europe.

RESULTS

In this paper, we propose a General Framework that describes the process leading from assessing nutritional requirements to policy applications, based on evidence from science, stakeholder interests and the sociopolitical context. The framework envisions the derivation of nutrient recommendations as scientific methodology, embedded in a policy-making process that also includes consumer issues, and acknowledges the influences of the wider sociopolitical context by distinguishing the principal components of the framework: (a) defining the nutrient requirements for health, (b) setting nutrient recommendations, (c) policy options and (d) policy applications.

CONCLUSION

The General Framework can serve as a basis for a systematic and transparent approach to the development and review of micronutrient requirements in Europe, as well as the decision making of scientific advisory bodies, policy makers and stakeholders involved in this process of assessing, developing and translating these recommendations into public health nutrition policy.

Nutritional requirements during lactation. Towards European alignment of reference values: the EURRECA network

There is considerable variation in reference values for micronutrient intake during lactation across Europe. The European Micronutrients Recommendations Aligned project aims to harmonize dietary recommendations throughout Europe. Recommended nutrient intakes during lactation are based on limited data and are often extrapolated from known secretion of the nutrient in milk with adjustments for bioavailability, so that differences between values can be partly ascribed to differences in methodological approaches and how these approaches were applied. Few studies have considered the impact of lactation on the mother's nutritional status. Rather, focus has been placed on the influence of maternal nutritional status on the composition of her breast milk. Most common nutritional deficits in breast milk are the result of maternal deficiencies of the water-soluble vitamins, thiamine, riboflavin and vitamins B6 and B12. Other than maternal vitamin A status, which to some extent is reflected in breast milk, concentrations of fat-soluble vitamins and most minerals in breast milk are less affected by maternal status. Factors relating to suboptimal maternal nutritional status during lactation include maternal age, diet and lifestyle factors and spacing of consecutive births. Recent research is providing new knowledge on the micronutrient requirements of lactating women. Identifying needs for research and improving understanding of the differences in values that have been derived by various committees and groups across Europe will enhance transparency and facilitate the application of dietary recommendations in policy-making decision and their translation into recommendations for lactating women. Given the wide variation in breastfeeding practices across Europe, making nutritional recommendations for lactating women is complex and challenging. Thus, it is crucial to first examine the cultural practices within and across European populations and to assess its relevance before making recommendations.

Critical issues in setting micronutrient recommendations for pregnant women: an insight

The European Micronutrient Recommendations Aligned (EURRECA) Network aims to provide standardized approaches to reveal and beneficially influence variability within the European Union in micronutrient recommendations for vulnerable population groups. Characterization of the 'vulnerability' together with the 'variability' of micronutrient needs represents the first step to creating guidelines for setting micronutrient recommendations within target populations. This paper describes some of the key factors and characteristics relevant to assess micronutrient requirements and formulate recommendations of micronutrients in pregnancy. Nutritional requirements during pregnancy increase to support fetal growth and development as well as maternal metabolism and tissue accretion. Micronutrients are involved in both embryonal and fetal organ development and overall pregnancy outcomes. Several factors may affect directly or indirectly fetal nourishment and the overall pregnancy outcomes, such as the quality of diet including intakes and bioavailability of micronutrients, maternal age, and the overall environment. The bioavailability of micronutrients during pregnancy varies depending on specific metabolic mechanisms because pregnancy is an anabolic and dynamic state orchestrated via hormones acting for both redirection of nutrients to highly specialized maternal tissues and transfer of nutrients to the developing fetus. The timing of prenatal intakes or supplementations of specific micronutrients is also crucial as pregnancy is characterized by different stages that represent a continuum, up to lactation and beyond. Consequently, nutrition during pregnancy might have long-lasting effects on the well-being of the mother and the fetus, and may further influence the health of the baby at a later age.

The process of setting micronutrient recommendations: a cross-European comparison of nutrition-related scientific advisory bodies

Objective

To examine the workings of the nutrition-related scientific advisory bodies in Europe, paying particular attention to the internal and external contexts within which they operate.

Design

Desk research based on two data collection strategies: a questionnaire completed by key informants in the field of micronutrient recommendations and a case study that focused on mandatory folic acid (FA) fortification.

Setting

Questionnaire-based data were collected across thirty-five European countries. The FA fortification case study was conducted in the UK, Norway, Denmark, Germany, Spain, Czech Republic and Hungary.

Results

Varied bodies are responsible for setting micronutrient recommendations, each with different statutory and legal models of operation. Transparency is highest where there are standing scientific advisory committees (SAC). Where the standing SAC is created, the range of expertise and the terms of reference for the SAC are determined by the government. Where there is no dedicated SAC, the impetus for the development of micronutrient recommendations and the associated policies comes from interested specialists in the area. This is typically linked with anad hocselection of a problem area to consider, lack of openness and transparency in the decisions and over-reliance on international recommendations.

Conclusions

Even when there is consensus about the science behind micronutrient recommendations, there is a range of other influences that will affect decisions about the policy approaches to nutrition-related public health. This indicates the need to document the evidence that is drawn upon in the decisions about nutrition policy related to micronutrient intake.

Micronutrient bioavailability research priorities

A micronutrient bioavailability workshop, which involved international experts and members of the scientific community and the food industry, with interactive breakout sessions based on synectics principles, was organized by the International Life Sciences Institute Europe Addition of Nutrients to Food Task Force and the European Commission Network of Excellence European Micronutrient Recommendations Aligned. After presentations by experts, a series of "challenge statements" was discussed. The aim was to address topical issues, in particular those that linked bioavailability with the derivation of micronutrient requirements and dietary recommendations, to identify gaps in knowledge and to consider research priorities. Several generic research priorities were identified, including improving the quality of dietary surveys/food composition tables, the need for more metabolic studies that use stable isotopes and high-quality longer-term interventions, and the development of multifactorial mathematical models. Among the common recurrent factors identified as important were polymorphisms/genotype, consideration of the whole diet, chemical form of the micronutrient, and the determination of physiologic requirements. The involvement of all participants in the structured discussions ensured a broad overview of current knowledge, state-of-the-art research, and consideration of priorities for future research.