Determining Life-Stage Groups and Extrapolating Nutrient Intake Values (NIVs)

Dichotomous effect of dietary fiber in pediatrics: a narrative review of the health benefits and tolerance of fiber

Dietary fibers are associated with favorable gastrointestinal, immune, and metabolic health outcomes when consumed at sufficient levels. Despite the well-described benefits of dietary fibers, children and adolescents continue to fall short of daily recommended levels. This gap in fiber intake (i.e., "fiber gap") might increase the risk of developing early-onset pediatric obesity and obesity-related comorbidities such as type 2 diabetes mellitus into adulthood. The structure-dependent physicochemical properties of dietary fiber are diverse. Differences in solubility, viscosity, water-holding capacity, binding capability, bulking effect, and fermentability influence the physiological effects of dietary fibers that aid in regulating appetite, glycemic and lipidemic responses, and inflammation. Of growing interest is the fermentation of fibers by the gut microbiota, which yields both beneficial and less favorable end-products such as short-chain fatty acids (e.g., acetate, propionate, and butyrate) that impart metabolic and immunomodulatory properties, and gases (e.g., hydrogen, carbon dioxide, and methane) that cause gastrointestinal symptoms, respectively. This narrative review summarizes (1) the implications of fibers on the gut microbiota and the pathophysiology of pediatric obesity, (2) some factors that potentially contribute to the fiber gap with an emphasis on undesirable gastrointestinal symptoms, (3) some methods to alleviate fiber-induced symptoms, and (4) the therapeutic potential of whole foods and commonly marketed fiber supplements for improved health in pediatric obesity.

Dietary Reference Intakes of sodium for Koreans: focusing on a new DRI component for chronic disease risk reduction

Sodium is a physiologically essential nutrient, but excessive intake is linked to the increased risk of various chronic diseases, particularly cardiovascular. It is, therefore, necessary to accomplish an evidence-based approach and establish the Korean Dietary Reference Intakes (KDRIs) index, to identify both the nutritional adequacy and health effects of sodium. This review presents the rationale for and the process of revising the KDRIs for sodium and, more importantly, establishing the sodium Chronic Disease Risk Reduction Intake (CDRR) level, which is a new specific set of values for chronic disease risk reduction. To establish the 2020 KDRIs for dietary sodium, the committee conducted a systematic literature review of the intake–response relationships between the selected indicators for sodium levels and human chronic diseases. In this review, 43 studies published from January 2014 to December 2018, using databases of PubMed and Web of Science, were finally included for evaluating the risk of bias and strength of evidence (SoE). We determined that SoE of the relationship between dietary sodium and cardiovascular diseases, cerebrovascular disease, and hypertension, was moderate to strong. However, due to insufficient scientific evidence, we were unable to establish the estimated average requirement and the recommended nutrient intake for dietary sodium. Therefore, the adequate intake of sodium for adults was established to be 1,500 mg/day, whereas the CDRR for dietary sodium was established at 2,300 mg/day for adults. Intake goal for dietary sodium established in the 2015 KDRIs instead of the tolerable upper intake level was not presented in the 2020 KDRIs. For the next revision of the KDRIs, there is a requirement to pursue further studies on nutritional adequacy and toxicity of dietary sodium, and their associations with chronic disease endpoint in the Korean population.

Dietary Intake of Breastfeeding Mothers in Developed Countries: A Systematic Review and Results of the MEDIDIET Study

BACKGROUND

Lactation is a demanding period for women, and a good nutrition is crucial for optimal health of mothers and infants.

OBJECTIVES

To provide new data and summarize the overall evidence on maternal nutrient intakes during lactation in developed countries, we present a systematic review (SR) of the literature and concurrently original results of the Italian MEDIDIET study. We compared nutrient intakes with dietary reference values (DRVs) proposed by the European Food Safety Authority.

METHODS

Studies were identified searching PubMed/Embase databases up to February 2020. Observational studies reporting at least energy and macronutrient intakes of healthy breastfeeding mothers who followed non-restricted and non-specific diets were included. Studies on populations with severe nutritional deficiencies were excluded. The MEDIDIET study enrolled 300 healthy breastfeeding mothers at 6 ± 1 wk postpartum. Usual diet was concomitantly evaluated through a validated and reproducible FFQ. Nutrient intakes were estimated using a food composition database.

RESULTS

Twenty-eight articles regarding 32 distinct study populations were included. Maternal nutrient intakes were generally in agreement across studies included in the SR and conforming to DRVs. Within micronutrients, vitamin D intake was below the recommendation. In the MEDIDIET study, mean intakes of energy (1950 ± 445 kcal/d), carbohydrates (270 ± 20.1 g/d), proteins (87.8 ± 20.1 g/d), and fats (65.6 ± 18.9 g/d) were similar to those observed in the SR. Moreover, observed intakes seemed to reflect the typical Mediterranean diet, with low intakes of carbohydrates, SFAs, and PUFAs and high intakes of MUFAs and vitamins. Conversely, protein intake was mainly derived from animal sources.

CONCLUSIONS

This SR showed that nutrient intakes of breastfeeding mothers in developed countries are generally in line with DRVs despite different dietary patterns worldwide. Some nutritional deficiencies emerged, highlighting the need for additional nutritional advice. Mothers participating in the MEDIDIET study showed a nutritional profile in agreement with the Mediterranean diet.

Limited data exist to inform our basic understanding of micronutrient requirements in pregnancy

Women and pregnant people have historically been underrepresented in research; this may extend to the basic research informing nutrient reference values, such as the United States’ and Canada’s Dietary Reference Intakes (DRIs). After screening the DRI reports for 23 micronutrients, we extracted metadata from 704 studies. Women were excluded in 23% of studies, and they accounted for a smaller proportion of the sample size (29%). Pregnant or lactating people were included in 17% of the studies. Studies that used rigorous design elements, such as controlled feeding and stable isotope studies, were the most likely to include men only. The majority of studies (>90%) did not report race and ethnicity. Although nutrient reference values are intended for use in the general population, we find that the basic science informing these values may not be generalizable. We call urgently upon funders and researchers to address fundamental gaps in knowledge with high-quality research.

The need to study human milk as a biological system

Critical advancement is needed in the study of human milk as a biological system that intersects and interacts with myriad internal (maternal biology) and external (diet, environment, infections) factors and its plethora of influences on the developing infant. Human-milk composition and its resulting biological function is more than the sum of its parts. Our failure to fully understand this biology in a large part contributes to why the duration of exclusive breastfeeding remains an unsettled science (if not policy). Our current understanding of human-milk composition and its individual components and their functions fails to fully recognize the importance of the chronobiology and systems biology of human milk in the context of milk synthesis, optimal timing and duration of feeding, and period of lactation. The overly simplistic, but common, approach to analyzing single, mostly nutritive components of human milk is insufficient to understand the contribution of either individual components or the matrix within which they exist to both maternal and child health. There is a need for a shift in the conceptual approach to studying human milk to improve strategies and interventions to support better lactation, breastfeeding, and the full range of infant feeding practices, particularly for women and infants living in undernourished and infectious environments. Recent technological advances have led to a rising movement towards advancing the science of human-milk biology. Herein, we describe the rationale and critical need for unveiling the multifunctionality of the various nutritional, nonnutritional, immune, and biological signaling pathways of the components in human milk that drive system development and maturation, growth, and development in the very early postnatal period of life. We provide a vision and conceptual framework for a research strategy and agenda to change the field of human-milk biology with implications for global policy, innovation, and interventions.

Dietary fibre intake in childhood or adolescence and subsequent health outcomes: A systematic review of prospective observational studies

AIM

To determine whether higher fibre intakes during childhood or adolescence effect a broad range of intermediate markers of cardiometabolic risk or other health related issues.

MATERIALS AND METHODS

We used online searches up to January 2020 and manual searches to identify prospective observational studies reporting on childhood or adolescent intakes of dietary fibre, vegetables, fruit and refined or whole grains. Outcomes measured later in life were body weight, blood lipids, blood pressure, glycaemia, bone health, cognition, growth and bowel habits. Potential age-specific ranges for dietary fibre were extrapolated from published adult data.

RESULTS

We identified 45 publications reporting on 44 354 participants from 30 cohort studies. Mean age at dietary assessment varied from 1 to 19.3 years. Follow-up duration varied from 4 months to 27 years. Although well-conducted studies reported improvements in body weight, blood lipids and glycaemia, the diverse nature of studies precluded meta analysis. The quality of evidence was very low to low given the limited data available per outcome and the inability to synthesize results from multiple studies. Potential dietary fibre intake begins at 13-16 g a day for 2-year-olds and increases until the age of 10 years, when values are comparable with an adult range of 25-30 g a day.

CONCLUSIONS

Given the inconsistency in findings from cohort studies other than an absence of detrimental effects, it seems appropriate that recommendations regarding childhood fibre intake are extrapolated from relevant adult data.

Poor dietary diversity and low adequacy of micronutrient intakes among rural Indonesian lactating women from Sumedang district, West Java

Information on micronutrient adequacy of diets of rural Indonesian lactating women is lacking, despite their high nutrient requirements. This is of concern because deficits in micronutrient intakes may compromise the health of both mothers and infants. This study aimed to assess micronutrient adequacy and dietary diversity (DD) among rural lactating women and explore relationships between micronutrient adequacy, DD, and intakes of energy and food groups consumed. We measured in-home 12-h weighed food records and 12-h recalls over three non-consecutive days from 121 exclusively breastfeeding women at 2-5 months postpartum. Next, we calculated intakes of energy and 11 micronutrients and estimated probability of adequacy (PA) for usual intakes of 11 micronutrients for each women taking into account national fortification of wheat flour with thiamin, riboflavin, folate, zinc, and iron. We assessed DD from nine food groups consumed. Energy and macronutrient balance were within recommended ranges, yet population prevalence of adequacy was less than 50% for niacin, vitamins B6 and C, and less than 60% for calcium, vitamin B12 and vitamin A, all micronutrients not targeted by the national wheat flour fortification program. In contrast, population prevalence of adequacy for the fortified micronutrients was at least 60%, with iron and zinc attaining 79% and 97%, respectively. Overall mean population prevalence of micronutrient adequacy was 57% and mean (±SD) DD score was 4.3±1.2. Mean PAs, a composite measure based on individual PAs over 11 micronutrients, were strongly correlated with energy intakes and with DD scores. In the multivariate models with maternal education and wealth index as covariates, organ meats were the most important determinant of mean PA after controlling for energy intake. In conclusion, despite wheat flour fortification, lactating mothers remained at risk of multiple micronutrient inadequacies. Increasing intakes of animal source foods including organ meats, and fruits and vegetables should be considered.

Using Criteria to Establish Nutrient Intake Values (NIVs)

One of the most important of the nutrient intake values (NIVs) is the average nutrient requirement (ANR). The ANR is defined as an intake value that will be adequate for half of the individuals in a group of people with similar characteristics. It is used to estimate the prevalence of adequacy, and it serves as the basis for the individual nutrient level (INLx). The determination of adequacy is a complex process, with the resulting value of the ANR dependent on the criterion or functional outcome chosen to define nutrient adequacy. Because nutrients have multiple sites of action in human metabolism, it is possible to demonstrate abnormal function in one parameter measured or observed as a result of inadequate intake of a nutrient, while other parameters requiring the same nutrient appear normal or within normal ranges. Thus, depending on the criterion of adequacy selected, the requirement for a given nutrient may be at a lower or a higher intake amount. In harmonizing development of NIVs, it is important to clearly identify the criterion of adequacy selected and the rationale for its selection. Rarely are available data sufficient to provide dose—response information from which to select a level of intake at which half of the individuals demonstrate adequacy and half appear to demonstrate inadequacy. Three levels of intake, of which at least one level of intake is below the requirement for most of the individuals in the sample, and one level of intake is above their requirement, are useful for establishing a level at which half of the group might be considered to demonstrate adequacy. Types of human nutrient studies that may be used to obtain data are discussed, as well as characteristics of the sample size needed to demonstrate adequacy. The variation in requirements is also an important aspect in predicting levels of intake that will have defined probabilities of adequacy for groups (to develop the INLx, where x is the defined probability chosen). An analysis of the origins of different types of variability is presented. When estimating energy requirements, a special case of NIVs, important issues must be considered. Additionally, an example of evaluating data used to establish an ANR for vitamin A, and the effect of variability in requirements for vitamin A, is provided.

History of Nutrition: The Long Road Leading to the Dietary Reference Intakes for the United States and Canada

The Dietary Reference Intakes (DRIs) are reference values to guide the planning and assessing of nutrient intakes in the United States and Canada. The DRI framework was conceptualized in 1994, and the first reports were issued from 1997–2004, based on work by expert panels and subcommittees under the guidance of the Food and Nutrition Board of the Institute of Medicine. Numerous conventions, challenges, and controversies were encountered during the process of defining and setting the DRIs, including the definition of the framework, the use of chronic disease endpoints, lack of data on requirements for children and youth, and methods for addressing nonessential bioactive substances with potential health benefits. DRIs may be used to plan and assess the nutrient intakes of both individuals and population groups, but the new paradigm particularly improved methods used for groups. It is now possible to estimate both the prevalence of inadequate intake and the prevalence of potentially excessive intake within a group. The DRIs have served as a potent influence on national nutrition policies, including those related to dietary guidance, food labeling, nutrition monitoring, food assistance programs, and military nutrition standards. Because of this important impact on nutrition policy, the DRIs must be based on the best possible and most up-to-date science. Unfortunately, no updates to specific DRIs are currently planned. Despite the long and challenging road that led to the current DRIs, it must not finish in a dead end. Monetary resources and political will are crucial to maintaining and continuously updating the DRIs.

Breast milk composition and infant nutrient intakes during the first 12 months of life

BACKGROUND/OBJECTIVES

The objective of this study was to quantify human milk supply and intake of breastfed infants up to age 12 months. In addition, human milk composition was quantified per energetic macronutrient and fatty-acid composition in a subsample of lactating mothers.

SUBJECTS/METHODS

One hundred and seventy-four Italian breastfed children were followed using test-weighing and 3-day food protocols from birth to age 12 months. From a subsample of 30 mothers breast milk samples were collected at child ages one (T1), two (T2), three (T3) and six (T6) months, and were analyzed for the amount of protein, digestible carbohydrates, total lipids and fatty-acid composition.

RESULTS

One hundred and forty-two (82%) filled in at least one 3-day food protocol within the first 12 months of life and complied with test-weighing of all milk feeds. The number of valid food protocols declined from 126 infants at 1 month to 77 at 12 months of age. Only galactose, non-protein nitrogen and protein decreased significantly from age 1 to age 6 months of lactation. Maternal body mass index and age affected fatty-acid levels in human milk. Median human milk intake decreased from 625 ml at T1, over 724 ml at T3 to 477 ml/day at T6. Average energy and %energy from protein intake per day increased from 419 kcal (s.d. 99) and 8.4% (1.0) at T1, respectively, to 860 kcal (145) and 16.1% (2.6) at T12.

CONCLUSIONS

These data provide a reference range of nutrient intakes in breastfed infants and may provide guidance for defining optimal nutrient intakes for infants that cannot be fully breastfed.

Exploring the benefits and challenges of establishing a DRI-like process for bioactives

Bioactives can be defined as: “Constituents in foods or dietary supplements, other than those needed to meet basic human nutritional needs, which are responsible for changes in health status” (Office of Disease Prevention and Health Promotion, Office of Public Health and Science, Department of Health and Human Services in Fed Reg 69:55821–55822, 2004). Although traditional nutrients, such as vitamins, minerals, protein, essential fatty acids and essential amino acids, have dietary reference intake (DRI) values, there is no such evaluative process for bioactives. For certain classes of bioactives, substantial scientific evidence exists to validate a relationship between their intake and enhanced health conditions or reduced risk of disease. In addition, the study of bioactives and their relationship to disease risk is a growing area of research supported by government, academic institutions, and food and supplement manufacturers. Importantly, consumers are purchasing foods containing bioactives, yet there is no evaluative process in place to let the public know how strong the science is behind the benefits or the quantitative amounts needed to achieve these beneficial health effects. This conference, Bioactives: Qualitative Nutrient Reference Values for Life-stage Groups?, explored why it is important to have a DRI-like process for bioactives and challenges for establishing such a process.

Dietary intake of nutrients with adequate intake values in the dietary reference intakes for Japanese

The Adequate Intake (AI) values in the Dietary Reference Intakes for Japanese (DRIs-J) 2010 were mainly determined based on the median intakes from 2 y of pooled data (2005-2006) from the National Health and Nutrition Survey-Japan (NHNS-J). However, it remains unclear whether 2 y of pooled data from the NHNS-J are appropriate for evaluating the intake of the population. To clarify the differences in nutrient intakes determined from 2 and 7 y of pooled data, we analyzed selected nutrient intake levels by sex and age groups using NHNS-J data. Intake data were obtained from 64,624 individuals (age: ≥1 y; 47.4% men) who completed a semi-weighed 1-d household dietary record that was part of the NHNS-J conducted annually in Japan from 2003 to 2009. There were no large differences between the median intakes calculated from 2 or 7 y of pooled data for n-6 or n-3 polyunsaturated fatty acids (PUFAs), vitamin D, pantothenic acid, potassium, or phosphorus. When the AI values and median intakes were compared, there was no large difference in the values for n-6 or n-3 PUFAs, pantothenic acid, or phosphorus. Conversely, the AI values for vitamin D and potassium differed from the median intakes of these nutrients for specific sex and age groups, because values were not based on NHNS-J data. Our results indicate that 2 y of pooled data from the NHNS-J adequately reflect the population's intake, and that the current system for determination of AI values will be applicable for future revisions.

EURRECA-Evidence-based methodology for deriving micronutrient recommendations

The EURopean micronutrient RECommendations Aligned (EURRECA) Network of Excellence explored the process of setting micronutrient recommendations to address the variance in recommendations across Europe. Work centered upon the transparent assessment of nutritional requirements via a series of systematic literature reviews and meta-analyses. In addition, the necessity of assessing nutritional requirements and the policy context of setting micronutrient recommendations was investigated. Findings have been presented in a framework that covers nine activities clustered into four stages: stage one "Defining the problem" describes Activities 1 and 2: "Identifying the nutrition-related health problem" and "Defining the process"; stage two "Monitoring and evaluating" describes Activities 3 and 7: "Establishing appropriate methods," and "Nutrient intake and status of population groups"; stage three "Deriving dietary reference values" describes Activities 4, 5, and 6: "Collating sources of evidence," "Appraisal of the evidence," and "Integrating the evidence"; stage four "Using dietary reference values in policy making" describes Activities 8 and 9: "Identifying policy options," and "Evaluating policy implementation." These activities provide guidance on how to resolve various issues when deriving micronutrient requirements and address the methodological and policy decisions, which may explain the current variation in recommendations across Europe. [Supplementary materials are available for this article. Go to the publisher's online edition of Critical Reviews in Food Science and Nutrition for the following free supplemental files: Additional text, tables, and figures.].

Nutrient intake values for folate during pregnancy and lactation vary widely around the world

Folate is a B-vitamin with particular importance during reproduction due to its role in the synthesis and maintenance of DNA. Folate is well known for its role in preventing neural tube defects (NTDs) during the periconceptional period. There is also an increased need for folate throughout pregnancy to support optimal growth and development of the fetus and blood volume expansion and tissue growth of the mother. During lactation, women are at risk of folate deficiency due to increased demands to accommodate milk folate levels. Nutrient Intake Values (NIVs) for folate have been calculated to take into account additional needs during pregnancy and lactation. However, these values vary widely between countries. For example, the folate requirement that is set to meet the needs of almost all healthy women during pregnancy varies from 300 µg/day in the United Kingdom to 750 µg/day in Mexico. Currently, there is no accepted standardized terminology or framework for establishing NIVs. This article reviews country-specific NIVs for folate during pregnancy and lactation and the basis for setting these reference values.

Nährstoffbedarf

Die angemessene Deckung der Ernährungserfordernisse von Kindern und Jugendlichen ist von zentraler Bedeutung für Wachstum und Entwicklung, die kurz- und langfristige Gesundheit sowie die Leistungsfähigkeit (Koletzko et al. 2011, 2005a). Grundvoraussetzung für die normale Funktion des Organismus ist die Gewährleistung des metabolischen Bedarfs an Wasser, Energie sowie Makro- und Mikronährstoffen. Der Zufuhrbedarf eines Nährstoffs lässt sich definieren als „die Menge und chemische Form eines Nährstoffes, welche systemisch benötigt wird, um eine normale Gesundheit und Entwicklung zu ermöglichen, ohne den Stoffwechsel eines anderen Nährstoffes zu beeinträchtigen. Der entsprechende Nährstoffbedarf ist die Zufuhrmenge, welche ausreicht, um den physiologischen Bedarf zu decken. Idealerweise sollte dies ohne extreme homöostatische Prozesse oder ausgeprägte Verarmung bzw. Überschüsse der Körperdepots erreicht werden“ (ESPGHAN Committee on Nutrition 1997).

Association between vitamin B12intake and EURRECA's prioritized biomarkers of vitamin B12in young populations: a systematic review

Objective

To review evidence on the associations between vitamin B12intake and its biomarkers, vitamin B12intake and its functional health outcomes, and vitamin B12biomarkers and functional health outcomes.

Design

A systematic review was conducted by searching electronic databases, until January 2012, using a standardized strategy developed in the EURRECA network. Relevant articles were screened and sorted based on title and abstract, then based on full text, and finally included if they met inclusion criteria. A total of sixteen articles were included in the review.

Setting

Articles covered four continents: America (n4), Europe (n8), Africa (n1) and Asia (n3).

Subjects

Population groups included healthy infants, children and adolescents, and pregnant and lactating women.

Results

From the total number of 5815 papers retrieved from the initial search, only sixteen were eligible according to the inclusion criteria: five for infants, five for children and adolescents, and six for pregnant and lactating women.

Conclusions

Only one main conclusion could be extracted from this scarce number of references: a positive association between vitamin B12intake and serum vitamin B12in the infant group. Other associations were not reported in the eligible papers or the results were not provided in a consistent manner. The low number of papers that could be included in our systematic review is probably due to the attention that is currently given to research on vitamin B12in elderly people. Our observations in the current systematic review justify the idea of performing well-designed studies on vitamin B12in young populations.

Defining the process of Dietary Reference Intakes: framework for the United States and Canada

The pioneering project of the harmonization of Dietary Reference Intakes (DRIs) for the United States and Canada resulted in the production of 13 reports from 1997 to 2006 that included 6 reports on specific nutrient groups, 3 reports in preparation for setting recommendations for fiber and antioxidants, 2 reports on applications of DRIs, a report of the synthesis of identified research gaps, and a summary report, Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. This bicountry collaborative effort to harmonize values of reference nutrient intakes has continued through meetings to evaluate the strengths and weaknesses of the first harmonized DRI process in North America and to refine the framework for future revisions of DRIs.

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.

Physiological and public health basis for assessing micronutrient requirements in children and adolescents. The EURRECA network

This paper provides an overview of the current knowledge relating to the nutritional requirements and corresponding recommended nutrient intake values of children and adolescents for micronutrients and specificities related to these requirements in the course of childhood and adolescence in Europe. Aspects that can influence micronutrient requirements, such as physiological requirements and bioavailability of the nutrients in the organism, are discussed. The methodology used to obtain the data and also the main knowledge gaps regarding these concepts are emphasized. Methodological critical points in achieving the data and physiological aspects of children and adolescents are important in order to standardize the reference values for micronutrients among Europe for these stages of life.

The nutritional requirements of infants. Towards EU alignment of reference values: the EURRECA network

This paper presents a review of the current knowledge regarding the macro- and micronutrient requirements of infants and discusses issues related to these requirements during the first year of life. The paper also reviews the current reference values used in European countries and the methodological approaches used to derive them by a sample of seven European and international authoritative committees from which background scientific reports are available. Throughout the paper, the main issues contributing to disparities in micronutrient reference values for infants are highlighted. The identification of these issues in relation to the specific physiological aspects of infants is important for informing future initiatives aimed at providing standardized approaches to overcome variability of micronutrient reference values across Europe for this age group.

Dietary intake of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in children - a workshop report

There is controversy whether children should have a dietary supply of preformed long-chain polyunsaturated n-3 fatty acids EPA and DHA. The aims of the workshop were to review evidence for a possible benefit of a preformed EPA and/or DHA supply, of data required to set desirable intakes for children aged 2-12 years, and of research priorities. The authors concluded that EPA and DHA intakes per kg body weight may often be low in 2- to 12-year-old children, relative to intakes per kg body weight of breast-fed infants and adult intakes, but reliable data are scarce. Little information is available that increasing dietary intakes of EPA or DHA in children has benefits to physical or mental function or other health endpoints. Studies addressing EPA and DHA intakes and tissue status among groups of children with different dietary habits, and measures of relevant development and health endpoints, are needed for developing potential advice on desirable intakes of EPA and/or DHA in children. At this time it appears prudent to advise that dietary intakes in childhood are consistent with future eating patterns supporting adult health, such as prevention of metabolic disorders and CVD, supporting immune function, and reproductive health. In conclusion, the available information relating dietary EPA and DHA intakes in children aged 2-12 years to growth, development and health is insufficient to derive dietary intake recommendations for EPA and DHA. Adequately designed studies addressing dietary intakes, measures of status and relevant functional or health effects across this age group are needed.

Does dietary DHA improve neural function in children? Observations in phenylketonuria

Children with phenylketonuria (PKU) have a restricted protein intake and thus low dietary intakes of long-chain polyunsaturated fatty acids (LC-PUFA), which may cause subtle neurological deficits. We measured plasma phospholipid fatty acids and visual evoked potential (VEP) in 36 children with well-controlled PKU (6.3+/-0.6 years, 19 girls), before and after 3 months of supplementing fish oil capsules providing 15 mg docosahexaenoic acid (DHA)/kg daily. The motometric Rostock-Oseretzky Scale (ROS) was performed before and after supplementation in the 24 PKU children aged >4 years. VEP latencies and ROS were also assessed in omnivorous, age-matched controls without fish oil supply at baseline and after 3 months. Fish oil supply increased plasma phospholipid eicosapentaenoic acid (EPA) (0.40+/-0.03 vs 3.31+/-0.19%, p<0.001) and DHA (2.37+/-0.10 vs 7.05+/-0.24%, p<0.001), but decreased arachidonic acid (AA) (9.26+/-0.23 vs 6.76+/-0.16%, p<0.001). Plasma phenylalanine was unchanged. VEP latencies and ROS results significantly improved after fish oil in PKU children, but remained unchanged in controls. The improvements of VEP latencies, fine motor and coordination skills indicate that preformed n-3 LC-PUFA are needed for neural normalcy in PKU children. The optimal type and dose of supply still needs to be determined. Since PKU children are generally healthy and have normal energy and fatty acid metabolism, these data lead us to conclude that childhood populations in general require preformed n-3 LC-PUFA to achieve optimal neurological function.

Omega-3 LC-PUFA supply and neurological outcomes in children with phenylketonuria (PKU)

Children with phenylketonuria (PKU) follow a diet with very low intakes of natural protein, which is devoid of food sources of the omega-3 docosahexaenoic acid (DHA). A resulting DHA depletion has been demonstrated in PKU children and may account for detectable subtle neurological deficits that are not explained by variation in plasma phenylalanine concentrations. We supplemented 36 children with PKU ages 1 to 11 years for 3 months with encapsulated fish oil providing a daily dose of 15 mg DHA/kg body weight. DHA supplementation resulted in significantly faster visual evoked potential latencies, indicating more rapid central nervous system information processing. In addition, DHA significantly improved outcomes in a test of motor function and coordination. No changes over time were seen in age-matched healthy controls. Because the PKU children had a good supply of the omega-3 precursor alpha-linolenic acid, these observations lead us to conclude that endogenous conversion of alpha-linolenic acid is not sufficient to provide adequate amounts of DHA that support optimal function, and hence DHA appears to be a conditional essential substrate for children with PKU. Because early treated PKU children are healthy, with normal fatty acid turnover, these data may indicate a need to supply some DHA to children in general. Further studies are ongoing aiming at establishing quantitative DHA requirements in children.

Nutrient intake values (NIVs): a recommended terminology and framework for the derivation of values

Although most countries and regions around the world set recommended nutrient intake values for their populations, there is no standardized terminology or framework for establishing these standards. Different terms used for various components of a set of dietary standards are described in this paper and a common set of terminology is proposed. The recommended terminology suggests that the set of values be called nutrient intake values (NIVs) and that the set be composed of three different values. The average nutrient requirement (ANR) reflects the median requirement for a nutrient in a specific population. The individual nutrient level (INLx) is the recommended level of nutrient intake for all healthy people in the population, which is set at a certain level x above the mean requirement. For example, a value set at 2 standard deviations above the mean requirement would cover the needs of 98% of the population and would be INL98. The third component of the NIVs is an upper nutrient level (UNL), which is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects for almost all individuals in a specified life-stage group. The proposed framework for deriving a set of NIVs is based on a statistical approach for determining the midpoint of a distribution of requirements for a set of nutrients in a population (the ANR), the standard deviation of the requirements, and an individual nutrient level that assures health at some point above the mean, e.g., 2 standard deviations. Ideally, a second set of distributions of risk of excessive intakes is used as the basis for a UNL.

Harmonization of nutrient intake values

The conceptual framework for the various NIVs is depicted in figure 1 along with the methodological approaches and applications. The NIVs consist of two values derived from a statistical evaluation of data on nutrient requirements, the average nutrient requirement (ANR), or nutrient toxicities, the upper nutrient level (UNL). The individual nutrient levelx (INLx) is derived from the distribution of average nutrient requirements. The percentile chosen is often 98%, which is equivalent to 2 SD above the mean requirement. Concepts underlying the NIVs include criteria for establishing a nutrient requirement, e.g., ferritin stores, nitrogen balance, or serum vitamin C. Once the requirement for the absorbed nutrient is determined, it may be necessary to adjust the value for food sources, i.e., bioavailability, or host factors, such as the effect of infection on nutrient utilization. Other concepts that committees may want to consider when establishing NIVs include the effects of genetic variation on nutrient requirements and the role of the nutrient in preventing long-term disease. Two fundamental uses of NIVs are for assessing the adequacy of nutrient intakes and for planning diets for individuals and populations. Establishing the NIV using the statistical framework proposed in this report improves the efficacy of the values for identifying risks of nutrient deficiency or excess among individuals and populations. NIVs also are applied to a number of aspects of food and nutrition policy. Some examples include regulatory issues and trade, labeling, planning programs for alleviating public health nutrition problems, food fortification, and dietary guidance.