1 Specific Aspects of Childhood Nutrition Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 29–33 DOI: 10.1159/000369234
1.3 Nutritional Needs
1.3.1. Nutrient Intake Values: Concepts and Applications
1
Berthold Koletzko
Nutrient recommendations · Nutrient requirements · Upper safe levels of intake · Extrapolation · Interpolation
Key Messages • Nutrient intake values (NIV) provide estimates on appropriate dietary substrate supply for populations of healthy people • The average nutrient requirement is the estimated median requirement for a particular age- and sexspecific group • The population reference intake is the intake that meets the nutrient needs of practically all healthy individuals in a particular population • Major uncertainties exist in the establishment of NIV for infants, children and adolescents due to limited scientific data. Deriving NIV from observed nutrient intakes (e.g. the nutrient supply provided by human milk) or extrapolation from other age groups has considerable limitations © 2015 S. Karger AG, Basel
Introduction
Nutrient intake values (NIV) comprise a set of recommendations on dietary substrate supply for populations of healthy people. NIV are used to
assess intake data from dietary surveys and food statistics; to provide guidance on appropriate dietary composition, meal provision and foodbased dietary guidelines, they serve as the basis for national or regional nutrition policies, nutritional education programmes and food regulations and provide reference points for the labelling of food products if nutrient contents are expressed as a percentage of an NIV [1, 2]. The term NIV has been agreed upon by an expert consultation convened by the United Nations University’s Food and Nutrition Programme in collaboration with the FAO, WHO and UNICEF [3], rather than the terms ‘nutrient reference values’ (previously used in Australia and New Zealand), ‘reference values for nutrient supply’ (in Germany/ Austria/Switzerland), ‘dietary reference values’ (in the UK), ‘dietary reference intakes’ or, previously, ‘recommended dietary allowances’ (RDA; in the USA and Canada) [3]. Conceptually, NIV are based on physiological requirements, which are defined as the amounts and chemical forms of nutrients needed systematically to maintain normal health and development without disturbance of the metabolism of any other nutrient and without extreme homoeostatic processes, excessive depletion and/or surplus in bodily depots [1, 4–6]. The dietary reDownloaded by: Kellogg Health Sciences Libr. 129.173.72.87 - 5/17/2015 8:48:07 PM
Key Words
tistical distribution of requirements, the PRI is set at a level of intake that meets the needs of 97% of the population (mean + 2 SD) (fig. 1). The PRI value is generally used as the target for provision of essential nutrients to populations and as the reference point for the nutrient labelling of foods, with the exception of energy, where the ANR is used because the provision of energy equivalent to the PRI would result in overfeeding and induction of obesity in about one half of the population. The upper nutrient level (UNL; or upper tolerable intake level) is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects for almost all individuals of a particular age- and sex-specific group. Ideally, the UNL is based on an analysis of the statistical distribution of risk for high nutrient intakes. The UNL is generally set at a level where the risk of excessive intake is practically non-existent. A nutrient intake equal to or higher than the UNL should be avoided on a chronic basis. Examples of NIV for children and adolescents are provided in Annex 4.3.
Definitions of NIV
Limitations to the Estimation of NIV
NIV for populations are generally estimated based on the concept that individual requirements follow a statistically normal distribution (bell-shaped curve in fig. 1). The average nutrient requirement (ANR; also called ‘estimated average requirement’) is the estimated average of the median requirement of a specific nutrient in the population derived from a statistical distribution of requirement criterion and for a particular ageand sex-specific group based on a specific biological end point or biochemical measure. The population reference intake (PRI; also called ‘individual nutrient level 97%’, ‘reference nutrient intake’ or RDA) is the nutrient intake considered adequate to meet the known nutrient needs of practically all healthy individuals in a particular ageand sex-specific group. Based on the assumed sta-
The concept of a near-normal, symmetrical distribution of nutrient requirements (fig. 1) is known not to be correct for a number of nutrients. Examples are the nutrient needs for iron, vitamin D and polyunsaturated fatty acids. Iron requirements are not normally distributed, with high needs in menstruating women, particularly in those with substantial blood losses. Vitamin D requirements depend on endogenous synthesis in the skin and hence on variation of UV light exposure with geographic location and the time of the year, as well as on biological determinants such as the degree of skin pigmentation and genetic variations in the vitamin D receptor. The dietary needs of essential fatty acids vary considerably with genetic polymorphisms for the fatty acid desaturation enzymes Δ6 and Δ5 desaturases that
30
Koletzko
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 29–33 DOI: 10.1159/000369234
Downloaded by: Kellogg Health Sciences Libr. 129.173.72.87 - 5/17/2015 8:48:07 PM
quirement of a nutrient is the intake sufficient to meet the physiological requirement, considering nutrient bioavailability from foodstuffs. NIV reflect the estimated distributions of nutrient intakes required to achieve a specific outcome in a defined population considered healthy, but for many nutrients, this distribution of requirements and the modifying biological and environmental factors are not well known, which results in considerable uncertainty regarding NIV. Therefore, NIV should be considered approximations that reflect the often limited data available. NIV are even more uncertain for infants and young children, on whom original data are particularly scarce, and, hence, NIV are often derived from the interpolation of data from other age groups, which must be expected to yield inaccurate values. It is important to remember that NIV refer to populations but not to individuals. NIV do not allow us to determine an insufficient nutrient intake or a nutrient deficiency in an individual, or to accurately determine nutrient needs in disease states.
Average nutrient requirement (ANR) estimated median of distribution
Frequency
Population reference intake (PRI) ~97.5th percentile or mean + 1.96 SD
Upper nutrient level (UNL) highest level of daily nutrient intake that poses no risk
1
Increasing nutrient intake
Fig. 1. Conceptual basis for NIV.
health and are achieving their full genetic potential and that their diets are quantitatively and qualitatively appropriate and free from adverse long-term effects. The concerns with respect to this approach are strengthened by the recent evidence on the long-term effects of early nutrition on metabolic programming and the subsequent risk of hypertension, obesity, diabetes mellitus and cardiovascular disease in adult life [9–11]. The derivation of NIV from observed intakes is a standard approach for infants during the first 6 months of life, when the intakes of breastfed babies are considered an appropriate guide to optimal nutritional supply. However, this approach has major limitations because the actual metabolizable substrate intakes of breastfed infants are not well determined. The volume of milk consumed varies between about 550 and 1,100 ml/ day, and milk composition differs between women and with changes during the course of lactation, during the day and even during a single feeding. Moreover, the bioavailability of sub-
Nutrient Intake Values: Concepts and Applications
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 29–33 DOI: 10.1159/000369234
31
Downloaded by: Kellogg Health Sciences Libr. 129.173.72.87 - 5/17/2015 8:48:07 PM
determine the relative turnover of polyunsaturated fatty acids [7]. The establishment of NIV for infants, children and adolescents is further hampered by severe limitations to the available scientific data obtained from healthy children [8]. This is unfortunate because infants, children and adolescents have relatively large nutrient needs due to their growth and development, and adequate substrate supply is of utmost importance to support their short- and long-term health, well-being and performance [5]. Current reference values for nutrient intakes vary considerably (see Annex 4.3), partly due the limitations to the available scientific database and partly due to major differences in underlying concepts, definitions and terminology [8]. Due to a lack of adequate scientific studies, NIV for children are often based on observed nutrient intakes of groups of children in apparent good health. However, this approach is weak, because it assumes that the subjects are in good
strates and their metabolism differs between infants fed human milk and those fed infant formula and complementary feeds, which can result in differences in dietary requirements. Therefore, human milk composition and the nutrient supply to breastfed infants may not always provide useful guidance for infants that are not exclusively breastfed. Due to the paucity of original research data for estimating nutrient requirements in the paediatric age group, very often NIV are extrapolated from data for other age groups. Frequently, this involves extrapolation from adults to children and adolescents. Examples of extrapolation methods that are used include body size (weight or metabolic weight), energy intakes for age, or factorial estimates of requirements for growth [8]. However, there is no truly correct method for extrapolation that would result in physiologically adequate NIV for infants, children and adolescents. It is important that the rationale or scientific basis for the method chosen should be completely transparent and thoroughly described for each nutrient and life stage group. Extrapolation is always the second choice, and the use of innovative, non-invasive methods or of existing methods (e.g. stable isotopes) is encouraged to determine nutrient requirements of infants, children and adolescents [8].
Conclusions
• NIV provide an estimate for adequate nutrient provision to populations considered healthy, but they do not determine the optimal nutrient supply for an individual • PRI (also called reference nutrient intakes or RDA) are the levels of intake that meet the needs of almost all healthy individuals of a given age and sex group • The diet for healthy children should generally provide nutrient intakes matching the PRI, except for energy, where ANR provide guidance on appropriate intakes for groups • Children affected by disease or malnutrition, or those in whom catch-up growth is desired, may have nutrient needs that differ markedly from PRI
Acknowledgements The author’s work is carried out with partial financial support from the Commission of the European Communities, the 7th Framework Programme, contract FP7289346-EARLY NUTRITION, and the European Research Council Advanced Grant ERC-2012-AdG – No. 322605 META-GROWTH. This manuscript does not necessarily reflect the views of the Commission and in no way anticipates the future policy in this area.
References
32
weight infants; in Koletzko B, Poindexter B, Uauy R (eds): Nutritional Care of Preterm Infants. Basel, Karger, 2014, pp 300–305. 3 King JC, Garza C: Harmonization of nutrient intake values. Food Nutr Bull 2007;28:S3–S12. 4 Hermoso M, Vollhardt C, Bergmann K, Koletzko B: Critical micronutrients in pregnancy, lactation, and infancy: considerations on vitamin D, folic acid, and iron, and priorities for future research. Ann Nutr Metab 2011;59:5–9. 5 Iglesia I, Doets EL, Bel-Serrat S, Roman
B, Hermoso M, Pena Quintana L, Garcia-Luzardo MR, Santana-Salguero B, Garcia-Santos Y, Vucic V, Andersen LF, Perez-Rodrigo C, Aranceta J, Cavelaars A, Decsi T, Serra-Majem L, Gurinovic M, Cetin I, Koletzko B, Moreno LA: Physiological and public health basis for assessing micronutrient requirements in children and adolescents. The EURRECA network. Matern Child Nutr 2010;6(suppl 2):84–99. 6 Uauy R, Koletzko B: Defining the nutritional needs of preterm infants. World Rev Nutr Diet 2014;110:4–10.
Koletzko
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 29–33 DOI: 10.1159/000369234
Downloaded by: Kellogg Health Sciences Libr. 129.173.72.87 - 5/17/2015 8:48:07 PM
1 Aggett PJ, Bresson J, Haschke F, Hernell O, Koletzko B, Lafeber HN, Michaelsen KF, Micheli J, Ormisson A, Rey J, Salazar de Sousa J, Weaver L: Recommended dietary allowances (RDAs), recommended dietary intakes (RDIs), recommended nutrient intakes (RNIs), and population reference intakes (PRIs) are not ‘recommended intakes’. J Pediatr Gastroenterol Nutr 1997; 25: 236–241. 2 Koletzko B, Poindexter B, Uauy R: Recommended nutrient intake levels for stable, fully enterally fed very low birth
9 Brands B, Demmelmair H, Koletzko B; EarlyNutrition Project: How growth due to infant nutrition influences obesity and later disease risk. Acta Paediatr 2014;103:578–585. 10 Berti C, Cetin I, Agostoni C, Desoye G, Devlieger R, Emmett PM, Ensenauer R, Hauner H, Herrera E, Hoesli I, KraussEtschmann S, Olsen SF, Schaefer-Graf U, Schiessl B, Symonds ME, Koletzko B: Pregnancy and infants’ outcome: nutritional and metabolic implications. Crit Rev Food Sci Nutr 2014, Epub ahead of print.
11 Koletzko B, Brands B, Chourdakis M, Cramer S, Grote V, Hellmuth C, Kirchberg F, Prell C, Rzehak P, Uhl U, Weber M: The power of programming and the early nutrition project: opportunities for health promotion by nutrition during the first thousand days of life and beyond. Ann Nutr Metab 2014;64:141– 150.
Nutrient Intake Values: Concepts and Applications
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 29–33 DOI: 10.1159/000369234
1
33
Downloaded by: Kellogg Health Sciences Libr. 129.173.72.87 - 5/17/2015 8:48:07 PM
7 Koletzko B, Lattka E, Zeilinger S, Illig T, Steer C: Genetic variants of the fatty acid desaturase gene cluster predict amounts of red blood cell docosahexaenoic and other polyunsaturated fatty acids in pregnant women: findings from the Avon Longitudinal Study of Parents and Children. Am J Clin Nutr 2011;93:211– 219. 8 Atkinson SA, Koletzko B: Determining life-stage groups and extrapolating nutrient intake values (NIVs). Food Nutr Bull 2007;28:S61–S76.
1.3 Nutritional Needs
1.3.1. Nutrient Intake Values: Concepts and Applications
1
Berthold Koletzko
Nutrient recommendations · Nutrient requirements · Upper safe levels of intake · Extrapolation · Interpolation
Key Messages • Nutrient intake values (NIV) provide estimates on appropriate dietary substrate supply for populations of healthy people • The average nutrient requirement is the estimated median requirement for a particular age- and sexspecific group • The population reference intake is the intake that meets the nutrient needs of practically all healthy individuals in a particular population • Major uncertainties exist in the establishment of NIV for infants, children and adolescents due to limited scientific data. Deriving NIV from observed nutrient intakes (e.g. the nutrient supply provided by human milk) or extrapolation from other age groups has considerable limitations © 2015 S. Karger AG, Basel
Introduction
Nutrient intake values (NIV) comprise a set of recommendations on dietary substrate supply for populations of healthy people. NIV are used to
assess intake data from dietary surveys and food statistics; to provide guidance on appropriate dietary composition, meal provision and foodbased dietary guidelines, they serve as the basis for national or regional nutrition policies, nutritional education programmes and food regulations and provide reference points for the labelling of food products if nutrient contents are expressed as a percentage of an NIV [1, 2]. The term NIV has been agreed upon by an expert consultation convened by the United Nations University’s Food and Nutrition Programme in collaboration with the FAO, WHO and UNICEF [3], rather than the terms ‘nutrient reference values’ (previously used in Australia and New Zealand), ‘reference values for nutrient supply’ (in Germany/ Austria/Switzerland), ‘dietary reference values’ (in the UK), ‘dietary reference intakes’ or, previously, ‘recommended dietary allowances’ (RDA; in the USA and Canada) [3]. Conceptually, NIV are based on physiological requirements, which are defined as the amounts and chemical forms of nutrients needed systematically to maintain normal health and development without disturbance of the metabolism of any other nutrient and without extreme homoeostatic processes, excessive depletion and/or surplus in bodily depots [1, 4–6]. The dietary reDownloaded by: Kellogg Health Sciences Libr. 129.173.72.87 - 5/17/2015 8:48:07 PM
Key Words
tistical distribution of requirements, the PRI is set at a level of intake that meets the needs of 97% of the population (mean + 2 SD) (fig. 1). The PRI value is generally used as the target for provision of essential nutrients to populations and as the reference point for the nutrient labelling of foods, with the exception of energy, where the ANR is used because the provision of energy equivalent to the PRI would result in overfeeding and induction of obesity in about one half of the population. The upper nutrient level (UNL; or upper tolerable intake level) is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects for almost all individuals of a particular age- and sex-specific group. Ideally, the UNL is based on an analysis of the statistical distribution of risk for high nutrient intakes. The UNL is generally set at a level where the risk of excessive intake is practically non-existent. A nutrient intake equal to or higher than the UNL should be avoided on a chronic basis. Examples of NIV for children and adolescents are provided in Annex 4.3.
Definitions of NIV
Limitations to the Estimation of NIV
NIV for populations are generally estimated based on the concept that individual requirements follow a statistically normal distribution (bell-shaped curve in fig. 1). The average nutrient requirement (ANR; also called ‘estimated average requirement’) is the estimated average of the median requirement of a specific nutrient in the population derived from a statistical distribution of requirement criterion and for a particular ageand sex-specific group based on a specific biological end point or biochemical measure. The population reference intake (PRI; also called ‘individual nutrient level 97%’, ‘reference nutrient intake’ or RDA) is the nutrient intake considered adequate to meet the known nutrient needs of practically all healthy individuals in a particular ageand sex-specific group. Based on the assumed sta-
The concept of a near-normal, symmetrical distribution of nutrient requirements (fig. 1) is known not to be correct for a number of nutrients. Examples are the nutrient needs for iron, vitamin D and polyunsaturated fatty acids. Iron requirements are not normally distributed, with high needs in menstruating women, particularly in those with substantial blood losses. Vitamin D requirements depend on endogenous synthesis in the skin and hence on variation of UV light exposure with geographic location and the time of the year, as well as on biological determinants such as the degree of skin pigmentation and genetic variations in the vitamin D receptor. The dietary needs of essential fatty acids vary considerably with genetic polymorphisms for the fatty acid desaturation enzymes Δ6 and Δ5 desaturases that
30
Koletzko
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 29–33 DOI: 10.1159/000369234
Downloaded by: Kellogg Health Sciences Libr. 129.173.72.87 - 5/17/2015 8:48:07 PM
quirement of a nutrient is the intake sufficient to meet the physiological requirement, considering nutrient bioavailability from foodstuffs. NIV reflect the estimated distributions of nutrient intakes required to achieve a specific outcome in a defined population considered healthy, but for many nutrients, this distribution of requirements and the modifying biological and environmental factors are not well known, which results in considerable uncertainty regarding NIV. Therefore, NIV should be considered approximations that reflect the often limited data available. NIV are even more uncertain for infants and young children, on whom original data are particularly scarce, and, hence, NIV are often derived from the interpolation of data from other age groups, which must be expected to yield inaccurate values. It is important to remember that NIV refer to populations but not to individuals. NIV do not allow us to determine an insufficient nutrient intake or a nutrient deficiency in an individual, or to accurately determine nutrient needs in disease states.
Average nutrient requirement (ANR) estimated median of distribution
Frequency
Population reference intake (PRI) ~97.5th percentile or mean + 1.96 SD
Upper nutrient level (UNL) highest level of daily nutrient intake that poses no risk
1
Increasing nutrient intake
Fig. 1. Conceptual basis for NIV.
health and are achieving their full genetic potential and that their diets are quantitatively and qualitatively appropriate and free from adverse long-term effects. The concerns with respect to this approach are strengthened by the recent evidence on the long-term effects of early nutrition on metabolic programming and the subsequent risk of hypertension, obesity, diabetes mellitus and cardiovascular disease in adult life [9–11]. The derivation of NIV from observed intakes is a standard approach for infants during the first 6 months of life, when the intakes of breastfed babies are considered an appropriate guide to optimal nutritional supply. However, this approach has major limitations because the actual metabolizable substrate intakes of breastfed infants are not well determined. The volume of milk consumed varies between about 550 and 1,100 ml/ day, and milk composition differs between women and with changes during the course of lactation, during the day and even during a single feeding. Moreover, the bioavailability of sub-
Nutrient Intake Values: Concepts and Applications
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 29–33 DOI: 10.1159/000369234
31
Downloaded by: Kellogg Health Sciences Libr. 129.173.72.87 - 5/17/2015 8:48:07 PM
determine the relative turnover of polyunsaturated fatty acids [7]. The establishment of NIV for infants, children and adolescents is further hampered by severe limitations to the available scientific data obtained from healthy children [8]. This is unfortunate because infants, children and adolescents have relatively large nutrient needs due to their growth and development, and adequate substrate supply is of utmost importance to support their short- and long-term health, well-being and performance [5]. Current reference values for nutrient intakes vary considerably (see Annex 4.3), partly due the limitations to the available scientific database and partly due to major differences in underlying concepts, definitions and terminology [8]. Due to a lack of adequate scientific studies, NIV for children are often based on observed nutrient intakes of groups of children in apparent good health. However, this approach is weak, because it assumes that the subjects are in good
strates and their metabolism differs between infants fed human milk and those fed infant formula and complementary feeds, which can result in differences in dietary requirements. Therefore, human milk composition and the nutrient supply to breastfed infants may not always provide useful guidance for infants that are not exclusively breastfed. Due to the paucity of original research data for estimating nutrient requirements in the paediatric age group, very often NIV are extrapolated from data for other age groups. Frequently, this involves extrapolation from adults to children and adolescents. Examples of extrapolation methods that are used include body size (weight or metabolic weight), energy intakes for age, or factorial estimates of requirements for growth [8]. However, there is no truly correct method for extrapolation that would result in physiologically adequate NIV for infants, children and adolescents. It is important that the rationale or scientific basis for the method chosen should be completely transparent and thoroughly described for each nutrient and life stage group. Extrapolation is always the second choice, and the use of innovative, non-invasive methods or of existing methods (e.g. stable isotopes) is encouraged to determine nutrient requirements of infants, children and adolescents [8].
Conclusions
• NIV provide an estimate for adequate nutrient provision to populations considered healthy, but they do not determine the optimal nutrient supply for an individual • PRI (also called reference nutrient intakes or RDA) are the levels of intake that meet the needs of almost all healthy individuals of a given age and sex group • The diet for healthy children should generally provide nutrient intakes matching the PRI, except for energy, where ANR provide guidance on appropriate intakes for groups • Children affected by disease or malnutrition, or those in whom catch-up growth is desired, may have nutrient needs that differ markedly from PRI
Acknowledgements The author’s work is carried out with partial financial support from the Commission of the European Communities, the 7th Framework Programme, contract FP7289346-EARLY NUTRITION, and the European Research Council Advanced Grant ERC-2012-AdG – No. 322605 META-GROWTH. This manuscript does not necessarily reflect the views of the Commission and in no way anticipates the future policy in this area.
References
32
weight infants; in Koletzko B, Poindexter B, Uauy R (eds): Nutritional Care of Preterm Infants. Basel, Karger, 2014, pp 300–305. 3 King JC, Garza C: Harmonization of nutrient intake values. Food Nutr Bull 2007;28:S3–S12. 4 Hermoso M, Vollhardt C, Bergmann K, Koletzko B: Critical micronutrients in pregnancy, lactation, and infancy: considerations on vitamin D, folic acid, and iron, and priorities for future research. Ann Nutr Metab 2011;59:5–9. 5 Iglesia I, Doets EL, Bel-Serrat S, Roman
B, Hermoso M, Pena Quintana L, Garcia-Luzardo MR, Santana-Salguero B, Garcia-Santos Y, Vucic V, Andersen LF, Perez-Rodrigo C, Aranceta J, Cavelaars A, Decsi T, Serra-Majem L, Gurinovic M, Cetin I, Koletzko B, Moreno LA: Physiological and public health basis for assessing micronutrient requirements in children and adolescents. The EURRECA network. Matern Child Nutr 2010;6(suppl 2):84–99. 6 Uauy R, Koletzko B: Defining the nutritional needs of preterm infants. World Rev Nutr Diet 2014;110:4–10.
Koletzko
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 29–33 DOI: 10.1159/000369234
Downloaded by: Kellogg Health Sciences Libr. 129.173.72.87 - 5/17/2015 8:48:07 PM
1 Aggett PJ, Bresson J, Haschke F, Hernell O, Koletzko B, Lafeber HN, Michaelsen KF, Micheli J, Ormisson A, Rey J, Salazar de Sousa J, Weaver L: Recommended dietary allowances (RDAs), recommended dietary intakes (RDIs), recommended nutrient intakes (RNIs), and population reference intakes (PRIs) are not ‘recommended intakes’. J Pediatr Gastroenterol Nutr 1997; 25: 236–241. 2 Koletzko B, Poindexter B, Uauy R: Recommended nutrient intake levels for stable, fully enterally fed very low birth
9 Brands B, Demmelmair H, Koletzko B; EarlyNutrition Project: How growth due to infant nutrition influences obesity and later disease risk. Acta Paediatr 2014;103:578–585. 10 Berti C, Cetin I, Agostoni C, Desoye G, Devlieger R, Emmett PM, Ensenauer R, Hauner H, Herrera E, Hoesli I, KraussEtschmann S, Olsen SF, Schaefer-Graf U, Schiessl B, Symonds ME, Koletzko B: Pregnancy and infants’ outcome: nutritional and metabolic implications. Crit Rev Food Sci Nutr 2014, Epub ahead of print.
11 Koletzko B, Brands B, Chourdakis M, Cramer S, Grote V, Hellmuth C, Kirchberg F, Prell C, Rzehak P, Uhl U, Weber M: The power of programming and the early nutrition project: opportunities for health promotion by nutrition during the first thousand days of life and beyond. Ann Nutr Metab 2014;64:141– 150.
Nutrient Intake Values: Concepts and Applications
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 29–33 DOI: 10.1159/000369234
1
33
Downloaded by: Kellogg Health Sciences Libr. 129.173.72.87 - 5/17/2015 8:48:07 PM
7 Koletzko B, Lattka E, Zeilinger S, Illig T, Steer C: Genetic variants of the fatty acid desaturase gene cluster predict amounts of red blood cell docosahexaenoic and other polyunsaturated fatty acids in pregnant women: findings from the Avon Longitudinal Study of Parents and Children. Am J Clin Nutr 2011;93:211– 219. 8 Atkinson SA, Koletzko B: Determining life-stage groups and extrapolating nutrient intake values (NIVs). Food Nutr Bull 2007;28:S61–S76.
