The Health Council of the Netherlands published new Dutch dietary reference intakes (DRIs) for energy, proteins, fats and digestible carbohydrates (Table 1; Health Council of the Netherlands, 2001). The previous Dutch values were primarily aimed at the prevention of deficiency symptoms, whereas the current Dutch values aim at the prevention of both deficiency and chronic diseases. Values were specified for infants, young children, adolescents, adults, elderly people and for pregnant and lactating women. The age groups are similar to those used in the United States (Institute of Medicine, 2002). The report provides a comparison of the new Dutch dietary reference intakes with previous Dutch values and with the values used in Scandinavia, Germany, Switzerland, Austria, Great Britain and the European Community. At that time, the new American DRIs for energy and macronutrients were not yet available. Therefore, we now present a comparison with the new American values (Institute of Medicine, 2002). The full report can be read and downloaded from internet site www.gr.nl.
Terminology and definitions
The term ‘dietary reference intakes’ is a collective term for the ‘estimated average requirement’, ‘recommended dietary allowance’, ‘adequate intake’ and ‘tolerable upper intake level’. Both the recommended dietary allowance and the adequate intake reflect the intake level at which no signs of deficiency are observed, and at which the risk of chronic diseases, as far as influenced by the nutrient, is kept as small as possible. Given a requirement with a normal distribution, the estimated average requirement is the level of intake that is adequate for half of the population. The tolerable upper intake level is the level of intake above which there is a chance that adverse effects will occur. The definitions of the DRIs are similar to those in the new American reports on dietary reference intakes. In the American report on energy and macronutrients, apart from these DRIs, acceptable macronutrient distribution ranges have been estimated.
The Dutch report presents estimated average requirements for energy, with the remark that for the prevention of undesirable weight gains, everyone's energy intake should conform to their personal requirement rather than to this estimated average requirement. Therefore, the report also contains formulae with which individuals can estimate their personal energy requirement on the basis of age, body weight and level of physical activity.
The estimated average requirements for children were based on the energy needs for growth and on the daily energy expenditure. Results of measurements with the doubly labelled water method were used to estimate the average daily energy expenditure of children. For adults, a meta-analysis of data obtained with the doubly labelled water method was used to describe the influence of physical activity on energy needs. The estimated average requirement was then calculated by multiplying the estimated average basal metabolic rate of reference men and women by the average physical activity level in the Netherlands. Reference adults were defined as men and women of average body height with an optimal body mass index. For the age groups between 18 and 50 y, 22.5 kg/m2—the average of 20 and 25 kg/m2—was taken as the optimal value for the body mass index; for those aged 51–70 y this was 24 kg/m2 and for people older than 70 y 25 kg/m2.
For adults with the characteristics of the Dutch reference men and women, the new American estimated energy requirements are very close to the Dutch estimated average requirements.
The estimated average requirements for proteins are based on the nitrogen losses with urine, faeces, hair, nails and sweat, the nitrogen requirements for growth, the nitrogen content of body proteins, the efficiency with which body protein is synthesized from amino-acids, and the digestibility and amino-acid composition of dietary proteins. The recommended dietary allowances for healthy adults with a mixed diet are 8–11% of the energy intake, depending on age group and sex. The values for individuals with a lacto-ovo vegetarian dietary pattern and a vegan dietary pattern are respectively 1.2 and 1.3 times higher, as a result of the different amino-acid composition of the dietary proteins. The new recommended dietary allowances are lower than the previous Dutch values, but show greater conformity with those in other countries, including the USA.
The new Dutch tolerable upper intake level for proteins is 25% for all groups aged 4 y or more. For the first 6 months of life, the tolerable upper intake level was set at 10% of the energy intake; for 6 months to 1 y at 15 energy % and for the age group from 1 to 3 y at 20 energy %.
With regard to the total consumption of fat, the Health Council of the Netherlands distinguishes people with an optimum weight from those who are overweight or who have undesirable weight gains. This is a new element, relative to foreign dietary reference intakes and to previous Dutch dietary reference intakes. For individuals with an optimal and constant body weight, any level of fat intake between 20 and 40% of total energy intake is considered adequate. For individuals who are overweight or who have undesirable weight gains, the range of adequate intake levels for fats has the same lower limit (20% of total energy intake), but a lower upper limit (30–35% of total energy intake). The reason for this distinction is the finding that a low-fat diet can lead to a reduction of body weight or can combat the weight gain with increasing age. Energy, rather than fat, is the deciding factor: even low-fat diets result in weight gain if energy intake is excessive. However, individuals on a high-fat diet are more likely to consume excessive amounts of energy. The effect on body weight is quite modest. A reduction of the fat content of the diet from 40 to 30% of energy intake was estimated to reduce body weight with 2–3 kg. However, according to the Health Council of the Netherlands, even such slight effect on body weight can contribute to the prevention of diabetes mellitus type II and (to a lesser extent) coronary artery disease.
The new American acceptable macronutrient distribution range for fat is similar to the Dutch adequate intake for people who are overweight or who have undesirable weight gains: 20–35% of energy.
In addition to the dietary reference intakes for total fat consumption, the Dutch report focuses to a large extent on the composition of dietary fat. Distinguished are saturated fatty acids, trans fatty acids, monounsaturated fatty acids and (some) polyunsaturated fatty acids.
The Health Council of the Netherlands states that the intake of saturated fatty acids and trans fatty acids should be as low as possible, since these substances increase the risk of coronary artery disease. The tolerable upper intake level is 10% of energy intake for saturated fatty acids and 1% of energy intake for trans fatty acids. Both values were based on the current tenth percentile of intake in the Netherlands, which implies that 90% of the Dutch population is advised to reduce their intake of these fatty acids. The American committee also recommends that the intake of both groups of fatty acids be as low as possible, but did not set a tolerable upper intake level.
Replacing saturated fatty acids by unsaturated fatty acids can reduce the risk of coronary artery disease. Most of the fatty acids consumed should therefore be unsaturated. The Health Council of the Netherlands sees no reason to limit the intake of monounsaturated fatty acids and considers the scientific evidence insufficient to set tolerable upper intake levels for individual polyunsaturated fatty acids. For all polyunsaturated fatty acids together, the Health Council recommends a tolerable upper limit of 12% of energy intake.
The adequate intake for linoleic acid is based on the prevention of deficiency: 2% of energy intake. The American committee sets the acceptable macronutrient distribution range for linoleic acid at 5–10% of energy intake; the lower boundary level is based on the median intake in the United States and corresponds to the new American adequate intake, which is formulated in grams per day.
Although some studies suggest that the consumption of large quantities of α-linolenic acid may increase the risk of prostate cancer, the Health Council of the Netherlands takes the view that there is insufficient scientific evidence for this adverse effect. The adequate intake for α-linolenic acid, 1% of energy intake, is based on the beneficial effect on the risk of coronary artery disease. In the American report the acceptable macronutrient distribution range for α-linolenic acid is set at 0.6–1.2% of energy. As for linoleic acid, the lower boundary level is based on the median intake in the United States and corresponds to the new American adequate intake, formulated in grams per day.
Based on the beneficial effect on the risk of coronary artery disease, the Health Council of the Netherlands sets the adequate intake for n-3 fatty acids from fish at 0.2 g/day. The American committee states that up to 10% of the acceptable macronutrient distribution range for α-linolenic acid may be consumed as n-3 fatty acids from fish.
The new estimated average requirement and recommended dietary allowance for digestible carbohydrates are based on the finding that a certain intake level is needed to minimize the production of glucose from amino acids, and thus to prevent the breakdown of body protein. The recommended dietary allowance must therefore be considered a lower limit for the intake of carbohydrates, in analogy to the recommended dietary allowances for micronutrients. As a result of this new approach, the sum of the recommended dietary allowances for carbohydrates and proteins and the adequate intake of fats are less then 100% of energy intake. (In practice, part of this gap will be filled by the consumption of alcoholic beverages. According to the 1998 Dutch Food Consumption Survey, Dutch adults obtain on average 3–5% of their energy from alcohol). By not setting an upper limit for carbohydrate intake, the Health Council of the Netherlands indicates that carbohydrates can be used freely to meet the energy requirements. The new Dutch recommended dietary allowances for carbohydrates are lower than the adequate intakes in most other reports, which treat carbohydrates as a way of balancing the energy needs. The new American recommended dietary allowances, however, are considerably lower than the Dutch values, as they are based on the glucose utilization by the brain. The American committee also provides an acceptable macronutrient distribution range of 45–65% of energy for carbohydrates, based on minimizing the risk of coronary heart disease. The lower limit of this range is 5% higher than the new Dutch recommended dietary allowance.
Health Council of the Netherlands (2001): Dietary Reference Intakes: Energy, Proteins, Fats and Digestible Carbohydrates. Publication no. 2001/19E. The Hague: Health Council of the Netherlands.
Institute of Medicine (2002): Dietary Reference Intakes for Energy, Carbohydrates, Fiber, Fat, Fatty acids, Cholesterol, Protein and Amino acids. Washington: National Academy Press.
The Health Council of the Netherlands acknowledges all members of the Committee on Dietary Reference Intakes and of the Working Group which prepared the dietary reference intakes for energy and the macronutrients: Professor Dr HKA Visser, Chairman of the Committee; Dr H van den Berg; Professor Dr PA van den Brandt; BC Breedveld; Professor Dr RJ Heine; Professor Dr RP Mensink; Professor Dr WHM Saris, Chairman of the Working Group; Professor Dr HP Sauerwein; Professor Dr G Schaafsma; Professor Dr JC Seidell; Professor Dr WA van Staveren; Dr P van't Veer; Professor Dr CE West; Dr JA Weststrate; Dr PL Zock.
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Spaaij, C., Pijls, L. New dietary reference intakes in the Netherlands for energy, proteins, fats and digestible carbohydrates. Eur J Clin Nutr 58, 191–194 (2004). https://doi.org/10.1038/sj.ejcn.1601788
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