Concepts and General Principles Rosario S. Sagum, PhD and Maria Regina A. Pedro, PhD INTRODUCTION The Department of Science and Technology-Food and Nutrition Research Institute (DOST-FNRI) is the lead agency in the review and revision of the Recommended Energy and Nutrient intakes (RENI) for Filipinos. The set of dietary standards is periodically revised, approximately by the decade, to keep pace with new knowledge on nutrition and updated growth references. Dietary reference standards for energy and nutrient intakes are constantly being modified as concepts of health and nutritional adequacy change; new data ‘on nutritional requirements become available; and new roles of nutrients are discovered. It was in this light that the DOST-FNRI created a committee composed of authorities in health, nutrition, biochemistry, and allied professions to review the 2002 edition of the Philippine RENI. ‘twas agreed that the collective term, Philippine Dietary Reference Intakes {PORI), be adopted in this current revision to refer to the broader, multi-level reference values for energy and nutrients.REVIEW PROCESS the RENI (formerly Recommended Daily Allowances A ral na ies woo and now POR), a systematic process for setting he next recommendations was followed. The Committee on Dietary Reference Intakes (POR! Committee) was formed, composed of experts in health and nutrition, biochemistry, and relevant fields, with the Supervising Science Research Specialist (SRS) of the Nutrition and Food Research and Development Division designated as Chair. A Technical Working Group (TWG) was Created, which consisted of 19 SRS of FNRI, 5 of whom were also in the PDRI Committee, with each memberresponsiblefor reviewing available data and newinformation on energy or a specific nutrient or group of nutrients. Task Forces (TF) for energy and specific nutrients, composed of 1-2 PDRI Committee members and a TWG member, reviewed and drafted rec Proposed recommendations to the PDRI Committee en banc for deliberation, were reviewed by an External Panel (a second group of experts), and presented i Stakeholders’ Meeting with a 9f0up of stakeholders including users of RENI rom various lonists and dietitians, clinicians, academics, Iture, food industry, and regulatory sectors. tarted in 2010 and was completed in 2015. fields such as Nutriti Organization of PDRI Committee, TWG, and TE | Review of Literature and New Data (TWG) 5 | Discussion and Drafting of | Proposed Recommendations (TWG and TF) External Review Review ang Revision (TWG and TF) Stakeholders’ Meeting Figure 1-1, Proce 85 for th *7evlew and revision ofthe 2002 RENI for the 2015 PDR! Vo | 2015 PHILIPP Bes: INE DIETARY RUFERENGE itiesFRAMEWORK FOR PDRI 2015 DEVELOPMENT The basic concepts that underpinned the establishment of the 2015 PDAI were as follows: 1, The dietary reference intakes would meet the needs of apparently healthy individuals 2. The reference weights for infants and children reflected the WHO growth standards and those for adults based on the weight to achieve a BMI of 22 kg/m’ using the 2013 National Nutrition Survey (NS) median height at 19 y of age. 3. The age groupings were revised to reflect the current knowledge of biological patterns and feeding guidelines (eg, exclusive breastfeeding for the first 6 mo), For most nutrients, the chosen criterion for the recommended intake was the prevention of nutrient deficiency in the group, while, for some, the prevention of chronic disease endpoints was desirable, Because of the unavailability of sufficient data on the average requirements for some specific age yroups (ie, children and older adults), extrapolation methods were applied. These underlying concepts are further discussed in this chapter and in the specific nutrient chapters, The PDRI Committee, after due consideration, agreed to adopt a multi-level approach based on the United States Canada DRI and the Recommended Nutrient Intakes of the Food and Agriculture Organization (FAO), World Health Organization (WHO), and the United Natlons University (UNU); to use PDRI as the collective term comprising the set of multi-level reference values for energy and nutrients;and to retain RENIas the specific erm describing the intake level peeded to meet the requirements of neatly all of the healthy population of individuals, The mult/-level nutrient reference values include REN fstimated Average Requirement, Adequate Intake, Tolerable Upper Level of Intake or Upper Limit, and Acceptable Macronutrient Distribution Range commended Energy and Nutrient Intake (RE! or ANI) refers to the level of intake of energy or nutrient that ts considered adequate for the maintenance ‘of health and well-being. The ANI meets the nutrient requirement of nearly all healthy individuals in a partic ular life stage and sex group. Based on a statistical distribution, it is the average requirement of the group for the nutrient, corrected for incomplete utilization or dietary nutrient bioavailability, and translated into a recommended intake level by adding an allowance of twice Rec the standard deviation (5D) of the requirements 10 cover for the needs of 97% 98% of individuals in the group, At this daily intake level, the risk of nadequacy is only 2% 3%. For energy, the recommended intake (RE) corresponds to the Concepts and General Principles waaverage requirement of individuals in the group. The addition of 2 SD does not apply to energy intake. verage| ‘t (EAR) relates to the average daily intake level rere eon veering Sicha of half the healthy individuals a particular life stage and sex group, corrected for incomplete utilization day nutrient bioavailability. It is the average or median in the statistical distribution of nutrient requirements of individuals in a defined group as derived from primary research data. Thus, about 50% of the individuals in 2 specified population group would have nutrient requirements that do not exceed the EAR. This is equivalent to a 50:50 chance of randomly selected individuals from the population meeting their requirement at this intake level (OM-FNB, 2005a). ‘Adequate Intake (Al) pertains to the daily nutrient intake level that is based on ‘observed or experimentally-determined. approximation of the average nutrient intake by 2 group (or groups) of apparently healthy people, and is assumed to = @ defined nutritional state, such as adequate circulating nutrient values eae ee Growth. This is used when there are insufficient primary data and RN are othe distribution of individual requirements from which EAR ants otherwise established. In the case of infants below 6 mo of age fot man milkis the recommended sole source of food, the Al is based on the mean daily nutrien : i ifans NOMEN ae his supplied by human milk for healthy full-term Te rg Pe nae Level or Upper Limit (UL) applies to the highest ree niles ent intake level likely to pose no adverse health effects teucan nals in the general population. As intake increases 200% addon Uial risk of adverse effects increases. The risks of inadequay eed for sent Cot close to 0 at intakes between the RNI and the UL. TE any 9 Ut grew out of the popular practice of frtfying foods wi termes 204 the increasing use of large doe of dietary supplements T™ beneficial eff DPE take level” is chosen to avoid implying any poss thee roe et intended to be a recommended level of intake ® nefit rien the NI or ar ‘DostrnnooeeahY individuals having nut o intakes for 5 @sociateg Distribution Range (AMDR) denotes the (2% energy source (carbohydrate, protein, of fat takes of Nisk of chronic diseases while prowding 2 energy intake i Putrents. The AMDR is expressed as a percentage oes CODY foe) soureen tS Fequitement, in a classical sense, is a factor os 'C€S OF of the total energy requirenyent of the indimdual a. 15 PHILIPPINE Die UPPINE DIETARY REFERENCE INTAKES 2 particular with reducedNUTRIENTS REVIEWED The PORI 2015 has retained 27 of the 28 nutrients reported in RENI 2002, ‘omitted manganese, and added n-6 and n-3 polyunsaturated fatty acids Table 1-1. Nutrients for which reference values were established ‘Macronutrients Vitamins Minerals G Protein Vitamin A Niacin Calcium Selenium Fat Vitamin D Folate Phosphorus —Flouride w-6 fatty acid Vitamin E Vitamin B, Magnesium Sodium, 9-3 fatty acid Vitamink — VitaminB,, Iron Potassium Carbohydrate. Thiamin Vitamin C lodine Chloride Dietary fiber Riboflavin Zinc Water LIFE STAGE AND AGE GROUPINGS Age groupings were defined to reflect the current knowledge of biological Patterns as well as the application of guidelines for breastfeeding duration and complementary feeding, as shown below (Table 1-2). Table 1-2. Age/physiologic groupings ‘Age Group Rationale Infants, mo 0-5 Rapid growth, period of exclusive breastfeeding on Decreasing growth velocity, period of complementary feeding Children, y 12 Eatly childhood, period of complementary feeding 35 Start of preschool, steady growth 6-9 Primary school years, steady growth 10-12 Onset of puberty (generally for girls), growth spurt 13-15 Adolescence, continued growth spurt 16-18 Cut-off from adolescence to adulthood Adults, y 19:29 Farly adulthood, higher nutrient intakes for optimal genetic potential for bone mass 30-49 ‘Mid-adult, decreasing mean energy metabolism 50-69 Adulthood, active work years for most adults 270y Older adults, significant decline in Physical activity and general Concepts and General Principles Pi | metabolism‘ete REFERENCE BODY WEIGHTS The reference weights for infants and young children 0-5 y were adopted og the World Health Organization (WHO) Child Growth Standards median vl for-age at the midpoint of each target age range (WHO, 2006) to elect the objective of achieving the children’s growth potential, For the age groups 6-9 y and 10-18 y, the reference weights were based cn the WHO Growth Reference Standards (de Onis et al,, 2007) median weight for-height and median of the height-based BMI, respectively, using the 201) NS median height of Filipino children with normal nutritional status, Thee standards were selected with the objective of promoting healthy growth lic ‘overweight and obesity prevention) and in consideration that Filipino children with normal weight-for-height based on the WHO Growth Standards were relatively shorter than the reference height-for-age. For the rest of the age groups from 19 y, the reference weight was based onthe weight to achieve BMI of 22 kg/m? using the median height of Filipino 19 y-oé adolescents from NNS sample with normal nutritional status. The reference weights for the PDRI 2015 update are shown in Table 1:3. Table 1-3. Reference weights Reference weights (kg) Life stage/age group Male Forsia’t Infants, mo. 0-5 65 60 on 90 80 Children, y 12 12.0 us 35 75 170 6-9 230 25 10-12 33.0 360 13-15 48.5 460 16-18 590 1S Adults, y 19-29 60.5 S25 30-49 605 525 50.59 605 525 60-69 605 525 ' 270 605 528 Pn | 7015 PHILIPPINE DIETARY REFERENCE INTAKES. osESTIMATING NUTRIENT REQUIREMENTS AND RECOMMENDED INTAKES The first step in establishing recommended intakes was to determine the average physiologic requirement based on available studies. From the data reviewed, a requirement was defined as the lowest nutrient intake that maintained a level of nutriture among apparently healthy individuals; thus, the absence of disease based on clinical signs and symptoms of micronutrient deficiency or excess, and normal function as assessed by laboratory methods and physical examination (WHO/FAO, 2004). For most nutrients, the chosen criterion was the prevention of nutrient deficiency. For some nutrients, the criterion was different across life stages (e.g., calcium and phosphorus). Published and unpublished reports (including the complete description of experimental design, characteristics of subjects, analysis, and interpretation of results) of local studies on nutrient requirements among subjects consuming local rice-based diets, studies on protein quality and bioavailability of iron from local meals, breast milk volume, and nutrient composition were covered in the review. Published foreign studies, many of which were also reviewed by the IOM-FNB and FAO/WHO/UNU expert panels for the DRI (IOM-FNB, 2011, 2005a, 2005b, 2001, 2000b, 1998, 1997) and vitamin and mineral requirements for humans (WHO/FAO, 2004, 1996), were also reviewed. The recommendations by the IOM-FNB and FAO/WHO/UNU were relied upon heavily for most of the nutrients. The content of each nutrient chapter included: 1. Introduction Functions Metabolism Dietary sources Deficiency and excess Estimating requirements Reference intakes Future research directions SNA awn In setting the RNIas EAR plus 2 SD (except energy) to cover the needs of almost all apparently healthy individuals, where the distribution of requirement values was not known, a Gaussian or normal distribution was. assumed. With this, it was expected that the mean requirement plus 2 SD will cover the nutrient needs of the 97%-98% of the population. Where the SD was not known, a coefficient of variation (CV) in the range of 10%-12%, based on the nutrient’s physiology and variation, was assumed. Thus, RNI=EAR+2SD or RNI=EAR+2CV Coeets an Geren Pcs ML» 10% CV for EAR was assumed for most nutrients| based on the data on variation in basal metabolic rates and 12.5% estimated for protein requirements in adults (WHO/FAO/UNU, 2007; Garby and Lammert, 1984; Elia, 1992). A higher CV was adopted, where available data indicated that greater variation was probable (eg, vitamin A, iodine). If data were insufficient to establish an EAR (and thus RNI), Al was set either by utilizing experimental evidence or by adopting the most recently available usual intake of populations that were not deficient for that particular nutrient. Both the RNI and Al can be used to establish the goal for individual intakes; however, less certainty can be confirmed for the AI value since this can be significantly higher than RNI. For some nutrients (vitamins A, B,, C, D, niacin, folate, iodine, zinc, fluoride iron, selenium, and magnesium), the UL established by WHO/FAO or JOM were adopted. The UL include intakes from all sources including foods, nutrients added to foods, pills, capsules, or medicines. Estimating requirements for young infants For infants 0-5 mo old, Al were established for most nutrients and were base? on breast milk intake (da Costa et al, 2010; Butte et al,, 2002; WHO, 1998) an¢ composition (Picciano, 2001). An average human milk intake of 780 mL/day fo" infants aged 0-5 mo was based on the pooled analysis of data from human mit intake studies from 12 countries across 5 continents, which used the dose! mother deuterium oxide turnover method (da Costa et al,, 2010) and on Published data on human milk intake during the first 6 mo of life in wellnourshed environment, obtained by the 24-hour test weighing reat &t al, 2002), The same breast milk volume was used to estimate ene ‘équirement for lactation in the first semester, while the 650-mL breast schune for the second semester of lactation was based on the WHO " lute etal, 2002; WHO, 1998), Esti ‘mating requirements for older infants, young children, and older adults Rel rs ms Scientific data that are age-specific are unavailable for many se a, for infants over 6 mo of age and young children, a8 a sat: The general approach to estimating the nutrient needs O Using weigh 2 the extrapolation of values from one life stage f° Pix rence, "ing factors for body size, energy requirement, and other ™ aa 2015 PPILIPEIME DIETARY REFERENCE INTAKESThe extrapolation formula of IOM-FNB (IOM-FNB, 1998, 2005a) for the Al of older infants aged 6-11 mo was obtained from age 0-5 mo: Ale smo XF Al ‘11 mo = where F = (Weight, ,,,../ Weight, ...)°”> Extrapolations from adult EAR to children’s requirements were mostly done using the formula: EAR ug = EAR yg X F where F = (Weight,,, /Weight,,,,)°”x (1 + Growth Factor) The growth factors used (Table 1-4) were derived from the approximate proportional increase in protein requirements for growth (FAO/WHO/UNU, 1985; IOM-FNB, 1998). Table 1-4. Growth factors 7mo-3y 030 48 0.15 9-13 01S 14-18 Males 0.15 Females 0.00 Estimating requirements for pregnant and lactating women For pregnant women, additional requirements were based on the amount laid down in fetal and maternal tissues, while the requirements for lactating women were based on the amounts of nutrient secreted in breast milk. These amounts are added to the requirements of non-pregnant, non-lactating women. cee eee Coneipe a Gow Princes MAINTERPRETATION OF THE PDRI NS. The distriburion are assumed Gaussian or normal, ut in adaptation from the IOM-FNB, ework of the ();) and the relationship of the different alUeS anc the Probability of risks of inadequacy an » 3 zg z 3 F = 2 E : 3 j 2 i Observed level of intake Figure 1-2. Relationship among the Dietary Reference intakes (adapted from IOM-FNB, 2005) Estimated Avera ge Requirement (EAR) s the intake at which the riskof inadequacy ose individual. Recommended Nutrient intake (RNI)is the intake at which the rskof nase EARlLonly 002-0003 (2%-39), Adequate intake (Al does not bear any consistent nei EAR or RNI because itis assumed ‘without an estimate of the requirement, and ed id of eX NL and the UL. At intakes between the RNI and the UL the risks of inadequacy SToS€ 100. At Intakes above the UL the risk of adverse effect increases. et isk of nade Asreflected in the figure, when nutrient intake increases, the f e ‘ of advers “creases; conversely, with excessive intakes, the risk accelerates, 2015 PHILIPPINE DIETARY REFERENCE INTAKESUSES AND APPLICATIONS The primary uses of the PORI are to assess and to plan dietary intakes. In this regard, appreciating the concept that both nutrient requirements and nutrient. intakes represent distributions is essential (Beaton, 2007). For both dietary assessment and planning, it is also essential to underscore that nutrient requirement is the lowest level of daily average intake of a nutrient that will maintain a defined level of nutriture based on a specified criterion of adequacy. Assessment of diets Assessment involves determining the probable adequacy or the risk of inadequate or excessive usual intakes by an individual, and determining the Prevalence of adequate or inadequate or potentially excessive intakes of a group oF population, Because nutrient requirements represent a distribution, the best estimate for an individual's requirement, and the appropriate ORI to use to assess intake, is EAR, which is the average or median requirement (except for the iron requirement among pregnant women, as is explained in the corresponding chapter). The probability of the adequacy of intakes below the EARis < 0.5. The RNI is not a useful standard to assess an individual's intake because it cannot be assumed that intake below the RNI is inadequate. By definition, the RNI exceeds the requirement of all but 2%-3% of the population and a number of those whose intakes are below the RNI may be meeting their individual requirements (1OM-FNB, 2000a). If the DRI is Al because EAR could Not be determined, all that can be confidently concluded is that the intake is either above or below the Al. From Figure 1-2, intakes above the Al have a high ey of adequacy. However, at intakes below the Al, the probability of ieee cannot be determined. Caution must therefore be exercised when ‘Erbreting intakes relative to the Al (1OM-FNB, 2000a). AS with the asse: SOUPS must be from at least 2 'ssment of diets for individuals, the dietary assessment for based on estimates of usual intake. Usual intake is determined Adjusted to reg) Of food and nutrient intake data records, which have been apubac he eove the effects of day-to-day variation (IOM-FNB, 2000a). From the populane Perspective, the information that is critical is the proportion of Fequitement, yn au? With usual intake of a nutrient that is less than their i depts cite the appropriate DRI is EAR. The EAR cut-point approach which me determining the prevalence of inadequacy in @ group, the EAR JOM hun. 22th Proportion of the group with usual intakes below intake because 8, 2000a). The RNI is inappropriate for assessment of group erin Ther cetintion the RNI exceeds the requirements of 97%- 98% of Ne gtOUp (Mur p Mean ima gan * €QUalS ors gre “Fore, using it overestimates the prevalence of inadequacy in 8nd Vorster, 2007). Moreover, the old practice of comparing he RNI has yielded misteading conclusions. A mean intake “ater than the RNI, for example, was interpreted as adequate concepts an Gener Pees ial. in fact, a substantial and suggested no community action, when, in Proportion « ‘the group had usual intakes less than their requirement. For groups. the usual intake distribution is examined. The fraction of the Population with nutrient intake exceeding the UL is the fraction that may beat Tisk of adverse effect due to e excessive intakes. Planning of diets Planning involves the Setting of intake targets for individuals and peterar the desirable intake distributions for Groups or the population. The goa! etary planning forthe individuals tonchrocen low probability of inadequat® iro ile not exceeding the UL With intakes atthe RNI, the probability WaCY is very low for individuals, and is, as such, the approprat at a Planning diets at the individual level, while ensuring that total nt intakes from food, water, and supplements do not exceed the ve evel dit “i SPPlications for Planning diets for individuals include individual ee “Ounseting and developing food-based dietary guidelines, which aim individuals in making good food choices (Vorster et al, 2007). ns intake blanning a diet that will satisfy @ low probability of inadea 2nd potential intake of mac risk of excess, itis desirable that the individual’ in Fonutrients, 's within the AMDR. ; cornu feeding 99 diets fora group such as planning food fortificat a! intake disrioe’ 25tance program, the goal is to obtain 2 desf0 ae t cistibution, where the prevalence of usual nutrient ee e is acceptani e™* €Quirements of most indivduals in the a - 'Ndividualsin gre ME Program planner sets the cut-O! jy nave KE eo" the: EAR 5 sin the group F Population that would still on one fort! © feeding” 3%: 8nd determines the futrient gap Writ og 3 1m yo" Ceding peo%"@™ Would have to satisfy while aiming athe UL For food Product development that "! 205 Phipps = PHILIPPI DIETARY REFERENCE INTAKES EE =...of nutrients through fortification or enrichment, the EAR an derive an acceptable oF safe range of intake and to evalua: new product (Vorster et al, 2007), 'd UL are needed to te the safety of the Table 1-5 outlines the application and uses of the PDRI for planni assessment for individual and group, Planning and Table 1.5. Applications and uses of PORI Individual Group or Population EAR: This value examines the EAR; This value estimates the probability of inadequacy (or prevalence of inadequacy (or adequacy) of reported usual adequacy) of the usual intakes within intakes of the individual. agroup. Al: Intake at this level has a Al: Mean intake at this level implies a low probability of inadequacy. low prevalence of inadequacy. Its use is Use only if the nutrient has no not valid for estimating the population EAR, prevalence of inadequacy for anutrient (unless the median nutrient intake of a healthy population has been set as the Al). Use if the nutrient has no EAR, UL: Usual intakes above this UL: This is used to estimate the level place the individual prevalence of potentially excessive at potential risk of adverse intakes, or the proportion of the group offects that may be at risk of adverse effects. RNI: Its use serves as a goal EAR: Its use in conjuction with the for daily intake in order to measure of a group’s usual intake achieve a low probability of sets the goal for the median intake Inadequate intake (i.e, 2%- of a specific population such that the 3%). Any intake level can also probability of inadequate nutrient be chosen at which the risk to intake in the group is acceptably low. the individual is either higher or lower than the 2%-3% level of risk, Al: Intake at this level has a low probability of inadequacy. UL: Intake above this levelhas UL: This serves as the reference value A tisk of adverse effects. for determining whether or not the nutrient intakes will pose a risk of adverse effects. Diet planning should target a low prevalence of excessive nutrient intakes for the group's overall intake. Concens ant Gena PencilsNutrient labeling Related to planning diets is the application of the DRI for nutrition labetin such as the nutrition facts table and the nutrient content claims that line in pre-packaged foods. Nutrition labeling impacts on the levels of Nutrients that food manufacturers choose to add to foods as well as influences the food choices of consumers. The Philippine Food and Drug Administration (FON, following guidelines from the Codex Alimentarius, prescribes a minimum Percentage of a defined Dietary or Nutrient Reference Value (ORV or NAV) that a portion or serving of food should Provide to make a nutrient content claim (FDA, 2014). Using the RNI for nutrition labeling is said to be consistent with the educational objective of food labels to guide the consumer on how (one serving can help meet an individual’ intake goals (ie, achieving a lon Probability of inadequacy). A reference population of individuals 4 y of age and older, excluding pregnant and lactating women, has been suggested t represent the general population for which a population-weighted DRV/NAV for food for the general Population may be established (refer to Appendix I. The IOM-FNB (2003) provides guiding principles for selecting reference values for nutrition labeling. SUMMARY The Philippine Dietary Reference intakes are energy and nutrient reference standards for the health ¥y Filipino population. The PDRI 2015 edition updates expands upon, and replaces the Recommended Energy and Nutrient Intakes Flipinos 2002. This new set of dietary standards was established by acommit® of health and Nutrition experts through a review process led by the Food a! Nutrition Research Institute. The PORI consists of four reference values: Estimated Average Require Recommended Energy or Nutrient Intake, Adequate Intake, and To! ia ot {Per intake Level, each of which having specific use or application. nade 4 these DRis, macronutrients have an Acceptable Macronutrient Dist" nge The two general u: assessment of indi For dietary planni individuals, while ie” SeS of PORI are to assess and to plan diets. fol Viduals and groups, the EAR/REL Al and UL may PY sé | Al and UL may apply to dietary | \d UL may be used for groups of PoP! ing, the RNI/REI, aio" the EAR/REI an .