Dietary reference values (DRVs) are established within a population as a measure

of nutritional adequacy. As such they are aimed at preventing deficiencies rather

than pre- venting nutrition related diseases. However, DRVs are used as the basis
for dietary based food guidelines, such as the eatwell plate, and dietary
recommendations that are aimed at optimising health and preventing disease
related to over- and under-nutrition (see Chapter 4.2).

The first DRVs were devised in the late 19th century and international values were
established by the League of Nations (the forerunner of the United Nations) in
1936–1938 to prevent deficiencies in a population group (Beaton, 1991). Many
countries have their own values and international values have been published by
the Food and Agriculture Organization of the United Nations (FAO)/ World
Health Organization (WHO)/United Nations Uni- versity (UNU). In Europe the
European Food Safety Agency (EFSA) has begun publishing a series of scientific
opinions on DRVs, with the most recent being average requirements for energy
intake for infants, children, preg- nant and breastfeeding women and adults. To
date, the EFSA has also published scientific opinions on DRVs for water (see
Chapter 6.6), carbohydrates and fats, fibre, and protein.

In a separate initiative, the European Commission funded the EURRECA

(EURopean micronutrient RECom- mendations Aligned) project to harmonise
micronutrient recommendations across Europe. This project included scientists
from 17 countries and aimed to deliver an aligned set of standards that provided a
robust scientific basis for establishing micronutrient requirements and for devising
micronutrient recommendations. It focused on

the needs of specific vulnerable groups, e.g. infants, chil- dren and adolescents,
adults, pregnant and lactating women, the elderly, people with low income and
immi- grants. In addition, EURRECA evaluated the impact of socioeconomic
status, ethnic origin, interindividual vari- ability and vulnerability due to genetics,
environmental factors and epigenetic phenomena on dietary require- ments. A full
list of publications is available at www .eurreca.org.

In the UK, the Department of Health Committee on Medical Aspects of Food

Policy (COMA) revised DRVs for nutrients in 1991 (Department of Health, 1991)
with the exception of energy, which was revised in 2011 by COMA’s successor,
the Scientific Advisory Committee on Nutrition (SACN) SACN, 2011a.

Development of dietary reference values

Dietary reference values are developed by an expert group reviewing the evidence;
DRVs are then derived by the expert group, e.g. WHO, for a specific population of
a country or a group of countries. The values are based on the assumption that
individual requirements for a nutrient within a population or group are normally
dis- tributed and that 95% of the population will have require- ments within two
standard deviations of the mean, as shown in Figures 2.1.1 and Figure 2.1.2. They
assume that individuals are healthy and also consider gender, age, growth and
physiological status, i.e. pregnancy and lacta- tion. Guiding principles for the
development of recom- mendations for micronutrients have been developed by
EURRECA (van’t Veer et al., 2012).

Manual of Dietetic Practice, Fifth Edition. Edited by Joan Gandy.© 2014 The British Dietetic
Association. Published 2014 by John Wiley & Sons, Ltd. Companion Website:
www.manualofdieteticpractice.com

SECTION 2

42

Section 2: Nutritional status

Nutrient needs of

2.5% of the 50% of the 97.5% of the population population population

x y z
– 2 SD + 2 SD Mean

Lower reference nutrient intake (LRNI)

Frequency distribution of individual intakes

Estimated average requirement (EAR)

Reference nutrient intake (RNI)

nutrient requirements

Figure 2.1.1 Derivation and definition of dietary reference values in the UK (source:
Public Health England 1991. Reproduced with permission of Public Health England)

Assuming the distribution of intakes is identical to the distribution of requirements

Estimated risk with adjustmentRisk of deficiency

2 SDNutrient intake

2 SD

100 80 60

% 40

20 0

Figure 2.1.2 Dietary intakes and risk of defi- ciency (source: Public Health England
1991. Repro- duced with permission of Public Health England)

The first UK dietary reference standards were estab- lished in 1950 as a single set
of recommended daily amounts (RDA). In 1991, the standards were extensively
reviewed and replaced by a range of reference standards for use in different
applications (Department of Health, 1991). Several terms were used in this report,
with DRVs as the collective term for the standards. The DRVs will vary according
to the country or organisation responsible for the recommendation. Table 2.1.1
gives the definitions of the DRVs used in the UK and by other expert groups, such
as WHO and the Institute of Medicine (USA).

Limitations

While DRVs are useful, they are open to misuse and the inherent problems
associated with developing recom- mendations for an entire population should be
consid-

ered. It is assumed that nutrient requirements are normally distributed for a

population; however, the data may be skewed or sufficient data may not be
available to establish normality. Robust data are required for the expert group to
evaluate requirements; these data may be derived from tissue levels, balance
studies, body pool size, etc., amount required to prevent symptoms of defi- ciency,
or a measure of function of the nutrient. However, these data are not always
available. When there is insuf- ficient data the expert group will recommend a safe
level of intake rather than a recommended intake value. It is important to
remember that DRVs are recommended for healthy populations and many factors
may affect dietary requirements, as shown in Table 2.1.2.

In particular, it is important to consider bioavailability; while the majority of

macronutrient intake is absorbed, the absorption of micronutrients is more
variable. This is

SECTION 2

2.1 Dietary reference values 43

Table 2.1.1 Definitions of dietary reference values Definitions used in the UK

(Department of Health, 1991)

Recommended daily amount (RDA)

Recommended Intakes

Requirement

Estimated average requirement (EAR)

Lower reference nutrient intake (LRNI)

Reference nutrient intake (RNI)

Safe level

Average amount of the nutrient that should be provided per head in a group of people if
needs of practically all members of the group are to be met (Department of Health, 1979)

Amounts sufficient, or more than sufficient, for the nutritional needs of practically all
healthy persons in a population. Intake emphasises that the recommendations relate to
food actually eaten (Department of Health, 1969)

The amount of a nutrient that needs to be consumed in order to maintain normal

nutritional status

The mean requirement of a nutrient for a population or group of people. On average, 50%
will consume more than the EAR and 50% less (point y in Figure 2.1.2)

The level at which only approximately 2.5% of the population or group will have an
adequate intake; it will not be enough for most people. An individual with this intake may
be meeting their requirement but it is highly probable that they are not (point x in Figure
2.1.2)

At this level, intake will be adequate for 97.5% of the group or population. It is possible
that an individual’s intake at this level will not meet their requirement, but it is highly
improbable

This is given when insufficient information is available to derive requirements. It is an

average requirement plus 20% and is believed to be adequate for most people’s needs.
The panel judged that there is no risk of deficiency at this level and that there is no risk of
undesirable effects above this level

Other values used for dietary reference values (DRVs)

Protective nutrient intake (PNI)

Upper tolerable nutrient intake level [upper limit (Ul)]

Recommended dietary allowance (RDA)

Adequate intake (AI)

Estimated energy requirement (EER)

Dietary reference intake (DRI)

Nutrient reference value (NRV)

Daily value (DV)

Amount >RNI for some micronutrients that may be protective against a specified health
or nutritional risk of public health relevance. PNI are expressed as daily value or an
amount to be consumed witha meal

The maximum intake of some micronutrients that is unlikely to pose risk of adverse
health effects in almost all (97.5%) apparently healthy individuals in a gender and age
specific population

Average daily dietary intake that meets the requirements of nearly all (97–98%) healthy
persons

Established for a nutrient when available data are insufficient to estimate an intake that
would maintain adequacy. The AI is based on observed intakes by a group of healthy
persons

The average dietary energy intake that is predicted to maintain energy balance in a
healthy adult of a defined age, gender, weight, height and level of physical activity
consistent with good health

A term used in the USA and Canada to broaden the use of RDAs, particularly in food
labelling and fortification

A collective term for recommended values; used by some expert groups instead of DRVs
(see Chapter 4.5)

These were developed by the US Food and Drug Administration (FDA) to help
consumers compare the nutrient contents among products within the context of a total
daily diet

Table 2.1.2 Factors affecting dietary requirements

FactorMetabolic requirements

Bioavailability

Example

Age, gender, body sizeLifestyle (smoking, obesity, physical activity, etc.) Disease, e.g.
fever, catabolismTraumaGrowthPregnancy and lactation

Malabsorption or altered absorption, e.g. milk calcium is better absorbed than non-milk
calcium Reduced utilisationIncreased losses, e.g. diarrhoea, burns, renal disease
Environment, e.g. heating of nutrients
Drugs, e.g. diuretics Dietary concentration Dietary interactions Drug–nutrient
interactions

SECTION 2

44

Section 2: Nutritional status

recognised to an extent by DRVs, e.g. DRVs for iron are calculated to reflect the
fact that only 15% of dietary iron is absorbed. However, they cannot take into
account other factors that affect bioavailability, such as amount consumed, body
stores, the presence or absence of other nutrients or dietary constituents, the form
of the nutrient, e.g. haem or non-haem iron, and the food source from which it is
derived (Hurrell & Egli, 2010). These factors may have considerable impact on the
adequacy of dietary intake.

Reference values are devised to cover the requirements of the majority of a

population and therefore will overes- timate the needs of a significant part of that
population. It is important to remember that DRVs reflect the needs of healthy
people and may not be appropriate in many clinical circumstances. While they are
a useful basis to calculate individual needs, they cannot be used alone and other
factors, including those shown in Table 2.1.1, must be considered. This is
discussed further in Chapter 6.1.

Uses of dietary reference values

They should be used with caution in the dietary assess- ment of individuals as it
must be remembered that DRVs are based on populations and groups, and the
nutritional needs of individuals within that group or population, as well as the
factors discussed earlier, will vary. Within a population the nutritional
requirements of individuals form a continuum and where a particular individual
lies on that continuum will be unknown. It is therefore impossible to determine
whether an individual’s needs are being met on the basis of a DRV. It is only
possible to assess the degree of probability that an individual’s needs will or will
not have been met. If the estimated average requirement (EAR) for a nutrient is
being consumed, there is an approximately 50% chance that needs will be met. If
intake is at or above the reference nutrient intake (RNI), it is highly likely that
needs are being met (and probably exceeded). If intake is below the lower RNI
(LRNI), it is highly unlikely that sufficient is being con- sumed, unless that person
is part of the 2.5% of the popu- lation with unusually low requirements.
The diet of groups or populations may be assessed by comparison with DRVs;
however, it is important that the group or population is comparable to that for
which the recommendations are derived. Dietary reference values are also used for
the development of diets for groups of people, e.g. prisoners, and the provision of
supplies, e.g. school meals. Nutrient reference values are also used in food
labelling, fortification and formulation.

UK dietary reference values for specific nutrients

DRVs have been set for many nutrients but not all have an EAR, RNI and LRNI.
It is clearly inappropriate to set a RNI (covering the needs of 97.5% of the
population) for energy because such an amount would far exceed the needs of
most people and, if consumed, would lead to

weight gain and associated health problems. The DRV for energy is therefore only
set as an EAR. Similarly, the DRVs for the main energy yielding nutrients, such as
fat, carbo- hydrate, sugars and starch, are also expressed in terms of average needs.

Energy

Estimated average requirements for energy are based on regression analyses of

measured basal metabolic rate (BMR) against gender, age and weight. The
analyses have been used to generate prediction equations. Numerous equations are
available and ideally they should be popula- tion specific. In 1991, the Department
of Health used the equations of Schofield et al. (1985), but in 2010 SACN
recommended the use of the Henry (2005) equations for this purpose. Energy
prediction equations are discussed further in Chapter 6.1. Appendix A8 shows age
and gender specific equations with additional data on men aged 60–70 years
(Department of Health, 1991). Incre- ments are also added for the last trimester of
pregnancy and for lactation. As energy requirement is given as an average, 50% of
a population will need more than the EAR and 50% less.

In healthy populations, the total daily energy expendi- ture (TEE) is traditionally
calculated by the factorial method, where BMR is multiplied by a physical activity
level (PAL), e.g. a sedentary 40-year-old man weighing 90kg with a PAL of 1.4
and BMR, as derived from predic- tion equations, of 7.973MJ (1880kcal) would
have a TEE of 11.16 MJ (2665 kcal). In their report on DRVs for energy, SACN
(2011b) do not recommend this approach but recognise that there no viable
alternative is currently available. In 1991, the Department of Health defined the
following PALs:

1.4 – inactive men and women (this applies to most people in the UK)

1.6 – moderately active women 1.7 – moderately active men 1.8 – highly active
women1.9 – highly active men

The methodology for deriving the current UK dietary recommendations for energy
is described in more detail by Millward (2012).