A. van Leeuwenhoeklaan MA Bilthoven Postbus BA Bilthoven KvK Utrecht T F

Transcription

1 A. van Leeuwenhoeklaan MA Bilthoven Postbus BA Bilthoven KvK Utrecht T F info@rivm.nl The habitual micronutrient intake of Dutch adults (VCP 27-21) compared with dietary reference values set by the Health Council of the Netherlands (214) and EFSA (21-217) Date 18 September 218 Our reference VCP-MEMO 18-2 Your reference additional research Dealt with by Janneke Verkaik-Kloosterman Caroline van Rossum Marja Beukers Elly Buurma-Rethans Centre for Nutrition, Prevention, and Health Services T Janneke.Verkaik@RIVM.nl Copy to Enclosure(s) Version: 1 Page1 of 36

2 Content Content Introduction Methods Results Vitamin A Vitamin B Vitamin B Vitamin B Vitamin B Folate/folic acid Vitamin B Vitamin C Vitamin D Vitamin E Vitamin K Calcium Copper Iron Magnesium Phosphorus Potassium Selenium Zinc References Version: 1. Page2 of 36

3 1. Introduction Dietary reference values give information about the amount of nutrients necessary to take in for normal functioning of the body, growth, and to prevent (deficiency) diseases. Recently, European Food Safety Authority (EFSA) finished their job to set dietary reference values [2]. In the Netherlands, the Health Council sets these values. In 214, ad interim values were set [4]. The ad-interim dietary reference values as set by the Health Council of the Netherlands in 214 and the EFSA s dietary reference values differ for some nutrients. Since 216, a commission of the Health Council is evaluating the EFSA s dietary reference values for the Dutch situation. The aim of our study was to estimate the habitual intake of micronutrients in the Dutch adult (19-5 years.) population. An additional objective was to visualize, how the habitual intake distribution relates to the Dutch ad-interim and the EFSA s dietary reference values. For our study data from the Dutch National Food Consumption Survey [5] was used and combined with food composition data from NEVO-213 [6]. This memo gives a brief overview of the methodology used and general interpretation guidelines for the results. The results are presented in tables and figures by each micronutrient. Only the micronutrients for which there is an ad-interim Dutch and EFSA s dietary reference value are included, as well as only micronutrients for which it was possible to estimate the intake of Dutch adults. This was the case for vitamins A, B 1, B 3, B 5, B 6, B 12, C, D, E, and K, folate, as well as for, calcium, phosphorus, potassium, magnesium, copper, selenium, iron, and zinc. The research described in this memo was conducted by order of the Dutch Ministry of Health, Welfare and Sports (knowledge question ( ) additional research ) to support the commission Nutrition of the Health Council of the Netherlands and the by this commission established working group on dietary reference values. Version: 1. Page3 of 36

4 2. Methods Data from the Dutch National Food Consumption Survey was used in this study. Details of this study are described in detail elsewhere [5, 7]. In brief, this survey was conducted among children and adults aged 7-69 years. All subjects were interviewed twice about their food consumption of the previous day (24-hr recall). To estimate the micronutrient intake, the consumption data were combined with food composition data of NEVO 213 [6]. For our study, only data were used from Dutch adults aged 19-5 years. The habitual intake of micronutrients from foods was estimated. The micronutrient intake from dietary supplets was not included. For the micronutrients with a dietary reference value expressed per unit of energy intake, the ratio of the micronutrient and energy intake was calculated prior to estimating the habitual intake. The habitual intake is the long-run average intake (also referred to as usual intake). The population distribution of habitual intake only includes between-person variation and no withinperson variation. To estimate the habitual intake from 24-hr recall data on two nonconsecutive days, the statistical program to assess dietary exposure (SPADE version ) was used [8]. For all micronutrients, the SPADE 1-part model was applied, as virtually the whole population daily consumed all micronutrients. In the SPADE 1-part model, only the habitual intake amounts are estimated and not the habitual intake frequency, as this frequency is daily for all subjects. The habitual intake distribution is presented separately for and wo by means of the average intake and the intake at the 5 th, 25 th, 5 th (median), 75 th, and 95 th percentile. All results were weighted for small deviations in socio-demographic characteristics compared to the Dutch population in 28, and for deviations from an equal distribution over the seasons and days of the week. Bootstrap (1 iterations) was used to quantify the modeling uncertainty and presented as 95%-confidence interval. The habitual intake distributions were compared with the Dutch and EFSA s dietary reference values [2, 4]. There are several types of dietary reference values available: average requiret (EAR), recomded daily allowance (RDA), and adequate intake (AI). The different organizations use their own specific terminology for the same type of DRVs. An overview is presented in Box 1. For this research the proportion lower or equal to the average intake was estimated using the EAR-cut point approach [3]. Based on several underlying assumptions, this proportion is a valid estimate of the proportion of the population with an inadequate intake. In addition, the percentile of the intake distribution at which the RDA is reached was calculated. For micronutrients for which no EAR was set, the percentile of the intake distribution at which the AI is reached was calculated. With an AI only a qualitative evaluation is possible. If the median habitual intake is above the AI the risk of inadequate intake is considered to be low in the population. However, if the median habitual intake is below the AI no statet can be made about the adequacy of intake in the population. In that case, additional research e.g. nutritional status, is required to evaluate the adequacy of the intake. An overview of guidelines for the interpretation is presented in Box 2. Version: 1. Page4 of 36

5 Box 1. Terminology Table A. Overview of terminology: Health Council of the EFSA Nordic Council Institute of Medicine Netherlands (in Dutch) Voedingsnorm Dietary reference value (DRV) Dietary reference value (DRV) Dietary reference intake (DRI) A Gemiddelde Average Average Estimated average B C D behoefte (GB) Aanbevolen hoeveelheid (AH) Adequate inname (AI) requiret (AR) Population reference intake (PRI) Adequate intake (AI) requiret (AR) Recomded intake (RI) Recomded intake (RI) Lower intake level (LI) requiret (EAR) Recomded daily allowance (RDA) Adequate intake (AI) Definitions: A: The level of intake of a nutrient that is required by half of the subjects in a specific population group B: The level of intake of a nutrient that is sufficient for almost all the individuals in a specific population group. Under assumption of a normal distribution of the individual requirets, it is calculated as the (estimated) average requiret (A) + 2 SD (virtually 97.5%) C: When the underlying data is insufficient to set an (estimated) average, requiret an adequate intake is established instead. This is a single estimate without knowledge on the distribution of individual requirets in a population. The AI is the intake level associated with adequate (markers of) health in (almost) all individuals. It is expected to be equal to or higher than the RDA/AH/PRI/RI if there would have been sufficient data to set such a value. D: The level of intake that could lead to clinical signs of deficiency in virtually the whole population. It is set as the (estimated) average requiret 2 SD. Version: 1. Page5 of 36

6 probability adverse health effect Box 2. Interpretation of evaluation of nutrient intake in a population with dietary reference values With dietary reference values, it is possible to assess the adequacy of a population s intake to some extent. The way of evaluating the nutrient intake of a population depends on the type of dietary reference value. Figure A shows an overview of the different dietary reference values and their mutual relationship as well as their relationship with the habitual intake and probability of adverse health effects. EAR RDA AI* UL NOAEL* LOAEL* uncertainty factor 2*SD (requiret) uncertainty factor (habitual) intake Figure A. Schematic overview of the relationship between (habitual) intake and probability of adverse health effects including the different nutritional reference intakes [1]. * AI, NOAEL and LOAEL do not have exact relation with requiret (or intake); therefore the lines are dashed and surrounded by a shaded area. EAR: estimated average requiret; RDA: recomded daily allowance; AI: adequate intake; UL: tolerable upper intake level; NOAEL: no observed adverse effect level; LOAEL: lowest observed adverse effect level; SD: standard deviation. Evaluating with average requiret The average requiret can be used to estimate the proportion of the population with inadequate intakes using the EAR-cut point approach [3], as long as several assumptions are met. The idea behind the EAR-cut point approach is that the proportion below the average requiret predicts the proportion of the population with intakes below their individual requirets. This is a valid prediction if the intake and requiret are independent, the distribution of requirets is symmetrical, and the variance of the distribution of requirets is small compared to the variance of the intake distribution. As such, this method will not provide valid estimates of the proportion with inadequate intakes for energy as the intake and requirets are not independent. As well as for iron, for which there is a non-symmetrical distribution of the requirets, especially for wo of childbearing age. A general rule of thumb is that with small proportions (i.e. < 1%) no public health Version: 1. Page6 of 36

7 Continue Box 2. Interpretation of evaluation of nutrient intake in a population with dietary reference values problem from inadequate intakes is expected. Evaluating with adequate intake An adequate intake can only be used for qualitative evaluation of the nutrient intake. If the population habitual median intake is above the adequate intake the risk on inadequate intake in the population is judged to be low. If this is not the case, no statet about the adequacy can be given, additional research is needed, e.g. nutritional status. Evaluating with Recomded Daily Allowance The recomded daily allowance cannot be used to predict inadequate intake at a population or individual level. However, it can be used as a guideline for individual advice. The individual requiret is unknown, but this value would be sufficient for most people. As it is expected to be the amount which is sufficient to full-fill the requiret of 97.5% of the population. Consequently, it is a higher amount than most people would require based on their individual requiret, if known. On the other hand, for some people it is still not sufficient. Version: 1. Page7 of 36

8 3. Results The results are described separately for each micronutrient for which EFSA did set a dietary reference value recently and for which it was possible to estimate the habitual intake. In paragraphs 3.1 to 3.11, the vitamins are presented followed by the minerals in paragraphs 3.12 to For some micronutrients, the unit of the ad interim dietary reference values set by the Dutch Health Council differs from the unit used by EFSA, for these micronutrients the results are presented in both units in separate Tables and Figures. Otherwise, the results are presented in the same Table and Figure. All results are presented separately for and wo. Version: 1. Page8 of 36

9 3.1 Vitamin A The EFSA s reference values are expressed in retinol equivalents (RE), while the ad interim Dutch reference values of the Health council are expressed in retinol activity equivalents (RAE). The difference is the way in which the pro-vitamin A carotenoids are converted using conversion factors before adding to the retinol intake. As a result, the vitamin A intake expressed in RAE is lower than when expressed in RE. EFSA: Retinol-equivalent (RE) 1 µg RE = 1µg retinol = 6 µg β-carotene = 12µg other carotenoids with provitamin A activity Ad-interim Health Council: Retinol-activity-equivalent (RAE) 1 µg RAE = 1 µg retinol = 2 µg β-carotene from supplets = 12 µg of β- carotene from food = 24 µg other carotenoids met provitamin A activity As the Dutch Health Council set different reference values compared to the ad interim Dutch reference values and the EFSA s reference values, a second figure is added to show the habitual vitamin A intake distribution with these newly set reference values (Figure 2). Table 1. The distribution (95%-CI) of habitual vitamin A (retinol activity equivalent) intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution vitamin A (µg RAE/d) mean P5 P25 P5 P75 P ,74 1,56 ( ) ( ) ( ) ( ) (1,26-1,132) (1,398-1,619) ,174 ( ) ( ) ( ) (63-684) ( ) (1,95-1,243) Table 2. The distribution (95%-CI) of habitual vitamin A (retinol equivalent) intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution vitamin A (µg RE/d) Mean P5 P25 P5 P75 P95 1, ,28 1,299 1,799 (1,48-1,156) ( ) ( ) (993-1,97) (1,245-1,382) (1,673-1,942) ,5 1,462 (838-91) ( ) ( ) (793-86) (1,1-1,94) (1,356-1,561) Version: 1. Page9 of 36

10 Table 3. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual vitamin A intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA). Ad interim Dutch reference values (214) (RAE) EFSA's reference values (21-217) (RE) intake intake AR AR RDA intake = RDA AR AR RDA intake = RDA (µg/d) (%) (µg/d) (percentile) (µg/d) (%) (µg/d) (percentile) th 5 19 th 6 (13-22) 9 (52-62) 57 (3-7) 75 (13-23) wo 5 22 (18-27) 7 56 th (53-61) 49 8 (5-1) th (21-3) (RAE) AR - NCM-212 RDA - NCM habitual vitamin A intake (µg RAE/d) wo (RAE) AR - NCM-212 RDA - NCM habitual vitamin A intake (µg RAE/d) (RE) AR - EFSA-215 PRI - EFSA habitual vitamin A intake (µg RE/d) wo (RE) AR - EFSA-215 PRI - EFSA habitual vitamin A intake (µg RE/d) Figure 1. Habitual vitamin A intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch DRV (left) or EFSA DRV (right). Version: 1. Page1 of 36

11 (RAE) AR - nieuw PRI - nieuw habitual vitamin A intake (µg RAE/d) habitual vitamin A intake (µg RAE/d) Figure 2. Habitual vitamin A intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the new Dutch DRV (: AR = 615 µg RAE, PRI = 8 µg RAE; wo: AR=525 µg RAE, PRI=68 µg RAE) wo (RAE) AR - nieuw PRI - nieuw Version: 1. Page11 of 36

12 3.2 Vitamin B 1 The EFSA s reference values are expressed in mg/mj/day and the ad interim Dutch references of the Health Council in mg/day, so the individual energy intake is taken into account in the comparison with the EFSA s reference values. Table 4. The distribution (95%-CI) of habitual vitamin B 1 (thiamin) intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution vitamin B 1 (mg/d) mean P5 P25 P5 P75 P ( ) (.8-1.) ( ) ( ) ( ) ( ) (1.-1.1) (.6-.7) (.8-.9) (1.-1.1) ( ) ( ) Table 5. The distribution (95%-CI) of habitual vitamin B 1 (thiamin)/energy intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution vitamin B 1 (mg/mj/d) mean P5 P25 P5 P75 P ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Table 6. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual vitamin B 1 (thiamin) intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA)..8 wo.8 Ad interim Dutch reference values (214) (mg/d) EFSA's reference values (21-217) (mg/mj/d) AR intake AR RDA intake = RDA AR intake AR RDA intake = RDA (mg/d) (%) (mg/d) (percentile) (mg/mj/d) (%) (mg/mj/d) (percentile) 2 (1-4) (1-19) th (13-28) th (53-65).72 (-3).1 (-1).1 11 th (6-26) 5 th (3-16) Version: 1. Page12 of 36

13 (mg/d) AR- HCNL-2 RDA - HCNL-2,5 1 1,5 2 2,5 3 habitual vitamin B 1 intake (mg/d) (mg/mj/d) AR - EFSA-216 PRI - EFSA-216,5,1,15,2,25 habitual vitamin B 1 intake (mg/mj/d) wo (mg/d) AR- HCNL-2 RDA - HCNL-2,5 1 1,5 2 2,5 3 habitual vitamin B 1 intake (mg/d) wo (mg/mj/d) AR - EFSA-216 PRI - EFSA-216,5,1,15,2,25 habitual vitamin B 1 intake (mg/mj/d) Figure 2. Habitual vitamin B 1 intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch DRV (top) or EFSA DRV (bottom). Version: 1. Page13 of 36

14 3.3 Vitamin B 2 Table 7. The distribution (95%-CI) of habitual B 2 (riboflavin) intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution vitamin B 2 (mg/d) mean P5 P25 P5 P75 P ( ) (1.-1.1) ( ) ( ) ( ) (2.8-3.) ( ) (.8-.8) ( ) ( ) ( ) ( ) Table 8. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual vitamin B 2 (riboflavin) intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA). Ad interim Dutch reference values (214) EFSA's reference values (21-217) AR intake AR RDA intake = RDA AR intake AR RDA intake = RDA (mg/d) (%) (mg/d) (percentile) (mg/d) (%) (mg/d) (percentile) (4-9) th (24-33) (12-19) th (31-4) wo.8 5 (4-7) th (2-27) (38-46) th (65-72) AR - HCNL-2 RDA - HCNL-2 AR - EFSA-217 PRI - EFSA-217,5 1 1,5 2 2,5 3 3,5 4 habitual vitamin B 2 intake (mg/d) wo AR - HCNL-2 RDA - HCNL-2 AR - EFSA-217 PRI - EFSA-217,5 1 1,5 2 2,5 3 3,5 4 habitual vitamin B 2 intake (mg/d) Figure 3. Habitual vitamin B 2 intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch or EFSA DRV. Version: 1. Page14 of 36

15 3.4 Vitamin B 3 The EFSA s reference values are expressed in mg/mj/day and the ad interim Dutch references of the Health Council in mg/day, so the individual energy intake is taken into account in the comparison with the EFSA s reference values. Both dietary reference values for vitamin B 3 are expressed as niacin equivalent (NE). In NEVO 213, only data on nicotinic acid (i.e. in Dutch nicotinic acid amide) and not tryptophan are included. The calculated vitamin B 3 intake only concerns the intake of nicotinic acid. Niacin-equivalent (NE): 1 mg NE = 1 mg nicotinic acid = 1/6 mg tryptophan Table 9. The distribution (95%-CI) of habitual vitamin B 3 intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution vitamin B 3 (mg/d) mean P5 P25 P5 P75 P ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Table 1. The distribution (95%-CI) of habitual vitamin B 3 /energy intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution vitamin B 3 (nicotinic acid) (mg/mj/d) mean P5 P25 P5 P75 P ( ) ( ) ( ) ( ) (2.7-3.) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Table 11. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual vitamin B 3 intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA). Ad interim Dutch reference values (214) (mg/d) intake intake = AR AR RDA RDA (mg/d) (%) (mg/d) (percentile) EFSA's reference values (21-217) (mg/mj/d) intake intake = AR AR RDA RDA (mg/mj/ d) (%) (mg/mj/d) (percentile) 12 (-1) 17 7 th (4-9) 1.3 (-1) th (2-8) wo 9 (-1) 13 8 th (6-12) 1.3 (-2) th (2-1) Version: 1. Page15 of 36

16 (mg/d) AR - HCNL-2 RDA - HCNL habitual vitamin B 3 intake (mg/d) (mg/mj/d) AR - EFSA-214 PRI - EFSA habitual vitamin B 3 intake (mg/mj/d) wo (mg/d) AR - HCNL-2 RDA - HCNL habitual vitamin B 3 intake (mg/d) wo (mg/mj/d) AR - EFSA-214 PRI - EFSA habitual vitamin B 3 intake (mg/mj/d) Figure 4. Habitual vitamin B 3 intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch DRV (top) or EFSA DRV (bottom). Version: 1. Page16 of 36

17 3.5 Vitamin B 6 Table 12. The distribution (95%-CI) of habitual vitamin B 6 intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution vitamin B 3 (mg/d) mean P5 P25 P5 P75 P ( ) ( ) ( ) ( ) ( ) ( ) ( ) (1.-1.1) ( ) ( ) ( ) ( ) Table 13. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual vitamin B 6 intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA). Ad interim Dutch reference values (214) EFSA's reference values (21-217) AR intake AR RDA intake = RDA AR intake AR RDA intake = RDA (mg/d) (%) (mg/d) (percentile) (mg/d) (%) (mg/d) (percentile) (-2) th (7-14) (7-14) th (15-24) wo (4-9) th (3-39) (14-22) th (38-48) AR - HCNL-23 RDA - HCNL-23 = AR - EFSA-216 AR - EFSA-216 PRI - EFSA habitual vitamin B 6 intake (mg/d) wo AR - HCNL-23 RDA - HCNL-23 AR - EFSA-216 PRI - EFSA habitual vitamin B 6 intake (mg/d) Figure 5. Habitual vitamin B 6 intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch or EFSA DRV. Version: 1. Page17 of 36

18 3.6 Folate/folic acid Table 14. The distribution (95%-CI) of habitual folate (excl. fortified foods) intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution folate (µg/d) mean P5 P25 P5 P75 P ( ) ( ) (22-239) (26-277) (33-321) ( ) ( ) (138-15) ( ) (28-218) ( ) ( ) Table 15. The distribution (95%-CI) of habitual folate (incl. fortified foods) intake in Dutch adults aged 19-5 years (DNFCS 27-21) wo Habitual intake distribution folate (µg folate-equivalent/d) mean P5 P25 P5 P75 P ( ) (17-193) ( ) (27-29) ( ) ( ) ( ) ( ) ( ) (22-231) ( ) ( ) Table 16. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual folate (excl. fortified foods) intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA). Ad interim Dutch reference values (214) EFSA's reference values (21-217) AR intake AR RDA intake = RDA AR intake AR RDA intake = RDA (µg/d) (%) (µg/d) (percentile) (µg/d) (%) (µg/d) (percentile) 11 7 th th 2 (7-14) 3 (64-74) 25 (32-44) 33 (79-87) wo 2 4 (35-43) 3 94 th (92-96) (73-8) th (97-99) Table 17. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual folate (incl. fortified foods) intakes, expressed as folate equivalents*, lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA) Ad interim Dutch reference values (214) EFSA's reference values (21-217) AR intake AR RDA intake RDA AR intake AR RDA intake RDA (µg/d) (%) (µg/d) (percentile) (µg/ d) (%) (µg/d) percentile) 2 11 (7-14) 3 62 th (56-66) (28-39) th (71-8) wo 2 32 (27-35) 3 89 th (86-92) (63-71) th (93-97) * Folate equivalents: 1 µg folate equivalent = 1 µg folate = 1,7 µg folic acid from fortified foods Version: 1. Page18 of 36

19 (excl. fortified foods) AR - HCNL-23 RDA - HCNL-23 AR - EFSA-214 PRI - EFSA habitual folate intake (µg folate-equivalent/d) - excl. fortified foods wo (excl. fortified foods) AR - HCNL-23 RDA - HCNL-23 AR - EFSA-214 PRI - EFSA habitual folate intake (µg folate-equivalent/d) - excl. fortified foods (incl. fortified foods) AR - HCNL-23 RDA - HCNL-23 AR - EFSA-214 PRI - EFSA habitual folate intake (µg folate-equivalent/d) - incl. fortified foods wo (incl. fortified foods) AR - HCNL-23 RDA - HCNL-23 AR - EFSA-214 PRI - EFSA habitual folate intake (µg folate-equivalent/d) - incl. fortified foods Figure 6. Habitual folate intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch or EFSA DRV. Excluding (left) or including (right) foods fortified with folic acid. Version: 1. Page19 of 36

20 3.7 Vitamin B 12 Table 18. The distribution (95%-CI) of habitual vitamin B 12 intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution vitamin B 12 (µg/d) mean P5 P25 P5 P75 P ( ) ( ) (4.-4.4) (5.-5.5) ( ) ( ) ( ) ( ) (3.-3.3) ( ) ( ) (6.2-7.) Table 19. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual vitamin B 12 intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA) and the adequate intake (AI). Ad interim Dutch reference values (214) EFSA's reference values (21-217) AR intake AR RDA intake = RDA AI intake = AI (µg/d) (%) (µg/d) (percentile) (µg/d) (percentile) 2 (-1) th (2-5) 4 23 th (16-25) wo 2 3 (1-4) th (12-2) 4 54 th (47-57) AR - HCNL-23 RDA - HCNL-23 AI - EFSA habitual vitamin B 12 intake (µg/d) wo AR - HCNL-23 RDA - HCNL-23 AI - EFSA habitual vitamin B 12 intake (µg/d) Figure 7. Habitual vitamin B 12 intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch or EFSA DRV. Version: 1. Page2 of 36

21 3.8 Vitamin C Table 2. The distribution (95%-CI) of habitual vitamin C intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution vitamin C (mg/d) mean P5 P25 P5 P75 P (98-17) (46-55) (71-8) (94-12) (119-13) ( ) (93-99) (41-48) (66-72) (88-94) ( ) ( ) Table 21. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual vitamin C intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA). Ad interim Dutch reference values (214) EFSA's reference values (21-217) intake intake = intake AR AR RDA RDA AR AR RDA intake = RDA (mg/d) (%) (mg/d) (percentile) (mg/d) (%) (mg/d) (percentile) th th 6 (8-14) 75 (2-29) 9 (36-46) 11 (58-67) wo 5 8 (6-11) th (28-35) 8 38 (34-41) th (51-58) AR - NCM-212 RDA - NCM-212 AR - EFSA-213 PRI - EFSA habitual vitamin C intake (mg/d) wo AR - NCM-212 RDA - NCM-212 AR - EFSA-213 PRI - EFSA habitual vitamin C intake (mg/d) Figure 8. Habitual vitamin C intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch or EFSA DRV. Version: 1. Page21 of 36

22 3.9 Vitamin D Table 22. The distribution (95%-CI) of habitual vitamin D intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution vitamin D (µg/d) mean P5 P25 P5 P75 P ( ) ( ) ( ) (3.7-4.) (4.6-5.) (6.2-7.) ( ) ( ) ( ) (2.8-3.) ( ) ( ) Table 23. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with percentile of habitual intake of vitamin D at the adequate intake (AI). Ad interim Dutch reference values (214) AI (µg/d) - 7 µg from skin production intake = AI (percentile) EFSA's reference values (21-217) AI (µg/d) - 7 µg from skin production intake = AI (percentile) 3 26 th (22-3) 8 99 th (98-99) wo 3 56 th (49-59) 8 1 th (1-1) AI - HCNL µg from skin production AI - EFSA µg from skin production habitual vitamin D intake (µg/d) wo AI - HCNL µg from skin production AI - EFSA µg from skin production habitual vitamin D intake (µg/d) Figure 9. Habitual vitamin D intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch or EFSA DRV. Version: 1. Page22 of 36

23 3.1 Vitamin E The vitamin E intake is presented as total vitamin E. Conversion factors are used to add up the different tocopherols. However, the dietary reference values have been expressed in another unit. The total vitamin E intake will be slightly higher than the intake of α- tocopherol (equivalents), but within total vitamin E, α-tocopherol is the largest source. Total vitamin E (NEVO): = mg α-tocoferol*1 + mg β-tocoferol*,4 + mg γ-tocoferol*,1 + mg δ- tocoferol*,1 α-tocoferol (EFSA): 1 mg all-rac-α-tocoferol =,5 mg RRR-α-tocoferol. α-tocoferol-equivalents (ad-interim Health Council): Vitamin E activity is shown as α-tocopherol. Only α-tocopherol in food and 2R-αtocopherol in food supplets contribute to vitamin E activity. The following conversion factors apply to supplets:,5 for all-rac-α-tocoferol,,455 for allrac-α-tocoferyl acetate and,91 for RRR-α-tocoferyl acetate. Table 24. The distribution (95%-CI) of habitual vitamin E intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution vitamin E (mg/d) mean P5 P25 P5 P75 P ( ) ( ) ( ) ( ) ( ) ( ) ( ) (7.-8.) ( ) ( ) ( ) ( ) Table 25. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual vitamin E intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA) and the adequate intake (AI). Ad interim Dutch reference values (214) EFSA's reference values (21-217) AR intake AR RDA intake = RDA AI intake = AI (mg/d) (%) (mg/d) (percentile) (mg/d) (percentile) 6 (-) 1 8 th (4-11) th (25-37) wo 5 (-) 8 8 th (5-12) th (37-5) Version: 1. Page23 of 36

24 AR - NCM-212 RDA - NCM-212 AI - EFSA habitual vitamin E intake (mg/d) wo AR - NCM-212 RDA - NCM-212 AI - EFSA habitual vitamin E intake (mg/d) Figure 1. Habitual vitamin E intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch or EFSA DRV. Version: 1. Page24 of 36

25 3.11 Vitamin K A difference between the dietary reference values of vitamin K is that the standard of EFSA has only been established for vitamin K 1 and the ad interim dietary standard of the Health Council has been established for both vitamin K 1 and K 2. Since 213 vitamin K values (total K 1 + K 2 ) are included in the Dutch nutrient database (NEVO-213) for a number of food groups only (i.e. vegetables, fruit, legumes and dairy products), the calculated vitamin K intake will therefore be an underestimation of the actual intake. The food groups for which vitamin K data are available are seen as the most important sources of vitamin K. The coverage ratio for vitamin K 1 is slightly lower than for total vitamin K (= K 1 +K 2 ). Table 26. The distribution (95%-CI) of habitual vitamin K intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution vitamin K (µg/d) mean P5 P25 P5 P75 P ( ) (43-62) (74-93) (14-124) ( ) (27-261) (97-112) (33-46) (59-72) (86-1) ( ) ( ) Table 27. The distribution (95%-CI) of habitual vitamin K 1 intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution vitamin K 1 (µg/d) mean P5 P25 P5 P75 P (92-113) (29-44) (54-71) (81-99) ( ) ( ) (81-98) (22-32) (44-56) (69-83) (13-124) ( ) Table 28. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with percentile of habitual intake of vitamin K and vitamin K 1 at the adequate intake (AI). Ad interim Dutch reference values (214) - vitamin K EFSA's reference values (21-217) - vitamin K 1 AI intake = AI AI intake = AI (µg/d) (percentile) (µg/d) (percentile) th (47-62) 7 34 th (24-4) wo 9 48 th (41-53) 7 44 th (38-51) Version: 1. Page25 of 36

26 Cumulative probability (%) (vit K) AI - IOM habitual vitamin K intake (µg/d) wo (vit K) AI - IOM habitual vitamin K intake (µg/d) (vit K 1 ) AI - EFSA habitual vitamin K 1 intake (µg/d) wo (vit K 1 ) AI - EFSA habitual vitamin K 1 intake (µg/d) Figure 11. Habitual intake distribution of total vitamin K (left) or vitamin K 1 (right) for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch DRV (left) or EFSA DRV (right). Version: 1. Page26 of 36

27 3.12 Calcium Table 28. The distribution (95%-CI) of habitual calcium intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution calcium (g/d) mean P5 P25 P5 P75 P ( ) (.6-.7) (.9-.9) ( ) ( ) ( ) (.9-1.) (.5-.6) (.7-.8) (.9-1.) ( ) ( ) Table 29. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual calcium intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA) and the adequate intake (AI). Ad interim Dutch reference values (214) EFSA's reference values (21-217) AI intake = AI AR intake AR RDA intake=rda (g/d) (percentile) (g/d) (%) (g/d) (percentile) 1 36 th (32-41).75/.86* 13 (11-16).95/1* 31 th (28-36) wo 1 57 th (54-61).75/.86* 26 (24-31).95/1* 51 th (48-56) * EFSA AR: years.86 g/d, 25 years.75 g/d; EFSA PRI: years 1 g/d, 25 years.95 g/d AI - HCNL-2 = PRI - EFSA-215 AR - EFSA yr. PRI - EFSA yr. AR - EFSA yr. PRI - EFSA yr.,5 1 1,5 2 2,5 habitual calcium intake (g/d) wo AI - HCNL-2 = PRI - EFSA-215 AR - EFSA yr. PRI - EFSA yr. AR - EFSA yr. PRI - EFSA yr.,5 1 1,5 2 2,5 habitual calcium intake (g/d) Figure 12. Habitual calcium intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch or EFSA DRV. Version: 1. Page27 of 36

28 3.13 Copper Table 3. The distribution (95%-CI) of habitual copper intake in Dutch adults aged 19-5 years (DNFCS 27-21) wo Habitual intake distribution copper (mg/d) mean P5 P25 P5 P75 P ( ) (.9-.9) ( ) ( ) ( ) ( ) ( ) (.7-.8) (.9-1.) (1.-1.1) ( ) ( ) Table 31. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual copper intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA) and the adequate intake (AI). Ad interim Dutch reference values (214) EFSA's reference values (21-217) AR intake AR RDA intake = RDA AI intake = AI (mg/d) (%) (mg/d) (percentile) (mg/d) (percentile).7 (-1).9 5 th (3-7) th (8-86) wo.7 2 (1-3).9 19 th (15-23) th (79-87) AR - NCM-212 RDA - NCM-212 AI - EFSA-215,5 1 1,5 2 2,5 habitual copper intake (mg/d) wo AR - NCM-212 RDA - NCM-212 AI - EFSA-215,5 1 1,5 2 2,5 habitual copper intake (mg/d) Figure 13. Habitual copper intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch or EFSA DRV. Version: 1. Page28 of 36

29 3.14 Iron Table 32. The distribution (95%-CI) of habitual iron intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution iron (mg/d) mean P5 P25 P5 P75 P ( ) ( ) (1.-1.5) ( ) ( ) ( ) (9.5-1.) ( ) ( ) ( ) ( ) ( ) Table 33. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual iron intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA). Ad interim Dutch reference values (214) EFSA's reference values (21-217) AR intake AR RDA intake = RDA AR intake AR RDA intake = RDA (mg/d) (%) (mg/d) (percentile) (mg/d) (%) (mg/d) (percentile) 1 11 th 36 th 7 (1-2) 9 (8-13) 6 (-) 11 (32-4) wo 1 57 (53-63) th (99-1) 7 5 (4-7) 16 1 th (1-1) AR - NCM-212 RDA - NCM-212 AR - EFSA-215 PRI - EFSA habitual iron intake (mg/d) wo AR - NCM-212 RDA - NCM-212 AR - EFSA-215 PRI - EFSA habitual iron intake (mg/d) Figure 14. Habitual iron intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch or EFSA DRV. Version: 1. Page29 of 36

30 3.15 Magnesium Table 34. The distribution (95%-CI) of habitual magnesium intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution magnesium (mg/d) mean P5 P25 P5 P75 P (39-46) ( ) (33-346) (384-4) ( ) ( ) (31-314) (27-221) ( ) (297-31) ( ) (42-426) Table 35. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with the percentile of habitual intake of magnesium at the adequate intake (AI). Ad interim Dutch reference values (214) EFSA's reference values (21-217) AI intake = AI AI intake = AI (mg/d) (percentile) (mg/d) (percentile) th (27-34) th (27-34) wo th (31-39) 3 47 th (43-52) AI - NCM-212 = EFSA-215 AI - EFSA habitual magnesium intake (mg/d) wo AI - NCM-212 AI - EFSA habitual magnesium intake (mg/d) Figure 15. Habitual magnesium intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch or EFSA DRV. Version: 1. Page3 of 36

31 3.16 Phosphorus Table 36. The distribution (95%-CI) of habitual phosphorus intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution phosphorus (g/d) mean P5 P25 P5 P75 P ( ) ( ) ( ) ( ) (2.-2.1) ( ) ( ) (.9-1.) ( ) ( ) ( ) ( ) Table 37. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual phosphorus intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA) and the adequate intake (AI). EFSA's reference values Ad interim Dutch reference values (214) (21-217) AR intake AR RDA intake = RDA AI intake = AI (g/d) (%) (g/d) (percentile) (g/d) (percentile).45 (-).6 th (-).55 th (-) wo.45 (-).6 th (-).55 th (-) AR - NCM-212 RDA - NCM-212 AI - EFSA habitual phosphorus intake (g/d) wo AR - NCM-212 RDA - NCM-212 AI - EFSA habitual phosphorus intake (g/d) Figure 16. Habitual phosphorus intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch or EFSA DRV. Version: 1. Page31 of 36

32 3.17 Potassium Table 38. The distribution (95%-CI) of habitual potassium intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution potassium (g/d) mean P5 P25 P5 P75 P (3.8-4.) ( ) ( ) (3.8-4.) ( ) ( ) ( ) (2.-2.2) ( ) (2.9-3.) ( ) ( ) Table 39. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with the percentile of habitual intake of patassium at the adequate intake (AI). Ad interim Dutch reference values (214) EFSA's reference values (21-217) AI intake = AI AI intake = AI (g/d) (percentile) (g/d) (percentile) th (26-34) th (26-34) wo th (53-62) th (76-83) AI - NCM-212 = EFSA-216 AI - EFSA habitual potassium intake (g/d) wo AI - NCM-212 AI - EFSA habitual potassium intake (g/d) Figure 17. Habitual potassium intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch or EFSA DRV. Version: 1. Page32 of 36

33 3.18 Selenium Table 4. The distribution (95%-CI) of habitual selenium intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution selenium (µg/d) mean P5 P25 P5 P75 P ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Table 41. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual selenium intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA) and the adequate intake (AI). EFSA's reference values Ad interim Dutch reference values (214) (21-217) AR intake AR RDA intake = RDA AI intake = AI (µg/d) (%) (µg/d) (percentile) (µg/d) (percentile) 35 3 (1-4) 6 69 th (64-74) 7 89 th (85-92) wo 3 8 (5-11) 5 84 th (78-88) 7 1 th (99-1) AR - NCM-212 RDA - NCM-212 AI - EFSA habitual selenium intake (µg/d) wo AR - NCM-212 RDA - NCM-212 AI - EFSA habitual selenium intake (µg/d) Figure 18. Habitual selenium intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch or EFSA DRV. Version: 1. Page33 of 36

34 3.19 Zinc The EFSA dietary standard of zinc is derived for different categories of phytate intake. There are no data available about the phytate intake in the Netherlands. Therefore, in this comparison, the phytate intake is based on the average of the four categories tioned by EFSA and the associated average requiret for zinc. Table 42. The distribution (95%-CI) of habitual zinc intake in Dutch adults aged 19-5 years (DNFCS 27-21). wo Habitual intake distribution zinc (mg/d) mean P5 P25 P5 P75 P ( ) (8.3-9.) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Table 43. Percentages (95%-CI) of adults aged 19-5 years (DNFCS 27-21) with habitual zinc intakes lower than the average requiret (AR) and percentile of intake at the recomded daily allowance (RDA). Ad interim Dutch reference values (214) AR intake AR RDA intake = RDA (mg/d) (%) (mg/d) (percentile) 6 (-) 9 7 th (5-1) wo 5 (-1) 7 1 th (7-12) EFSA's reference values (21-217) by level of phytate consumption AR intake AR RDA intake = RDA (mg/d) (%) (mg/d) (percentile) phytate 3 mg (1-2) th (8-14) wo (2-5) th (12-19) phytate 6 mg (7-13) th (37-46) wo (14-2) th (44-53) phytate 9 mg 11 3 (26-34) th (72-79) wo (36-45) 11 8 th (75-83) phytate 12 mg (53-62) th (91-95) wo (61-71) th (92-96) Version: 1. Page34 of 36

35 (AR) AR - EFSA mg phytate AR - EFSA mg phytate AR - EFSA mg phytate AR - EFSA mg phytate AR - NCM habitual zinc intake (mg/d) (PRI) PRI - EFSA mg phytate PRI - EFSA mg phytate PRI - EFSA mg phytate PRI - EFSA mg phytate RDA - NCM habitual zinc intake (mg/d) wo (AR) AR - EFSA mg phytate AR - EFSA mg phytate AR - EFSA mg phytate AR - EFSA mg phytate AR - NCM habitual zinc intake (mg/d) wo (PRI) PRI - EFSA mg phytate PRI - EFSA mg phytate PRI - EFSA mg phytate PRI - EFSA mg phytate RDA - NCM habitual zinc intake (mg/d) Figure 19. Habitual zinc intake distribution for Dutch adult (blue) and wo (red) aged 19-5 years (DNFCS 27-21) in comparison with the ad interim Dutch and EFSA AR (top) or current Dutch RDA and EFSA PRI (bottom). Version: 1. Page35 of 36

36 4. References 1. Verkaik-Kloosterman, J., Estimation of micronutrient intake distributions. Developt of methods to support food and nutrition policy making, in Humane voeding en epidemiologie. 211, Wageningen University: Wageningen. 2. EFSA. Dietary reference values and dietary guidelines. [cited June]; Available from: 3. Carriquiry, A.L., Assessing the prevalence of nutrient inadequacy. Public Health Nutr, (1): p Kromhout, D., Ad-interim voedingsnor - brief aan Drs. M. Sonnema Ministerie van VWS Van Rossum, C.T.M., et al., Dutch National Food Consumption Survey Diet of children and adults aged 7 to 69 years. 211, RIVM: Bilthoven. 6. RIVM, NEVO-online versie 213/ , RIVM: BIlthoven. 7. RIVM. VCP 27-21, 7-69 jaar. 211 [cited June]; Available from: lconsumptiepeilingen/vcp_basis_7_69_jaar_27_ Dekkers, A.L., et al., SPADE, a new statistical program to estimate habitual dietary intake from multiple food sources and dietary supplets. J Nutr, (12): p Version: 1. Page36 of 36