Outline of presentation
Macronutrient Requirements in South
East Asia (SEA)
Focus on Protein Requirements of Infants and Young
Children
Dietary recommendations in SEA
Chronology of development
Harmonization of SEA RDAs
Seminar on Re-Assessing Macronutrient Needs Requirement, Quality and Health Impact
Latest protein requirement recommendations in
SEA
Acceptable Macronutrient Distribution Ranges
Health implications
Concluding remarks
Geok Lin Khor PhD
Emeritus Professor, Universiti Putra Malaysia
3-4 May 2017
Bangkok
Khor GL 2017
Chronology of RDA development in SEA
been a long-standing activity of FAO and WHO perhaps the
longest existing technical activity. The first FAO Expert Committee
on requirements met in Washington, DC, in 1949, only four years
Vietnam (V)
1996
Protein requirements. Report of the FAO Committee. Rome,
Food and Agriculture Organization of the United Nations, 1957
(FAO Nutritional Studies, No. 16).
Protein requirements. Report of a Joint FAO/WHO Expert
Group, Geneva, World Health Organization, 1965 (WHO
Technical Report Series, No. 301).
Energy and protein requirements. Report of a Joint FAO/WHO
ad hoc Expert Committee. Geneva, World Health Organization,
1973 (WHO Technical Report Series, No. 522).
3
V 2007
Indonesia (I)
1994
Thailand (T)
1989
T 2003
2007)
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V 2016
I 2014
Singapore (S)
1988
Philippines (P)
1941
1947
1953
1960 1965
1970
1940
1960
1970
Malaysia (M)
1975
M 2005
P 1989
1975
1980
1985
1990
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P 2002
1995
2000
M 2017
P 2015
2005
2010
2015
4
Current Status of Recommended Dietary Allowances in Southeast Asia: A
Regional Overview. E-SiongTee Nutrition Reviews, 56: SIO-S18 , 1998
RDA Harmonization in SEA
Table 2. RDAs in selected Southeast countries: Protein
1997: ILSI SEA called for a better understanding of RDAs in
the region
1998: Agreed on a framework for harmonization
The goal of the harmonized
RDAs was to obtain consensus
among the SEA countries on:
1. Definition of RDAs for SEA
2. Minimum list of core nutrients
3. Population age groupings
4. Reference body weights
Protein quality: NPU = 70 for Malaysia, Philippines, Singapore; protein usage = 60 for
Vietnam; digestibility of 85% for Thailand;
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Figure: Reference body weights: SEA-RDAs (2005) vs FAO/WHO (2002)
2005
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Table 2.1 Population groupings and reference body weights within the SEA-RDA framework
Population Groups
Reference Body Weight (Kg)
Age categories
Reference body weights for infants and children up to 9 years
based on the NCHS 50th percentile weights for male; reference
weights for older children assumed between young adults and
7-9 years.
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The SEA-RDA population groupings are consistent with those in
FAO/WHO (2002)
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SEA RDAs (2005) Recommendation for Protein Requirement (based on
1985 FAO/WHO/UNU recommendations and *reference body weights)
Protein (gram per day)
High quality protein
diet
Adjusted for 80%
protein quality
Adjusted for 70%
protein quality
0-5m
6-11m
11
14
1-3yrs
4-6yrs
7-9yrs
16
21
27
20
26
34
23
29
39
Boys yrs
10-12
13-14
15
16-18
34
45
45
49
42
56
56
62
48
64
64
71
Girls yrs
10-12
13-14
15
16-18
35
41
41
40
44
51
51
50
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50
58
58
57
* Shown in previous slide
Among the primary objectives of
this Report was :
To review, revise and update
protein and amino acid
requirements for all age groups,
and for women during pregnancy
and lactation
Protein Requirements of infants and children
KG Dewy, G Beaton, C Fjel, B Lönnerdal and P Reeds
Eur J Clin Nutr 50 (Suppl 1): S93-S95, 1996
Published in Eur J Clin Nutr 50 (Suppl 1): 1996
NS Scrimshaw, JC Waterlow,
B Schürch (Editors)
Dewey et al. (1996) re-examined
the assumptions and evidence
for the derivation of factorial
estimates of protein
requirements for the breastfed
infant from birth to 6 months
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Report of a Joint FAO/WHO/UNU Expert
Consultation. World Health Organization
Tech
Rep Ser 935. WHO: Geneva, 2007.10
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GL 2017
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Energy and Protein Requirements
Proceedings of the International Dietary Energy Consultative
Group (IDECG) Workshop, 1994;
Energy and protein requirements
knowledge and field
experience have now moved far
enough forward that a review of
the expert opinion
11
FAO/WHO/UNU 1985
IDECG, 1996
1.
Estimated protein intakes of
breastfed infants, based on
total N x 6.25
A substantial proportion (20-27%)
of human milk N is from nonprotein N (NPN): urea, creatine ,
choline, nucleotides.
2.
Used NCHS reference for
body weights of infants , but
majority of whom were
bottle-fed
Estimated protein intake from
exclusively breastfed infants aged
1-6 months (Butte et al, 1984;
Heinig et al, 1993)
3.
Calculated protein intake
from breast milk from 2
studies
Under estimation owing to loss of
insensible water not accounted
for during test weighing of infant
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Dewey et al. (1996) suggested that the requirement
values for breastfed infants should be 10 25% lower
than those in the 1985 report.
Safe level of protein intake for infants less than 6
months of age
2007
WHO/FAO/UNU
1985
This was achieved by adopting a lower maintenance
value (90 mg nitrogen/kg per day) and replacing the 50%
increase in the protein allowance for growth to cover
day-to-day variation with an increase in the coefficient
of variation for growth.
The growth rates assumed were derived from the WHO
1994 breastfed pooled dataset (WHO 1994)
The efficiency of utilization of dietary protein for growth
was again assumed to be 70%.
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Chronology of RDA development in SEA
Vietnam (V)
1996
V 2007
Indonesia (I)
1994
Thailand (T)
1989
T 2003
V 2016
I 2014
Singapore (S)
1988
Philippines (P)
1941
1947
1953
1960 1965
1970
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15
1940
1960
1970
Malaysia (M)
1975
M 2005
P 1989
1975
1980
1985
1990
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P 2002
1995
2000
M 2017
P 2015
2005
2010
2015
16
Latest recommendations for protein
requirement in SEA (g/day)
Indonesia 2014
Philippines 2015
Vietnam 2016
References for body weight and height of children in latest
dietary recommendations in SEA
Malaysia 2017
0-6 mo
12
0-5 mo
9m 8f
0-5 mo
11
0-5 mo 8
7-12
18
6-11
17 m 15 f
6-8
18
6-11
10
9-11
20
1-3 yrs
26
1-2 yrs
18 m 17 f
1-2 yrs
20 m 19 f
1-3 yrs
12
4-6
35
3-5
22 m 21 f
3-5
25
4-6
16
7-9
49
6-9
30 m 29 f
6-7
33 m 32 f
7-9
23
8-9
40
10-12
56 m 60 f
10-12
43 m 46 f
10-11
50 m 48 f
10-12
30 m 31 f
13-15
72 m 69 f
13-15
62 m 57 f
12-14
65 m 60 f
13-15
45 m 42 f
16-18
66 m 59 f
16-18
73 m 61 f
15-19
74 m 63 f
16-19
51 m 42 f
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The reference weights for infants and children up to 5 years are
the median values of the WHO Multicentre Growth Reference
Study Group (2006) for weight-for-age to achieve growth
potential.
The median weight-for-height and median height-based BMI
were used for the 6-9 years and 10-18 years, respectively, using
the median height of Filipino child with normal nutritional
status (2013, NNS).
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References for body weight and height of children in
latest dietary recommendations in SEA
Country
References
Indonesia Median body
(2014)
weight and height
of Indonesian with
normal nutritional
status
Riset Kesehatan Dasar
(Riskesdas) 2007 and 2010
Malaysia
(2017)
WHO weight-for-age median
Based on NHMS 2015:
Equivalent to WHO BMI-for-age
median
Equivalent to BMI=22.0
0-9 years:
10-18 years:
Adults
Acceptable Macronutrient Distribution
Range (AMDR)
19
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Acceptable Macronutrient Distribution Range
Fats, carbohydrates, and proteins can substitute for one
energy
needs.
References
Protein Total Fat Carbohydrate
Percent of total energy
Acceptable ranges of intake for each of these energy sources.
termed Acceptable Macronutrient Distribution Ranges
(AMDRs), are defined as a range of intake for a particular
energy source that is associated with reduced risk of chronic
diseases, while providing adequate intakes of essential
nutrients.
These ranges are also based on adequate energy intake and
physical activity to maintain energy
IOM (2006)
1-3 years
4-18 years
Adults
5-20
10-30
10-35
30-40
25-35
20-35
45-65
45-65
45-65
EFSA (2012)
10-35
20-35
45-65
WHO (2013) 10-15
20-35
50-75
2006
(IOM, 2006)
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Acceptable Macronutrient Distribution Range
Protein
Total Fat
Carbohydrate
Percent of total energy
Philippines (2015)
0-5 mo
6-11 mo
1-2 yrs
3-18 yrs
5
8-15
6-15
6-15
40-60
30-40
25-35
15-30
35-55
45-62
50-69
55-79
-5 months was based on actual ratios of protein EARs
and energy requirements;
For older infants and children upper limit of 15% was in consideration
of Koletzko et al (2009) - infants receiving follow-on formula with
protein content at 17.6% of energy had increased risk of OW & obesity
in thefirst
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2013
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Macronutrient distribution of dietary intake of rural and
urban children aged 0.5 - 12 years (SEANUTS, 2013)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
35.6
33.2
33.7
32
Fat
52
12.5
Indonesia
n=7211
48.1
50.7
53.4
Carbohydrate
Protein
18.6
Vietnam
n=2872
15.6
Thailand
n=3119
14.6
Malaysia
n=3542
WHO (2013) AMDR: 10-15% protein; 20-35% fat; 50-75% carbohydrate
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Scaling up nutrition (SUN). SUN Movement annual progress report. September
2015 (http://scalingupnutrition.org/wp-content/uploads/2015/10/SUN
Macronutrient intake patterns of young
children in SEA: health implications
Southeast
Asia
Cambodia
Indonesia
Myanmar
Philippines
Vietnam
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Stunting in children < 5 years in SEA in 2015
50
45
40
35
30
Global stunting trend 1990- 2015
39.6
35.7
32.7
25
Lao PDR 43.8
Cambodia 40.9
29.4
26.2
20
23.2
Malaysia 17.1
Thailand 16.3
15
10
5
0
Indonesia 36.4
Myanmar 35.1
Philippines 30.3
Vietnam 23.3
Brunei
1990
1995
2000
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2005
2010
2.3
2015
27
Childhood stunting: a global perspective
M de Onis and F Branca. Maternal & Child Nutrition 2016, 12
(Suppl. 1): 12 26
In most SEA countries, stunting and underweight remain
the main forms of malnutrition in children below five
50%
45
40
35
30
25
20
15
10
5
0
wasting
stunting
underweight
overweight
Stunting is a chronic form of undernutrition that results from
some combination of prenatal and postnatal linear growth
faltering.
Infants who are born with a low birth weight are
particularly vulnerable to frequent infections and
malnutrition, which result in linear growth faltering and
poor cognitive development.
The severe irreversible physical and neurocognitive damage
that accompanies stunted growth is a major barrier to human
development.
(WHO Health
Statistics,
2016; Malaysia NHMS 2016)29
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CAUSES
WHO Childhood Stunting Conceptual Framework
(Stewart et al., 2013)
Household & Family
Factors
Inadequate Complementary Feeding
Poor
quality
foods
*Poor
micronutrient
quality
*Low
dietary
diversity
*Low
intake of
animal
source
foods
Breastfeeding Infection
Inadequate Food &
practices
water
safety
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The Impact of Nutritional Interventions beyond the First 2 Years
of Life on Linear Growth: A Systematic Review and Meta-Analysis
Roberts, JL and AD Stein; Adv Nutr 2017;8:323 36.
The aim of this analysis was to evaluate the effectiveness of
several nutrition-based interventions, specifically iron, zinc,
calcium, iodine, vitamin A, multiple (> 2) micronutrients, protein,
and food, at improving growth in children above 2 y of age.
Zinc (mean effect size: 0.15; 95% CI: 0.06, 0.24), vitamin A
(0.05; 95% CI: 0.01, 0.09), multiple micronutrients (0.26; 95%
CI: 0.13, 0.39), and protein (0.68; 95% CI: 0.30, 1.05) had
significant positive effects on linear growth, with baseline
height-for-age z score as a significant inverse predictor of the
effect size.
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Iron, calcium, iodine, and food-based interventions had no
significant effect on growth.
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Dietary reference Intakes (DRIs): Acceptable
Macronutrient Distribution Ranges
Range (percent of energy)
Children
1-3 y
Adults
Dietary fats
Goals (% total
energy )
Total fat
15-30
Saturated FA s
AMDR of Fatty Acids
N-6 PUFA
(linoleic acid)
N-3 PUFA
(alpha- linolenic acid)
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Children
4-18 y
Ranges of population
nutrient intake goals
(WHO, 2013)
33
PUFAs
< 10
6-10
5-10
N-6 PUFAs
5-8
0.6-1.2
N-3 PUFAs
1-2
Trans FA
<1
MUFAs
By difference
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Association between maternal intake of n-6 to n-3 fatty acid
ratio during pregnancy and infant neurodevelopment at 6
months of age: results of the MOCEH cohort study
Hyejin Kim et al Nutrition J 16:23, 2017
The recommended dietary n-6/n-3 PUFAs ranges from 5:1 15:1 in
Europe and from 4:1 10:1 in the United States and South Korea
Conclusions: Both the maternal dietary n-6/n-3 PUFAs and
LA/ALA intake were significantly associated with the mental
and psychomotor development of infants at 6 months of age.
Thus, maintaining low n-6/n-3 PUFAs and LA/ALA is encouraged
for women during pregnancy.
Recommended Nutrient Intakes for Malaysia 2017
General population (% of total energy)
N-6 PUFA (linoleic acid)
3-7
N-3 PUFA (ALA+EPA+DHA)
0.3 1.2
Saturated fatty acids
Less than 10
MUFA
Trans fatty acids
12-15
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Less than 1
35
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Recommendations
In both adults and children, WHO
recommends reducing the intake of
*free sugars to less than 10% of total
energy intake (strong
recommendation).
the intake of free sugars to below 5% of
total energy intake (conditional
recommendation).
2015
(2015)
*Free sugars include monosaccharides and disaccharides
added to foods and beverages by the manufacturer, cook or
consumer, and sugars naturally present in honey, syrups, fruit
juices and fruit juice concentrates.
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Mei Chung, Tufts Univ. ILSI Regional Symp Sugar and Sweeteners, Oct 2015,
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Southeast Asia : wide ranging economic and health status
Countries in SEA
according to income
status
Concluding remarks
Singapore
39
Life expectancy at birth
(2015)
Years
Male
Female
55,150
80
86
Brunei
37,320
77
81
Malaysia Upper middle
11,120
73
77
Thailand
5,780
71
78
Indonesia Low middle
3,630
67
71
Philippines
3,500
65
72
Vietnam
1,890
71
81
Lao PDR
1,660
65
68
Myanmar
1,270
64
68
1,020
67
71
Cambodia
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High
GNI per capita
USD (World Bank,
2015)
Low
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(WHO 2014; 2015)
40
Challenges in addressing high prevalence of
stunting in children
Information Gaps in SEA
Evidence of dietary intake of children meeting the
recommended quantity and quality of protein?
Evidence of health benefits in infants and young children
provided with the recommended n-6/n-3 PUFAs ratios?
Evidence of the applications of the Acceptable
Macronutrient Distribution Range values in improving the
nutritional status of young children
Gaps in DRI development in the region
- Recommendations of nutrient requirements are not available or
outdated in some countries Khor GL 2017
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Factorial values for infant protein requirements and growth for breastfed
infants at difference stages of lactation
assumption that human milk from a healthy well-nourished mother can
support the protein requirements for infants for the first 6 months of life.
2007
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