NORDIC NUTRITION RECOMMENDATIONS 2023

ABOUT THE NNR2023 PROJECT

The NNR collaboration

The Nordic Nutrition Recommendations (NNR) is an international collaboration among health and food authorities in Denmark, Finland, Iceland, Norway, and Sweden that was initiated more than 40 years ago. A major outcome of the collaboration has been a regular update of dietary reference values (DRVs). In the last edition, general advice on food-based dietary guidelines (FBDGs) was also included (Nordic Council of Ministers 2014). Each updated edition serves as science advice to the national authorities who establish country specific recommendations. Thus, NNR has constituted the scientific basis for national DRVs and FBDGs. In addition, NNR has served as a key scientific foundation for national food and health policies, food labelling, taxes and regulations, education, food and nutrition surveillance and research. The Baltic countries have used previous editions of NNR as a scientific background for their national DRVs, FBDGs and health policies. For the first time, representatives from the Baltic health authorities have participated as observers in the NNR2023 Committee.

The pre-project

Since the first publication in 1980, NNR has been updated every 8-10 years. The leadership and organisation for updating the NNR has rotated among the health and food authorities in the Nordic countries. At a meeting in Reykjavik in September 2016, the Working Group on Food, Diet and Toxicology (NKMT) under the auspices of the Nordic Committee of Senior Officials for Food Issues (ÄK-FJLS Livsmedel) decided to update the fifth edition of NNR and invited the Norwegian Directorate of Health to take on the task of administratively organise a sixth edition of the NNR. The health and food authorities in the Nordic countries established the following working group to assist in the development of a project plan for the new edition:

Denmark: Ellen Trolle, Technical University Denmark, Kgs. Lyngby, Rikke Andersen, Technical University Denmark, Kgs. Lyngby, and Lisa von Huth Smith, Danish Health Authority, Copenhagen

Finland: Sirpa Kurppa, Natural Resources Institute Finland, Helsinki, Heli Kuusipalo, Finish Institute for Health and Welfare, Helsinki, Ursula Schwab, University of Eastern Finland, Kuopio Campus, and Katja Borodulin, Age Institute, Helsinki

Iceland: Inga Þórsdóttir, University of Iceland, Reykjavík, Þórhallur Ingi Halldórsson, University of Iceland, Reykjavík, Gígja Gunnarsdóttir, Directorate of Health, Reykjavik, and Sigríður Lára Guðmundsdóttir, University of Iceland, Reykjavík

Norway: Rune Blomhoff (head of pre-project), University of Oslo, Oslo, Helle Margrete Meltzer, Norwegian Institute of Public Health, Oslo, and Sigmund Anderssen, Norwegian School of Sport Sciences, Oslo

Sweden: Hanna Eneroth, The Swedish Food Agency, Uppsala, Eva Warensjö Lemming, The Swedish Food Agency, Uppsala, and Marita Friberg, Public Health Agency, Stockholm

Based on funding from the Nordic Council of Ministers, the pre-project working group and the health and food authorities in the Nordic countries developed a project plan. In February 2018, the Norwegian Directorate of Health submitted the project plan to the Nordic Council of Ministers. Based on feedback from the Nordic Council of Ministers, an updated description of the project (NNR2023) was accepted and funded by the Nordic Council of Ministers for Fisheries, Aquaculture, Agriculture, Food and Forestry (MR-FJLS).

The major milestones in the accepted project description were:

Update dietary reference values for energy, macro- and micronutrients
Develop an evidence-based platform for national food-based dietary guidelines
Develop an evidence-based platform for integration of environmental sustainability into food-based dietary guidelines

The inclusion of milestones 2 and 3 represents a substantial extension from previous editions of NNR which focused on updating dietary reference values for energy, macro- and micronutrients (milestone 1).

Funding of the NNR project

The NNR project is funded by the Nordic Council of Ministers (NCM) and the food and health authorities in Denmark, Finland, Iceland, Sweden, and Norway. The following organs within the NCM, each with their respective mandates, have funded the project:

Ministers for Co-operation (MR-SAM)
Nordic Council of Ministers for Fisheries, Aquaculture, Agriculture, Food and Forestry (MR-FJLS)
Nordic working group for Healthy, Safe and Sustainable Diet (HSSD)

In kind contributions were substantial from the authors of this report and their affiliations.

NNR project period and project plan

The original project period was from January 2019 to December 2022. Due to delays during the COVID-19 pandemic, the delay in publication of the IPCC synthesis report from UN (IPCC 2023), and the extensive work related to preparing the background papers, the Nordic Council of Ministers decided to extend the project period to June 2023 based on an application from the NNR Committee. Some previous documents and background papers refer to the present NNR project as the NNR2022 project due to its originally planned delivery date. In this report we have corrected this and refer to the present NNR project as the NNR2023 project.

Based on the project description, the NNR Committee developed a project plan for project organization. The project plan also included general principles and methodologies for the project (Christensen et al. 2020). During the project period, the project plan and process has been developed further in collaboration with the Nordic Council of Ministers. The text in this report reflects the final description of the project by the NNR2023 Committee. During the project period, the Nordic Committee of Senior Officials for Fisheries, Aquaculture, Agriculture, Food and Forestry (EK-FJLS Executive and and EK-FJLS Foods) and the Healthy, Safe and Sustainable Diet (HSSD) working group were informed about project status and guided the development of the project.

Estonia, Latvia and Lithuania are associated members of Nordic Council of Ministers, and they have previously used NNR editions as the main source for their national DRVs and FBDGs. Thus, it was decided that these countries should be invited to participate in the project. Specifically, the health authorities in Estonia, Latvia and Lithuania were invited to participate in the NNR Committee with one observer each.

Organization of the NNR2023 project

The NNR2023 project is commissioned by the Nordic Council of Ministers. The Norwegian Directorate of Health, Oslo, Norway administered the NNR2023 project. Members of the Steering Committee and the NNR2023 Committee were recruited by the Nordic health and food authorities.

NNR2023 Steering Committee

The responsibilities of the Steering Committee were to approve the budget, set the criteria for conflict of interest, and evaluate the declarations of conflict of interest for the NNR2023 Committee. The Steering Committee regularly approved the progress and status reports from the NNR2023 Committee.

Head of Steering Committee: Henriette Øien, The Norwegian Directorate of Health, Oslo, Norway
Satu Männistö, Finnish Institute for Health and Welfare, Helsinki, Finland
Hólmfrídur Þorgeirsdóttir, Directorate of Health, Reykjavík, Iceland
Ulla-Kaisa Koivisto Hursti, Swedish Food Agency, Uppsala, Sweden
Anne Pøhl Enevoldsen/Else Molander, Danish Veterinary and Food Administration, Glostrup, Denmark

NNR2023 Committee

The NNR2023 Committee has been responsible for organizing and implementing the NNR2023 project and publishing the final NNR2023 report. The NNR2023 Committee has also been responsible for appointing the Scientific Advisory Group, the NNR Systematic Review Centre, background paper authors, referees, and for approving any conflict-of-interest forms for involved experts. The project organization is described in detail in Christensen et al. (Christensen et al. 2020).

Head of Committee:

Rune Blomhoff, University of Oslo and Oslo University Hospital, Oslo, Norway

NNR Committee members:

Ellen Trolle, Technical University of Denmark, Kgs. Lyngby, Denmark
Rikke Andersen, Technical University of Denmark, Kgs. Lyngby, Denmark
Maijaliisa Erkkola, University of Helsinki, Helsinki, Finland
Ursula Schwab, University of Eastern Finland, Kuopio Campus, Finland
Þórhallur Ingi Halldórsson, University of Iceland, Reykjavík, Iceland
Inga Þórsdóttir, University of Iceland and landspitali, Reykjavík, Iceland
Helle Margrete Meltzer, Norwegian Institute of Public Health, Oslo, Norway
Jacob Juel Christensen, University of Oslo, Oslo, Norway
Eva Warensjö Lemming, The Swedish Food Agency and Uppsala University, Uppsala, Sweden
Hanna Eneroth, The Swedish Food Agency, Uppsala, Sweden

Observers:

Tagli Pitsi, National Institute for Health Development, Tallinn, Estonia
Inese Siksna, Institute of Food Safety, Animal Health and Environment, Riga, Latvia/Lāsma Pikele, The Ministry of Health of the Republic of Latvia, Riga, Latvia
Almantas Kranauskas, Ministry of Health, Vilnius, Lithuania (until Dec. 2021), Ieva Gudanaviciene, Ministry of Health, Vilnius, Lithuania (from Dec. 2021)
Bjørg Mikkelsen, Food Department at Faroese Food and Veterinary Authority, Faroe Islands

Project administration:

Scientific project secretary: Ane Sørlie Kværner (11.02.19-01.07.19), Anne Høyer-Lund (01.11.19-30.06.23), Norwegian Directorate of Health, Oslo, Norway
Scientific advisor: Erik Kristoffer Arnesen (01.02.23-30.06.23), University of Oslo and the Norwegian Directorate of Health, Oslo, Norway

NNR2023 Scientific Advisory Group

The NNR2023 Committee recruited a Scientific Advisory Group after consultation with the Steering Committee. The group consisted of international leading scientists with experience in developing DRVs and FBDGs for national authorities or health organizations. The group has advised on principles and methodologies, they have given advice on general scientific issues related to the project, and peer-reviewed several background papers and the final NNR2023 report. The Scientific Advisory Group consisted of the following scientists:

Amanda MacFarlane, Agriculture, Food, and Nutrition Evidence Center, Texas A&M University System, Fort Worth TX, US
Joseph Lau, Center for Evidence Synthesis in Health, Brown University School of Public Health, US
Susan Fairweather‐Tait, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
Joao Breda, Head WHO European Office for Prevention and Control of Noncommunicable Diseases & a.i. Programme Manager Nutrition, Physical Activity and Obesity, Division of Noncommunicable Diseases and Promoting Health through the Life-course, Copenhagen, Denmark
Dominique Turck, Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Lille University Jeanne de Flandre Children's Hospital and Faculty of Medicine, Lille, France | Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France
Giota Mitrou, World Cancer Research Fund International, London, UK.
Wulf Becker, Uppsala University, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, Sweden

NNR2023 Systematic Review Centre

As the NNR2023 project aimed to develop de novo qualified systematic reviews (SRs), an independent Systematic Review Centre (SR Centre) was funded by the project. The following team members were recruited by the NNR2023 Committee based on competence and previous experience in developing SRs:

Agneta Åkesson, Karolinska Institutet, Sweden (SR Centre leader)
Christel Lamberg-Allardt, University of Helsinki, Finland.
Erik Kristoffer Arnesen, University of Oslo, Norway
Linnea Bärebring, University of Gothenburg, Sweden
Bright I. Nwaru, University of Tampere/University of Gothenburg, Finland/Sweden
Jutta Dierkes, University of Bergen, Norway
Birna Þórisdóttir, University of Iceland, Reykjavik, Iceland
Alfons Ramel, University of Iceland, Reykjavik, Iceland
Fredrik Söderlund, Karolinska Institutet, Sweden

Recruitment of other experts

Several hundred experts and scientists have contributed to the NNR2023 project. Two hundred and thirty one scientists have been recruited as authors, peer-reviewers and members of reference groups for the development of background papers. All scientists are acknowledged in each of the papers and in Appendix 1. The experts were appointed by the NNR2023 Committee based on a public call and after careful evaluation of their competence, experience and conflict of interest related to the tasks. To supplement the call, some experts were also recruited after invitation from the NNR2023 Committee. A fair distribution of experts among the Nordic countries was sought when appointing experts. In addition, a large number of scientists have also contributed with important input through 59 public consultations. Their names and input as well as the responses from the NNR2023 Committee will be published in a separate report.

Handling of conflict of interest and bias of experts involved

Almost all scientists may have some sort of direct or indirect conflict of interest. Conflict of interest may arise due to the role of the institution where the scientist is employed, external funding to the institution or the scientist, or to personal economic interests, voluntary activities and memberships, or other personal biases. All scientists must compete for internal and external resources for scientific activities. The external sources that fund most research span from national research funds that distribute resources from governmental budgets to patient or interest organizations (e.g., cancer, heart or diabetes funds) and commercial entities (e.g., pharmaceutical industry and food producers). Furthermore, governmental funds, including those resources distributed through the European Union and national research councils, often demand collaboration with commercial companies. While industry-sponsored research is a large part of modern medical and nutrition science, it is essential that all such ties are declared and openly available. Scientists with strong ties to industry or ideological organizations have been excluded from serving as experts.

The NNR2023 project is organised with several “checks and balances” (Christensen et al. 2020) to reduce the risk of such influence of biases and to minimize the influence of innate bias of the scientists involved. Some important features of this system with “checks and balances” were that:

the project was split into discrete parts done by separate experts to reduce experts influencing multiple parts of the process
the project involved many experts from several nutrition and non-nutrition sub-disciplines
background papers were peer-review by independent scientists
background papers and the final NNR2023 report were submitted to public consultation
several papers were also developed based on workshops and consultations with reference groups
the international Scientific Advisory Group peer-reviewed and advised on principles and methodologies and the final NNR2023 report

The central goal of the conflict-of-interest policies is to protect the integrity of professional judgement and to preserve public trust. The disclosure of individual and institutional conflict of interest, including financial relationships, is a critical step in the process of identifying and responding to conflict of interest. All NNR2023 experts, including all committee members, background paper authors and peer reviewers, have declared their conflict of interest according to standard procedures used when health authorities in the Nordic countries recruit scientists for outsourced expert tasks. The NNR2023 Committee handled all matters regarding conflict of interest of the experts. In cases of any uncertainty, the NNR2023 Committee sought advice from the Steering Committee. The NNR2023 Steering Committee handled all matters concerning potential conflict of interest for the NNR2023 Committee members.