NORDIC NUTRITION RECOMMENDATIONS 2023

RECOMMENDATIONS

Principles for setting DRVs in NNR2023

Ever since the nutrients were discovered, e.g., the vitamins between 1910-1950, societies have strived to give advice to avoid deficiency and protect health and wellbeing of people. Recommendations for nutrients were based on an estimation of the human body’s requirement from studies on the nutrients’ biochemical and physiological roles as reported in for example balance studies. Varying body weights and heights were typically used to estimate the distribution of the requirement in a population. In the first editions of NNR, the recommended intake (RI) of nutrients were based on various such studies and conclusions in Nordic expert committees. Among the major references for the recommendations were the “Recommended Dietary Allowances” produced by the Food and Nutrition Board of the US National Academy of Sciences (previously Institute of Medicine), UK’s Committee on Medical Aspects of Food Policy (COMA), and the World Health Organization (WHO). No formal criteria or systematic methodology were available and utilized to derive the RIs.

The ideal method to set RIs was early recognized, but rarely achieved. This method included: 1) determinations of average requirement (AR) of a healthy and representative segment of each age group for the nutrient under consideration; 2) assess statistically the variability among the individuals within the group; and 3) calculate from this the amount by which the average requirement must be increased to meet the need for nearly all healthy individuals (NASEM, 2019) (see Table 5 for definition of DRVs). Similar methodologies were developed for setting the tolerable upper intake level (UL), which is the dose where risk of excess in population is close to zero (IOM, 1998b).

While this is still the basic principle, the principles and methods have developed and improved considerably in recent years. The two major organizations that have contributed to this development of methodology are the Institute of Medicine (IOM) of the US National Academies (renamed and incorporated in 2011 into the National Academies of Science, Engineering, and Medicine (NASEM)), and the European Food Safety Authority (EFSA). The recent framework for developing DRVs are most comprehensively described in the following reports from IOM/NASEM, EFSA and NNR:

Scientific Opinion for principles for deriving and applying Dietary Reference Values, EFSA, (2010a)
Guiding principles for Developing Dietary Reference Intakes Based on Chronic Diseases, NASEM (2017)
The Nordic Nutrition Recommendations 2022 – principles and methodologies. Food & Nutrition Research, 2020 (Christensen et al. 2020)

Ideally, the first step is to identify the functional outcome or indicator used to set AR and UL for all life-stage groups of each micronutrient under consideration. The causality of the exposure-outcome pair should ideally be considered in a recent qSR, and the strength of evidence should be graded above a certain predefined level. Then, a dose-response curve should be established and the average requirement of a healthy and representative segment of each age group for the nutrient determinations. If data are not available for all life-stage groups, interpolation or extrapolation to the remaining life-stage groups is performed, so that all life-stage groups have a defined set of ARs and ULs (see Appendix 5). Based on the life-stage specific ARs, the corresponding RIs are then calculated. Typically, if normally distributed, the RI is calculated as AR + 2 standard deviations (SD) to cover the requirements of almost the whole population (97.5%). This ideal methodology is, however, often not possible to implement fully due to a lack of appropriate scientific data.

Table 5 Definition of different reference values (adapted from IOM (2006), EFSA (2010), NNR2012 and NASEM (2019)

Average Requirement (AR)	The average daily nutrient intake level that is estimated to meet the requirements of half of the individuals in a particular life-stage group in the general population. AR is usually used to assess adequacy of nutrient intake of groups of people, and may be used in planning for groups.
Recommended Intake (RI)	The average daily dietary nutrient intake level that is sufficient to meet the nutrient requirements of nearly all (usually 97.5%) individuals in a particular life-stage group in the general population. It can be used as a guide for daily intake by individuals. Usually used to plan diets for groups and individuals.
Adequate Intake (AI)	The recommended average daily intake level based on observed or experimentally determined approximations or estimates of nutrient intake by a group people that are assumed to be adequate. The AI has larger uncertainty than RI. Can be used when an RI cannot be determined. The AI is expected to meet or exceed the needs of most individuals in a life-stage group.
Provisional AR	The average daily nutrient intake level that is suggested to meet the requirements of half of the individuals in a particular life-stage group. The provisional AR, which is an approximation of AR, has larger uncertainty than AR. It is calculated by multiplying AI by a factor of 0.8. Can be used when an AR cannot be determined.
Recommended intake range of macronutrients	The recommended average daily nutrient range of an energy providing macronutrients expressed as percentage of total consumed energy intake (E%). The recommended intake range is associated with reduced risk of chronic diseases while providing adequate intake of essential nutrients. The recommended intake ranges of macronutrients should not be considered as an RI that provides a defined intake level. The ranges are provided to give guidance in dietary assessment and planning by taking into account the probabilities related to the role of the total diet for risk of chronic disease.
Recommended intake of subgroup of macronutrients	The recommended energy percent (E%) of a macronutrient.
Tolerable Upper Intake Level (UL)	The highest average daily nutrient intake level that is likely to pose no risk of adverse health effects to almost all individuals in the general population. As intake increases above the UL, the potential risk of adverse effects may increase.
Chronic Disease Risk Reduction Intake (CDRR)	The level above which intake reduction is expected to reduce chronic disease risk within a life-stage groups in the general population. The CDRR represents the level of intake for which there was sufficient strength of evidence to characterize a chronic disease risk reduction.

Similar formal methodologies have been developed to define recommended intake ranges of macronutrients and reference values for energy intakes (National Academies of Sciences, Engineering, and Medicine 2023).

There are considerable uncertainties about some of the DRVs. If AR cannot be formally defined, for example if a dose-response curve is not available or a factorial approach cannot be established, an adequate intake (AI) recommendation can be made based on observed intakes in a healthy population or other methods (Trolle, in press). In those cases, a “provisional AR” is calculated as AI x 0.8, i.e., assuming a CV of 12.5% as suggested by Allen et al. (2020). Importantly, as this is usually derived from observed intake in the general population, the provisional AR likely overestimates the true AR.

For some nutrients, AR, AI and UL are not defined at all due to lack of appropriate data.

Previous editions of NNR have not performed a formal setting of ARs, AIs, RIs, ULs for micronutrients, recommended intake ranges of macronutrients and reference values for energy intakes as described above. Values corresponding to the values set in IOM/NASEM and EFSA reports were used instead. Sometimes these values have been adjusted based on expert consensus and alternative scientific assessments or local conditions in the Nordic countries.

In each new edition of NNR, new scientific evidence published since last edition have been assessed. If significant new evidence for changing the DRVs of a nutrient was not found, the values were kept unchanged. If new significant evidence was detected, the DRVs were updated accordingly. Throughout the various updates, the visibility of the original basis for setting the DRVs and the reason for adjustments has varied. Therefore, while the DRVs in the previous editions of NNR were based on careful scrutiny of scientific evidence, the exact values may deviate from the lastest updates of IOM/NASEM and EFSA.

In NNR2023, we are more explicit in identifying the source document used for setting AR and UL (i.e., the specific IOM, NASEM or EFSA report). We have first identified the source document for AR and UL for each nutrient in the previous NNR editions. Then, we considered the most recent reports from IOM/NASEM and EFSA with an aim to harmonize the criteria for setting dietary reference values when warranted (see Allen et al., 2020; Yaktine et al., 2020). In general, we selected the most recent source document that was based on a methodology similar to that described in the NNR2023 methodology papers (Christensen et al. 2020; Arnesen et al. 2020b; Høyer et al. 2021). Harmonized criteria similar to EFSA was set for 22 nutrients, and similar to IOM/NASEM for 3 nutrients. The specific source document for each nutrient is presented in Tables 6 and 7.

Table 6 Basis for setting DRVs for vitamins in NNR2023¹

Nutrient	Type of reference value	Source	Criteria for setting reference values
Vitamin A	AR RI	EFSA (2015)	Factorial approach, target liver concentration of 20 μg retinol/g.
Vitamin D	AR RI	NNR2023 (Brustad and Meyer 2023)	Dose-response approach, biomarker (25(OH)D).
Vitamin E	AI Provisional AR	NNR2023 (Hantikainen and Lagerros 2023), Raederstorff et al. (2015) For infants: EFSA (2015)	Relationship to PUFA intake (prevention of PUFA oxidation) For infants: estimated intake from human milk.
Vitamin K	AI Provisional AR	EFSA (2017)	Observed intakes in European countries. Biomarkers. For new-borns: prevention of vitamin K deficiency bleeding
Thiamin	AR RI	EFSA (2016)	Erythrocyte transketolase activity coefficient, urinary excretion.
Riboflavin	AR RI	EFSA (2017)	Urinary riboflavin excretion.
Niacin	AR RI	EFSA (2014)	Urinary excretion of niacin metabolites.
Pantothenic acid	AI Provisional AR	EFSA (2014)	Observed intakes in European countries. For infants: estimated intake from human milk.
Vitamin B₆	AR RI	EFSA (2016)	Biomarker (plasma pyridoxal 5-phosphate).
Biotin	AI Provisional AR	EFSA (2014)	Observed intakes in European countries. For infants: estimated intake from human milk.
Folate	AR RI	EFSA (2014)	Biomarker (serum and red blood cell folate), plasma homocysteine.
Vitamin B₁₂	AI Provisional AR	EFSA (2015)	Vitamin B₁₂ biomarkers, and observed intakes in European countries.
Vitamin C	AR RI	EFSA (2013)	Biomarker (fasting plasma ascorbate concentration).
Choline	AI Provisional AR	EFSA (2016)	Observed intakes in European countries, and deficiency symptoms (organ dysfunction).

1 Scaling of all nutrients uses NNR2023 reference weights. AR: Average/provisional average requirement. RI: Recommended/provisional recommended intake.

Table 7 Basis for setting DRVs for minerals in NNR2023¹

Nutrient	Type of reference value	Source	Criteria for setting reference values
Calcium	AR RI	EFSA (2015)	Factorial approach, calcium balance and calcium accretion in bone. For infants: estimated intake from human milk.
Phosphorus	AI Provisional AR	EFSA (2015)	Scaled to RI for calcium (molar calcium to phosphorus ratio of 1.4:1).
Potassium	AI Provisional AR	EFSA (2016)	Prevention of high blood pressure and risk of stroke.
Sodium	Chronic Disease Risk Reduction Intake	NASEM (2019)	Sodium reduction trials and one balance study. Extrapolations to children and adolescents using NNR2023 reference energy intakes.
Magnesium	AI Provisional AR	EFSA (2015)	Observed intakes in European countries. For infants 7-11 months: midpoint between extrapolated values from infants 0-6 m and the highest range of observed intakes.
Iron	AR RI	NNR2023 (Domellöf & Sjöberg, 2023)	Factorial approach, replacement of daily iron loss, and need for growth.
Zinc	AR RI	EFSA (2014)	Factorial approach, zinc balance, accounting for phytate intake (assuming a phytate intake of 600 mg/day in adults).
Copper	AR ARI	IOM (2001)	A combination of copper biomarkers (including plasma copper, serum ceruloplasmin, platelet copper concentration). For infants: estimated intake from human milk and estimated additional intake from complementary foods in infants 7-11 months.
Iodine	AI Provisional AR	EFSA (2014), NNR2023 (Gunnarsdóttir & Brantsæter, 2023)	Biomarker (urinary iodine concentration), prevention of goitre.
Selenium	AI Provisional AR	EFSA (2014), NNR2023 (Alexander & Olsen, 2023)	Biomarker (plasma selenoprotein P, target >110 µg/L). For infants: estimated intake from human milk.
Fluoride	AI Provisional AR	EFSA (2013)	Prevention of caries (for adults: extrapolated from data in children).
Manganese	AI Provisional AR	EFSA (2013)	Observed intakes in European countries, and null balance. For infants 7-11 months: a combination of extrapolation from infants 0-6 months, extrapolation from adults’ AI, and observed intakes.
Molybdenum	AI Provisional AR	EFSA (2013)	Observed intakes in European countries, and null balance.

¹ Scaling of all nutrients uses NNR2023 reference weights. AI: Adequate intake. AR: Average/provisional average requirement. RI: Recommended intake.

The indicator used to set AR, AI and UL in each source document was then identified. The recent scientific evidence on the indicator is discussed in the corresponding nutrient background paper. Evidence based on new qSRs (see Table 1 and Appendix 2) were especially emphasized. If new evidence since the publication of the source document had appeared that changed the strength of evidence relative to the predefined criteria (Christensen et al. 2020), the corresponding change in AR, AI and UL were implemented. Additionally, if new SRs revealed new indicators, these were also implemented.

Next, we identify whether the AR and UL were set by dose-response or factorial approach. Again, the corresponding nutrient background papers were essential in assessing recent evidence published since the last edition of NNR. In specific cases, the NNR2023 project performed new meta-analyses (see list of de novo qSRs above). Otherwise, the NNR2023 project based the evaluation on dose-response curves in the source documents (see table 6 and 7).

If data were not available for all life-stage groups, interpolation or extrapolation to the remaining life-stage groups was performed in the NNR2023 project, so that all life-stage groups have a defined set of ARs and ULs. The methodology of scaling to other life stage groups was identified from the relevant source document (i.e., isometric scaling or allometric scaling, with or without a growth factor), as described in Appendix 5. When an AR could not be set, the extrapolation was performed with the AI.

An important basis for scaling is the representative healthy weights for each life-stage group. For life stage groups aged 18 years or more, healthy weights are, in agreement with the consideration in NNR2012, defined as a BMI of 23 kg/m²(calculated from the most recent population heights reported in national dietary surveys (Amcoff et al. 2012; Pedersen et al. 2015; Nurk et al. 2017; Valsta et al. 2018; Grīnberga et al. 2020; Abel and Totland 2020; S. Gunnarsdottir et al. 2022)). For children and adolescents aged 6-17 years, healthy weights were calculated based on height in the most recent growth curves in the Nordic and Baltic countries and corresponding healthy BMIs for age defined by WHO (World Health Organization 2007; Juliusson et al. 2013; Saari et al. 2011; Tinggaard et al. 2014; Wikland et al. 2002). For age groups 5 years and younger, healthy weights were based on the growth curves. For detailed values for weight, see Appendix 4. The new weight values are an important update from previous editions and ascertain that scaling is performed according to healthy weight curves representative for Nordic and Baltic countries. In addition, age groups have also been updated and harmonized with EFSA and IOM/NASEM.

A Physical Activity Level (PAL) of 1.6 is used when calculating AR for nutrients based on energy requirements. For the age groups 1-3 years, 4-10 years and 11-17 years, an average PAL of 1.4, 1.6 and 1.7 were used, respectively (see Reference values for energy intake and Cloetens and Ellegård, 2023).

The background papers on all individual nutrients (see table 6 and 7) have been essential in the assessments described above and have been used as a major source in developing the one-pagers on nutrients and the specific DRVs.

Based on the life-stage specific ARs, the NNR2023 project then calculated corresponding RIs (see Appendix 5 for details). The standard deviation used to calculate RIs is taken from the corresponding source document (Table 6 and 7). When an AR could not be set, a provisional AR was calculated from the corresponding AI.

Finally, standard rounding of all AR, AI, RI and UL values was performed according to the approach used in the source document.

The science advice for specific recommendations to authorities in the Nordic and Baltic countries are formulated in the text and tables below, and build on the detailed considerations described in the nutrient sections later in this report.

Life-stage groups in NNR2023

Different life-stage groups have been used when setting DRVs by NNR, EFSA and NASEM/IOM, making comparisons and harmonization difficult. Recently, Allen et al. (2020) suggested that life-stage groups should be harmonized according to those used by EFSA. NNR2023 has decided to change the life-stage groups used by the 5^th edition of NNR (Nordic Council of Ministers, 2014) and align them with EFSA. Thus, the standard life-stage groups used in NNR2023 are the age groups ≤ 6 months, 7-11 months, 1-3 years, 4-6 years and 7-10 years for infants and children. For females and males, DRVs are individually set for the age groups 11-14 years, 15-17 years, 18-24 years, 25-50 years, 51-70 years and > 70 years. Additionally, DRVs are set for pregnant and lactating women.

DRVs in age groups are often set for a “point age” or as a median age. For example, the point age in the age group 1-3 years is 2 years, while the median in the age group 1.0-3.99 is 2.5 years. In contrast, NNR2023 uses the median as the principle for setting and scaling to different age groups of children and adolescents. In addition to age groups presented in the report, Appendix 6 contains reference weights and DRVs for children and adolescents in 1-year increments.

New DRVs for Nordic and Baltic countries

NNR2023 includes recommended intake ranges for macronutrients, upper or lower threshold levels of certain subcategories, and ARs, AIs, RIs and ULs of essential micronutrients. The macronutrient sub-categories are polyunsaturated, monounsaturated, saturated, and trans-fatty acids, dietary fibre and added and free sugars.

Reference values for energy intake

Both excessive and insufficient energy intake in relation to energy requirements can lead to negative health consequences in the long term. For adults, an individual’s long-term energy intake and energy expenditure should be equal (Cloetens & Ellegård, 2023).

In Table 8, reference values are given for energy intake in MJ per day for groups of adults with three different physical activity levels (see Appendix 4 and Cloetens & Ellegård (2023) for methodology). An active lifestyle, corresponding to PAL 1.8, is considered desirable for maintaining good health. An activity level of PAL 1.6 is close to the population median and corresponds to a common lifestyle with sedentary work and some increased physical activity level during leisure time. The reference body weights used for the calculations are based on self-reported weights in Nordic populations (Appendix 4). The original weights have been adjusted so that all individuals would have a BMI of 23, as explained above. Therefore, the reference values indicate an energy intake that would maintain normal body weight in adults.

Specific recommendations for energy intake cannot be given due to the large variation among individuals with respect to metabolic rate, body composition and degree of physical activity.

Table 8 Reference values for energy intakes in groups of adults with sedentary and active lifestyles.

Age, years	Reference weight, kg¹	BEE, MJ/d²	Low active PAL 1.4, MJ/d	Average PAL 1.6, MJ/d	Active PAL 1.8, MJ/d
FEMALES
18-24 y	64.2	5.9	8.3	9.4	10.6
25-50 y	64.1	5.7	8	9.0	10.2
51-70 y	62.5	5.2	7.2	8.3	9.3
>70 y	60.6	5.1	7.1	8.2	9.2
Pregnant³
≤50 y	76.4	6.4	8.9	10.2	11.5
Lactating⁴
≤50 y	62.4	7.8	10.9	12.5	14.1
MALES
18-24 y	75.2	7.4	10.4	11.8	13.2
25-50 y	74.8	7.1	9.9	11.3	12.7
51-70 y	73.0	6.4	9	10.3	11.6
>70 y	70.6	6.3	8.8	10.1	11.3

¹ See Appendix 4 and Cloetens & Ellegård (2023) for sources and methodology as well as reference values per year of age.
² For corresponding values expressed as kilocalories (kcal)/day, see Appendix 4.
³ Weight gain of 14 kg during pregnancy, assuming a pre-pregnancy BMI of 18.5-24.9
⁴ Exclusive breastfeeding 0-6 months postpartum

Tables 9 and 10 present reference values for energy intakes in groups of children. It must again be mentioned that individual energy requirements might differ from these group-based average values.

Table 9 Reference values for estimated average daily energy requirements per kg body weight for children 6-12 months, assuming partial breastfeeding.

Age, months	Average daily energy requirements, kJ/kg body weight
	BOYS	GIRLS
6	339	342
12	337	333

Table 10 Reference values for estimated daily energy requirements (MJ/d) for children and adolescents, 1-17 years.

Age	Reference weight, kg¹	REE, MJ/d²	Estimated energy requirement, MJ/d³
1-3 y	13.6	3.3	4.6
4-6 y	20.7	4.0	6.3
7-10 y	30.8	4.9	7.8
FEMALES
11-14 y	46.5	5.4	9.2
15-17 y	57.8	5.9	10.1
MALES
11-14 y	48.2	6.2	10.5
15-17 y	65.6	7.5	12.7

¹ See Appendix 4 and Cloetens & Ellegård (2023) for sources and methodology.
² For corresponding values expressed as kcal/day, see Appendix 4.
³ PALs (average) for age groups: 1-3 years = 1.4; 4-10 years: 1.6; 11-17 years: 1.7

Recommended intake ranges of macronutrients

Macronutrients are nutrients required in relatively large quantities for energy and to support various bodily functions and overall health. These include proteins, fats, carbohydrates and fibre, which in general provide about 17, 37, 17 and 8 kJ/g, respectively. The energy provided vary somewhat among different types of proteins, fats, carbohydrates and fibre (Cloetens & Ellegård, 2023). Alcohol is also an energy-providing nutrient (29 kJ/g), but is not an essential nutrient. The conversion factors for joules and calories are: 1 kJ = 0.239 kcal; and 1 kcal = 4.184 kJ.

Macronutrients can to a certain degree substitute for each other to meet the body’s energy needs. Thus, increasing the proportion of one macronutrient necessitates decreasing the proportion of other macronutrients. In the 3^rd edition of NNR, recommendations of intake ranges for adults of fats (25-35 E%), carbohydrates (50-60 E%) and protein (10-20 E%) were included (Sandström, 1996). In the 5^th edition of NNR this was updated to 25-40 E%, 45-60 E% and 10-20 E% for fats, carbohydrate and proteins, respectively. The recommendations in NNR2023 are unchanged from the 5^th edition of NNR (Box #2).

Box 2: Recommended intake ranges of macronutrients for adults

Fats		25-40 E%
Cis-monounsaturated		10-20 E%
Cis-polyunsaturated		5-10 E%
Saturated fatty acids		<10 E%
Carbohydrates¹		45-60 E%
Dietary fibre		≥25-35 g/d
Added and free sugars		<10 E%
Proteins		10-20 E%
¹Including energy from dietary fibre

These ranges are defined as ranges of intakes (expressed as percentage of total energy) that are associated with low risk of chronic diseases while also providing adequate intake of essential nutrients. The ranges are also based on adequate energy intake and physical activity to maintain energy balance. If an individual consumes below or above these ranges, there is a potential for increasing the risk of a chronic disease, as well as increasing the risk of insufficient intakes of essential nutrients (EFSA, 2010; IOM, 2005; NASEM, 2023).

It is not possible to determine a definitive level of intake range for macronutrients at which chronic diseases may be prevented or may develop. Therefore, the recommended intake ranges of macronutrients should not be considered as an RI that provides a fixed intake level. The ranges are provided to give guidance in dietary assessment and planning by taking into account the role of the total diet for risk of chronic disease.

Evidence supporting these intake ranges is provided in the background reviews on protein (Geirsdóttir & Pajari, 2023), carbohydrates (Sonestedt & Øverby, 2023), dietary fibre (Carlsen & Pajari, 2023) and fatty acids (Retterstøl & Rosqvist, 2023). Besides the proportion of protein, fat and carbohydrates, the importance of the balance of their subcomponents (e.g., unsaturated fatty acids, fibre, amino acids) has gradually become more evident. For protein, an AR and RI is also established to maintain body nitrogen balance and support growth.

The recommended intake ranges for macronutrients vary among age groups (Box #3), and there are also some additional needs for pregnant and lactating women.

Age group up to 2 years of age

Exclusive breastfeeding for about 6 months is advised, with continued breastfeeding parallel to giving complementary foods from that age until 12 months of age, or longer if it suits mother and child. There is strong evidence that the risk of obesity in childhood and adolescence increases with increased protein intake higher than recommended during infancy and early childhood (Hörnell, Lagström, et al. 2013; Arnesen et al. 2022). The protein intake should increase from about 5 E% (the level in breast milk) to the intake range of 10–20 E% for older children and adults (Box #4).

Box 3: Fatty acids (expressed as triglycerides)

n-6 fatty acids should contribute at least 4 % of the total energy intake (E%) for children 6–11 months and 3 E % for children 12–23 months of age.
n-3 fatty acids should contribute at least 1 E% for children 6–11 months and 0.5 E% for children 12–23 months.
During the first year, the intake of trans fatty acids should be kept as low as possible.
From 12 months, the recommendation on saturated and trans fatty acids for older children and adults should be used.

Box 4: Recommended intake of fat, carbohydrates, and proteins

Expressed as percent of total energy intake (E%) for children 6–23 months¹

Age	E%
6–11 months
Protein	7–15
Fat	30–45
Carbohydrates²	45–60

12–23 months
Protein	10–15
Fat	30–40³
Carbohydrates²	45–60

Avoid foods and beverages with added and free sugars for children below two years.

For young children it is advisable not to exceed a range of 10-15 E% of protein intake.

¹Because exclusive breastfeeding is the preferable source of nutrition for infants <6 months, no recommendations for fat, protein, or carbohydrate intakes are given for this age group. For non-breastfed infants, it is recommended that the values for infant formula given in the EC legislation (REGULATION (EC) No 1243/2008 and Directive 2006/141/EC) is used.

²including energy from dietary fibre
3 Cis-monounsaturated and cis-polyunsaturated fatty acids should together constitute at least two thirds of the total fat intake.

Age groups 2 years and older

Fatty acids

Partly replacing saturated fatty acids with cis-polyunsaturated fatty acids and cis-monounsaturated fatty acids (oleic acid) from vegetable dietary sources (e.g., olive or rapeseed oils) is an effective way of lowering the serum LDL-cholesterol concentration. Replacement of saturated or trans-fatty acids with cis-polyunsaturated or cis-monounsaturated fatty acids also decreases the LDL/HDL-cholesterol ratio. Replacing saturated and trans-fatty acids with cis-polyunsaturated fatty acids reduces the risk of coronary heart disease, and replacement of saturated and trans-fatty acids with cis-monounsaturated fatty acids from vegetable sources (e.g., olive or rapeseed oils) has a similar effect (Box #5).

Box 5: Fatty acids (expressed as triglycerides)

Intake of cis-monounsaturated fatty acids should be 10-20 E%.
Intake of cis-polyunsaturated fatty acids should be 5–10 E%. N-3 fatty acids should provide at least 1 E%.
Cis-monounsaturated and cis-polyunsaturated fatty acids should constitute at least two thirds of the total fatty acids in the diet.
Intake of saturated fatty acids should be limited to less than 10 E%.
Intake of trans-fatty acids should be kept as low as possible.
The total fat recommendation is 25–40 E% and is based on the recommended ranges for different fatty acid categories.
Linoleic (n-6) and alpha-linolenic (n-3) acids are essential fatty acids and should contribute at least 3 E%, including at least 0.5 E% as alpha-linolenic acid.
For pregnant and lactating women, the essential fatty acids should contribute at least 5 E%, including 1 E% from n-3 fatty acids of which 200 mg/d should be docosahexaenoic acid, DHA (22:6 n-3).

Even though total fat intake varies widely, population and intervention studies indicate that the risk of atherosclerosis can remain quite low as long as the balance between unsaturated and saturated fatty acids is favourable (Retterstøl and Rosqvist, 2023). The recommended range for the total amount of fat is 25–40 E% based on the sum of the ranges of the recommendations for individual fatty acid categories.

For the intake of total fat, a suitable target for dietary planning is 32–33 E%.

At total fat intakes below 20 E%, it is difficult to ensure sufficient intake of fat-soluble vitamins and essential fatty acids. A reduction of total fat intake below 25 E% is not generally recommended because very low-fat diets tend to reduce HDL-cholesterol and increase triglyceride concentrations in serum and to impair glucose tolerance, particularly in susceptible individuals (Retterstøl and Rosqvist, 2023).

Carbohydrates and dietary fibre

Health effects of dietary carbohydrates are related to the type of carbohydrate and the food source. Carbohydrates found in whole-grain cereals, whole fruit, vegetables, pulses, nuts and seeds are recommended as the major sources of carbohydrates. Total carbohydrate intake in studies on dietary patterns associated with reduced risk of chronic diseases are in the range of 45–60 E% (including energy from dietary fibre). A reasonable range of total carbohydrate intake is dependent on several factors such as the quality of the dietary sources of carbohydrates and the amount and quality of fatty acids in the diet.

Just like the importance of the quality of fat, it is equally important to pay attention to the quality of carbohydrates and the amount of dietary fibre. The recommendations for dietary fibre and carbohydrates (with low intakes of added and free sugars) should be achieved through an ample supply of plant-based foods (Sonestedt and Øverby, 2023).

Box 6: Dietary fibre

Adults: At least 3 g/MJ. Based on the reference energy intake, this corresponds to at least 25 g/d for females and 35 g/d for males.
Children: An intake corresponding to 2-3 g/MJ or more is appropriate for children from 2 years of age. From school age, the intake should gradually increase to reach the recommended adult level during adolescence.

An adequate intake of dietary fibre reduces the risk of constipation and contributes to a reduced risk of colorectal cancer and several other chronic diseases such as cardiovascular disease and type 2 diabetes. Moreover, fibre-rich foods help maintain a healthy body weight. Intake of appropriate amounts of dietary fibre from a variety of foods is also important for children.

For dietary planning purposes, a suitable target is at least 3 g/MJ from natural fibre-rich foods such as vegetables, whole grains, fruits and berries, pulses, nuts and seeds (Box #6).

Box 7: Added and free sugars

Intake of added and free sugars should be below 10 E%, and preferentially lower

Restricting the intake of added and free sugars is important to ensure adequate intakes of micronutrients and dietary fibre (nutrient density) as well as to support a healthy dietary pattern. This is especially important for children and persons with a low energy intake. Consumption of sugar-sweetened beverages should be limited due to their association with increased risk of type 2 diabetes, cardiovascular disease, and excessive weight gain. Frequent consumption of foods with added and free sugars should be avoided to reduce the risk of dental caries. The recommended upper threshold for added and free sugars is also compatible with the food-based recommendation to limit the intake of sugar-rich beverages and foods. Higher consumption of added and free sugars contributes to a negative environmental impact (Box #7).

The recommended range for the total amount of carbohydrate is 45–60 E%. For dietary planning purposes, a suitable target for the amount of dietary carbohydrate is 52–53 E%.

Proteins

In order to achieve an optimal intake in a varied diet according to Nordic dietary habits, a reasonable range for protein intake is 10–20 E% (Box #8 and Table 11). This intake of protein should adequately meet the requirements for essential amino acids.

Box 8: Protein

AR and RI for adults are 0.66 and 0.83 g/kg, body weight, respectively (both males and females) (Table 11).
Adults and children from 2 years of age: Protein should provide 10–20% of the total energy intake (E%).
With decreasing energy intake (below 8 MJ/d) the protein E% should be increased accordingly.
Dietary proteins of animal origin or a combination of plant proteins from, for example, legumes and cereal grains, give a good distribution of indispensable amino acids.

Table 11 Average requirements and recommended intakes of protein by life stage

Age group	AR g/kg	RI g/kg
≤6 mo
7-11 mo	1.04	1.23
CHILDREN
1-3 y	0.82	1.05
4-6 y	0.70	0.86
7-10 y	0.75	0.91
FEMALES
11-14 y	0.72	0.88
15-17 y	0.68	0.84
18-24 y	0.66	0.83
25-50 y	0.66	0.83
51-70 y	0.66	0.83
>70 y	0.66	0.83
Pregnant	add 0.5/7.2/23 g/d¹	add 1/9/28 g/d¹
Lactating	add 10/15 g/d²	add 13/19 g/d²
MALES
11-14 y	0.74	0.9
15-17 y	0.71	0.87
18-24 y	0.66	0.83
25-50 y	0.66	0.83
51-70 y	0.66	0.83
>70 y	0.66	0.83

Adapted from EFSA (2012a)
¹ Pregnancy: Additional protein requirement per trimester.
² Lactation: Additional protein requirement for 0-6 months and >6 months postpartum.

For planning purposes, 15 E% protein can be recommended.

The AR and RI for both sexes, which is based on nitrogen balance, is the same for older adults (>70 years of age). The available evidence in qSRs is not sufficient to increase the AR for protein intake in older adults. However, for food planning purposes a suitable target for the amount of protein for a group of older adults intake should be 18 E% which may be higher than the RI. This corresponds to about 1.2 g protein per kg body weight per day for prevention of declined physical functioning (Geirsdóttir & Pajari, 2023).

Alcohol

Based on the overall evidence, it is recommended to avoid alcohol intake. If alcohol is consumed, the intake should be very low. Alcohol is not an essential nutrient, and from a nutritional point of view, energy contribution from a high intake of alcoholic beverages negatively affects diet quality. Based on this and new systematic reviews and recommendations, and that no threshold for safe level of alcohol consumption has currently been established for human health, the NNR2023 recommends avoidance from alcohol. For children, adolescents and pregnant women abstinence from alcohol is recommended. The consumption of alcoholic beverages contributes to a negative environmental impact.

Recommended intake of micronutrients

RI (Table 12) and AI (Table 13) for vitamins, RI (Table 14) and AI (Table 15) for minerals, expressed as average daily intakes over time, are given below. The values for RIs are intended mainly for planning diets for groups of individuals of the specified age intervals and sex. The values include a safety margin accounting for variations in the requirement of the group of individuals and are set to cover the requirements of 97.5% of the group. An alternative way to plan a diet is to use the requirements in combination with the distribution of reported or usual intakes for the specific nutrients (Murphy et al. 2021).

Table 12 RI for vitamins – all life-stage groups

Age group	Vitamin A RE²	Vitamin D µg³	Thiamin mg/MJ	Rioboflavin mg	Niacin NE/MJ⁴	Vitamin B₆ mg	Folate µg	Vitamin C mg
≤6 mo¹				0.3		0.1	64	30⁷
7-11 mo	250	10	0.1	0.4⁵	1.6	0.4⁵	90	30⁷
CHILDREN
1-3 y	300	10	0.1	0.6	1.6	0.6	120	25
4-6 y	350	10	0.1	0.7	1.6	0.7	140	35
7-10 y	450	10	0.1	1.0	1.6	1.0	200	55
FEMALES
11-14 y	650	10	0.1	1.4	1.6	1.3	280	75
15-17 y	650	10	0.1	1.6	1.6	1.5	310	90
18-24 y	700	10	0.1	1.6	1.6	1.6	330⁶	95
25-50 y	700	10	0.1	1.6	1.6	1.6	330⁶	95
51-70 y	700	10	0.1	1.6	1.6	1.6	330	95
>70 y	650	20⁸	0.1	1.6	1.6	1.6	330	95
Pregnant	750	10	0.1	1.9	1.6	1.9	600⁶	105
Lactating	1400	10	0.1	2.0	1.6	1.7	490	155
MALES
11-14 y	700	10	0.1	1.3	1.6	1.5	260	80
15-17 y	750	10	0.1	1.6	1.6	1.8	320	105
18-24 y	800	10	0.1	1.6	1.6	1.8	330	110
25-50 y	800	10	0.1	1.6	1.6	1.8	330	110
51-70 y	800	10	0.1	1.6	1.6	1.8	330	110
>70 y	750	20⁸	0.1	1.6	1.6	1.7	330	110

¹ Exclusive breastfeeding is the preferable source of nutrition for infants during the first six months of life. Values for infants 0-6 months are based on estimated intake from human milk. These values represent an AI.
² RE = Retinol equivalents (1 RE = 1 μg retinol = 2 μg of supplemental β-carotene, 6 μg of dietary β-carotene, or 12 μg other dietary provitamin A carotenoids, e.g., α-carotene and β-cryptoxanthin).
³ From 1-2 weeks of age, infants should receive 10 µg vitamin D₃ per day as a supplement. For people with little or no sun exposure, an intake of 20 µg/d is recommended.
⁴ NE = Niacin equivalent (1 NE = 1 mg niacin = 60 mg tryptophan).
⁵ Extrapolated from exclusively breast-fed infants 0-6 months. These values represent an AI.
⁶Values for pregnant women represent an AI. Most national authorities in the Nordic and Baltic countries recommend supplement of 400µg/d in addition to dietary intake for women in fertile age from planned pregnancy and throughout the first trimester.

⁷ AI, set to 3 times the intake known to prevent scurvy in infants. These values represent an AI.

⁸ For age group 75 years and older.

Table 13 Adequate intake¹ for vitamins – all life-stage groups

Age group	Vitamin E α-TE⁴	Vitamin K µg⁵	Pantothenic acid mg	Biotin µg	Vitamin B₁₂ _µg	Choline mg
≤6 mo²	4		2	4	0.4	120
7-11 mo	5³	10	3³	5³	1.5	170³
CHILDREN
1-3 y	7	15	4	20	1.5	150
4-6 y	8	20	4	25	1.7	170
7-10 y	9	30	4	25	2.5	250
FEMALES
11-14 y	10	45	5	35	3.5	350
15-17 y	11	60	5	35	4	390
18-24 y	10	65	5	40	4	400
25-50 y	10	65	5	40	4	400
51-70 y	9	60	5	40	4	400
>70 y	9	60	5	40	4	400
Pregnant	11	80	5	40	4.5	480
Lactating	12	65	7	45	5.5	520
MALES
11-14 y	11	50	5	35	3	330
15-17 y	12	65	5	35	4	400
18-24 y	11	75	5	40	4	400
25-50 y	11	75	5	40	4	400
51-70 y	11	70	5	40	4	400
>70 y	11	70	5	40	4	400

¹Adequate intake based on observed intakes in healthy people or approximations from experimental studies, used when an RI cannot be determined.
² Exclusive breastfeeding is the preferable source of nutrition for infants during the first six months of life. Values for infants 0-6 months are based on estimated intake from human milk.
³ Extrapolated from exclusively breast-fed infants 0-6 months.
⁴ Assuming a PUFA intake of 5 % of energy intake. α-TE = α-tocopherol equivalents (i.e., 1 mg RRR α-tocopherol).

⁵ 1 µg/kg body weight.

Table 14 RI for minerals – all life-stage groups

Age group	Calcium mg	Iron mg²	Zinc mg²	Copper µg
≤6 mo¹	120			200
7-11 mo	310³	10	3.0	220³
CHILDREN
1-3 y	450	7	4.5	340
4-6 y	800	7	5.8	400
7-10 y	800	9	7.7	570
FEMALES
11-14 y	1150⁴	13^5,6	10.8	780
15-17 y	1150⁴	15⁶	12.2	880
18-24 y	1000	15⁶	9.7	900
25-50 y	950	15⁶	9.7	900
51-70 y	950	8⁷	9.5	900
>70 y	950	7	9.3	900
Pregnant	950	26⁸	11.3	1000
Lactating	950	15	12.6	1300
MALES
11-14 y	1150⁴	11	11.1	740
15-17 y	1150⁴	11	14.0	900
18-24 y	1000	9	12.7	900
25-50 y	950	9	12.7	900
51-70 y	950	9	12.4	900
>70 y	950	9	12.1	900

1 Exclusive breastfeeding is the preferable source of nutrition for infants during the first six months of life. Values for infants 0-6 months are AIs based on estimated intake from human milk.
² Assuming a mixed animal/vegetable diet with a phytic acid intake of about 600 mg/d.
³ AI, extrapolated from exclusively breast-fed infants 0-6 months. These values represent an AI.
⁴ Average of females and males applied for age 11–17 y.
⁵If menstruating: 15 mg.
⁶If large menstruation bleedings, screening of iron status and supplementation as indicated.
⁷ If still menstruating, the RI for 25–50 y (15 mg/d) should be used.
⁸Screening of iron status and supplementation if indicated is recommended.

Table 15 Adequate intake¹ for minerals – all life-stage groups

Age group	Phosphorus mg³	Potassium mg	Magnesium mg	Iodine µg	Selenium µg	Fluoride mg⁶	Manganese mg	Molyb-denum µg
≤6 mo²		400	25	80-90⁵	10		12 µg
7-11 mo	170	700	80⁴	80-90⁵	20⁴	0.4	0.02-0.5⁷	10
CHILDREN
1-3 y	250	850	170	100	20	0.7	0.5	15
4-6 y	440	1150	230	100	25	1.0	1	20
7-10 y	440	1800	230	100	40	1.5	1.5	30
FEMALES
11-14 y	640	2400	250	120	60	2.3	2	50
15-17 y	640	2850	250	120	70	2.9	3	60
18-24 y	550	3500	300	150	75	3.2	3	65
25-50 y	520	3500	300	150	75	3.2	3	65
51-70 y	520	3500	300	150	75	3.1	3	65
>70 y	520	3500	300	150	75	3.0	3	65
Pregnant	530	3500	300	200	90	3.1	3	70
Lactating	530	3500	300	200	85	3.1	3	65
MALES
11-14 y	640	2550	300	130	65	2.4	2	45
15-17 y	640	3400	300	140	85	3.3	2.5	60
18-24 y	550	3500	350	150	90	3.8	3	65
25-50 y	520	3500	350	150	90	3.7	3	65
51-70 y	520	3500	350	150	90	3.7	3	65
>70 y	520	3500	350	150	85	3.5	3	65

¹ Adequate intake based on observed intakes in healthy people or approximations from experimental studies, used when an RI cannot be determined.
² Exclusive breastfeeding is the preferable source of nutrition for infants during the first six months of life. Values for infants 0-6 months are AIs based on estimated intake from human milk.
³ Assuming the RI of calcium is consumed.

⁴ Extrapolated from exclusively breast-fed infants 0-6 months.
⁵The AI for iodine in infants < 1 y is presented as a range with 80 µg/d in iodine sufficient populations and 90 µg/d in populations with mild to moderate iodine deficiency. The WHO recommends 90 µg/d for all infants.
⁶ Based on an adequate intake of 0.05 mg/kg bodyweight, using population reference weights. For pregnant and lactating women, this refers to pre-pregnancy weight.

⁷ Range based on upwards extrapolation from intake of infants 0-6 months, the mean of observed intakes and downwards extrapolation from adult AI.

Sodium as salt

In the U.S., the AI for sodium reference level of sodium intake (adequate intake) for adults was set to 1.5 g/d due to limited evidence of health effects of sodium intake at lower levels. It was advised to reduce the intake if above 2.3 g/d (NASEM, 2019). There is strong evidence to aim for a reduction of sodium intake in the Nordic and Baltic populations (Jula, 2023). Reductions in sodium intakes that exceed the chronic disease risk reduction (CDRR) of 2.3 g/d are expected to reduce chronic disease risk within the general population.

NNR2023 adapts the reasoning from NASEM to recommend limiting intake of sodium to 2.3 g/d in adults (Table 16), which corresponds to 5.75 g of salt/d.

Table 16 Chronic disease risk reduction intake of sodium – all life-stage groups¹.

Age group	Sodium, g
≤6 mo²	0.11
7-11 mo	0.37³
CHILDREN
1-3 y	1.1
4-6 y	1.4
7-10 y	1.7
FEMALES
11-14 y	2.0
15-17 y	2.3
18-24 y	2.3
25-50 y	2.3
51-70 y	2.3
>70 y	2.3
Pregnant	2.3
Lactating	2.3
MALES
11-14 y	2.0
15-17 y	2.3
18-24 y	2.3
25-50 y	2.3
51-70 y	2.3
>70 y	2.3

¹ Values for children and adolescents 11–14 years old are extrapolated from adults based on energy intake (NASEM, 2019).
² Values for infants 0-6 months are derived from estimated intake from human milk.
³ Estimated intake from breastmilk (70 mg/d) and complementary foods (300 mg/d) (NASEM, 2019)

Dietary supplements

Prolonged intakes of nutrients from supplements have generally not been associated with decreased risk of chronic diseases or other health benefits in healthy individuals eating a varied diet that covers their energy requirements. In contrast, there is a large body of evidence suggesting that elevated intakes of certain supplements, mainly vitamins with antioxidative properties, might increase the risk of certain adverse health effects, including mortality. Thus, there is no scientific justification for using supplements as a means for adjusting an unbalanced diet. Few exceptions for ensuring optimal intake are vitamin D supplementation for infants, pre-pregnant, pregnant and lactating women and elderly people, as well as folic acid supplementation for women aiming for pregnancy until the end of pregnancy week 12. Extensive dietary restrictions for health or ideological reasons, e.g., veganism, or use of certain medications often lead to the need for dietary supplements. For example, vitamin B12 supplementation is necessary when foods of animal origin are excluded from the diet, and folic acid supplementation is necessary with medication with properties of folate antagonism.

An energy intake of 6.5–8 MJ is considered a low-energy intake with an increased risk of an insufficient intake of micronutrients. A very low energy intake is defined as an energy intake below 6.5 MJ/d and is associated with a considerable risk of an insufficient intake of micronutrients. A very low energy intake may be related to either a very low physical activity level, low body weight or low small muscle mass and, therefore, to low energy expenditure. Very low energy intakes are found among persons on weight reduction diets, among persons with eating disorders, food intolerances and some other diseases or conditions. Such diets should be tailored according to individual needs under supervision from health professionals.

Reference values (AR and provisional AR) for assessing nutrient intakes in dietary surveys

Vitamins and minerals

Assessing nutrient adequacy

AR and provisional AR for vitamins and minerals are presented in Table 17-20. The values are intended for use in assessing results from dietary surveys. Before comparing intake data with these reference values, it is crucial to check whether the intake data derived from a particular survey are suitable for assessing adequacy. Assessments based on provisional ARs should take into account the higher uncertainty and the tendency to be higher than the AR values, and for some nutrients relationship to energy intake may be included in the assessment. More guidance on this topic and on how to use DRVs can be found in Trolle et al (Trolle, in press).

The AR is the value that should be used to assess the risk for inadequate intake of micronutrients in a certain group of individuals. The percentage of the individuals that has an intake below the AR is related to the proportion that have an increased risk of inadequate intake. AR values are also used as a tool when planning adequate diets for groups of people.

Table 17 Average requirements of vitamins.

Age group	Vitamin A RE²	Vitamin D µg	Thiamin mg/MJ	Rioboflavin mg	Niacin NE/MJ³	Vitamin B₆ mg	Folate µg	Vitamin C mg
≤6 mo¹				0.2		0.1	50	25⁶
7-11 mo	200	7.5	0.07	0.3⁴	1.3	0.3⁴	70⁴	25⁶
CHILDREN
1-3 y	240	7.5	0.07	0.5	1.3	0.5	90	20
4-6 y	270	7.5	0.07	0.6	1.3	0.6	110	30
7-10 y	340	7.5	0.07	0.8	1.3	0.9	160	45
FEMALES
11-14 y	490	7.5	0.07	1.2	1.3	1.1	220	60
15-17 y	500	7.5	0.07	1.3	1.3	1.3	240	75
18-24 y	540	7.5	0.07	1.3	1.3	1.3	250	75
25-50 y	540	7.5	0.07	1.3	1.3	1.3	250	75
51-70 y	530	7.5	0.07	1.3	1.3	1.3	250	75
>70 y	510	7.5	0.07	1.3	1.3	1.3	250	75
Pregnant	590	7.5	0.07	1.6	1.3	1.5	480⁵	75
Lactating	1060	7.5	0.07	1.6	1.3	1.4	380	75
MALES
11-14 y	520	7.5	0.07	1.1	1.3	1.2	200	65
15-17 y	600	7.5	0.07	1.3	1.3	1.5	250	85
18-24 y	630	7.5	0.07	1.3	1.3	1.5	250	90
25-50 y	630	7.5	0.07	1.3	1.3	1.5	250	90
51-70 y	610	7.5	0.07	1.3	1.3	1.5	250	90
>70 y	590	7.5	0.07	1.3	1.3	1.5	250	90

¹ Exclusive breastfeeding is the preferable source of nutrition for infants during the first six months of life. Values for infants 0-6 months are provisional AR based on estimated intake from human milk.
² RE = Retinol equivalents (1 RE = 1 μg retinol = 2 μg of supplemental β-carotene, 6 μg of dietary β-carotene, or 12 μg other dietary provitamin A carotenoids (e.g., α-carotene and β-cryptoxanthin).
³ NE = Niacin equivalent (1 NE = 1 mg niacin = 60 mg tryptophan).
⁴ Provisional AR, extrapolated from exclusively breast-fed infants 0-6 months.
⁵Provisional AR based on adequate intake (AI). Most national authorities in the Nordic and Baltic countries recommend supplement of 400µg/d in addition to dietary intake for women in fertile age from planned pregnancy and throughout the first trimester.

⁶ Provisional AR based on AI set to 3 times the intake known to prevent scurvy in infants.

Table 18 Provisional average requirements of vitamins¹.

Age group	Vitamin E α-TE⁴	Vitamin K µg	Pantothenic acid mg	Biotin µg	Vitamin B₁₂ _µg	Choline mg
≤6 mo²	3		1.6	3	0.3	96
7-11 mo	4³	5	2.2³	4³	1.1	134³
CHILDREN
1-3 y	6	10	3.2	16	1.2	119
4-6 y	7	15	3.2	20	1.4	139
7-10 y	7	25	3.2	20	2	199
FEMALES
11-14 y	8	35	4	28	2.8	276
15-17 y	9	45	4	28	3.1	310
18-24 y	8	50	4	32	3.2	320
25-50 y	8	50	4	32	3.2	320
51-70 y	8	50	4	32	3.2	320
>70 y	8	50	4	32	3.2	320
Pregnant	9	60	4	32	3.6	381
Lactating	10	50	5.6	35	4.2	416
MALES
11-14 y	9	40	4	28	2.6	259
15-17 y	10	50	4	28	3.2	318
18-24 y	9	60	4	32	3.2	320
25-50 y	9	60	4	32	3.2	320
51-70 y	9	60	4	32	3.2	320
>70 y	9	55	4	32	3.2	320

¹ Provisional average requirement (AR) calculated as 0.8 times the provisional recommended intake, assuming a CV of 12.5 %. This likely overestimates the true AR.
² Exclusive breastfeeding is the preferable source of nutrition for infants during the first six months of life. Values for infants 0-6 months are provisional AR based on estimated intake from human milk.
³ Extrapolated from exclusively breast-fed infants 0-6 months
⁴ Assuming a PUFA intake of 5% of energy intake. α-TE = α-tocopherol equivalents (i.e., 1 mg RRR α-tocopherol).

Table 19 Average requirements of minerals.

Age group	Calcium mg	Copper µg	Iron mg²	Zinc mg²
≤6 mo¹	96	160
7-11 mo	250³	180³	8	2.5
CHILDREN
1-3 y	400	260	6	3.8
4-6 y	700	300	5	4.8
7-10 y	675	440	7	6.4
FEMALES
11-14 y	980⁴	600	10	9.0
15-17 y	980⁴	680	9	10.2
18-24 y	870	700	9	8.1
25-50 y	750	700	9	8.1
51-70 y	750	700	6	7.9
>70 y	750	700	6	7.7
Pregnant	800	800	20	9.4
Lactating	800	1000	9	10.5
MALES
11-14 y	980⁴	570	9	9.2
15-17 y	980⁴	700	9	11.7
18-24 y	870	700	7	10.6
25-50 y	750	700	7	10.6
51-70 y	750	700	7	10.4
>70 y	750	700	7	10.1

¹ Exclusive breastfeeding is the preferable source of nutrition for infants during the first six months of life. Values for infants 0-6 months are provisional AR based on estimated intake from human milk.
² Assuming a mixed animal/vegetable diet with a phytic acid intake of about 600 mg/d.
³ Provisional AR, extrapolated from exclusively breast-fed infants 0-6 months.
⁴Average of physiological requirements for females and males 11–14 and 15–17 years of age.

Table 20 Provisional average requirements of minerals¹.

Age group	Phosphorus mg³	Potassium mg	Magnesium mg	Iodine µg	Selenium µg	Fluoride mg⁴	Manganese mg	Molybdenum µg
≤6 mo²		320	20	64-72	10		9.6 µg
7-11 mo	140	600	64⁵	64-72	15⁵	0.4	0.02-0.4⁶	7
CHILDREN
1-3 y	200	700	136	80	15	0.5	0.5	10
4-6 y	350	900	184	80	20	0.8	0.7	16
7-10 y	350	1450	184	80	35	1.2	1.1	24
FEMALES
11-14 y	510	1900	200	100	50	1.9	1.8	38
15-17 y	510	2250	200	100	55	2.3	2.2	48
18-24 y	440	2800	240	120	60	2.6	2.4	52
25-50 y	420	2800	240	120	60	2.6	2.4	52
51-70 y	420	2800	240	120	60	2.5	2.4	52
>70 y	420	2800	240	120	60	2.4	2.4	52
Pregnant	430	2800	240	160	75	2.5	2.5	55
Lactating	430	2800	240	160	70	2.5	2.3	51
MALES
11-14 y	510	2050	240	100	50	1.9	1.6	34
15-17 y	510	2700	240	110	70	2.6	2.1	46
18-24 y	440	2800	280	120	70	3.0	2.4	52
25-50 y	420	2800	280	120	70	3.0	2.4	52
51-70 y	420	2800	280	120	70	2.9	2.4	52
>70 y	420	2800	280	120	70	2.8	2.4	52

¹ Provisional average requirement (AR) is calculated as 0.8 times the adequate intake (AI), assuming a CV of 12.5%. This likely overestimates the true AR.

² Exclusive breastfeeding is the preferable source of nutrition for infants during the first six months of life. Values for infants 0-6 months are provisional AR based on estimated intake from human milk (except for iodine).

³ Assuming the recommended intake (RI) of calcium is consumed.

⁴ Based on an adequate intake of 0.05 mg/kg bodyweight, using population reference weights. For pregnant and lactating women, this refers to pre-pregnancy weight.

⁵ Extrapolated from exclusively breast-fed infants 0-6 months.

⁶ Range based on upwards extrapolation from intake of infants 0-6 months, the mean of observed intakes and downwards extrapolation from adult AI.

Tolerable upper intake level

For some nutrients, high intakes can cause adverse or even toxic symptoms. Tolerable upper intake levels (ULs) have been established for some nutrients (Table 21). For certain nutrients, especially preformed vitamin A (retinol), vitamin D, iron, and iodine, prolonged intakes above these levels can lead to an increased risk of toxic effects. For other nutrients the adverse effects might be different and milder, e.g., gastrointestinal problems or interference with the utilization of other nutrients. The ULs are not recommended levels of intake, but rather maximum levels of usual intakes judged to be unlikely to pose a risk of adverse health effects in humans. The ULs are derived for the general population, and values are given for adults. For other life stages, such as infants and children, specific data might exist for deriving specific values or such values could be extrapolated.

To establish whether a population is at risk for adverse effects, the fraction of the population exceeding the UL and the magnitude and duration of the excessive intake should be determined. There is a substantial uncertainty behind several of the ULs, and they must be used with caution on an individual basis. UL values do not necessarily apply in cases of prescribed supplementation under medical supervision.

The ULs are primarily based on the considerations in NNR2012. If EFSA has set an UL for a nutrient not covered by NNR2012, or the EFSA assessment is more recent, the EFSA values have been used. The footnotes to Table 21 indicate whether the ULs are based on NNR2012, EFSA or both.

Boron is a trace element that is naturally present in many foods and available in dietary supplements. While boron is not classified as an essential nutrient for humans, it may have adverse effects in high doses (EFSA, 2018). For boron, the most recent value from EFSA is included in Table 21 despite that this nutrient has not been assessed in any background paper in NNR2023.

Table 21 Tolerable upper intake levels of vitamins and minerals for adults.

		UL per day
Boron¹	mg/d	10
Calcium^1,2	mg/d	2500
Copper²	mg/d	5
Iodine ^1,2	μg/d	600
Iron³	mg/d	60
Magnesium^1,4	mg/d	250
Molybdenum¹	mg/d	0.6
Phosphorus²	mg/d	3000
Selenium⁵	μg/d	255
Zinc^1,2	mg/d	25
Fluoride¹	mg/d	7
Folic acid (synthetic)^1,2	μg/d	1000
Nicotinamide^1,2	mg/d	900
Nicotinic acid^1,2	mg/d	10
Vitamin A^1,2,6	μg RE/d	3000
Vitamin B6⁷	mg/d	12
Vitamin D^1,2	μg/d	100
Vitamin E^1,2	mg/d	300

¹ Based on EFSA (2018)
² Based on NNR2012
³Background paper on Iron (Domellöf & Sjöberg, 2023)
⁴ Readily dissociable magnesium salts (e.g. chloride, sulphate, aspartate, and lactate) and compounds like magnesium oxide (MgO) in food supplements, water or added to foods; does not include magnesium naturally present in foods and beverages.
⁵ EFSA (2023b)
⁶ Retinol and retinyl esters
⁷ EFSA (2023a)

Comparison between RI set by NNR2023 and NNR2012

Since all DRVs have been recalculated in NNR2023, we have compared the RI values with the corresponding values set by NNR2012. Some important differences are due to the most recent principles used by EFSA or NASEM, such as updated weight curves and life-stage groups in the new edition of NNR and change from RI to AI for some nutrients when a formal AR and RI cannot be defined due to insufficient evidence. The AI can be used in line with traditional RI values. However, the uncertainty in the AI values is larger than in the RI. Comparisons between the AI in NNR2023 previous RI in NNR2012 should therefore be done with care. An AI will usually be higher than an RI derived from average requirement (AR), but it does not necessarily imply evidence for an actual increase in the physiological requirement from those of the previous editions of NNR.

As shown in Table 22, for some nutrients, an RI in NNR2012 has been changed to AI in NNR2023 due to updated evidence or improved methodology. For eight nutrients (vitamin K, biotin, pantothenic acid, choline, sodium, manganese, molybdenum, and fluoride), which were not set in NNR2012, a new AI has been set in NNR2023.

For most nutrients, there are only minor changes, despite the comprehensive recalculations in NNR2023. The changes can often be attributed to updated methodology (see Table 2 and 3) and the new reference weights used in NNR2023.

For more details on the calculations and life-stage groups, please refer to the nutrient sections later in the report, the corresponding background papers, and Appendix 5.

Table 22 Comparison between RI and AI set by NNR2023 (25-50 years) and NNR2012 (31-60 years). AI is shown in italics

	NNR2023		NNR2012		Comments
	RI or AI		RI
	FEMALES	MALES	FEMALES	MALES
Vitamin A, RE	700	800	700	900
Vitamin D, µg	10	10	10	10
Vitamin E, α-TE	10	11	8	10	AI in NNR2023
Vitamin K, µg	65	75	ND	ND	AI in NNR2023
Thiamin, mg	0.9	1.1	1.1	1.3
Riboflavin, mg	1.6	1.6	1.3	1.6
Niacin, NE	14	18	14	18
Vitamin B₆, mg	1.6	1.8	1.2	1.5
Folate, µg	330	330	300	300
Vitamin B₁₂, µg	4	4	2	2	AI in NNR2023
Biotin, µg	40	40	ND	ND	AI in NNR2023
Pantothenic acid, mg	5	5	ND	ND	AI in NNR2023
Choline, mg	400	400	ND	ND	AI in NNR2023
Vitamin C, mg	95	110	75	75
Calcium, mg	950	950	800	800
Phosphorus, mg	520	520	600	600	AI in NNR2023
Magnesium, mg	300	350	280	350	AI in NNR2023
Sodium, g	1.5	1.5	ND	ND	AI in NNR2023
Potassium, g	3.5	3.5	3.1	3.5	AI in NNR2023
Iron, mg	15	9	15	9
Zinc, mg	9.7	12.7	7	9
Iodine, µg	150	150	150	150	AI in NNR2023
Selenium, µg	75	90	50	60	AI in NNR2023
Copper, µg	900	900	900	900
Manganese, mg	3	3	ND	ND	AI in NNR2023
Molybdenum, µg	65	65	ND	ND	AI in NNR2023
Fluoride, µg	3.2	3.7	ND	ND	AI in NNR2023

Comparison between AR in NNR2023 and NNR2012, and comparison with national mean intake data

We have also compared the recalculated AR values with the corresponding values set by NNR2012, and national representative intake data for the Nordic and Baltic countries (Table 23).

First, for the nine micronutrients vitamin K, biotin, pantothenic acid, choline, magnesium, potassium, manganese, molybdenum and fluoride, which did not have ARs in NNR2012, provisional ARs have been defined. Second, for the five micronutrients vitamin E, vitamin B₁₂, phosphorus, iodine and selenium, which all had ARs in NNR2012, the values have been changed to provisional ARs. The arguments for setting these provisional ARs are related to the harmonized methodologies utilized in NNR2023 and the updated scientific evidence. The arguments are clearly stated in each of the nutrient summaries in this report.

Nine of the ARs and provisional AR values, for the age group 25-50 years, in NNR2023 have increased by 20% or more compared to the corresponding AR values in NNR2012. All other values were within ± 20% of the NNR2012 AR values. The reasons for these increases have been discussed above, and in the corresponding nutrient summaries.

When comparing the ARs and the provisional AR values with national representative intake data in the Nordic countries (Lemming & Pitsi, 2022) we observed that the mean intake data for vitamin D, vitamin E, potassium and selenium were lower in one or more of the Nordic countries. In one or more of the Baltic countries, national representative intake data (Lemming & Pitsi, 2022) for vitamin D, vitamin E, riboflavin, vitamin B₆, folate, vitamin B₁₂, potassium, iodine and selenium were lower than the corresponding ARs or provisional AR values.

In the comparisons, we have only used data for adults (i.e., the age group 25-50 years in NNR2023 and the age group 31-60 years in NNR2012). National authorities in countries where representative intake data for nutrients are lower than the ARs or provisional ARs should consider further investigations of nutrient status in specific risk groups before implementation of carefully planned nutritional interventions or programs to improve the respective nutrient intake. In such considerations, care should be taken to also include the uncertainties in the assessment of nutrient intakes, including distribution of intake, and the uncertainty in the provisional AR values. Especially, an intake lower than the provisional AR on group level does not necessarily point to inadequacy. Similar assessments may also be performed for other life-stage groups.

Table 23 Comparison between AR and provisional AR set by NNR2023 (25-50 yrs) and NNR2012 (31-60 yrs), and national intake data.

	Range of mean intakes in		Range of mean intakes in		NNR2023		NNR2012		Comments
	Nordic countries		Baltic countries		AR and provisional AR		AR
	FEMALES	MALES	FEMALES	MALES	FEMALES	MALES	FEMALES	MALES
Vitamin A, RE	747-1110	812-1556	666-942	666-1155	540	630	500	600
Vitamin D, µg	4.3-10.0	5.3-11.0	4.3-9.1	5.5-7.2	7.5	7.5	7.5	7.5
Vitamin E, α-TE	8.8-11.7	9.5-13.2	7.8-12.9	9.4-14.9	8	9	5	6	Provisional AR in NNR2023
Vitamin K, µg	NA	NA	NA	NA	50	60	ND	ND	Provisional AR in NNR2023
Thiamin, mg	1.1-1.4	1.4-1.9	0.8-1.3	1.1-1.4	0.7	0.8	0.9	1.2
Riboflavin, mg	1.4-1.6	1.7-2.1	1.0-1.2	1.2-1.4	1.3	1.3	1.1	1.4
Niacin, NE	29-32	39-41	12.7-23.7	13.1-32.9	12	15	12	15
Vitamin B₆, mg	1.4-1.8	1.8-2.3	1.2-1.715	1.5-1.9	1.3	1.5	1.1	1.3
Folate, µg	222-329	247-370	164-216	198-383	250	250	200	200
Vitamin B₁₂, µg	4.9-6.0	6.0-8.9	2.9-5.8	3.3-8.0	3.2	3.2	1.4	1.4	Provisional AR in NNR2023
Biotin, µg	NA	NA	NA	NA	32	32	ND	ND	Provisional AR in NNR2023
Pantothenic acid, mg	NA	NA	NA	NA	4	4	ND	ND	Provisional AR in NNR2023
Choline, mg	NA	NA	NA	NA	320	320	ND	ND	Provisional AR in NNR2023
Vitamin C, mg	96-115	93-113	69-132	72-116	75	90	50	60
Calcium, mg	811-1038	945-1188	546-659	660-768	750	750	500	500
Phosphorus, mg	1242-1384	1541-1788	867-1061	1186-1392	420	420	450	450	Provisional AR in NNR2023
Magnesium, mg	263-346	335-439	277-295	331-349	240	280	ND	ND	Provisional AR in NNR2023
Potassium, g	2.6-3.4	3.4-4.2	2.4-3.0	2.9-3.8	2.8	2.8	ND	ND	Provisional AR in NNR2023
Iron, mg	9.4-10.0	11-13	9.6-13.0	12.3-14.5	9	7	10	7
Zinc, mg	8.8-10.5	12.4-14.1	7.2-8.3	10.1-11.4	8.1	10.6	5	6
Iodine, µg	142-227	195-268	25-105	30-134	120	120	100	100	Provisional AR in NNR2023
Selenium, µg	42-68	50-88	20-47	31-65	60	70	30	35	Provisional AR in NNR2023
Copper, mg	1.1	1.3-1.3	1.1-1.7	1.5-2.1	0.7	0.7	0.7	0.7
Manganese, mg	NA	NA	NA	NA	2.4	2.4	ND	ND	Provisional AR in NNR2023
Molybdenum, µg	NA	NA	NA	NA	52	52	ND	ND	Provisional AR in NNR2023
Fluoride, µg	NA	NA	NA	NA	2.6	3.0	ND	ND	Provisional AR in NNR2023

*Values are labeled in YELLOW if one or more countries have a national representative intake data lower than the corresponding AR/provisional AR / Provisional AR is shown in italics / NA: Not available /ND: Not determined /The intake data of Lemming & Pitsi (2022) is used in this table.

Major reasons for changes in DRVs from NNR2012 to NNR2023

For most nutrients, there are only minor changes, despite the comprehensive recalculations in NNR2023. The changes can be attributed to updated methodology, the new reference weights and the new age groups used in NNR2023 (see nutrient summaries, appendices and background papers). For nine nutrients, one or more DRVs changed more than 20% compared to the NNR2012 values. The main reasons are listed below.

Vitamin E. While NNR2012 defined a RI for vitamin E, NNR2023 define an AI. The AI is based on a basal vitamin E requirement (4 mg) plus a factor based on the dietary intake of 5 E% PUFA. The provisional AR is calculated from the AI.

Vitamin B₆. A new cut-off value for the indicator (plasma PLP concentration 30 nmol/l) is used to define AR, in line with EFSA. It is not based on protein intake as in NNR2012. Due to less data for males, the female AR is extrapolated to males with allometric scaling. RI is calculated from AR.

Folate: A new cut-off value for the indicator is used to define AR, in line with EFSA. RI is calculated from AR.

Vitamin B₁₂. While NNR2012 defined a RI for vitamin B₁₂, NNR2023 define an AI. A combination of new indicators is used to define an AI in line with EFSA. Cobalamin intake of 4 μg/day and greater is associated with serum concentrations of holoTC and cobalamin within the reference ranges derived from healthy subjects. These cobalamin serum concentrations together with total homocysteine and methylmalonic acid concentrations below the cut-off values for adults, are indicative of an adequate cobalamin status. Provisional AR is calculated from AI.

Vitamin C. A new cut-off value for the indicator is used to define AR in line with EFSA. A target plasma ascorbate concentration of 50 µmol/L was used in NNR2023 (32 µmol/L was used in NNR2012) to set the AR in males and extrapolated to females with isometric scaling. RI is calculated from AR.

Thiamine. NNR2023 and NNR2012 both used 0.1 mg/MJ as the basis for AR. New weight curves and age categories are used in in NNR2023. RI is calculated from AR.

Zinc. NNR2023 based the AR on a higher intake of phytate (600 mg) which resulted in a reduced absorption efficiency. The new RI is calculated from AR using updated regression analyses.

Selenium. While NNR2012 defined a RI for selenium, NNR2023 define an AI. In NNR2023, the dose-response curve of the indicator was re-evaluated (SelenoP in plasma). The intake of selenium needed to achieve a plasma concentration of about 110 µg/L is used as cut-off. An average daily intake of dietary selenium of about 1.2 µg/kg body weight would be sufficient to achieve an optimal selenium concentration and maximum expression level of SelenoP in plasma.

Calcium. The AR of calcium for adults applied in NNR2012 was derived from one Norwegian balance study in male convicts. In NNR2023, the DRVs are updated and adopted from EFSA. The updated AR for adults takes into account several balance studies, in which the mean calcium intake necessary to equal excretion was found to be 715 mg/day. Additionally, an allowance for 40 mg/day of dermal losses of calcium, which was not measured in the studies, was added to derive the revised AR of 750 in males and females aged ≥25 years.

Principles for developing a framework for setting FBDGs in NNR2023

Country-specific national FBDGs must be built on 5 pillars

The role of national FBDGs is to inform country-specific public food and nutrition, health and agricultural policies and nutrition education programs to foster healthy eating habits and lifestyles. More than 100 countries worldwide, all EU countries and all EU associated countries have developed healthy FBDGs. The national FBDGs vary across countries, because several country-specific dimensions need to be considered when formulating national FBDGs.

The scientific evidence for health effects of foods and food groups are more or less universal: similar health effects are established for the same foods or food groups independent of the country where the study population originate. There are exceptions to this rule, but these exceptions are few and will be discussed when relevant.

National FBDGs are not only informed by the universal health effect of foods. They are also informed by several country-specific factors (Food-based dietary guidelines, FAO (FAO, 2023); Sustainable healthy diets: guiding principles, WHO/FAO (2019); Food-based dietary guidelines in the WHO European Region (WHO, 2003); Preparation and use of food-based dietary guidelines (FAO/WHO, 1996)).

First, they need to respond to the public health challenges in the individual countries. While the Nordic and Baltic countries are relatively similar compared with many other countries, there are significant differences in burden of diseases in the countries that need to be addressed. This is why we have included a separate background paper on burden of diseases in the 8 Nordic and Baltic countries in the present NNR report. There may be other public health factors relevant for national FBDGs other than those described in the NNR report. Thus, national authorities should consider carefully all relevant public health factors.

Second, food consumption patterns vary considerably across and within countries and are dependent on national food culture and tradition. While nutrient adequacy can be met by a huge variety of cultural diets, it is essential to consider whether national food patterns are in accordance with national nutrient recommendations. This is why we have included a separate background paper on food and nutrient intakes in the 8 Nordic and Baltic countries in the present NNR report. We recommend that national authorities perform calculations and modelling to assess macro- and micronutrient adequacy related to the new updated DRVs. This must be performed at the national level, since food composition tables and diet intakes are different in the Nordic and Baltic countries.

Third, food availability varies considerably across countries and is dependent for example on the country’s ability for food production, national agricultural policies and import restrictions. For example, Japanese FBDGs include recommendations on rice, and Greek FBDGs include recommendations on olives. Thus, the global food production and a country’s food availability need to be taken into account when developing country-specific FBDGs. While food availability is briefly discussed and considered in general terms in the NNR report, these factors are dependent on national policies and priorities, and are not taken into consideration in the NNR framework for developing FBDGs. National authorities may or may not align their country-specific food availability when they formulate national FBDGs.

Fourth, there are sociocultural or socioeconomic aspects that need to be considered and prioritised. A general overview of socio-economical aspects relevant for the Nordic and Baltic countries is described in Jackson and Holm (2023). These are also country-specific issues that depend on national policies that need to be considered by the national authorities.

Fifth, the project description of the present NNR project includes milestones not only for the development of a framework for setting FBDGs, but also a framework for integrating environmental sustainability into the FBDGs. That is why we have included several background papers on environmental sustainability in the present report and include specifically environmental issues when we give science advice in the NNR framework for formulation of country-specific healthy and environment-friendly FBDGs. Sustainable healthy diets should promote all dimensions of indivuduals’ health and well-being, have low environmental pressure and impact, be accessible, affordable, safe and equitable, and culturally acceptable, as described by FAO and WHO (2019).

Thus, the major contribution of the present NNR for the national authorities in the 8 Nordic and Baltic countries, is to give science advice on health and environmental effects of food. It is important to realize that certain country-specific aspects other than those assessed in the NNR report may need to be considered by the national authorities when formulating their national FBDGs.

Assessing health effects of foods and food groups in NNR2023

During the last decades, nutritional sciences have revealed that foods contribute to overall health beyond simply providing the appropriate amounts of essential nutrients. The health effects of foods extend the effect on known essential nutrients, especially when it comes to chronic diseases. These health effects of foods are the major foundation for FBDGs. There has been a considerable development in new methodologies to assess health effects of foods. To improve quality and reduce bias, health effects of foods are ideally considered through qSRs. Recent developments and harmonization of common principles and methodologies for synthesizing totality of evidence in qSR enable the NNR project to use qSRs developed from other national or international health authorities that used similar methodologies. The list of qSRs that are the main foundation of the FBDGs in NNR is presented in Table 1 and 2 and Appendix 2.

First, it is essential to evaluate the causality of each individual food/food group and various relevant health outcome pairs. This exercise may result in the identification of indicators that may be used to formulate FBDGs. If strength of evidence is graded above a certain predefined level, this indicator may be used for FBDG setting (Arnesen et al., 2020a, b; Christensen et al., 2020).

Then, a dose-response curve should be considered in a meta-analysis or qSR. If a dose-response curve can be established, a quantitative FBDG may be formulated. If no adequate dose-response curve can be established, in general, a qualitative FBDG may still be formulated (Arnesen et al., 2020a; Christensen et al., 2020).

Some food groups may have a quantitative FBDG, even without an established dose-response relationship with a health outcome (e.g., dairy). In such cases, the quantitative FBDG is based on the significance of the food group for nutritional adequacy and the intake of specific nutrients.

In general, all quantitative FBDGs are formulated as guidelines for individuals. FBDGs are formulated more generally than the DRVs for nutrients, although the causal associations of foods and health outcomes can be stronger than for nutrients and health outcomes. As with DRVs, there are seldom precise calculations behind the quantitative FBDGs. The precise FBDGs are based on best scientific knowledge and most often decided as consensus among expert groups. FBDGs are typically formulated for adults, not for all life-stage groups. Thus, when using the FBDGs for health guidance, care should be taken when considering the total amount of foods and energy consumed. For example, the general FBDGs should be scaled down for children, and other relevant populations such as elderly with low energy intake.

There is considerable uncertainty about health effects for some foods/food groups. If FBDGs cannot be formally defined, it does not necessarily mean that there are not any health effects of the foods/food groups. It simply means that the present scientific evidence is not strong enough to formulate a FBDG.

Assessing environmental effects of foods and food groups in NNR2023

In accordance with the scope and mandate from NCM we have assessed environmental effects of foods and food groups.

The primary assessment is based on the four environment background papers (summarized in the section "Summary of background papers on environmental sustainability"). The sixth assessment reports from the Intergovernmental Panel on Climate Change (IPCC) (IPCC, 2022a, b) and the Global Assessment Report on Biodiversity and Ecosystem Services from the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES) (IPBES, 2019) are pillars in the evaluation of environmental impact of food consumption in NNR2023. The most recent synthesis report from IPCC (IPCC, 2023) concludes with “high confidence” that human activities have unequivocally caused global warming, with global surface temperature reaching 1.15 °C above pre-industrial levels. Global GHG emissions continue to increase, with unequal historical and ongoing contributions arising from unsustainable energy use, land use and land-use changes, lifestyles and patterns of consumption and production across regions, and between and within countries. Global GHG emissions in 2030 implied by nationally determined contributions announced by October 2021 make it likely that global warming will exceed 1.5 °C within a few years and make it much harder to limit warming below 2 °C. Without strengthening of policies, global warming of 3.2 °C [2.2-3.5] °C is projected by 2100 (medium confidence).

The IPCC report also concludes with “very high confidence” that climate change is a threat to human well-being and planetary health and that there is a rapidly closing window of opportunity to secure a liveable and sustainable future for all. Rapid and far-reaching transitions across all sectors and systems are therefore necessary. These system transitions involve a significant upscaling of a wide portfolio of mitigation and adaptation options across systems and regions.

IPCC estimates that the share of food systems in global anthropogenic GHG emissions is 23–42% (IPCC, 2022b). While there are many options that may provide adaptation and mitigation benefits that could be up-scaled in the near-term across most regions, the demand-side measures, such as shifting to sustainable healthy diets and reducing food loss/waste, are essential parts of these adaptions and mitigations. The report concludes with high confidence that a diet featuring plant-based foods, such as one based on whole grains legumes, fruits and vegetables, nuts and seeds, and animal-sourced food produced in resilient, sustainable, and low-GHG emission systems, present major opportunities for adaptation and mitigation while generating significant co-benefits in terms of human health.

The background papers on environmental sustainability contribute with science-based inputs on environmental (including climate) effects of foods and diets from a global and regional, as well as national perspectives. The background papers also provide status on the current FBDGs in the Nordic countries and suggestions for the approach to be used by the national authorities when developing or updating FBDGs that integrate environmental sustainability. The NNR2023 project initially considered optimization models for integration of environmental sustainability. While these are useful tools, we conclude that they should not be used in the present NNR. Openness and transparency are essential; however, in modelling it is less transparent how different assumptions used in models influence the outcomes.

We base our science advice on expert judgement of literature reviews of scientific evidence, and systematic reviews of available science. We did not use optimization as an overarching principle for developing science advice for FBDGs in NNR. However, several different studies, also using optimization methodologies and referred to in the background papers, informed the science advice.

The four steps for developing healthy and environment-friendly FBDGs

Weighing of health versus environment when formulating FBDGs is essential and dependent on many factors and priorities. No formal mathematical weighing of health versus environment is performed in the science advice for developing FBDGs in the NNR report. We describe the considerations transparently and conclude by formulating quantitative or qualitative science advice for each individual food group.

Diet is a complex system of interacting components that cumulatively affect health. Foods are not consumed in isolation and decreasing the intake of one food group usually entails increasing the intake of another food group to make up for the reduction in energy and nutrients. Therefore, there is a strong inter-connectivity between the science advice of different food groups (partially visible with cross-references). Food group-specific advice should always be interpreted in relation to the whole diet.

The FBDGs have an emphasis on plant-based sources of nutrients, based on health outcomes alone or in combination with the effort to reduce environmental impact of diets. Many new products have emerged on the market with the aim of replacing meat or dairy products in a meal. Such products may be part of a healthy diet, but the nutrient content of these products may vary considerably (Trolle et al., 2023). The NNR2023 project has not evaluated the nutritional content of these products separately.

When developing a framework for integrating environmental sustainability into healthy FBDGs, we used the following strategy and principles:

First, we considered health effects of food groups. Health effects were given priority. The background papers of respective food groups were the main background for assessment. We focused primarily on evidence from qSRs on chronic disease outcomes. If there is strong evidence that a causal effect is established, we defined the range that is associated with low risk of diseases. The range spans a value larger than 0 up to the maximal intake. Alternatively, we set an upper level (in the case of adverse effect of high intakes) or a lower level (in the case of no relevant upper level).
Second, we considered whether the food group contributes significant amounts of essential nutrients in the general population in Nordic and Baltic countries. If significant contribution, the range spans a value larger than 0 up to the maximal intake. If no significant contribution, the range spans a value from 0 up to the maximal intake.
Third, we considered public health challenges related to health effects of the food group. Health effects related to prevalent chronic diseases were given priority.
Fourth, we considered the environmental impact of consumption of the food groups. We gave priority to changes in dietary patterns that reduce the environmental impact of the food group. We first considered whether narrowing the health defined ranges of intakes can contribute to reducing the environmental impact without compromising the beneficial health effects.

Science advice for a healthy and environment-friendly diet in Nordic and Baltic Countries

Based on the scientific evidence documented in the NNR2023 report and the NNR2023 background papers regarding associations between food and food patterns and risk of chronic disease, health effects of nutrients, the current food intake and burden of diseases, and the environmental footprint of current food consumption, several general guidelines for a healthy and environment-friendly diet can be defined for the Nordic and Baltic Countries.

Among the food groups, there are, in general, few conflicts between a healthy diet and an environment-friendly diet. While specific conflicts may occur among individual foods, the general guidelines concerning consumption of the food groups cereals, vegetables, fruits, berries, nuts and seeds, red meat, eggs, fats and oils, sweets and alcohol are supported both by their effects on health outcomes and their environmental footprint. The recommendations to increase consumption of potatoes and legumes, and to reduce white meat, are mainly based on their environmental footprints. For fish, the health-based advice for increased consumption should be primarily from sustainably managed stocks. For milk and dairy, a moderate intake is suggested which may be in conflict with the environmental impact. The suggested general guidelines and their consequences for health outcomes and environmental footprint are summarized below. For more details, see Table 24, the food groups sections in this report, and the four environmental sustainability background papers (Benton et al., 2022; Harwatt et al., 2023; Meltzer et al., 2023; Trolle et al., 2023).

Cereals: Increased intake of whole grains supported both by effects on health outcomes and environmental footprint.
Vegetables, fruits and berries: Increased intake supported both by effects on health outcomes and environmental footprint.
Potatoes: Higher consumption is recommended, mainly due to environmental aspects.
Pulses: Higher consumption is recommended, mainly due to environmental aspects and nutrient contribution.
Nuts: Increased intake supported both by effects on health outcomes and environmental footprint.
Fish: Increased intake from sustainably managed stocks supported both by effects on health outcomes and environmental footprint.
Red meat: Reduced intake supported both by effects on health outcomes and environmental footprint.
White meat (poultry): Preferentially lower intake due to environmental impact.
Milk and dairy: Moderate intake of low-fat milk recommended mainly due to nutrient adequacies, high intakes not compatible with low environmental impact.
Eggs: Low intake may be included in the diet due to nutrient adequacy, high intakes may not be compatible with beneficial health effects and low environmental impact.
Fats and oils: Moderate intake recommended mainly due to nutrient adequacies and low environmental impact.
Sweets: Reduced intake supported both by effects on health outcomes and environmental footprint.
Alcohol: Reduced intake supported both by effects on health outcomes and environmental footprint.

It is important to note that the healthy and environmental-friendly FBDGs suggested in this report are only based on human food consumption. Several agriculture production methods, processing procedures, transport, packing and waste, as well as many other aspects of the food system may greatly influence the environmental footprint related to human food consumption. National authorities may also consider the potential for reduced country-specific environmental footprints by taking into account the complete food system. Additionally, other dimensions of sustainability may also be considered. The five sustainability background papers included in the extended NNR2023 report may serve as a scientific foundation for such national considerations.

Overall, we recommend a predominantly plant-based diet rich in vegetables, fruits, berries, pulses, potatoes and whole grains, ample amounts of fish and nuts, moderate intake of low-fat dairy products, limited intake of red meat and poultry, and minimal intake of processed meat, alcohol, and processed foods containing high amounts of added fats, salt and sugar.

Thus, at the population level, and for most individuals, the NNR2023 report recommends an increased intake of vegetables, fruits, berries, pulses, potatoes, whole grains, nuts and seeds, and fish, and reduced intake of red and processed meat, and foods containing high amounts of added fats, salt and sugar, and alcohol.

Refined cereals should be replaced by whole grain products, butter and butter-based spreads should be replaced by vegetable oils and vegetable oil-based fat spreads, while high fat dairy should be replaced by low-fat dairy. Red meat and processed meat consumption should be reduced in favour of plant foods, such as legumes, and fish from sustainably managed stocks.

Diets dominated by naturally fibre-rich plant foods (e.g., vegetables, pulses, fruits and berries, nuts and seeds, and whole grains) will generally be lower in energy and higher in micronutrients compared to diets dominated by animal food. The energy density is generally higher in food products high in fat and sugar (e.g., desserts, sweets, cakes and biscuits, savoury snacks, some breakfast cereals, and ice-cream).

A reduction in consumption of SSB will contribute to increased micronutrient density and reduced intake of added and free sugars. Fatty fish, nuts and seeds, vegetable oils and vegetable oil-based fat spreads high in unsaturated fat should largely replace butter, high-fat meat, and meat products. A switch from high-fat to low-fat dairy will also improve the dietary fat quality while sustaining micronutrient density.

Processed food products provide a high proportion of the total fat, sugar, and salt intake. A reduced intake can be achieved by choosing varieties containing lower amounts, or by choosing more whole foods instead of processed foods.

Figure 1 Dietary changes that promote a healthy and environment-friendly diet in Nordic and Baltic populations

Increase	Exchange	Limit
Vegetables	Refined cereals → whole grain products	Processed meat Red meat
Fruits and berries	Butter and butter-based spreads → vegetable oils, vegetable oil-based spreads	Sugar-sweetened beverages
Pulses	High-fat dairy → low-fat dairy	Processed foods with high amounts of added fats, salt and sugar
Potatoes	Processed foods with high amounts of added fats, salt and sugar → whole foods and varieties containing low amounts	Alcohol
Whole grains
Nuts
Fish

A short summary of individual considerations and the main science advice from the NNR Committee is summarized in Table 24. The specific conclusions and advice, which are also summarized in the corresponding summaries in this report, build on the corresponding NNR2023 food group background papers as well as the NNR2023 background papers on food and diet intake, burden of diseases and environmental sustainability.

The main principle, when developing the NNR2023 recommendations, is that the effects on health are initially and primarily assessed. Then, the effect of food consumption on environmental impact is assessed and integrated. No recommendation has been adjusted by environmental impact in such a way that it is in conflict with the health-based recommendations.

All quantitative recommendations are based on health effects. The direction for further changes in food consumption due to environmental impact is clearly stated. It is up to the national authorities in the eight countries to define further quantitative recommendations which are in accordance with described directions for change due to environmental impact.

As guided by the NNR2023 Steering Committee and the NNR2023 project description, no exact quantitative recommendation is set based on environmental impact, rather a framework for integrating environmental impact of food consumption has been described.

We expect all countries to follow this NNR2023 framework and define ambitious quantitative environment-based recommendations to achieve more environment-friendly recommendations, such as the most recent Danish FBDGs (Ministry of Food, 2021). Even more ambitious initiatives would be in line with the NNR2023 framework, international obligations and relevant declarations from Nordic Council of Ministers.

Adults in the general population are the target for the food based dietary guidelines in Table 24 unless otherwise stated.

Table 24 Science advice for food groups for adults

Food group	Health effects of foods on chronic diseases not attributed to specific nutrients	Health effects of foods based on nutritional adequacy and effects of specific nutrients	Environmental impacts of foods consumed	Advice to authorities in Nordic and Baltic countries
Beverages	A moderate intake of coffee may reduce the risk of some cancers. High intake of unfiltered coffee may increase LDL-cholesterol levels. High SSB consumption probably increases risk of obesity, CVD, type 2 diabetes and dental caries.	Negative health effects of caffeine more than 400 mg/d. SSB consumption displaces nutrient-dense foods and may contribute to excess energy and added sugars intake.	The high coffee and SSB consumption can contribute to a higher total environmental footprint in the Nordic and Baltic diet and consumption should therefore be limited. High-quality tap water should be the preferred choice before SSB, LNCSB and bottled water.	Moderate consumption of filtered coffee (about 1-4 cups/day) and tea may be part of a healthy diet. The total consumption of caffeine from all sources should be limited to 400 mg caffeine/day. For children, a safe level of caffeine intake is 3 mg per kg body weight per day. Consumption of unfiltered coffee and SSB should be limited. High-quality tap water should be the preferred choice of beverage.
Cereals	Intake of at least 90 grams/day (dry weight) of whole grains (including whole grains in products), reduces the risk of CVD, CRC, T2D and all-cause mortality, with likely further benefits of higher intakes.	Contribute with energy, protein, dietary fibre and many essential nutrients, such as thiamin, folate, vitamin E, iron, and zinc.	Due to the low climate impact of cereals and cereal-based foods, rice being an exception, they are key foods in the transition to an environment-friendly diet.	It is recommended to have an intake of at least 90 grams/day of whole grains (including whole grains in products), with likely further benefits of higher intakes. Whole-grain cereals other than rice should preferentially be used.
Vegetables, fruits, berries	High consumption (500-800 grams/day) reduces the risk of several cancers, CVD, all-cause mortality.	Contribute with many essential nutrients, such as dietary fibre, vitamin C, vitamin E, vitamin K, folate, and potassium. Cruciferous vegetables provide calcium, and leafy green vegetables provides, iron, zinc, calcium, magnesium, carotenoids.	Vegetables fruits and berries have in general low climate and environmental impact/footprints per weight unit. Environmental impacts are mainly related to pesticide use and impacts on biodiversity, locally and globally. Fruits and vegetables that store well will reduce waste and thereby reduce negative impacts.	It is recommended to consume a variety of vegetables, fruits, and berries, 500-800 grams, or more, per day in total. A variety of different types of both vegetables and fruits (including berries) should be consumed, with emphasis on dietary fibre contribution (potatoes and pulses are not included). Limit intake of products prepared with added/free sugars. Please refer to separate recommendation on fruit juice.
Potatoes	Not sufficient evidence to inform a quantitative FBDG	Common staple food, contribute with fibre and some essential nutrients. Negative health effects of potato products with added salt and fat.	The environmental impacts are among the lowest among food products, supporting potatoes as part of a plant-based healthy diet.	Potatoes can be part of a healthy and environment-friendly diet. Potatoes should be included as a significant part in the regular dietary pattern in the Nordic and Baltic countries. Intake of boiled or baked potatoes and potatoes prepared with low content of fat and salt should be preferred. Intake of deep-fried potatoes should be limited.
Fruit juices	Not sufficient evidence to inform a quantitative FBDG.	Contributes with energy and many essential nutrients. May contribute with fibre.	Climate and environmental impact of fruit juice depend on the fruits and berries they contain, and climate impact is generally low.	Low to moderate intake of fruit juice may be part of a healthy diet. Intake of fruit juice should be limited for children.
Pulses	Intake of pulses may protect against cancer and all-cause mortality. Not sufficient evidence to inform a quantitative FBDG.	Contribute with protein, fibre and many essential nutrients such as folate, potassium, magnesium, iron, zinc, and thiamine, as well as bioactive compounds such as phytochemicals.	Pulses have low climate impact while environmental impacts vary depending on production method and production site.	Pulses should be included as a significant part in the regular dietary pattern in the Nordic and Baltic countries. Pulses are important providers of nutrients such as dietary fibre, protein, iron and zinc.
Nuts and seeds	Reduced risk of CVD from intake of 20-30 grams nuts/day.	High nutrient density. Contribute with unsaturated fatty acids, protein, fibre and micronutrients.	Nuts and seeds have a low GHG emissions. However, when increased consumption is achieved, more detailed recommendations are warranted to avoid the potential water stress and biodiversity loss associated with nut and seed consumption.	It is recommended to consume 20-30 grams nuts per day. It is also recommended to include seeds in the diet due to the nutrient content; however, evidence for a certain quantity is not available. Nuts and seeds are important in plant-based diets as they have low GHG emissions and high nutrient density.
Fish and seafood	Intake of 300-450 grams fish/week (of which at least 200 grams fatty fish/week) reduces risk of CVD, Alzheimer's disease, cognitive decline, and all-cause mortality.	Contribute to n-3 fatty acids and essential nutrients such as protein, vitamin D, vitamin B₁₂ and iodine.	Fish and seafood from sustainably managed farms and wild stocks should be prioritized and consumption of species with high environmental impact should be limited.	It is recommended to consume 300–450 grams fish/week (ready-to-eat or cooked weight), of which at least 200 grams/week should be fatty fish. It is recommended to consume fish from sustainably managed fish stocks.
Red meat	Intake above 350 grams/week increases the risk of CRC. Intake of processed meat increases risk of CRC.	Contributes with many essential nutrients, such as protein, iron and vitamin B₁₂ but also a source of saturated fatty acids, and processed meat is a source of sodium.	High environmental impact. The high consumption of red meat is the most important contributor to GHG emissions from the diet in the Nordic and Baltic countries. Negative environmental impact is related to methane emissions from ruminants, and feed which contribute through fertilizer, pesticide, water and land use and thereby reduced biodiversity. Positive environmental impact may be related to grazing and biodiversity. GHG emission from pigs is lower than ruminants but there are environmental issues related to the feed production and manure management.	For health reasons, it is recommended that consumption of red meat from cattle, sheep, goats and pigs (including red meat in products and processed foods) should be low and not exceed 350 grams/week ready-to-eat (cooked) weight. Processed red meat should be as low as possible. For environmental reasons the consumption of red meat should be considerably lower than 350 grams/week (ready-to-eat weight). The choice of meat should comply with the recommendations for fatty acids. The reduction of red meat consumption should not result in an increase in white meat consumption. To minimize environmental impact, meat consumption should be replaced by increased consumption of plant foods, such as legumes and fish from sustainably managed stocks.
White meat (poultry)	Not sufficient evidence to inform a quantitative FBDG. Intake of processed meat increases risk of CRC.	Contributes with many essential nutrients, such as protein, iron and vitamin B₁₂.	In general, lower environmental impact across many environmental metrics compared to red meat. Negative environmental impact is related to feed production and manure management. Due to negative environmental impacts, it is not desirable to increase white meat consumption from current levels.	It is recommended that consumption of processed white meat should be as low as possible. To minimize environmental impact, consumption of white meat should not be increased from current levels, and may be lower. Instead, meat consumption should be replaced by increased consumption of plant foods, such as legumes and fish from sustainably managed stocks.
Milk and dairy	Moderate consumption may reduce risk of CRC. High consumption of high-fat milk may increase risk of CVD.	Contributes with many essential nutrients, such as protein, calcium, iodine, riboflavin and vitamin B₁₂.	In general, dairy, especially concentrated products such as hard cheese, is associated with high environmental impact. The high consumption of milk and dairy is an important contributor to GHG emissions from the diet in the Nordic and Baltic countries. Negative environmental impact is related to methane emissions from the enteric fermentation of ruminants. Feed contributes through fertilizer, pesticide, water and land use, and thereby reduced biodiversity. Positive environmental impact is related to grazing and biodiversity.	Intake of between 350 ml to 500 ml low fat milk and dairy products per day is sufficient to meet dietary requirements of calcium, iodine and vitamin B₁₂ if combined with adequate intake of legumes, dark green vegetables and fish (varies among different species). The range depends on national fortifications programs and diets across the Nordic and Baltic countries. If consumption of milk and dairy is lower than 350 gram/day, products may be replaced with fortified plant-based alternatives or other foods.
Eggs	Not sufficient evidence to inform a quantitative FBDG.	Contributes with all essential nutrients except vitamin C.	Egg consumption is associated with lower GHG emissions than meat, but feed production demands land and may contribute negatively to biodiversity.	A moderate intake of egg may be part of a healthy and environment-friendly diet.
Fats and oils	Not sufficient evidence to inform a quantitative FBDG.	Vegetable oils contribute with essential fatty acids and some fat-soluble vitamins.	A shift from animal to plant-based fats it is recommended to contribute to lower GHG emissions and it is recommended to avoid oils that contribute to deforestation.	It is recommended to consume at a minimum of 25 g/day vegetable oil (or similar amounts of fatty acids from whole foods) considering a sufficient intake of ALA (minimum of 1.3 g/day per 10 MJ/day) and limiting the consumption of butter and tropical oils.
Sweets	High intake of sweets, including other sugary foods, as well as SSB increases risk of chronic metabolic diseases, reduces diet quality and increases risk of caries.	Sweets, cakes and biscuits contribute to high energy intake of sugar and fat.	Even though the GHG emission from sugar production is low, the high consumption of the food group contributes to the relatively high GHG emissions in the Nordic countries. Sweets also contribute to decreased biodiversity by land use change and intensive large-scale cropping systems with low diversity.	Limiting the consumption of sweets and other sugary foods is recommended.
Alcohol	Intake increases risk of several cancers and total mortality.	High intake reduces diet quality.	The consumption of alcoholic beverages contributes to negative environmental impact.	No safe lower limit for alcohol consumption has been established. For children, adolescents and pregnant women abstinence from alcohol is advised.
Dietary patterns	Healthy dietary patterns are associated with beneficial health outcomes, such as reduced risk of CVD, T2D, obesity, cancer, bone health, and premature death.	Healthy dietary patterns are often micronutrient dense, including high intake of unsaturated fats and fibre, and low intake of saturated fats, added/free sugars and sodium.	Transitioning towards a healthy dietary pattern, i.e., a more plant-based dietary pattern, will reduce several negative environmental effects of the diet. However, the environmental impact of dietary patterns depends on the specific foods included. Limiting food waste and overconsumption is important for limiting the environmental impact.	A dietary pattern, characterized by high intakes of vegetables, fruits, whole grains, fish, low-fat dairy, and legumes and low in red and processed meats, sugar-sweetened beverages, sugary foods, and refined grains, would benefit health and will lower the climate impacts. Food group-specific considerations are essential to simultaneously reduce the environmental impacts and achieve nutritional adequacy of dietary patterns.

Abbreviations: CVD, cardiovascular disease; CRC, colorectal cancer; GHG, greenhouse gas; LNCSB, low- and no-calorie sweetened beverages; SSB, sugar-sweetened beverages; T2D, type 2 diabetes.

Processing of foods

Many of the FBDGs summarized in Table 24 are related to food processing. In general, food processing is the transformation of agricultural and fish products into human foods. Some kind of food processing is needed to make most foods edible and accessible, while extensive food processing may have a role in overeating and overnutrition. Food processing takes place at home in the kitchen and by the food industry.

Many terms have been used to describe the degree and type of processing of foods such as whole foods, minimally processed foods, unrefined foods, unprocessed foods, processed foods, refined foods, highly processed foods and ultra-processed foods.

In general, a processed food is any food that has been altered in some way during preparation. Historically, the main food processing techniques have been heating, drying, fermenting, smoking, milling, canning or salting. Some foods need processing to make them safe, such as milk, which needs to be pasteurised to inactivate harmful bacteria. Salt, sugar and fat are often added to processed foods to make their flavour more appealing and savoury, to extend their shelf life, and to improve the food's structure.

Consumption of processed foods, especially highly processed foods, may contribute to intakes higher than the recommended amounts of sugar, salt, total and saturated fat and energy and lower amounts of fibre and micronutrients.

The NNR2023 report includes a number of recommendations related to food processing (see respective nutrient and food group summaries for more details), such as:

Breastfeeding should be preferred compared to infant formulas
Consumption of SSB and energy drinks should be limited
Whole grain cereal products should preferentially be used instead of refined cereal products
Fruit and vegetable products with added sugar should be limited
Intake of deep-fried potatoes and potato products with added fat and salt should be limited
High intake of fruit juices should be avoided
Intake of processed red and white meat (poultry) should be limited
Milk and dairy products with high amounts of saturated fat should be limited
Some vegetable oils should be preferred over butter and butter-mixes, hard margarine and tropical oils.
Sweets, confectioneries and other sugary foods should be limited
Advice on selecting more whole foods instead of processed foods for environmental reasons
A dietary pattern with limited amounts of added total fat, saturated fat, salt and sugar is recommended
In addition to these FBDGs, several DRVs also have high relevance for food processing, including limitation of trans fatty acids, saturated fatty acids, salt and added sugar.

The background paper by Juul and Bere (2023) concludes that there are increased risks for several health outcomes with high intake of so-called ultra-processed foods. Despite the observed association between ultra-processed foods as a category and health outcomes, the NNR2023 Committee decided not to formulate any specific recommendations on ultra-processed foods. NNR2023 includes a number of recommendations related to specific types of processed foods (see above). The NNR Committee’s view is that the current categorization of foods as ultra-processed foods does not add to the already existing food classifications and recommendations in NNR2023. These FBDGs and DRVs greatly overlap with many aspects of ultra-processed foods. In addition, the Nova classification of ultra-processed foods also includes many food products which are not associated with any apparent adverse health effect. The decisions not to give specific guideline on ultra-processed foods is in line with the FBDGs in USA (Dietary Guidelines Advisory Committee, 2020; U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020), Canada (Health Canada, 2019) and most European countries (FAO, 2023). Some countries, like Brazil (Ministry of Health of Brazil, 2015), Israel (Israeli Ministry of Health, 2019) and Malaysia (NCCFN, 2021), as well as the American Heart Association (Lichtenstein et al., 2021), have decided to include ultra-processed foods in their FBDGs.

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