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Original Paper

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Revised Reference Values for the Intake of Sodium and Chloride

Strohm D.a · Bechthold A.a · Ellinger S.b · Leschik-Bonnet E.a · Stehle P.c · Heseker H.d · German Nutrition Society (DGE)

Author affiliations

aGerman Nutrition Society, Bonn, Germany
bFaculty of Food, Nutrition and Hospitality Sciences, Hochschule Niederrhein, University of Applied Sciences, Moenchengladbach, Germany
cDepartment of Nutrition and Food Sciences, University of Bonn, Bonn, Germany
dDepartment of Sports and Health, University of Paderborn, Paderborn, Germany

Corresponding Author

Dr. Daniela Strohm

Department of Science, German Nutrition Society

Godesberger Allee 18

DE–53175 Bonn (Germany)

E-Mail strohm@dge.de

Related Articles for ""

Ann Nutr Metab 2018;72:12–17

Abstract

Background: In January 2017, the nutrition societies of ­Germany, Austria and Switzerland revised the reference values for sodium and chloride intake. Methods: For adults, the estimated value for sodium intake was derived on the basis of a balance study. The estimated values for children and adolescents were extrapolated from this estimated value considering differences in body mass. For infants aged 0 to under 4 months, an estimated value was set based on the sodium intake via breast milk. From this value the estimated value for infants aged 4 to under 12 months was also derived by extrapolation. The estimated value for lactating women takes into account the fact that the sodium loss via breast milk is compensated through homoeostatic mechanisms. Except for infants, the reference values for chloride intake were derived based on the estimated values for sodium intake. Results: For adults, pregnant and lactating women, the estimated values for sodium and chloride intake are set at 1,500 and 2,300 mg/day. Discussion and Conclusion: Reference values for sodium and chloride can be derived in terms of estimated values. Considering dietary recommendations for sodium and chloride, it must be taken into account that high intake of sodium chloride (salt) is associated with adverse health effects, for example, hypertension and cardiovascular diseases. Therefore, it is necessary to lower salt intake in the general population.

The Author(s). Published by S. Karger AG, Basel


Introduction

The D-A-CH ‘reference values for nutrient intake’ [1] are jointly issued by the nutrition societies of Germany, Austria and Switzerland (the abbreviation D-A-CH arises from the initial letters of the common country identification for the countries Germany [D], Austria [A] and ­Switzerland [CH]). They elaborated the revised reference values for sodium and chloride, which were published in German in January 2017. This paper gives a summary of this work.

Reference value is a collective term for recommended intake values, estimated values and guiding values. A recommended intake value, according to its definition, meets the requirement of nearly any person (approximately 98%) of a defined group of healthy people. Estimated values are given when human requirements cannot be determined with desirable accuracy. Guiding values are stated in terms of aids for orientation [1]. Different scientific bodies derived dietary reference values for sodium and chloride: For adults, intake values range from 920–2,300 mg/day for sodium [2-4] and an intake value is set at 2,300 mg/day for chloride [2].

Quantitatively, sodium (Na+) and chloride are the most abundant electrolytes in the extracellular space [5, 6]. Both electrolytes occur in almost all foods, where they are found naturally or are added during processing, cooking or at the table.

Sodium and chloride are osmotically active in the extracellular fluid. They serve to maintain osmotic pressure as well as water, electrolyte and acid-base balance and affect extracellular volume [7] and blood pressure [8, 9]. At cellular level, sodium is involved in maintaining membrane potential and in facilitating the active transport of molecules across cell membranes. For instance, glucose is transported together with sodium through a coupled mechanism (symport) in small intestinal enterocytes and in renal tubular epithelial cells [5, 7, 10]. Chloride is essential for the production of hydrochloric acid in the parietal cells of the stomach. As a component of gastric juice, hydrochloric acid is involved in digestion and in the defense activities against unspecific pathogens [5].

Criteria to Assess the Supply with Sodium and Chloride

It is difficult to precisely assess sodium and chloride supply using dietary assessment methods due to the variable extent of salt addition. In fact, it has been demonstrated that dietary assessment methods typically underestimate salt intake [11, 12]. Due to homoeostasis, plasma concentration of sodium and chloride is also not suitable to assess the supply with sodium and chloride. A more accurate measurement of supply is the assessment of 24-h urinary excretion. Based on sodium supply, chloride supply can be determined.

Measurement of 24-h urinary sodium excretion is considered the gold standard method for the assessment of sodium intake [13]. However, 24-h urine collections are complex and require a high level of compliance. Therefore, this method is of limited suitability for large population studies. Thus, in order to assess the sodium intake in the general population, 24-h sodium excretion is often estimated based on spot urinary sodium concentrations. However, due to, for example, large within-person variation, spot urine samples provide relatively inaccurate estimates of sodium intake in individuals. To determine sodium intake in an individual using renal sodium excretion, several 24-h urine samples would be required [14]. It is also possible to extrapolate from spot urine concentration to daily sodium excretion by using a set of published equations [15].

Derivation of the Reference Values for the Intake of Sodium and Chloride

Sodium requirement is dependent on individual and environmental factors and is thus subject to high individual variability. It is therefore not possible to set average requirements for certain population groups. Thus, the reference values for sodium intake are set as estimated values.

Intake of chloride usually occurs together with sodium, due to the addition of salt in food processing and in preparation or intake of foods [5, 16]. Thus, except for infants, the reference values for chloride intake were derived based on the estimated values for sodium intake on the molar level considering the molecular weight of chloride. One mmol sodium is equivalent to 23.0 mg sodium and 1 mmol chloride is equivalent to 35.5 mg chloride, which means that 1 mg sodium (0.04 mmol) corresponds to 1.54 mg chloride.

Adults

In extreme conditions, it is possible to survive on very low sodium intake of about 23 mg/day (1 mmol/day) due to adaptive mechanisms regarding sodium excretion through sweat, urine and faeces [17, 18]. However, such a low sodium intake cannot be compared to the physiological requirement in population groups under different circumstances, which can only be determined individually. In most population groups, sodium intake exceeds sodium requirement by a multiple. Only few studies determined the sodium intake that is required for health in persons adapted to low sodium intake over a longer period [19].

In the balance study by Allsopp et al. [20, 21], sodium balance in male subjects was determined at different sodium intake levels (1,500, 4,000, and 8,000 mg/day) over a period of 8 days based on urinary sodium excretion. At a sodium intake of 1,500 mg/day, sodium balance was negative during the first 4 days with increased sodium loss through sweat due to moderate physical activity and heat exposure (from day 4 onwards for 12 h/day at 40°C) in non-acclimatised subjects. However, on the 8th day, mean sodium balance was positive (36.8 ± 117.3 mg/day) at a sodium intake of 1,500 mg/day under the conditions mentioned above. In addition, with a diet providing 1,500 mg sodium/day, the other reference values for nutrient intake except for iodine and fluoride intake are reached [22, 23]. Therefore, the estimated value for adequate sodium intake is set to 1,500 mg/day (Table 1).

Table 1.

Estimated values for adequate intake of sodium and chloride

/WebMaterial/ShowPic/908842

Corresponding to the estimated value for sodium intake, the equimolar estimated value for chloride intake for adults from the age of 19 years is set to 2,300 mg/day (Table 1).

It is not considered useful to derive gender-specific estimated values for the intake of sodium and chloride for adults.

Children and Adolescents

No data are available regarding the sodium requirement for children and adolescents. Therefore, the reference values for children and adolescents are based on the values compiled for adults and taking into account differences in body weight and growth factors to consider the requirements for growth (Table 2). Growth factors at the different ages were calculated as the proportional increase in protein requirement for growth relative to the maintenance requirement according to WHO [1, 24]. When ­using the age groups and reference body weights, the ­D-A-CH reference values are based upon [1] the resulting estimated values for sodium intake range from 400 mg/day (for 1 to under 4-year-olds) to 1,500 mg/day (for 15 to under 19-year-olds; Tables 1, 2).

Table 2.

Estimated values for sodium intake for children and adolescents taking into account differences in average body weight and growth factors

/WebMaterial/ShowPic/908840

The estimated values for chloride intake for children and adolescents are set in equimolar amounts corresponding to the estimated values for sodium. The resulting estimated values for chloride intake range from 600 mg/day (for 1 to under 4-year-olds) to 2 300 mg/day (for 15 to under 19-year-olds; Table 1).

Also, for children and adolescents, it is not considered useful to derive gender-specific estimated values for the intake of sodium and chloride.

Infants

The reference values for the intake of sodium and chloride for infants aged 0 to under 4 months were derived based on the sodium and chloride content of breast milk, which is considered to be the optimal diet for infants [26, 27]. The reference values for infants are therefore estimated values.

The average breast milk intake of an exclusively breastfed infant is 750 mL/day [28]. Based on a mean sodium and chloride content of breast milk of 17 mg/100 mL [29-35] and 40 mg/100 mL [31-34, 36] within the first 4 months, the estimated value for the intake of sodium and chloride for breastfed infants aged 0 to under 4 months is set at 130 and 300 mg/day respectively (Table 1).

The consumption of breast milk declines along with the introduction of solid foods. Since no data is available from Germany with regard to sodium and chloride intake via solid foods, the estimated value for infants aged 0 to under 4 months is used to derive the reference value for infants over 4 months of age (Table 3). Taking into account the differences of the average body weight, an estimated value of 200 mg sodium/day and of 450 mg chloride/day for infants aged 4 to under 12 months was derived (Tables 1, 3).

Table 3.

Estimated value for the intake of sodium and chloride for infants aged 4 to under 12 months

/WebMaterial/ShowPic/908838

Pregnancy

In order to maintain the increase in plasma and interstitial fluid volume during pregnancy, additional 70 mg sodium/day is necessary [38]. The organism can provide this quantity due to homoeostatic mechanisms [18, 39]. Thus, the estimated value for sodium intake for pregnant women does not differ from that for non-pregnant women and is set to 1,500 mg/day. Accordingly, the estimated value for chloride intake for pregnant women is set to 2,300 mg/day.

Lactation

A total of 130 mg sodium/day is secreted with breast milk [29-35], assuming an average breast milk intake of 750 mL/day of an exclusively breastfed infant [28]. The lactating organism can compensate these losses through homoeostatic mechanisms [18]. Thus, the estimated value for sodium intake for lactating women is also set to 1,500 mg/day. Accordingly, the estimated value for chloride intake for lactating women does not differ from that of non-lactating women and is set to 2,300 mg/day.

Preventive Aspects

Sodium and chloride are usually consumed together in the form of sodium chloride or salt. The role of sodium, chloride or salt in the prevention of nutrition-related diseases has recently been summarized by the DGE in a scientific statement on salt intake [40].

There is convincing evidence for an association between salt intake and blood pressure: High salt intake is associated with increased or suboptimal blood pressure and low salt intake with normotensive or optimal blood pressure1. High blood pressure is a main cardiovascular disease risk factor and thus there is convincing evidence for an indirect effect of high salt intake on the risk of cardiovascular diseases. However, there is currently insufficient evidence for a direct association between high salt intake and risk of cardiovascular diseases due to different and partly contradictory results [40, 41].

Discussion and Conclusion

There is a high individual variability in sodium requirement, as it is dependent on individual and environmental factors. It is therefore not possible to set an average sodium requirement for a certain population group and the reference values for sodium intake are set as estimated values. Measurement of 24-h urinary sodium excretion is the most accurate measurement of sodium supply.

For adults, the derivation of the reference values is based on one study investigating sodium balance by sodium excretion in male subjects at different sodium intake levels over a period of 8 days. Based on this balance study and the fact that with a diet providing 1,500 mg sodium/day, the other reference values for nutrient intake except for iodine and fluoride intake are reached, the estimated value for sodium intake for adults is set to 1,500 mg/day. Except for infants, the reference values for chloride intake were derived based upon the estimated values for sodium intake on the molar level taking into account the molecular weight of chloride. The estimated value for chloride intake for adults is set to 2,300 mg/day.

Considering dietary recommendations for sodium and chloride, it must be taken into account that high intake of sodium and chloride as salt (sodium chloride) is associated with adverse health effects. For the prevention of hypertension and cardiovascular diseases, it is therefore necessary to lower salt intake in the general population [40].

Acknowledgement

The authors thank Anna M. Amini, Professor Dr. Stefan Lorkowski, Friederike Maretzke, Birte Peterson-Sperlich, Professor Dr. Bernhard Watzl and Professor Dr. Günther Wolfram for their valuable suggestions and contribution to the preparation of the revised reference values for sodium and chloride intake.

Disclosure Statement

The authors have no conflicts of interest to declare.


Footnotes

Systolic blood pressure <120 mm Hg and diastolic blood pressure <80 mm Hg are regarded as optimum [42, 43].


References

  1. Deutsche Gesellschaft für Ernährung, Österreichische Gesellschaft für Ernährung, Schweizerische Gesellschaft für Ernährung (eds): Referenzwerte für die Nährstoffzufuhr, ed 2, Update 1, Bonn, 2016.
  2. IOM (Institute of Medicine) (ed): Dietary Reference Intakes for Water, Potassium, Sodium, Chloride and Sulfate. Washington, National Academies Press, 2005.
  3. Nordic Council of Ministers (ed): Nordic Nutrition Recommendations 2012: Integrating Nutrition and Physical Activity, ed 5. Kopenhagen, 2014.
  4. NHMRC (National Health and Medical Research Council) (ed): Nutrient reference values for Australia and New Zealand: Including recommended dietary intakes. Canberra, 2006.
  5. Strain JJ, Cashman KD: Minerals and trace elements; in Gibney MJ, Lanham-New SA, Cassidy A, Vorster HH (eds): Introduction to Human Nutrition, ed 2. The Nutrition Society Textbook Series. Chichester, Wiley-Blackwell, 2009, pp 188–237.
  6. Luft FC: Salt, water, and extracellular ­volume regulation; in Ziegler EE, Filer LJ (eds): Present Knowledge in Nutrition, ed 7. Washington, ILSI Press, 1996, pp 265–271.
  7. Bailey JL, Sands JM, Franch HA: Water, electrolytes, and acid-base metabolism; in Ross AC, Caballero B, Cousins RJ, Tucker KL, Ziegler TR (eds): Modern Nutrition in Health and Disease, ed 11. Philadelphia, Lippincott Williams & Wilkins, 2014, pp 102–132.
  8. Kotchen TA: Contributions of sodium and chloride to NaCl-induced hypertension. Hypertension 2005; 45: 849–850.
  9. Preuss HG, Clouatre DL: Sodium, chloride, and potassium; in Erdman JW, MacDonald IA, Zeisel SH (eds): Present Knowledge in Nutrition, ed 10. Oxford, Wiley-Blackwell, 2012, pp 475–492.
  10. Scientific Committe on Food (ed): Nutrient and Energy Intakes for the European Community. Luxemburg, 1993.
  11. Gemming L, Ni Mhurchu C: Dietary under-reporting: what foods and which meals are typically under-reported? Eur J Clin Nutr 2016; 70: 640–641.
  12. Macdiarmid J, Blundell J: Assessing dietary intake: who, what and why of under-reporting. Nutr Res Rev 1998; 11: 231–253.
  13. McLean RM: Measuring population sodium intake: a review of methods. Nutrients 2014; 6: 4651–4662.
  14. Mente A, O’Donnell MJ, Dagenais G, Wielgosz A, Lear SA, McQueen MJ, Jiang Y, Xingyu W, Jian B, Calik KB, Akalin AA, Mony P, Devanath A, Yusufali AH, Lopez-Jaramillo P, Avezum A Jr, Yusoff K, Rosengren A, Kruger L, Orlandini A, Rangarajan S, Teo K, Yusuf S: Validation and comparison of three formulae to estimate sodium and potassium excretion from a single morning fasting urine compared to 24-h measures in 11 countries. J Hypertens 2014; 32: 1005–1014.
  15. Klenow S, Thamm M, Mensink GBM: Sodium intake in Germany estimated from sodium excretion measured in spot urine samples. BMC Nutr 2016; 2: 251.
    External Resources
  16. He FJ, MacGregor GA: Reducing population salt intake worldwide: from evidence to implementation. Prog Cardiovasc Dis 2010; 52: 363–382.
  17. Dahl LK: Salt intake and salt need. N Engl J Med 1958; 258: 1152–1157.
  18. Oliver WJ, Cohen EL, Neel JV: Blood pressure, sodium intake, and sodium related hormones in the Yanomamo Indians, a ‘no-salt’ culture. Circulation 1975; 52: 146–151.
  19. EFSA (European Food Safety Authority): Opinion of the scientific panel on dietetic products, nutrition and allergies on a request from the commission related to the tolerable upper intake level of sodium. EFSA J 2005; 209: 1–26.
  20. Allsopp AJ: The Effects of Altered Salt Ingestion; INM Report No. 97020. Alverstoke, 1997.
  21. Allsopp AJ, Sutherland R, Wood P, Wootton SA: The effect of sodium balance on sweat sodium secretion and plasma aldosterone concentration. Eur J Appl Physiol Occup Physiol 1998; 78: 516–521.
  22. Deutsche Gesellschaft für Ernährung: DGExpert, Version 1.7.6. (BLS 3.02). Bonn, 2014.
  23. Jungvogel A, Michel M, Bechthold A, Wendt I: Die lebensmittelbezogenen Ernährungsempfehlungen der DGE: Wissenschaftliche Ableitung und praktische Anwendung der Modelle. Ernaehrungs Umschau 2016; 63: M474–M481.
  24. WHO (World Health Organization): Protein and Amino Acid Requirements in Human Nutrition. WHO Technical Report Series. Genf, 2007.
  25. RKI (Robert Koch-Institut): Referenzperzentile für anthropometrische Maßzahlen und Blutdruck aus der Studie zur Gesundheit von Kindern und Jugendlichen in Deutschland (KiGGS) 2003–2006. Gesundheitsberichterstattung des Bundes. Berlin, 2011.
  26. Bührer C, Genzel-Boroviczény O, Jochum F, Kauth T, Kersting M, Koletzko B, Mihatsch W, Przyrembel H, Reinehr T, Zimmer P: Ernährung gesunder Säuglinge. Monatsschr Kinderheilkd 2014; 162: 527–538.
  27. Butte NF, Lopez-Alarcon MG, Garza C: Nutrient Adequacy of Exclusive Breastfeeding for the Term Infant during the First Six Months of Life, 2002. www.who.int/nutrition/publications/­infantfeeding/nut_adequacy_of_exc_­bfeeding_eng.pdf (accessed June 25, 2013).
  28. Neville MC, Keller R, Seacat J, Lutes V, Neifert M, Casey C, Allen J, Archer P: Studies in human lactation: milk volumes in lactating women during the onset of lactation and full lactation. Am J Clin Nutr 1988; 48: 1375–1386.
    External Resources
  29. Dewey KG, Lönnerdal B: Milk and nutrient intake of breast-fed infants from 1 to 6 months: relation to growth and fatness. J Pediatr Gastroenterol Nutr 1983; 2: 497–506.
    External Resources
  30. Morriss FH, Brewer ED, Spedale SB, Riddle L, Temple DM, Caprioli RM, West MS: Relationship of human milk pH during course of lactation to concentrations of citrate and fatty acids. Pediatrics 1986; 78: 458–464.
    External Resources
  31. Souci SW, Fachmann W, Kraut H (eds): Die Zusammensetzung der Lebensmittel. Nährwert-Tabellen, ed 7, Revised. Stuttgart, Medpharm, 2008.
  32. Lemons JA, Moye L, Hall D, Simmons M: Differences in the composition of preterm and term human milk during early lactation. Pediatr Res 1982; 16: 113–117.
  33. Gross SJ, David RJ, Bauman L, Tomarelli RM: Nutritional composition of milk produced by mothers delivering preterm. J Pediatr 1980; 96: 641–644.
  34. Picciano MF, Calkins EJ, Garrick JR, Deering RH: Milk and mineral intakes of breastfed infants. Acta Paediatr Scand 1981; 70: 189–194.
  35. Keenan BS, Buzek SW, Garza C, Potts E, Nichols BL: Diurnal and longitudinal variations in human milk sodium and potassium: implication for nutrition and physiology. Am J Clin Nutr 1982; 35: 527–534.
    External Resources
  36. Bauer J, Gerss J: Longitudinal analysis of macronutrients and minerals in human milk produced by mothers of preterm infants. Clin Nutr 2011; 30: 215–220.
  37. WHO (World Health Organization): WHO Child Growth Standards – Length/Height-for-Age, Weight-for-Age, Weight-for-Length, Weight-for-Height and Body Mass Index-for Age. Genf, 2006.
  38. Brown MA, Gallery ED: Volume homeostasis in normal pregnancy and pre-eclampsia: physiology and clinical implications. Baillieres Clin Obstet Gynaecol 1994; 8: 287–310.
  39. van Buul BJ, Steegers EA, Jongsma HW, Rijpkema AL, Eskes TK, Thomas CM, Baadenhuysen H, Hein PR: Dietary sodium restriction in the prophylaxis of hypertensive disorders of pregnancy: effects on the intake of other nutrients. Am J Clin Nutr 1995; 62: 49–57.
    External Resources
  40. Strohm D, Boeing H, Leschik-Bonnet E, Heseker H, Arens-Azevêdo U, Bechthold A, Knorpp L, Kroke A: Salt intake in Germany, health consequences, and resulting recommendations for action. Ernaehrungs Umschau 2016; 63: 62–70.
  41. WHO (World Health Organization) (ed): Guideline. Potassium Intake for Adults and Children: Potassium Intake for Adults and Children. Genf, 2012.
  42. ESH/ESC Task Force: 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC). J Hypertens 2013; 31: 1925–1938.
  43. Deutsche Gesellschaft für Kardiologie – Herz- und Kreislaufforschung e. V., Deutsche Hochdruckliga e. V. DHL (eds): Leitlinien für das Management der arteriellen Hypertonie. Grünwald, Bruckmeier, 2013.

Author Contacts

Dr. Daniela Strohm

Department of Science, German Nutrition Society

Godesberger Allee 18

DE–53175 Bonn (Germany)

E-Mail strohm@dge.de


Article / Publication Details

First-Page Preview
Abstract of Original Paper

Received: May 15, 2017
Accepted: October 04, 2017
Published online: December 12, 2017
Issue release date: February 2018

Number of Print Pages: 6
Number of Figures: 0
Number of Tables: 3

ISSN: 0250-6807 (Print)
eISSN: 1421-9697 (Online)

For additional information: https://www.karger.com/ANM


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References

  1. Deutsche Gesellschaft für Ernährung, Österreichische Gesellschaft für Ernährung, Schweizerische Gesellschaft für Ernährung (eds): Referenzwerte für die Nährstoffzufuhr, ed 2, Update 1, Bonn, 2016.
  2. IOM (Institute of Medicine) (ed): Dietary Reference Intakes for Water, Potassium, Sodium, Chloride and Sulfate. Washington, National Academies Press, 2005.
  3. Nordic Council of Ministers (ed): Nordic Nutrition Recommendations 2012: Integrating Nutrition and Physical Activity, ed 5. Kopenhagen, 2014.
  4. NHMRC (National Health and Medical Research Council) (ed): Nutrient reference values for Australia and New Zealand: Including recommended dietary intakes. Canberra, 2006.
  5. Strain JJ, Cashman KD: Minerals and trace elements; in Gibney MJ, Lanham-New SA, Cassidy A, Vorster HH (eds): Introduction to Human Nutrition, ed 2. The Nutrition Society Textbook Series. Chichester, Wiley-Blackwell, 2009, pp 188–237.
  6. Luft FC: Salt, water, and extracellular ­volume regulation; in Ziegler EE, Filer LJ (eds): Present Knowledge in Nutrition, ed 7. Washington, ILSI Press, 1996, pp 265–271.
  7. Bailey JL, Sands JM, Franch HA: Water, electrolytes, and acid-base metabolism; in Ross AC, Caballero B, Cousins RJ, Tucker KL, Ziegler TR (eds): Modern Nutrition in Health and Disease, ed 11. Philadelphia, Lippincott Williams & Wilkins, 2014, pp 102–132.
  8. Kotchen TA: Contributions of sodium and chloride to NaCl-induced hypertension. Hypertension 2005; 45: 849–850.
  9. Preuss HG, Clouatre DL: Sodium, chloride, and potassium; in Erdman JW, MacDonald IA, Zeisel SH (eds): Present Knowledge in Nutrition, ed 10. Oxford, Wiley-Blackwell, 2012, pp 475–492.
  10. Scientific Committe on Food (ed): Nutrient and Energy Intakes for the European Community. Luxemburg, 1993.
  11. Gemming L, Ni Mhurchu C: Dietary under-reporting: what foods and which meals are typically under-reported? Eur J Clin Nutr 2016; 70: 640–641.
  12. Macdiarmid J, Blundell J: Assessing dietary intake: who, what and why of under-reporting. Nutr Res Rev 1998; 11: 231–253.
  13. McLean RM: Measuring population sodium intake: a review of methods. Nutrients 2014; 6: 4651–4662.
  14. Mente A, O’Donnell MJ, Dagenais G, Wielgosz A, Lear SA, McQueen MJ, Jiang Y, Xingyu W, Jian B, Calik KB, Akalin AA, Mony P, Devanath A, Yusufali AH, Lopez-Jaramillo P, Avezum A Jr, Yusoff K, Rosengren A, Kruger L, Orlandini A, Rangarajan S, Teo K, Yusuf S: Validation and comparison of three formulae to estimate sodium and potassium excretion from a single morning fasting urine compared to 24-h measures in 11 countries. J Hypertens 2014; 32: 1005–1014.
  15. Klenow S, Thamm M, Mensink GBM: Sodium intake in Germany estimated from sodium excretion measured in spot urine samples. BMC Nutr 2016; 2: 251.
    External Resources
  16. He FJ, MacGregor GA: Reducing population salt intake worldwide: from evidence to implementation. Prog Cardiovasc Dis 2010; 52: 363–382.
  17. Dahl LK: Salt intake and salt need. N Engl J Med 1958; 258: 1152–1157.
  18. Oliver WJ, Cohen EL, Neel JV: Blood pressure, sodium intake, and sodium related hormones in the Yanomamo Indians, a ‘no-salt’ culture. Circulation 1975; 52: 146–151.
  19. EFSA (European Food Safety Authority): Opinion of the scientific panel on dietetic products, nutrition and allergies on a request from the commission related to the tolerable upper intake level of sodium. EFSA J 2005; 209: 1–26.
  20. Allsopp AJ: The Effects of Altered Salt Ingestion; INM Report No. 97020. Alverstoke, 1997.
  21. Allsopp AJ, Sutherland R, Wood P, Wootton SA: The effect of sodium balance on sweat sodium secretion and plasma aldosterone concentration. Eur J Appl Physiol Occup Physiol 1998; 78: 516–521.
  22. Deutsche Gesellschaft für Ernährung: DGExpert, Version 1.7.6. (BLS 3.02). Bonn, 2014.
  23. Jungvogel A, Michel M, Bechthold A, Wendt I: Die lebensmittelbezogenen Ernährungsempfehlungen der DGE: Wissenschaftliche Ableitung und praktische Anwendung der Modelle. Ernaehrungs Umschau 2016; 63: M474–M481.
  24. WHO (World Health Organization): Protein and Amino Acid Requirements in Human Nutrition. WHO Technical Report Series. Genf, 2007.
  25. RKI (Robert Koch-Institut): Referenzperzentile für anthropometrische Maßzahlen und Blutdruck aus der Studie zur Gesundheit von Kindern und Jugendlichen in Deutschland (KiGGS) 2003–2006. Gesundheitsberichterstattung des Bundes. Berlin, 2011.
  26. Bührer C, Genzel-Boroviczény O, Jochum F, Kauth T, Kersting M, Koletzko B, Mihatsch W, Przyrembel H, Reinehr T, Zimmer P: Ernährung gesunder Säuglinge. Monatsschr Kinderheilkd 2014; 162: 527–538.
  27. Butte NF, Lopez-Alarcon MG, Garza C: Nutrient Adequacy of Exclusive Breastfeeding for the Term Infant during the First Six Months of Life, 2002. www.who.int/nutrition/publications/­infantfeeding/nut_adequacy_of_exc_­bfeeding_eng.pdf (accessed June 25, 2013).
  28. Neville MC, Keller R, Seacat J, Lutes V, Neifert M, Casey C, Allen J, Archer P: Studies in human lactation: milk volumes in lactating women during the onset of lactation and full lactation. Am J Clin Nutr 1988; 48: 1375–1386.
    External Resources
  29. Dewey KG, Lönnerdal B: Milk and nutrient intake of breast-fed infants from 1 to 6 months: relation to growth and fatness. J Pediatr Gastroenterol Nutr 1983; 2: 497–506.
    External Resources
  30. Morriss FH, Brewer ED, Spedale SB, Riddle L, Temple DM, Caprioli RM, West MS: Relationship of human milk pH during course of lactation to concentrations of citrate and fatty acids. Pediatrics 1986; 78: 458–464.
    External Resources
  31. Souci SW, Fachmann W, Kraut H (eds): Die Zusammensetzung der Lebensmittel. Nährwert-Tabellen, ed 7, Revised. Stuttgart, Medpharm, 2008.
  32. Lemons JA, Moye L, Hall D, Simmons M: Differences in the composition of preterm and term human milk during early lactation. Pediatr Res 1982; 16: 113–117.
  33. Gross SJ, David RJ, Bauman L, Tomarelli RM: Nutritional composition of milk produced by mothers delivering preterm. J Pediatr 1980; 96: 641–644.
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