Design of an In Vitro Model to Screen the Chemical Reactivity Induced by Polyphenols and Vitamins during Digestion: An Application to Processed Meat

Processed meats’ nutritional quality may be enhanced by bioactive vegetable molecules, by preventing the synthesis of nitrosamines from N-nitrosation, and harmful aldehydes from lipid oxidation, through their reformulation. Both reactions occur during digestion. The precise effect of these molecules during processed meats’ digestion must be deepened to wisely select the most efficient vegetable compounds. The aim of this study was to design an in vitro experimental method, allowing to foresee polyphenols and vitamins’ effects on the chemical reactivity linked to processed meats’ digestion. The method measured the modulation of end products formation (specific nitroso-tryptophan and thiobarbituric acid reactive substances (TBARS)), by differential UV-visible spectrophotometry, according to the presence or not of phenolic compounds (chlorogenic acid, rutin, naringin, naringenin) or vitamins (ascorbic acid and trolox). The reactional medium was supported by an oil in water emulsion mimicking the physico-chemical environment of the gastric compartment. The model was optimized to uphold the reactions in a stable and simplified model featuring processed meat composition. Rutin, chlorogenic acid, naringin, and naringenin significantly inhibited lipid oxidation. N-nitrosation was inhibited by the presence of lipids and ascorbate. This methodology paves the way for an accurate selection of molecules within the framework of processed meat products reformulation.

Reformulation of Muffins Using Inulin and Green Banana Flour: Physical, Sensory, Nutritional and Shelf-Life Properties

This study demonstrates a scenario of industrial reformulation by developing muffins that resemble store-branded ones and testing the possibility of reformulating them using inulin and green banana flour (GBF). Ten different formulations were created through reducing 10% or 30% of sugar and/or fat. Physical characteristics, consumer acceptance and purchase preferences, baking losses, nutritional properties, shelf-life, as well as cost and industrial processability were considered and discussed. Results on physical properties showed that firmness had increased in reformulated muffins while springiness only decreased when both sugar and fat were reduced by 30% (p < 0.05). Texture and sensory properties of reformulated muffins were acceptable, and the purchase intent rate was high. Regarding the nutritional properties, muffins incorporating more than 10% of fibres allowed the addition of nutritional claims. The incremental area under the curve iAUC_120min of blood glucose in healthy adults (n = 13) was significantly lower than control after ingesting 30% reduced sugar or fat muffins using inulin (p < 0.01). The microbial profile was not affected by reformulation during storage at 25 °C for 10 days. This study concluded that there is a significant potential to industrially produce reduced sugar or fat muffins using inulin or GBF up to 30% without significantly deteriorating quality attributes.

Breakfast Cereals Intended for Children: Opportunities for Reformulation and Potential Impact on Nutrient Intake

Ready-to-eat cereals (RTECs) have become a popular breakfast option claiming to provide important nutrients to children's diets, despite being a source of excess sugar and, therefore, a health concern. Thus, food reformulation constitutes an important public health strategy that could benefit from inputs provided by nutrient profiling. This study aimed to assess the adequacy of the RTECs for children available in Portuguese supermarkets, applying three nutrient profile models (NPMs)-the nutrient profile model of the World Health Organization's Regional Office for Europe (WHO-EURO), the profile of the private-sector EU Pledge (EU-Pledge), and the national model developed by the Directorate-General of Health (NPM-PT)-in order to explore the potential for reformulation of the RTECs identified as not adequate and evaluate the impact of RTECs' reformulation on the nutritional quality of Portuguese children's diets. In total, 78 RTECs intended for children were assessed and two scenarios-current (not considering reformulation) and alternative (considering reformulation to accomplish the nutrient profile requirements)-were considered to assess the impact of reformulation on nutritional quality. Across all RTECs, only 5.1% could be promoted to children according to the considered NPMs. The most common nutrients requiring reformulation were sugar, saturated fatty acids (SFA), salt, and dietary fiber. The scenarios of reformulation considered could reduce the RTECs average content of total sugars, SFA, and salt by 43%, 8.7%, and 1.1%, respectively, and dietary fiber intake could be increased by 34%. Thus, these results support policies to implement reformulation strategies for developing healthier food products to be promoted to children.

Updated Database and Trends of Declared Low- and No-Calorie Sweeteners From Foods and Beverages Marketed in Spain

Background: The past few years have witnessed an increase in the availability of food products containing one or more low- and no-calorie sweeteners (LNCS) in the Spanish market, mostly due to the new massive reformulation plan. However, these are not included in food composition tables or databases, and, therefore, assessment of their intake among the population is complex. This study aims to update a database including commercialized foods and beverages.

Method: A systematic search of ingredients information from the different food and beverage categories was undertaken during 2019 by recording the availability and type of LNCS declared in the information of the product from labels and online shopping platforms of retailers from Spain to update a previous food composition database compiled in 2017.

Results: A total of 1,238 products were identified. The major groups were sugar and sweets (24%), non-alcoholic beverages (21%), cereals and grains (19%), and milk and dairy products (14%) accounting for >70% of total products. The mainly declared LNCS were sorbitol (19.5%), sucralose (19.5%), and acesulfame K (19.2%).

Conclusion: There is a wide variety of products that include LNCS as a main ingredient with higher availability than when compared with the results of database of 2017, consequently, it might be expected that LNCS are commonly consumed at present in the Spanish diet.

Growth of Ready Meals in Australian Supermarkets: Nutrient Composition, Price and Serving Size

Pre-prepared, or ready meals (frozen, chilled and shelf-stable) are increasingly available in supermarkets in developed countries. This study aimed to investigate how the range of ready meals in Australian supermarkets has changed from 2014 to 2020, and how products vary by price, serving size, nutrient composition and Health Star Rating. Product information was obtained from the FoodTrack™ packaged food database for the years 2014 to 2019 and from an instore audit of products available in Adelaide, Australia for 2020. There was a 13% annual average increase in the number of ready meals available in supermarkets. Serving size did not change (median 350 g, p-trend = 0.100) and price increased modestly from 2014 to 2020 (median $1.67 to $1.79/100 g, p-trend < 0.001), with chilled ready meals being the most expensive. A modest decrease in sodium density from 2014 to 2020 (median 275 to 240 mg/100 g, p-trend < 0.001) was seen. However, the category has a wide range in Health Star Ratings and nutrient composition, highlighting the importance of appropriate consumer choice to optimise health benefits. With the increasing availability of ready meals, global improvements within this category should be encouraged and consumers guided to choose healthier products.

Potassium chloride-based replacers: modeling effects on sodium and potassium intakes of the US population with cross-sectional data from NHANES 2015-2016 and 2009-2010

BACKGROUND

Sodium intake in the USA exceeds recommendations. The replacement of added sodium chloride (NaCl) with potassium chloride (KCl) provides a potential strategy to reduce sodium intake.

OBJECTIVE

The purpose of this study was to quantitatively estimate changes in intakes of sodium and potassium by the US population assuming use of potassium-based NaCl replacers in top dietary sodium sources.

METHODS

Data collected in the What We Eat in America (WWEIA) component of the 2015-2016 and 2009-2010 NHANES were used to identify top-ranking sources of dietary sodium among the population aged 2 y and older based on contributions from food categories aligning with the FDA draft guidance for voluntary sodium reduction. Predicted nutrient intakes were estimated in models assuming total and feasible and practical (F&P) replacement of added NaCl with KCl in foods and ingredients within the top food sources of sodium. An expert elicitation was conducted to collect information on the F&P KCl replacement of added NaCl.

RESULTS

Using 2015-2016 consumption data, the total replacement of added NaCl with KCl in the 18 top-ranking sources of dietary sodium results in a predicted sodium intake of 2004 mg/d from the replacement of 1406 mg/d sodium with 1870 mg/d potassium as KCl. Modeled F&P replacement predicted sodium intakes of 3117 mg/d (range of 2953 to 3255 mg/d) from the replacement of 294 mg/d sodium (155 to 457 mg/d) with 390 mg/d potassium (206 to 608 mg/d). Similar results are seen with 2009-2010 data.

CONCLUSIONS

The F&P replacement of NaCl with KCl in top-ranking sources of dietary sodium modeled in this study can result in decreased sodium to a level consistent with the short-term intake goal targeted by the FDA of 3000 mg/d, with the mean potassium intake remaining in the range recommended for the apparently healthy population.

Contribution of reformulation, product renewal, and changes in consumer behavior to the reduction of salt intakes in the UK population between 2008/2009 and 2016/2017

BACKGROUND

The UK salt reduction program started in 2003, consisting of education campaigns to raise awareness about the risks associated with a high-salt diet and of a reformulation strategy for food manufacturers. This program is often cited as an example of a successful public health program.

OBJECTIVES

This study aimed to assess: 1) the impacts of changes in food composition and changes in consumer behavior on sodium intakes; and 2) whether changes were similar across socioeconomic groups.

METHODS

Food intakes for the UK population were derived from food diaries in the UK National Diet and Nutrition Survey for 2008/09 (year 1; n = 1334) and 2016/17 (year 9; n = 995). Year-specific sodium densities of foods were used to calculate the average sodium density of all food and beverage consumed. Changes in sodium density between the 2 years were explained by changes in food composition (change in sodium density of products) and/or changes in behavior (type and quantity of food consumed) using a decomposition approach.

RESULTS

The program was linked to a 16% (95% CI: -21% to -12%) decrease in sodium intake between years 1 and 9, while the sodium density of foods consumed decreased by 17% (95% CI: -21% to -12%). This decrease was largely driven by reformulation (-12.0 mg/100 g). Changes in food choices reinforced the effects of the program, but had a smaller impact (-1.6 mg/100 g). These effects were similar across socioeconomic groups, whether stratified by education or income, with a consistent effect of reformulation across groups and no differences between groups in behavioral responses to the program.

CONCLUSIONS

A multi-component sodium reduction strategy deployed in the United Kingdom starting in 2003 corresponded to an important reduction in sodium intakes for the population. This reduction was mostly driven by changes in the food environment (reformulated food products to reduce the sodium density of foods) and, to a smaller extent, by changes in food choices. Impacts were consistent across socioeconomic groups.

Potential impact of gradual reduction of fat content in manufactured and out-of-home food on obesity in the United Kingdom: a modeling study

BACKGROUND

Manufactured and out-of-home foods contribute to excessive calories and have a critical role in fueling the obesity epidemic. We propose a 20% fat reduction in these foods.

OBJECTIVES

To evaluate the potential impact of the proposed strategy on energy intake, obesity and related health outcomes in the population.

METHODS

We used the National Diet and Nutrition Survey rolling program (NDNS RP) data to calculate fat and energy contributions from 46 manufactured and out-of-home food categories. We considered a gradual fat reduction-focusing on SFA-in these categories to achieve a 20% reduction in 5 years. We estimated the reduction in energy intake in the NDNS RP population and predicted the body weight reduction using a weight loss model. We scaled up the body weight reduction to the UK adult population. We estimated reductions in overweight/obesity and type 2 diabetes cases. We calculated the reductions of LDL, ischemic heart disease (IHD), and stroke deaths that could be prevented from the SFA reduction.

RESULTS

The selected categories contributed to 38.6% of the population's energy intake. By the end of the fifth year, our proposed strategy would reduce the mean energy intake by 67.6 kcal/d/person (95% CI: 66.1-68.8). The energy reduction would reduce the mean body weight by 2.7 kg (95% CI: 2.6-2.8). The obesity prevalence would be reduced by 5.3% and the overweight prevalence by 1.5%, corresponding to 3.5 and 1 million cases of obesity and overweight, respectively, being reduced in the United Kingdom. The body weight reduction could prevent 183,000 (95% CI: 171,000-194,000) cases of type 2 diabetes over 2 decades. Energy from SFA would fall by 2.6%, lowering LDL by 0.13 mmol/L and preventing 87,560 IHD deaths (95% CI: 82,260-112,760) and 9520 stroke deaths (95% CI: 4400-14,660) over 20 years.

CONCLUSIONS

A modest fat reduction (particularly in SFA) in widely consumed foods would prevent obesity, type 2 diabetes, and cardiovascular disease.

Gels as fat replacers in bakery products: a review

Several strategies have been studied to replace or decrease fat content in bakery products aiming improving their nutritional profile. This paper reviewed the effect of different vehiculization systems (hydrogels, emulgels and oleogels) as fat replacers in different types of bakery goods, focusing on technological and nutritional properties of the reformulated products. The most commonly used fat source for replacement purposes were vegetable oils with high monounsaturated fatty acid content, such as olive oil and canola oil (44% of the revised papers used them), whereas high polyunsaturated fatty acid content oils were used in 34% of papers. Oleogelation was the most frequent used method of oil structuring, using waxes and fibers as stabilizers. Reductions of total fat between 19% and 46% and saturated fatty acid between 33% and 87% were achieved, enough to reach the minimum legal limit to state nutrition claims, under the EU legislation, on several products. Sensory evaluation results showed that partially replaced products (<75% replacement) were more appreciated by panelists than fully replaced ones. This review highlights the wide range of alternatives within gel-like fat replacers, that have potential to be applied in different bakery products and the challenge to produce nutritionally enhanced foods and technologically and sensory acceptable.

Evaluation of Dantrolene Granules Extemporaneously Reformulated from Capsules in a Pharmacy

Dantrolene capsule, an effective therapeutic agent for the treatment of spasticity, is administered to children who cannot swallow the capsule after reformulation into a powder. The powdered drug can alter the specified dosage and it is also difficult to dispense the powdered formulation because of its bulky and sticky nature. To resolve these problems, we reformulated dantrolene capsules into granules using a centrifugal planetary mixer in the pharmacy. The granules containing lactose-cornstarch, D-mannitol, or microcrystalline cellulose as a diluent were examined to determine particle size distribution, flowability, drug content uniformity, and disintegration time. The granules with microcrystalline cellulose were superior to the other forms, owing to their smaller size, good drug content uniformity, and rapid disintegration. We further investigated the usability of the granules in the dispensing procedure (dividing and packing) and in the dosing process (retrieval from package) using the powders as controls. The deviation of the divided amount and loss on dosing were reduced relative to the powders. In addition, drug dissolution properties and storage stability for 12 months were the same as those of the powders. Therefore, we concluded that dantrolene granules are excellent alternatives as an extemporaneous preparation in pharmacies.

The Development and Application of a Tool for Quantifying the Strength of Voluntary Actions and Commitments of Major Canadian Food Companies to Improve the Nutritional Quality of Their Products

BACKGROUND

Canada's food supply is high in nutrients of public health concern, contributing to poor diet quality and increased noncommunicable disease risk. Food companies shape the healthfulness of the food supply, yet little is known about companies' voluntary actions and commitments concerning product (re)formulation.

OBJECTIVE

This study aimed to develop and apply a tool for quantifying the strength of voluntary actions and commitments of major food companies in Canada to improve the healthfulness of their products.

METHODS

Twenty-two top packaged food and beverage companies were selected based on Canadian market share. Recent actions and/or commitments to reduce energy/portion sizes, sodium, saturated fat, trans fat, and sugars were identified from company websites and public documents, verified by company representatives (where possible), and scored based on breadth of application across the product portfolio, magnitude(s) of reduction, measurability, nutritional significance, national/global applicability, and transparency using the Food Company Reformulation scoring tool. Companies offering beverages only (n = 4) were not assessed for sodium, saturated fat, or trans fat (re)formulation.

RESULTS

Seventeen of 22 companies reported reductions and/or commitments concerning sodium (72.2%, n = 13/18), trans fat (61.1%, n = 11/18), sugars (59.1%, n = 13/22), saturated fat (55.6%, n = 10/18), and/or energy/portion sizes (50.0%, n = 11/22). Scores ranged from 0/155 to 122/155 for food companies (median = 49/155) and 0/65 to 42/65 for beverage companies (median = 17/65). Companies generally performed best for sodium reduction (median = 21/32; range = 0-32) and poorest for energy/portion-size reductions (median = 2/30; range = 0-24). Multinational companies had significantly higher total scores than domestic companies (P = 0.004). Higher total scores were associated with greater market shares in the beverage manufacturing sector (P = 0.04), but not packaged food (P = 0.50).

CONCLUSIONS

Many of Canada's leading food companies report limited or no action to reduce nutrients of concern in their products, suggesting a need for government intervention and strengthened accountability mechanisms to encourage alignment of reformulation efforts with government and expert recommendations.

Nutrition-Oriented Reformulation of Extruded Cereals and Associated Environmental Footprint: A Case Study

The global food system faces a dual challenge for the decades ahead: to (re)formulate foods capable to feed a growing population while reducing their environmental footprint. In this analysis, nutritional composition, recipe, and sourcing data were analyzed alongside five environmental indicators: climate change (CC), freshwater consumption scarcity (FWCS), abiotic resource depletion (ARD), land use impacts on biodiversity (LUIB), and impacts on ecosphere/ecosystems quality (IEEQ) to assess improvement after three reformulation cycles (2003, 2010, 2018) in three extruded breakfast cereals. A life cycle assessment (LCA) was performed using life cycle inventory (LCI) composed by both primary data from the manufacturer and secondary data from usual third-party LCI datasets. Reformulation led to improved nutritional quality for all three products. In terms of environmental impact, improvements were observed for the CC, ARD, and IEEQ indicators, with average reductions of 12%, 14%, and 2% between 2003 and 2018, respectively. Conversely, the FWCS and LUIB indicators were increased by 57% and 70%, respectively. For all indicators but ARD, ingredients contributed most to the environmental impact. This study highlights the need for further focus on the selection of less demanding ingredients and improvements in agricultural practices in order to achieve environmental and nutritional improvements.

The Effects of a Supermarket-Based Intervention on the Nutritional Quality of Private-Label Foods: A Prospective Study

Private-label products, products owned by supermarkets, are a growing area of the food supply. The aim of this study was to assess the effect of an intervention that provided an Australian supermarket (‘intervention supermarket’) with comparative nutrition data to improve the healthiness of their private-label range. Between 2015 and 2016, the intervention supermarket received reports that ranked the nutritional quality of their products against competitors. Changes in the nutrient content (sodium, sugar, saturated fat, energy and Health Star Rating) of products from the intervention supermarket between 2015 and 2018 were compared against changes achieved for three comparators (private-label products from two other supermarkets and branded products). The intervention supermarket achieved a significantly greater reduction in the sodium content of their products relative to all three comparators, which ranged between −104 and −52 mg/100 g (all p < 0.05). Conversely, the three comparators each achieved a greater relative reduction in the sugar content of their products by between −3.5 and −1.6 g/100 g (all p < 0.05). One of the comparators also had a greater relative reduction in the saturated fat and energy content of their products compared to the intervention supermarket (both p < 0.05). There were negligible differences in the Health Star Rating of products between the intervention supermarket and comparators (all p > 0.05). Providing comparative nutrition information to a supermarket may be ineffective in improving the healthiness of their private-label products, likely due to competing factors that play a role in the decision-making process behind product reformulation and product discontinuation/innovation.

Effects of Menu Labeling Policies on Transnational Restaurant Chains to Promote a Healthy Diet: A Scoping Review to Inform Policy and Research

There is insufficient evidence that restaurant menu labeling policies are cost-effective strategies to reduce obesity and diet-related non-communicable diseases (NCDs). Evidence suggests that menu labeling has a modest effect on calories purchased and consumed. No review has been published on the effect of menu labeling policies on transnational restaurant chains globally. This study conducted a two-step scoping review to map and describe the effect of restaurant menu labeling policies on menu reformulation. First, we identified national, state, and municipal menu labeling policies in countries from global databases. Second, we searched four databases (i.e., PubMed, CINHAL/EBSCO, Web of Science, and Google Scholar) for peer-reviewed studies and gray-literature sources in English and Spanish (2000–2020). Step 1 identified three voluntary and eight mandatory menu labeling policies primarily for energy disclosures for 11 upper-middle and high-income countries, but none for low- or middle-income countries. Step 2 identified 15 of 577 studies that met the inclusion criteria. The analysis showed reductions in energy for newly introduced menu items only in the United States. We suggest actions for governments, civil society organizations, and the restaurant businesses to develop, implement, and evaluate comprehensive menu labeling policies to determine whether these may reduce obesity and NCD risks worldwide.

Assessing the Healthy Food Partnership's Proposed Nutrient Reformulation Targets for Foods and Beverages in Australia

Non-communicable diseases (NCDs) are the leading cause of mortality and morbidity worldwide. Unhealthy diets are one of four main behavioral risk factors contributing to the majority of NCDs. To promote healthy eating and reduce dietary risks, the Australian Commonwealth Government established the Healthy Food Partnership (HFP). In 2018, the HFP consulted on proposed nutrient reformulation targets for 36 food categories to improve the overall quality of the food supply. This study assessed whether the proposed targets were feasible and appropriate. The HFP used a five-step approach to inform the proposed targets. We replicated and extended this approach using a different nutrient composition database (FoodSwitch). Products in FoodSwitch were mapped to the proposed HFP targets. The proportion of products meeting each target was calculated and the FoodSwitch data were compared with HFP data to determine whether the proposed target nutrient levels were appropriate or whether a more stringent target was feasible. Products from the FoodSwitch database (10,599) were mapped against the proposed HFP categories: 8434 products across 30 categories for sodium, 2875 products across seven categories for sugar, and 612 products across five categories for saturated fat. The analyses revealed that 14 of 30 proposed HFP targets for sodium, one of seven targets for sugar, and one of five targets for saturated fat were feasible and appropriate. For the remaining 26 reformulation targets, the results indicate that these target levels could be more stringent and alternative targets are proposed. The draft HFP targets are feasible but the majority are too conservative. If Australia is to meet its commitment to a 30 per cent reduction in the average population salt intake by 2025, these targets could be implemented as interim targets to be reached within two years. However, the opportunity exists to improve the food supply and strengthen the HFP's population health impact by adopting more ambitious and incremental targets. Reformulation programs should be prioritized and closely monitored as part of a coordinated, multi-faceted national food and nutrition strategy.

Sugar Content in Processed Foods in Spain and a Comparison of Mandatory Nutrition Labelling and Laboratory Values

To reduce the sugar content of processed foods through reformulation, the first step is to determine the content of the largest sources of sugars in each country's diet. The aim of this work was to describe the sugar content in the most commonly consumed processed foods in Spain and to compare that sugar's labelling and laboratory analysis values (LVs and AVs, respectively) to confirm its adequacy. A sample of the 1173 most commonly consumed processed foods in Spain (28 groups; 77 subcategories) was collected. For each product, the total sugar content was compared according to its AV and LV. The median (25th -75th percentiles, interquartile range) sugar content by group was calculated for the total sample, and the groups were classified as "high sugar content" when this value was above 22.5 g/100g of product. The adequacy of the LV, according to the European Union (EU) tolerance requirements, was then evaluated, and each subcategory median was compared with the AV to determine its appropriateness via a median test for independent samples (p < 0.05). In total, 10 out of 28 groups presented high sugar content. Moreover, 98.4% of the products met the EU tolerance ranges. Finally, only one subcategory ("cured ham") presented significant differences between the AV and LV median values (0.4 g vs. 0.1 g sugar/100g, p < 0.05). The groups of food products whose sugar content reduction could have the greatest impact on public health were identified. In addition, our study showed the high adequacy of LV with the EU labeling tolerance requirements, as well as the LV's appropriateness as a tool to implement actions aimed at reducing sugar consumption.

Reformulation initiative for partial replacement of saturated with unsaturated fats in dairy foods attenuates the increase in LDL cholesterol and improves flow-mediated dilatation compared with conventional dairy: the randomized, controlled REplacement of SaturatEd fat in dairy on Total cholesterol (RESET) study

BACKGROUND

Modifying dairy fat composition by increasing the MUFA content is a potential strategy to reduce dietary SFA intake for cardiovascular disease (CVD) prevention in the population.

OBJECTIVES

To determine the effects of consuming SFA-reduced, MUFA-enriched (modified) dairy products, compared with conventional dairy products (control), on the fasting cholesterol profile (primary outcome), endothelial function assessed by flow-mediated dilatation (FMD; key secondary outcome), and other cardiometabolic risk markers.

METHODS

A double-blind, randomized, controlled crossover 12-wk intervention was conducted. Participants with a 1.5-fold higher (moderate) CVD risk than the population mean replaced habitual dairy products with study products (milk, cheese, and butter) to achieve a high-fat, high-dairy isoenergetic daily dietary exchange [38% of total energy intake (%TE) from fat: control (dietary target: 19%TE SFA; 11%TE MUFA) and modified (16%TE SFA; 14%TE MUFA) diet].

RESULTS

Fifty-four participants (57.4% men; mean ± SEM age: 52 ± 3 y; BMI: 25.8 ± 0.5 kg/m2) completed the study. The modified diet attenuated the rise in fasting LDL cholesterol observed with the control diet (0.03 ± 0.06 mmol/L and 0.19 ± 0.05 mmol/L, respectively; P = 0.03). Relative to baseline, the %FMD response increased after the modified diet (0.35% ± 0.15%), whereas a decrease was observed after the control diet (-0.51% ± 0.15%; P< 0.0001). In addition, fasting plasma nitrite concentrations increased after the modified diet, yet decreased after the control diet (0.02 ± 0.01 μmol/L and -0.03 ± 0.02 μmol/L, respectively; P = 0.01).

CONCLUSIONS

In adults at moderate CVD risk, consumption of a high-fat diet containing SFA-reduced, MUFA-enriched dairy products for 12 wk showed beneficial effects on fasting LDL cholesterol and endothelial function compared with conventional dairy products. Our findings indicate that fatty acid modification of dairy products may have potential as a public health strategy aimed at CVD risk reduction. This trial was registered at clinicaltrials.gov as NCT02089035.

Nutritional Content, Labelling and Marketing of Breakfast Cereals on the Belgian Market and Their Reformulation in Anticipation of the Implementation of the Nutri-Score Front-Of-Pack Labelling System

Objective: Breakfast cereals are frequently consumed in Belgium, especially among children. We investigated the nutritional content, labelling and marketing of breakfast cereals and the changes in nutrient content and reformulation in anticipation of the implementation of the Nutri-Score front-of-pack label. Design: Pictures were taken of cereal packages. The WHO-Europe nutrient profiling tool was used to classify cereals into ‘permitted’/‘not-permitted’ to be marketed to children, while the nutritional quality was assessed using Nutri-Score. The proportion of cereals with nutrition and health claims and/or promotional characters on the front-of-pack was compared between permitted and not-permitted cereals and between different Nutriscore categories using Chi-squared tests. The average nutrient contents per 100g were compared between 2017 and 2018 using paired t-tests. Setting: Belgium. Participants: All breakfast cereals in the major supermarkets (n = 7) in 2017 and 2018. Results: Overall, 330 cereals were included. About 77.2% of cereals were not permitted to be marketed to children but, of those, 22.0% displayed promotional characters. More claims (68.9% of all claims) were found on ‘not-permitted’ compared with ‘permitted’ cereals, particularly nutrition claims. Most claims were displayed on cereals with the allocated Nutri-Score A (42.0%) and C (37.0%). A significant reformulation of cereals was found between 2017 and 2018, with reductions in total sugar (−5%) (p < 0.001) and sodium (−20%) (p = 0.002) and increases in fibre (+3%) (p = 0.012) and proteins (+2%) (p = 0.002). Conclusion: Breakfast cereals on the Belgian market are predominantly unhealthy and frequently carry claims and promotional characters. Minimal reformulation occurred over one year. Policy recommendations include restrictions on claims and marketing for not-permitted cereals.

Formulating a Stable Mannitol Infusion while Maintaining Hyperosmolarity

Mannitol infusion is commonly used in the treatment of intracranial hypertension following traumatic brain injury. It has long been known to have stability issues, specifically, mannitol recrystallises from solutions greater than 10% w/v in ambient conditions. This can happen at any time, whether on the pharmacy shelf or during a medical procedure. This study describes the stability limits of 20% w/v mannitol infusion (the most common strength used clinically) and proposes a number of safer, stable and tuneable hyperosmotic formulations of mannitol in combination with clinically acceptable osmotic agents (NaCl, sorbitol and glycerol).

Salt content of sauces in the UK and China: cross-sectional surveys

OBJECTIVES

(1) To assess the changes in the salt content of sauces in the UK in the past 10 years; (2) to compare the salt content of sauces in China with equivalent products sold in the UK and (3) to calculate the proportion of sauce products meeting the salt targets set by the UK Department of Health (DoH).

DESIGN

Cross-sectional surveys from the nutrition information panels of sauces.

SETTING

Major retailers in London, Beijing and Shijiazhuang operating at data collection times.

MAIN OUTCOME MEASURE

Salt content of sauces.

RESULTS

Relative change in the median salt content of UK products ranged from -70.6% to +3.0% in sauces for which salt targets were set, whereas it ranged from -27.1% to +111.5% in sauces without targets. Median salt contents were on average 4.4-fold greater in Chinese sauces compared with their UK equivalents surveyed during the same period (2015-2017). Only 13.4% of the Chinese products met the UK 2017 salt targets, compared with 70.0% of UK products.

CONCLUSION

In the UK, the target-based approach contributed to the reduction in the salt content of sauces over the course of the past 10 years. Currently, large variations in salt content exist within the same categories of sauces and 70% of the products have met DoH's 2017 targets, demonstrating that further reductions are possible and lower salt targets should be set. In China, salt content of sauces is extremely high with similarly large variations within same categories of sauces, demonstrating the feasibility of reducing their salt content. As processed foods (including sauces) are expected to become an important contributor to salt intake in China, national salt reduction efforts such as setting salt targets would be a valuable, proactive strategy.

Cross-Sectional Survey of the Amount of Sugar and Energy in Chocolate Confectionery on Sold in the UK in 1992 and 2017

The study aimed to compare the sugar (1992, 2017) and energy (2017) content of chocolate confectionery available in the UK between 1992 and 2017 using cross-sectional surveys. All major UK retailers operating at the time were included. Sugar content in 1992 was obtained from a booklet and sugar and energy content from 2017 were collected from product packaging in-store. In 1992, the average sugar content of chocolate confectionery was 46.6 ± 10.3 g/100 g and in 2017 it was 47.3 ± 12.1 g/100 g. Sugar content ranged from 0.5 to 75.2 g/100g, with large variations between different categories of chocolate and within the same category of chocolate. There were 23 products found in both 1992 and 2017. The average sugar content per 100 g for these products was 44.6 ± 9.4 g in 1992 and 54.7 ± 6.3 g in 2017, representing a 23% increase in sugar content (p < 0.001). The results show that the sugar content of chocolate confectionery has increased since 1992, which is concerning. However, they also suggest sugar levels can be reduced because (a) lower sugar versions of the same products existed in 1992 and (b) there is a large variation in sugar and energy content between different categories of chocolate and within the same category in 2017.

Reformulation and Priorities for Reducing Energy Density; Results from a Cross-Sectional Survey on Fat Content in Pre-Packed Cakes and Biscuits Sold in British Supermarkets

Cakes and biscuits contribute to energy, total and saturated fat and sugar in British diets. So far, the UK government has prompted manufacturers to reduce energy density in these products through a reduction of their sugar content. We conducted a cross-sectional survey of the fat content of cakes and biscuits available in nine UK supermarket chains. In cakes (n = 381), the mean total fat content was 17.9 ± 5.2 g/100 g (39% of the overall energy); range (1.4-35.6 g/100 g) and the average saturated fat content in cakes was 5.9 ± 3.4 g/100 g (13% of the overall energy); range (0.3-20 g/100 g). In biscuits (n = 481), the mean total fat content was 21.8 g ± 6.3 g/100 g (40% of the overall energy); range (0.7-38.9 g/100 g) and the average saturated fat content was 11.4 ± 4.9 g/100 g (23% of the overall energy); range (0.3-22.3 g/100 g). In both cakes and biscuits, total and saturated fat content was positively correlated with energy density. Our results show that cakes and biscuits sold in UK supermarkets are high in total and saturated fat, and that fat content contributes substantially to product energy density. Fat reformulation in these products would effectively reduce energy density, calorie intake and help prevent obesity. Fat reformulation should be implemented simultaneously with sugar reformulation and be focused on saturated fat, as this will have the additional effect of lowering LDL cholesterol.

Nutritional quality and reformulation of a selection of children's packaged foods available in Australian supermarkets: Has the Health Star Rating had an impact?

AIM

To examine whether the nutritional quality of children's packaged food products available in Australian supermarkets improved between 2013 and 2016, and whether any change could be detected in product reformulation since the introduction of the Health Star Rating (HSR) labelling scheme.

METHODS

Packaged food products marketed towards children were purchased from three Australian supermarkets in July 2013 (for a previous study) and July 2016. Nutritional quality was assessed using the Food Standards Australian New Zealand Nutrient Profiling Scoring Criterion. Comparisons were made between the nutrient composition and formulation of products (a) available in 2013 and 2016; and (b) with and without HSR graphics.

RESULTS

Of the 252 children's packaged products analysed, 53.6% were classified as 'less healthy'. HSR-labelled products had a significantly higher proportion classified as 'healthy' than those without the HSR (χ² = 26.5; P < 0.0001; 73.8% and 59.0%, respectively). Overall, 28.5% displayed the HSR; the majority (81.5%) having a rating of ≥3.0 stars. Cereal-based products had the greatest uptake of the scheme, with HSR-labelled products having significantly lower mean energy and saturated fat content (P < 0.01) and higher mean protein and fibre content (P < 0.001) than non-HSR products. Reformulation of products that were available in 2013 had occurred in 100% of HSR-labelled products in comparison to 61.3% of non-HSR labelled products.

CONCLUSIONS

Despite the introduction of the HSR, more than half of children's packaged foods sampled are 'less healthy'. However, early indications suggest that the HSR may stimulate healthier product reformulation.

Clients' experience of change: An exploration of the influence of reformulation tools in cognitive analytic therapy

Case formulation is considered important in both the development of the therapeutic relationship and in starting the process of therapeutic change. Cognitive analytic therapy (CAT) describes the developmental origins and maintenance of a client's problems in both written (reformulation letter) and diagrammatic form (sequential diagrammatic reformulation). This study aimed to investigate the effects of these reformulation tools on insight and symptom change. A small-N repeated measures design was employed with quantitative and qualitative measures collected from six therapist/client dyads. Participating therapists kept a record of their delivery of CAT reformulation tools. Participating clients completed the insight subscale of the Self-Reflection and Insight Scale every fourth session and the Clinical Outcomes in Routine Evaluation-10 every session. Qualitative data from client change interviews regarding their experiences of CAT and attributions of change was explored using template analysis. Participants demonstrated improvements (symptom reduction and insight increases) over the course of the intervention. Administration of reformulation tools did not consistently result in significant changes on insight and symptom measures. However, the tools were identified by participants as leading to insight and emotional change within the context of a good therapeutic relationship. These findings suggest that a genuine therapeutic relationship is an important change mechanism operating through, and strengthened by, CAT-specific tools.

Reformulation as an Integrated Approach of Four Disciplines: A Qualitative Study with Food Companies

In 2014, the Dutch government agreed with the food sector to lower salt, sugar, saturated fat and energy in foods. To reformulate, an integrated approach of four disciplines (Nutrition & Health, Food Technology, Legislation, and Consumer Perspectives) is important for food companies (Framework for Reformulation). The objective of this study was to determine whether this framework accurately reflects reformulation processes in food companies. Seventeen Dutch food companies in the bakery, meat and convenience sector were interviewed with a semi-structured topic list. Interviews were transcribed, coded and analysed. Interviews illustrated that there were opportunities to lower salt, sugar and saturated fat (Nutrition & Health). However, there were barriers to replacing the functionality of these ingredients (Food Technology). Most companies would like the government to push reformulation more (Legislation). Traditional meat products and luxury sweet bakery products were considered less suitable for reformulation (Consumer Perspectives). In addition, the reduction of E-numbers was considered important. The important role of the retailer is stressed by the respondents. In conclusion, all four disciplines are important in the reformulation processes in food companies. Reformulation does not only mean the reduction of salt, saturated fat and sugar for companies, but also the reduction of E-numbers.