Scientific Opinion on principles for deriving and applying Dietary Reference Values

Exploring dietary patterns and their association with environmental sustainability and body mass index in children and adolescents: Insights from the National Food, Nutrition and Physical Activity Survey 2015-2016

OBJECTIVE

To adapt four dietary patterns for children and adolescents, and study their associations with sustainability (greenhouse-gas emissions-GHGE and land use-LU), and health (body mass index-BMI) indicators.

RESEARCH METHODS & PROCEDURES

Dietary intake of children (3-9y) and adolescents (10-17y) from the National Food, Nutrition and Physical Activity Survey 2015-2016, Portugal (n = 1153) was assessed through two non-consecutive interviews: one-day food diaries (children), and 24-h recalls (adolescents), using an automated multiple-pass method, including a picture book for portion sizes estimation. Adherence to the Eat-Lancet and World Health Organization (WHO) recommendations, Mediterranean and Atlantic diets were evaluated using adapted versions for pediatrics of the World Index for Sustainability and Health (WISH), Diet Quality Index (DQI), Mediterranean Diet Score (MDS) and Southern-European Atlantic Diet (SEAD), respectively. Diet-related GHGE and LU were estimated using the SHARP-Indicators database. BMI (measured) z-scores were classified according to WHO criteria. A standardized weighted health-sustainability composite index was created (BMI + 0.5*GHGE+0.5*LU). Adjusted linear regression models were computed.

RESULTS

WISH, DQI, MDS, and SEAD had weighted mean scores (range) of 50 (0-130), 24 (9-36), 20 (8-32), and 17 (8-32), respectively. All dietary patterns were associated with lower environmental impact, particularly in children, but not with BMI. Only MDS explained both health and sustainability indicators in childhood (composite index: sd.β = -0·223,95%CI:-0·347,-0·072,R2 = 25.1 %), and adolescence (composite index: sd.β = -0·159,95%CI:-0·315,-0·003,R2 = 31.3 %).

CONCLUSION

The Mediterranean diet was the most related to (higher) environmental sustainability and (lower) BMI. However, in children (not adolescents), the WISH, DQI, and SEAD showed then same associations.

Unfavorable nutrient intakes in children up to school entry age: results from the nationwide German KiESEL study

Background

Nutrition in the first years of life is a cornerstone for child development and long-term health, yet there is a lack of current data on energy and nutrient intake among toddlers and preschoolers in Germany.

Objective

To analyze energy and nutrient intake in toddlers (1- to 2-year-olds) and preschoolers (3- to 5-year-olds) in Germany and compare the results with the Dietary Reference Values (DRVs) by the European Food Safety Authority.

Design

Dietary intake was assessed by weighed food record data (3 + 1 day) of 890 children from the representative cross-sectional Children's Nutrition Survey to Record Food Consumption (KiESEL), carried out in 2014-2017 as a module of the German Health Interview and Examination Survey for Children and Adolescents Wave 2. For the calculation of energy and nutrient intake, the German Nutrient Database BLS 3.02, LEBTAB, and a supplement database were used.

Results

Median intakes of energy and most nutrients met or exceeded the DRVs in both toddlers and preschoolers. However, low intakes relative to DRVs were found for vitamin D (6-9% of DRV, including supplements) and iodine (57-65% of DRV). Age specific downward deviations were observed for iron intake in toddlers (75% of DRV) and for calcium intake in preschoolers (67-77% of DRV). In contrast, intakes were high for saturated fatty acids (SFA) (14-16 E%), mono-/disaccharides (60-87 g/day), and protein [2.1-2.6 g/(kg body weight*day)].

Conclusion

Nutrient imbalances in toddlers and preschoolers in Germany, which are partly age-related, give rise to concern. Research is needed to determine if routine vitamin D supplementation should be extended beyond infancy. Public health efforts to increase the rate of use of iodized salt and to reduce the intake of SFA and mono-/disaccharides in children's diets are to be strengthened.

The imprecision of micronutrient requirement values: the example of vitamin D

Food, not nutrients, is the fundamental unit in nutrition. Nutrient requirement values and recommended daily intakes have long been determined and organized in tables by several regulators. These figures, however, overlook the complexity of mixing different foods in a diet and the mediation by human gut microbiota on digestion, metabolism, and health. The microbiome molecular mechanisms and its potential influence on nutrient requirements are far from clear. Guidelines should depend on the sort of intake, along with the dietary habits, rather than focusing on single nutrients. Despite many decades of attempts to investigate the proximate nutrient composition of foods consumed by different world populations, there are still neither standardization of food composition databases nor harmonized dietary intake methods of assessment of nutrients. No all-inclusive attempt was yet made to emphasize the requirements of the various micronutrients, phytonutrients, and non-nutrients on gut microbiota and vice versa, and thereafter reflected into dietary guidelines. New multifaceted methods have been advanced to reevaluate the way nutrients and nutrient requirements are assessed within the intricate biological systems. Our main goal here was to enhance the fact that existing food guidelines hold inherent strengths and limitations but fail, in many aspects, namely, in not taking into account essential geographical, ethnic and cultural differences, and the different stages of life, infant nutrition, and the microbiota impact on several micronutrient requirements. Vitamin D is given as an illustration on present inaccuracy of its requirements. Defining dietary reference intakes is therefore an ongoing process specific for each population.

Physico-Chemical and Nutritional Properties of Chia Seeds from Latin American Countries

In the last few decades, chia (Salvia hispanica L.) cultivation has expanded around the world, and the seeds have become well known due to their rich composition of nutrients and bioactive compounds. The aim of this work was to evaluate the physical, chemical, and nutritional profile of eight types of chia seeds grown in different Latin-American countries (Argentina, Bolivia, Chile, Ecuador, Mexico, Paraguay, and Peru). The results showed that several nutritional parameters of the seeds, such as the protein content and amino acid profile, dietary fiber content, lipid content, mineral composition, and presence of phytate, depend on the location in which they were grown. Other parameters, such as ash content, fatty acid profile, or various physical parameters, were uniform across locations (except for color parameters). The results support the notion that the nutritional characteristics of seeds are determined by the seeds' origin, and further analysis is needed to determine the exact mechanisms that control the changes in the seed nutritional properties of chia seeds.

An Evaluation of Food and Nutrient Intake among Pregnant Women in The Netherlands: A Systematic Review

Nutritional deficiencies during pregnancy can have serious consequences for the health of the (unborn) child. This systematic review provides an updated overview of the available food and nutrient intake data for pregnant women in The Netherlands and an evaluation based on the current recommendations. Embase, MEDLINE, and national institute databases were used. Articles were selected if they had been published since 2008 and contained data on food consumption, nutrient intake, or the status of healthy pregnant women. A qualitative comparison was made with the 2021 Dutch Health Council recommendations and reference values. A total of 218 reports were included, representing 54 individual studies. Dietary assessments were primarily performed via food frequency questionnaires. Protein, vitamin A, thiamin, riboflavin, vitamin B₆, folate, vitamin B₁₂, vitamin C, iron, calcium, and magnesium intakes seemed to be adequate. For folate and vitamin D, supplements were needed to reach the recommended intake. The reasons for concern are the low intakes of fruits, vegetables, and (fatty) fish, and the intakes of alcohol, sugary drinks, and salt. For several foods and nutrients, no or limited intake data were found. High-quality, representative, and recent data are needed to evaluate the nutrient intake of pregnant women in order to make accurate assessments and evaluations, supporting scientific-based advice and national nutritional policies.

Optimal Protein Intake in Healthy Children and Adolescents: Evaluating Current Evidence

High protein intake might elicit beneficial or detrimental effects, depending on life stages and populations. While high protein intake in elder individuals can promote beneficial health effects, elevated protein intakes in infancy are discouraged, since they have been associated with obesity risks later in life. However, in children and adolescents (4–18 years), there is a scarcity of data assessing the effects of high protein intake later in life, despite protein intake being usually two- to three-fold higher than the recommendations in developed countries. This narrative review aimed to revise the available evidence on the long-term effects of protein intake in children and adolescents aged 4–18 years. Additionally, it discusses emerging techniques to assess protein metabolism in children, which suggest a need to reevaluate current recommendations. While the optimal range is yet to be firmly established, available evidence suggests a link between high protein intake and increased Body Mass Index (BMI), which might be driven by an increase in Fat-Free Mass Index (FFMI), as opposed to Fat Mass Index (FMI).

Prevalence of nutritional inadequacy in children aged 12-36 months: EPACI Portugal 2012

Adequate nutritional intake in the first years of life is crucial for future health. The purpose of this study is to assess the adequacy of nutritional intake in Portuguese toddlers. The EPACI Portugal 2012 is a cross-sectional study of a representative sample of toddlers (n = 2230), aged between 12 and 36 months. Data on diets were collected by trained interviewers. The current analysis included 853 children with full data from 3-day food diaries completed by parents/caregivers. Intakes of energy, macro- and micronutrients were estimated through Statistical Program to Assess Dietary Exposure (SPADE). Nutritional adequacy was evaluated using Dietary Reference Values established by the European Food Safety Authority. A large proportion of children exceeded the recommended energy intake. The median daily protein intake was 4.7 g/kg/day, five times more than that recommended. About 9% and 90% of the children consumed a lower proportion of energy than the lower limit of the Reference Intake range for carbohydrates and fat, respectively. Around a third consumed less fibre and magnesium and 100% less vitamin D than the recommended Adequate Intake (AI). Almost a third consumed less vitamin A than the recommended Average Requirement (AR) and 86% of the children showed excessive sodium consumption. Portuguese toddlers consumed a low proportion of energy from fat, had energy and protein intakes above the recommendations and excessive intakes of sodium, and inadequate intakes of vitamin A. Every child consumed less than the recommended AI for vitamin D.

The study of physicochemical and technological properties of boiled sausage recommended for the older adults

A recipe for cooked sausages of the herodietic direction using protein hydrolysate in the amount of 3%, 5%, and 7% of the mass of raw materials is proposed. The recipe is based on "Beef Sausage". Organoleptic evaluation of the prototypes showed that when protein hydrolysate was added in an amount of 7%, a specific taste characteristic of by-products was present in the prototype. Based on the sensory evaluation results, it was decided to continue the study of samples with the addition of 3% and 5% protein hydrolysate. The results of the study of the physicochemical parameters of the prototypes with the addition of protein hydrolysate 3% and 5%, showed the values of the mass fraction of protein 16.65% and 19.29%, fat 9.85% and 12.25%, carbohydrates 2.85% and 3.07% respectively, indicating an increase in the amount of protein and a decrease in the proportion of fat compared to the control sample. A significant increase in the content of such essential amino acids as lysine and valine and interchangeable amino acids as arginine, glycine, and serine in the test samples confirms that the protein hydrolysate introduced into the prototype is rich and well-balanced in amino acid composition. To study the effect of protein hydrolysate on the quality of meat products, the moisture binding capacity was determined, which was 3% and 5% in the experimental samples with the addition of protein hydrolysate – 75.62% and 79.13%, which is 3.4% and 8.2% higher than that of the control sample, respectively. The sample with the addition of 5% hydrolysate (80.01) has the greatest moisture-retaining ability, which is 9% higher than that of the sample with 3% hydrolysate and 15.8% higher than the control indicator.  The study results of the fat-holding capacity in the samples also showed positive dynamics.

[B vitamins and brain dysfunction]

An unbalanced diet and some other factors are the reason for the extreme prevalence of hypovitaminosis among the population of both developing and developed countries. The metabolic relationships of B vitamins determine the more frequent occurrence of poly-, rather than monovitamin deficiency. Since B vitamins play an important role in the processes of energy production and in the functioning of neurotransmitter systems, the first symptoms of such polyhypovitaminosis are signs of brain dysfunction: asthenia, depression, anxiety, cognitive disorders. Correct diagnosis of polyhypovitaminosis based on the identification of risk groups of patients and the determination of their subclinical or early manifesting signs of brain dysfunction is the most important task of a practicing physician. Detection of insufficient intake and vitamin content, as well as verification of the onset of symptoms of brain dysfunction and the appointment of adequate therapy can significantly increase the effectiveness of treatment, as well as prevent asthenic, psycho-emotional and cognitive disorders in patients with polyhypovitaminosis.

Relationship between front-of-pack labeling and nutritional characteristics of food products: An attempt of an analytical approach

The adoption of supplementary nutrition information, i.e., front-of-pack labeling (FOPL), on pre-packed food products is advocated as a tool to improve the consumers' knowledge of the nutrient content or the nutritional quality of foods, but also to drive products reformulation by the food industry. Ultimately, FOPL should help people to select foods in order to compose an overall balanced diet, which is essential for health. However, the extent to which the different FOPL systems proposed in the European Union (EU) (interpretative or informative) are effectively able to convey the information useful to improve both food choices and dietary habits of the consumers is still under debate and needs to be analyzed in detail. The use of 3 FOPL schemes proposed within the EU (Nutri-Score, Keyhole and NutrInform Battery) to compare products available on the Italian market within different food categories, highlights some critical issues: (1) different FOPL provide to consumers different kinds of information; (2) systems based on similar theoretical approaches can provide conflicting information; (3) the algorithms on which interpretative FOPL are based can give the same summary information for products differing in nutrient composition, impact on the overall dietary balance and therefore on the health of people with different characteristics, physiological/pathological conditions, and nutritional requirements; (4) on the other hand, products with similar nutrient composition can obtain different interpretative FOPL; (5) informative systems are generally more complex and require greater both attention and knowledge from the consumer; (6) FOPL based on 100 g of product overlook the role of portion (and frequency of consumption) in determining the nutrient intake without informing on the contribution of a single food to the overall diet; (7) FOPL based on scoring systems could promote the reformulation of selected products, especially with a composition very close to the threshold limits; (8) for the portion-based informative FOPL systems, the incentive for reformulation could essentially involve the reduction of portion size. Finally, the importance of nutritional education interventions, which are required to encourage the use by consumers of informative FOPL systems, cannot be neglected to improve the quality of diets regardless of the FOPL used.

Dietary Patterns vs. Dietary Recommendations

Dietary Reference Values (DRVs) are important for developing labeling laws, identifying populations at risk of over- or under-consumption, and promoting public health interventions. However, the process of developing DRVs is quite complex, and they should not be viewed as recommendations ready to use or goals for individuals. Rather, they require interpretation by professionals and can form the basis of dietary advice. On the other hand, focusing on foods rather than macronutrients can assist individuals in understanding a healthy diet by taking into consideration many variables that may help compliance with a healthy dietary style. Evolution, tradition within specific geographical and historical contexts, taste, economic affordability, season-associated local dietary resources, and lifestyle may all explain the increasing popularity of dietary patterns that are highly successful today. Three models (the Mediterranean, New Nordic, and Japanese) have been recently characterized for geographical setting and food composition, as well as the associated lifestyle. Of note, all these three models rely on pyramids sharing a large basis made up of local vegetal resources and a top of red meats (allowed in many cases, but in limited amounts), thus allowing for the urgent demand of sustainability for the planet's health. This mini-review aimed to summarize the meaning of DRVs and to describe the dietary patterns that better contemplate health, diet diversity, and sustainability.

Scientific advice related to nutrient profiling for the development of harmonised mandatory front-of-pack nutrition labelling and the setting of nutrient profiles for restricting nutrition and health claims on foods

Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver scientific advice related to nutrient profiling for the development of harmonised mandatory front‐of‐pack nutrition labelling and the setting of nutrient profiles for restricting nutrition and health claims on foods. This Opinion is based on systematic reviews and meta‐analyses of human studies on nutritionally adequate diets, data from the Global Burden of Disease framework, clinical practice guidelines, previous EFSA opinions and the priorities set by EU Member States in the context of their Food‐Based Dietary Guidelines and associated nutrient/food intake recommendations. Relevant publications were retrieved through comprehensive searches in PubMed. The nutrients included in the assessment are those likely to be consumed in excess or in inadequate amounts in a majority of European countries. Food groups with important roles in European diets have been considered. The Panel concludes that dietary intakes of saturated fatty acids (SFA), sodium and added/free sugars are above, and intakes of dietary fibre and potassium below, current dietary recommendations in a majority of European populations. As excess intakes of SFAs, sodium and added/free sugars and inadequate intakes of dietary fibre and potassium are associated with adverse health effects, they could be included in nutrient profiling models. Energy could be included because a reduction in energy intake is of public health importance for European populations. In food group/category‐based nutrient profiling models, total fat could replace energy in most food groups owing to its high‐energy density, while the energy density of food groups with low or no fat content may be well accounted for by the inclusion of (added/free) sugars. Some nutrients may be included in nutrient profiling models for reasons other than their public health importance, e.g. as a proxy for other nutrients of public health importance, or to allow for a better discrimination of foods within the same food category.

Nutritional Quality and Safety of the Spirulina Dietary Supplements Sold on the Slovenian Market

The microalgae Spirulina may be a popular dietary supplement rich in essential nutrients and vitamins, but oversight of the supplement industry, in general, remains limited, and increasing incidents of adulteration, misbranding, and undeclared ingredients together with misleading claims create potential risks. In response, this study characterized the elemental, amino acid and fatty acid content of commercially available Spirulina supplements in Slovenia using EDXRF, ICP-MS and GC-MS and compared the results with their nutritional declaration. The gathered data confirm that Spirulina supplements are a good source of calcium (0.15 to 29.5% of RDA), phosphorous (3.36–26.7% of RDA), potassium (0.5 to 7.69% of RDA) and selenium (0.01 to 38.6% of RDA) when consumed within recommended amounts. However, although iron contents were relatively high (7.64 to 316% of RDA), the actual bioavailability of iron was much lower since it was mainly present as the ferric cation. This study also confirms that pure Spirulina supplements are a good source of essential and non-essential amino acids, and ω-6 but not ω-3 polyunsaturated fatty acids. The presence of additives resulted in significant variation in nutrient content and, in some instances, lower product quality. Moreover, a high proportion (86.7%) of inappropriate declarations regarding the elemental content was observed. Overall, the study conclusions underline the need for a stricter control system for Spirulina-based supplements.

Sportsmen's Attitude towards Dietary Supplements and Nutrition Knowledge: An Investigation in Selected Roman Area Gyms

The non-professional sport environment is a grey zone not as widely assessed as that of elite athletes. The purpose of this research was to investigate the dietary supplementation habits and the nutrition knowledge on sport (NKS) in a sample of gym users. The level of adequacy of NKS was set at ≥60% of correct answers. Almost half (46.4%) of respondents stated they used food supplements, in particular multivitamins (31.0%), amino acid pills (29.5%), minerals (29.1%), and protein powders (28.7%). Supplements were used to increase muscle mass (36.9%) and to repair muscle (35.1%). Gym trainers were the preferred source of information on the use of supplements, especially in males (84%). The NKS correct response rate was 57.1% and the proportion of respondents with a sufficient level of NKS was 47.3%. The prevalence of correct answers was highest in males (61.5%) and for respondents with the highest educational attainment levels (44.5% and 53%). This study demonstrated that non-professional sportsmen do not have sufficient knowledge of nutrition and that the gym environment does not facilitate the circulation of the correct information on the role of supplementation. Considering the importance of nutrition for sportsmen, it is necessary to put in place actions aimed at increasing the knowledge of nutrition of gym users and their trainers.

Guidance for establishing and applying tolerable upper intake levels for vitamins and essential minerals: Draft for internal testing

Vitamins and essential minerals are micronutrients that are essential for the normal functioning of the human body. However, they may lead to adverse health effects if consumed in excess. The concept of a tolerable upper intake level (UL) is a science-based reference value, which was introduced to support policy-makers and other relevant actors in managing the risks of excess nutrient intake. EFSA's principles for establishing ULs for vitamins and minerals were originally developed by the Scientific Committee on Food in 2000. Since then, experience has been gained and the scientific field developed. This guidance from the EFSA Panel on Nutrition, Novel Foods and Food Allergens provides an updated framework to support EFSA's UL assessments. It covers aspects related to the planning of the risk assessment (problem formulation and definition of methods) and its implementation (evidence retrieval, appraisal, synthesis, integration, uncertainty analysis). As in the previous framework, the general principles developed for the risk assessment of chemicals in food are applied (hazard identification, hazard characterisation, intake assessment, risk characterisation). Peculiar to nutrients are their biochemical and physiological roles and the specific and selective mechanisms that maintain the systemic homoeostasis and body burden of the nutrient. These must be considered when conducting a risk assessment of nutrients. This document constitutes a draft guidance that will be applied in EFSA's assessments during a 1-year pilot phase and be revised and complemented as necessary. Before finalisation of the guidance, a public consultation will be launched.

Evolution of energy and nutrient intake in Brazil between 2008-2009 and 2017-2018

OBJECTIVE

To assess the evolution of energy and nutrient intake and the prevalence of inadequate micronutrients intakes according to sociodemographic characteristics and Brazilian regions.

METHODS

The food consumption of 32,749 individuals from the National Dietary Survey of the Household Budget Survey 2008-2009 was analyzed by two food registries, as well as 44,744 subjects from two 24-hour recalls in 2017-2018. Usual intake and percentage of individuals with consumption below the average recommendation for calcium, magnesium, phosphorus, copper and zinc, vitamins A, C, D, E, thiamine, riboflavin, pyridoxine and cobalamin were estimated. Sodium intake was compared to the reference value to reduce the risk of chronic diseases. Analyses were stratified by sex, age group, region and income.

RESULTS

Mean daily energy intake was 1,753 kcal in 2008-2009 and 1,748 kcal in 2017-2018. The highest prevalence of inadequacy (> 50%) in the two periods were calcium; magnesium; vitamins A, D and E; pyridoxine and, only among adolescents, phosphorus. There was an increase in the prevalence of inadequate vitamin A, riboflavin, cobalamin, magnesium, and zinc among women, and riboflavin among men. The prevalence of inadequacy decreased for thiamine. Sodium intake was excessive in approximately 50% of the population in both periods. The highest variations (about 50%) in the prevalence of inadequacy between the lowest and highest income (< 0.5 minimum wage and > 2 minimum wages per capita) were observed for vitamin B12 and C in both periods. The North and Northeast regions had the highest prevalence of inadequacy.

CONCLUSION

Both surveys found high prevalence of inadequate nutrient intake and excessive sodium intake. The inadequacy varies according to income strata, increasing in the poorest regions of the country.

The Nordic Nutrition Recommendations 2022 – prioritisation of topics for de novo systematic reviews

Background

As part of the process of updating national dietary reference values (DRVs) and food-based dietary guidelines (FBDGs), the Nordic Nutrition Recommendations 2022 project (NNR2022) will select a limited number of topics for systematic reviews (SRs).

Objective

To develop and transparently describe the results of a procedure for prioritisation of topics that may be submitted for SRs in the NNR2022 project.

Design

In an open call, scientists, health professionals, national food and health authorities, food manufacturers, other stakeholders and the general population in the Nordic and Baltic countries were invited to suggest SR topics. The NNR2022 Committee developed scoping reviews (ScRs) for 51 nutrients and food groups aimed at identifying potential SR topics. These ScRs included the relevant nominations from the open call. SR topics were categorised, ranked and prioritised by the NNR2022 Committee in a modified Delphi process. Existing qualified SRs were identified to omit duplication.

Results

A total of 45 nominations with suggestion for more than 200 exposure–outcome pairs were received in the public call. A number of additional topics were identified in ScRs. In order to omit duplication with recently qualified SRs, we defined criteria and identified 76 qualified SRs. The NNR2022 Committee subsequently shortlisted 52 PI/ECOTSS statements, none of which overlapped with the qualified SRs. The PI/ECOTSS statements were then graded ‘High’ (n = 21), ‘Medium’ (n = 9) or ‘Low’ (n = 22) importance, and the PI/ECOTSS statements with ‘High’ were ranked in a Delphi process. The nine top prioritised PI/ECOTSS included the following exposure–outcome pairs: 1) plant protein intake in children and body growth, 2) pulses/legumes intake, and cardiovascular disease and type 2 diabetes, 3) plant protein intake in adults, and atherosclerotic/cardiovascular disease and type 2 diabetes, 4) fat quality and mental health, 5) vitamin B¹² and vitamin B¹² status, 6) intake of white meat (no consumption vs. high consumption and white meat replaced with red meat), and all-cause mortality, type 2 diabetes and risk factors, 7) intake of n-3 LPUFAs from supplements during pregnancy, and asthma and allergies in the offspring, 8) nuts intake and cardiovascular disease (CVD) and type 2 diabetes in adults, 9) dietary fibre intake (high vs. low) in children and bowel function.

Discussion

The selection of topics for de novo SRs is central in the NNR2022 project, as the results of these SRs may cause adjustment of existing DRVs and FBDGs. That is why we have developed this extensive process for the prioritisation of SR topics. For transparency, the results of the process are reported in this publication.

Conclusion

The principles and methodologies developed in the NNR2022 project may serve as a framework for national health authorities or organisations when developing national DRVs and FBDGs. This collaboration between the food and health authorities in Denmark, Estonia, Finland, Iceland, Latvia, Lithuania, Norway and Sweden represents an international effort for harmonisation and sharing of resources and competence when developing national DRVs and FBDGs.

Veggie burgers in the EU market: a nutritional challenge?

Nutritional information of burgers launched in the EU market during 2020 was retrieved from their labels. Products were initially classified into four types: i.e., veggie, red meat-, fish- and poultry-based. Gluten, wheat, and soy were the most declared allergens regardless of the burgers type. Veggie burgers showed levels of energy, fat, and saturate fatty acids (SFA) similar to fish- and poultry-based burgers, but lower than red meat burgers. Compared to conventional burgers, veggie had higher amounts of carbohydrates and sugars and a lower content of proteins, but no difference in salt. Due to the high compositional intra-variability in the veggie burgers, vegetarian and vegan burgers were further analyzed separately. Vegan burgers had higher levels of energy, fat, SFA and protein than vegetarian burgers, but lower carbohydrates and sugars. Once again large differences in the nutritional parameters were observed in both vegan and vegetarian burger categories due to the wide range of ingredients and formulations employed in these types of products. A clear and comprehensive informative labeling is especially needed for vegan and vegetarian burgers to allow the consumer to make a rational decision based on the nutritional facts of these products.

Indicators and Recommendations for Assessing Sustainable Healthy Diets

Research coupling human nutrition and sustainability concerns is a rapidly developing field, which is essential to guide governments' policies. This critical and comprehensive review analyzes indicators and approaches to "sustainable healthy diets" published in the literature since this discipline's emergence a few years ago, identifying robust gauges and highlighting the flaws of the most commonly used models. The reviewed studies largely focus on one or two domains such as greenhouse gas emissions or water use, while overlooking potential impact shifts to other sectors or resources. The present study covers a comprehensive set of indicators from the health, environmental and socio-economic viewpoints. This assessment concludes that in order to identify the best food option in sustainability assessments and nutrition analysis of diets, some aspects such as the classification and disaggregation of food groups, the impacts of the rates of local food consumption and seasonality, preservation methods, agrobiodiversity and organic food and different production systems, together with consequences for low-income countries, require further analysis and consideration.

Statement on the derivation of Health-Based Guidance Values (HBGVs) for regulated products that are also nutrients

This Statement presents a proposal for harmonising the establishment of Health-Based Guidance Values (HBGVs) for regulated products that are also nutrients. This is a recurrent issue for food additives and pesticides, and may occasionally occur for other regulated products. The Statement describes the specific considerations that should be followed for establishing the HBGVs during the assessment of a regulated product that is also a nutrient. It also addresses the elements to be considered in the intake assessment; and proposes a decision tree for ensuring a harmonised process for the risk characterisation of regulated products that are also nutrients. The Scientific Committee recommends the involvement of the relevant EFSA Panels and units, in order to ensure an integrated and harmonised approach for the hazard and risk characterisation of regulated products that are also nutrients, considering the intake from all relevant sources.

Making a Sustainable Diet Acceptable: An Emerging Programming Model With Applications to Schools and Nursing Homes Menus

Background: Food consumption is one of the most important drivers of the relation between human well-being and Earth's ecosystems. The current production level is difficult to sustain without compromising environmental integrity or public health. This calls for a decisive change in food consumption patterns in order to improve nutrition quality while respecting biodiversity and ecosystems. This change will produce some effect only if it is also culturally acceptable, accessible, economically fair and affordable. The design of food plans is traditionally carried out using mathematical optimization models, such as linear programming. This method has proved to be successful in providing nutritionally adequate diets while minimizing their economic and environmental impact. Nevertheless, cultural habits as well as attractiveness and variety of meals is very difficult to deal with, and no fully satisfactory way to include these issues in linear programming has been found. Objective: The aim of this paper is to move from traditional linear programming to a new programming methodology in order to cope also with acceptability in the design of meal plans. Method: Binary integer linear programming is the new modeling paradigm. In the proposed model, meal plans consist of providing the sequence and composition of daily meals over a given period of time and each meal can be composed using dishes from a given set. Therefore, instead of defining just a level of consumption of food groups or food items, the proposed model provides a realistic menu. To cope with sustainability, the energy and nutritional content of each dish is calculated together with its price and environmental impact. Furthermore, acceptability can be explicitly taken into account in a very natural way, that is bounding the daily, weekly, or total repetitions of single dishes and of dishes in the same food groups. Results: The paper reviews three successful studies with increasing complexity considering lunch plans for schools and full-board menus for nursing homes. The case studies show a great reduction of the environmental impact of the meal plans while ensuring an adequate nutritional intake, affordable prices and most importantly the plans are varied and culturally acceptable.

Current State of Evidence: Influence of Nutritional and Nutrigenetic Factors on Immunity in the COVID-19 Pandemic Framework

The pandemic caused by the new coronavirus has caused shock waves in many countries, producing a global health crisis worldwide. Lack of knowledge of the biological mechanisms of viruses, plus the absence of effective treatments against the disease (COVID-19) and/or vaccines have pulled factors that can compromise the proper functioning of the immune system to fight against infectious diseases into the spotlight. The optimal status of specific nutrients is considered crucial to keeping immune components within their normal activity, helping to avoid and overcome infections. Specifically, the European Food Safety Authority (EFSA) evaluated and deems six vitamins (D, A, C, Folate, B6, B12) and four minerals (zinc, iron, copper and selenium) to be essential for the normal functioning of the immune system, due to the scientific evidence collected so far. In this report, an update on the evidence of the contribution of nutritional factors as immune-enhancing aspects, factors that could reduce their bioavailability, and the role of the optimal status of these nutrients within the COVID-19 pandemic context was carried out. First, a non-systematic review of the current state of knowledge regarding the impact of an optimal nutritional status of these nutrients on the proper functioning of the immune system as well as their potential role in COVID-19 prevention/treatment was carried out by searching for available scientific evidence in PubMed and LitCovid databases. Second, a compilation from published sources and an analysis of nutritional data from 10 European countries was performed, and the relationship between country nutritional status and epidemiological COVID-19 data (available in the Worldometers database) was evaluated following an ecological study design. Furthermore, the potential effect of genetics was considered through the selection of genetic variants previously identified in Genome-Wide Association studies (GWAs) as influencing the nutritional status of these 10 considered nutrients. Therefore, access to genetic information in accessible databases (1000genomes, by Ensembl) of individuals from European populations enabled an approximation that countries might present a greater risk of suboptimal status of the nutrients studied. Results from the review approach show the importance of maintaining a correct nutritional status of these 10 nutrients analyzed for the health of the immune system, highlighting the importance of Vitamin D and iron in the context of COVID-19. Besides, the ecological study demonstrates that intake levels of relevant micronutrients-especially Vitamins D, C, B12, and iron-are inversely associated with higher COVID-19 incidence and/or mortality, particularly in populations genetically predisposed to show lower micronutrient status. In conclusion, nutrigenetic data provided by joint assessment of 10 essential nutrients for the functioning of the immune system and of the genetic factors that can limit their bioavailability can be a fundamental tool to help strengthen the immune system of individuals and prepare populations to fight against infectious diseases such as COVID-19.

Bioavailability of Methionine-Coated Zinc Nanoparticles as a Dietary Supplement Leads to Improved Performance and Bone Strength in Broiler Chicken Production

Recently, nanotechnology has been widely adopted in many fields. The goal of this study was to evaluate the potential for amino acid coated nano minerals as a supplement in broiler feed. Zinc was selected as a model mineral for this test and supplementation of nano zinc, both coated and uncoated was compared with organic and inorganic commercial forms of zinc. A total of 48 pens (8 birds each) were assigned to one of the following dietary treatments: Control, methionine-Zinc chelate (M-Zn), nano zinc oxide (Nano-ZnO), and methionine coated nano zinc oxide (M-Nano-ZnO). All experimental diets were formulated with the same total zinc, methionine, protein, and energy content with just the zinc source as a variable. Bird weight, feed intake and feed conversion ratios were recorded weekly, with three birds culled (sacrificed) at day 21 and day 35 for sampling measures. Ileal digestibility of zinc was determined at day 21 and day 35 using titanium dioxide as an inert marker. Blood serum, liver and spleen samples were collected at day 21 and day 35 and analysed for zinc content via inductively coupled plasma mass spectrometry (ICP-MS). Tibia strength and morphometrics were measured from both legs of three birds per pen at day 21 and day 35. The study was conducted at Nottingham Trent University Poultry Unit, UK. The novel method of producing nano minerals coated with amino acids was successfully tested with zinc and material produced to test in the feeding study. Methionine coated nano zinc oxide supplementation significantly improved bird weight gain and the increased feed intake of broilers compared to an inorganic zinc form. Ileal digestibility was also improved with this methionine-nano zinc. Moreover, this supplementation improved the tibia strength of broilers at the age of 21 days, though this was not observed at day 35. Therefore, M-Nano-ZnO could be used to supplement broilers to improve both performance and digestibility with a limited positive impact on bone strength. The results of the current study suggest that the amino acid coating of nano minerals can improve the digestibility of minerals which may have further implications for the field of mineral nutrition in animal feeds.

High-Value Compounds in Fruit, Vegetable and Cereal Byproducts: An Overview of Potential Sustainable Reuse and Exploitation

Food waste (FW) represents a global and ever-growing issue that is attracting more attention due to its environmental, ethical, social and economic implications. Although a valuable quantity of bioactive components is still present in the residuals, nowadays most FW is destined for animal feeding, landfill disposal, composting and incineration. Aiming to valorize and recycle food byproducts, the development of novel and sustainable strategies to reduce the annual food loss appears an urgent need. In particular, plant byproducts are a plentiful source of high-value compounds that may be exploited as natural antioxidants, preservatives and supplements in the food industry, pharmaceuticals and cosmetics. In this review, a comprehensive overview of the main bioactive compounds in fruit, vegetable and cereal byproducts is provided. Additionally, the natural and suitable application of tailored enzymatic treatments and fermentation to recover high-value compounds from plant byproducts is discussed. Based on these promising strategies, a future expansion of green biotechnologies to revalorize the high quantity of byproducts is highly encouraging to reduce the food waste/losses and promote benefits on human health.

Vitamin D Deficiency: Defining, Prevalence, Causes, and Strategies of Addressing

There are variable definitions of vitamin D deficiency, based on different thresholds of serum 25-hydroxyvitamin D (25(OH)D); this has a major bearing on the prevalence estimates of vitamin D deficiency and consequently on the magnitude of the public health issue of low vitamin D status. Despite this, there is widespread acknowledgement of the presence of vitamin D deficiency, even using the most conservative serum 25(OH)D threshold of < 25/30 nmol/L, in both low- and high-income country setting and the pressing need to address this deficiency. While ultraviolet B-rich sunlight stimulates synthesis of vitamin D in skin, there are environmental factors and personal characteristics which prevent or impede such dermal synthesis. There are several complexities and concerns in advocating sun exposure as a public health approach for increasing vitamin D status. This places increased emphasis on addressing vitamin D deficiency through dietary means. However, naturally rich sources of vitamin D are few and infrequently consumed, and nutrition surveillance data from various countries have indicated that habitual vitamin D intakes in the population are much lower than the recommendations. There are a number of strategies that can be considered for the control of micronutrient malnutrition, these include (i) increasing the diversity of foods consumed, (ii) food fortification, and (iii) supplementation. The present narrative review will consider these strategies for addressing low dietary vitamin D intake and consequently lowering the risk of vitamin D deficiency.

Mineral and vitamin intake of infants and young children: the Nutri-Bébé 2013 survey

PURPOSE

Minerals and vitamins are essential for optimal growth and development, particularly during the first years of life. Therefore, regularly evaluating their intake makes sense. For this purpose, we report the data from the Nutri-Bébé 2013 survey in comparison with the European Food Safety Authority Adequate Intake (AI), or Average Requirement, (AR) according to age.

METHODS

This observational, nationally representative, cross-sectional survey was conducted in 1035 non-breastfed French children aged 0.5-35 months. Dietary intake was recorded using a food diary on three non-consecutive days, framed by two face-to-face interviews.

RESULTS

The intake of zinc, magnesium and water-soluble vitamins most of the time met the recommendations. From the first weeks of life, sodium intake exceeded the AI, with a maximum median intake of 1137 mg/day after the age of 30 months. However, it has decreased since 2005. Calcium median intake often exceeded the AI or AR, reaching a maximum of 780 mg/day between 18 and 23 months. Median vitamin A intake always exceeded the AI or AR but exceeded the recommended upper limit in only a few cases. After 2 years, median iron intake was clearly below the AR, i.e. lower than 6.0 mg/day. Dietary vitamin D intake was below the AI, thereby justifying adequate supplementation. Vitamin E intake was below the AI in 50-75% of toddlers.

CONCLUSION

This survey highlights excessive sodium intake as well as a shortfall of iron, vitamin D, and vitamin E intakes. The potential consequences of these discrepancies with respect to health outcomes remain to be assessed.

Calcium Intake and Health

There are striking inequities in calcium intake between rich and poor populations. Appropriate calcium intake has shown many health benefits, such as reduction of hypertensive disorders of pregnancy, lower blood pressure particularly among young people, prevention of osteoporosis and colorectal adenomas, lower cholesterol values, and lower blood pressure in the progeny of mothers taking sufficient calcium during pregnancy. Studies have refuted some calcium supplementation side effects like damage to the iron status, formation of renal stones and myocardial infarction in older people. Attention should be given to bone resorption in post-partum women after calcium supplementation withdrawal. Mechanisms linking low calcium intake and blood pressure are mediated by parathyroid hormone raise that increases intracellular calcium in vascular smooth muscle cells leading to vasoconstriction. At the population level, an increase of around 400–500 mg/day could reduce the differences in calcium intake between high- and middle-low-income countries. The fortification of food and water seems a possible strategy to reach this goal.

Proposed guidelines to evaluate scientific validity and evidence for genotype-based dietary advice

Nutrigenetic research examines the effects of inter-individual differences in genotype on responses to nutrients and other food components, in the context of health and of nutrient requirements. A practical application of nutrigenetics is the use of personal genetic information to guide recommendations for dietary choices that are more efficacious at the individual or genetic subgroup level relative to generic dietary advice. Nutrigenetics is unregulated, with no defined standards, beyond some commercially adopted codes of practice. Only a few official nutrition-related professional bodies have embraced the subject, and, consequently, there is a lack of educational resources or guidance for implementation of the outcomes of nutrigenetic research. To avoid misuse and to protect the public, personalised nutrigenetic advice and information should be based on clear evidence of validity grounded in a careful and defensible interpretation of outcomes from nutrigenetic research studies. Evidence requirements are clearly stated and assessed within the context of state-of-the-art 'evidence-based nutrition'. We have developed and present here a draft framework that can be used to assess the strength of the evidence for scientific validity of nutrigenetic knowledge and whether 'actionable'. In addition, we propose that this framework be used as the basis for developing transparent and scientifically sound advice to the public based on nutrigenetic tests. We feel that although this area is still in its infancy, minimal guidelines are required. Though these guidelines are based on semi-quantitative data, they should stimulate debate on their utility. This framework will be revised biennially, as knowledge on the subject increases.

Black Tea Source, Production, and Consumption: Assessment of Health Risks of Fluoride Intake in New Zealand

In countries with fluoridation of public water, it is imperative to determine other dietary sources of fluoride intake to reduce the public health risk of chronic exposure. New Zealand has one of the highest per capita consumption rates of black tea internationally and is one of the few countries to artificially fluoridate public water; yet no information is available to consumers on the fluoride levels in tea products. In this study, we determined the contribution of black tea as a source of dietary fluoride intake by measuring the fluoride content in 18 brands of commercially available products in New Zealand. Fluoride concentrations were measured by potentiometric method with a fluoride ion-selective electrode and the contribution of black tea to Adequate Intake (AI) and Tolerable Upper Intake Level (UL) was calculated for a range of consumption scenarios. We examined factors that influence the fluoride content in manufactured tea and tea infusions, as well as temporal changes in fluoride exposure from black tea. We review the international evidence regarding chronic fluoride intake and its association with chronic pain, arthritic disease, and musculoskeletal disorders and provide insights into possible association between fluoride intake and the high prevalence of these disorders in New Zealand.

Operationalising the health aspects of sustainable diets: a review

OBJECTIVE

Shifting towards a more sustainable food consumption pattern is an important strategy to mitigate climate change. In the past decade, various studies have optimised environmentally sustainable diets using different methodological approaches. The aim of the present review was to categorise and summarise the different approaches to operationalise the health aspects of environmentally sustainable diets.

DESIGN

Conventional keyword and reference searches were conducted in PubMed, Scopus, Web of Knowledge and CAB Abstracts. Inclusion criteria were: (i) English-language publication; (ii) published between 2005 and October 2015; (iii) dietary data collected for the diet as a whole at the national, household or individual level; (iv) comparison of the current diet with dietary scenarios; and (v) for results to consider the health aspect in some way.

SETTING

Consumer diets.

SUBJECTS

Adult population.

RESULTS

We reviewed forty-nine studies that combined the health and environmental aspects of consumer diets. Hereby, five approaches to operationalise the health aspect of the diet were identified: (i) food item replacements; (ii) dietary guidelines; (iii) dietary quality scores; (iv) diet modelling techniques; and (v) diet-related health impact analysis.

CONCLUSIONS

Although the sustainability concept is increasingly popular and widely advocated by nutritional and environmental scientists, the journey towards designing sustainable diets for consumers has only just begun. In the context of operationalising the health aspects, diet modelling might be considered the preferred approach since it captures the complexity of the diet as a whole. For the future, we propose SHARP diets: environmentally Sustainable (S), Healthy (H), Affordable (A), Reliable (R) and Preferred from the consumer's perspective (P).

Food science and food ingredients: the need for reliable scientific approaches and correct communication, Florence, 24 March 2015

This report summarises the proceedings of a conference organised by the Italian Association of Hospital Cardiologists. The aim was to consider the process by which dietary guidelines (DG) are developed and the quality of evidence underpinning these guidelines, as well as debating whether or not this has resulted in DG that are effective in terms of health improvement. Key points were a caution about false positives in research, the importance of holistic DG rather than single nutrient targets, the need for appropriate disease endpoints in studies and control of confounders, a plea for less reliance on observational studies which cannot address cause-and-effect relationships and a need to bear in mind unintended consequences. Options for improving the system and the quality of evidence were discussed.

Are restrictive guidelines for added sugars science based?

Added sugar regulations and recommendations have been proposed by policy makers around the world. With no universal definition, limited access to added sugar values in food products and no analytical difference from intrinsic sugars, added sugar recommendations present a unique challenge. Average added sugar intake by American adults is approximately 13% of total energy intake, and recommendations have been made as low 5% of total energy intake. In addition to public health recommendations, the Food and Drug Administration has proposed the inclusion of added sugar data to the Nutrition and Supplemental Facts Panel. The adoption of such regulations would have implications for both consumers as well as the food industry. There are certainly advantages to including added sugar data to the Nutrition Facts Panel; however, consumer research does not consistently show the addition of this information to improve consumer knowledge. With excess calorie consumption resulting in weight gain and increased risk of obesity and obesity related co-morbidities, added sugar consumption should be minimized. However, there is currently no evidence stating that added sugar is more harmful than excess calories from any other food source. The addition of restrictive added sugar recommendations may not be the most effective intervention in the treatment and prevention of obesity and other health concerns.

Knowledge and perceptions about diet and physical activity among Sri Lankan adults with diabetes mellitus: a qualitative study

Background

Diabetes mellitus (DM) is a rapidly growing health concern in Sri Lanka. Diet and physical activity are important modifiable risk factors affecting the incidence, severity and management of DM. The present study aims to evaluate the knowledge and perceptions about dietary patterns and physical activity among a group of adults with DM in Sri Lanka using qualitative research methods.

Methods

Fifty adults from a cohort of diabetic patients attending the medical clinics at the National Hospital of Sri Lanka were invited for the study. Data were collected via 10 Focus Group Discussions. Verbatim recording and documenting emotional responses were conducted by two independent observers. Directed content analysis of qualitative data was done with the help of NVIVO v10.0.

Results

Mean age was 61.2 ± 9.9 years and 46 % were males. Mean duration of diabetes was 10.4 ± 7.5 years. All were aware of the importance of diet in the management of DM. But most had difficulty in incorporating this knowledge into their lives mostly due to social circumstances. The majority described a list of ‘good foods’ and ‘bad foods’ for DM. They believed that ‘good’ foods can be consumed at all times, irrespective of quantity and ‘bad’ foods should be completely avoided. Many believed that fruits were bad for diabetes, while vegetables were considered as a healthy food choice. The majority thought that there were ‘special’ foods that help to control blood glucose, the most common being curry leaves and bitter-gourd. Most study participants were aware of the importance of being physical active. However, there was lack of consensus and clarity with regards to type, duration, timing and frequency of physical activity.

Conclusions

Despite understanding the importance of dietary control and physical activity in the management of diabetes, adherence to practices were poor, mainly due to lack of clarity of information provided. There were many myths with regards to diet, some of which have originated from health care professionals. More evidence is needed to support or refute the claims about ‘special’ foods that the participants believe as being good for diabetes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2518-3) contains supplementary material, which is available to authorized users.

Vitamin D: dietary requirements and food fortification as a means of helping achieve adequate vitamin D status

Vitamin D deficiency is evident in many parts of the globe, even in the sunnier regions, for a variety of reasons. Such deficiency contributes to risk of metabolic bone disease as well as potentially other non-skeletal chronic diseases in both early-life and later-life, and thus strategies for its prevention are of major public health importance. Dietary Reference Intervals (called Dietary Reference Intakes (DRI) and Dietary Reference Values (DRVs) in North America and Europe, respectively) for vitamin D have a key role in protecting against vitamin D deficiency in the population, and these have been re-evaluated in recent years on both sides of the Atlantic. The current DRI and DRVs for vitamin D and their basis will be overviewed in this review as well as some limitations that existed within the evidence-base and which contribute some degree of uncertainty to these new requirement estimates for vitamin D. The review will also compare current population intake estimates for children and adults in North America and Europe against the estimated average requirement (EAR) for vitamin D, as a benchmark of nutritional adequacy. While vitamin D supplementation has been suggested as a method of bridging the gap between current vitamin D intakes and new recommendations, the level of usage of vitamin D supplements in many countries as well as the vitamin D content of available supplements in these countries, appears to be low. The fortification of food with vitamin D has been suggested as a strategy for increasing intake with potentially the widest reach and impact in the population. The present review will highlight the need to re-evaluate current food fortification practices as well as consider new additional food-based approaches, such as biofortification of food with vitamin D, as a means of collectively tackling the low intakes of vitamin D within populations and the consequent high prevalence of low vitamin D status that are observed. This article is part of a Special Issue entitled '17th Vitamin D Workshop'.

Communication of scientific uncertainty: international case studies on the development of folate and vitamin D Dietary Reference Values

OBJECTIVE

Transparent evidence-based decision making has been promoted worldwide to engender trust in science and policy making. Yet, little attention has been given to transparency implementation. The degree of transparency (focused on how uncertain evidence was handled) during the development of folate and vitamin D Dietary Reference Values was explored in three a priori defined areas: (i) value request; (ii) evidence evaluation; and (iii) final values.

DESIGN

Qualitative case studies (semi-structured interviews and desk research). A common protocol was used for data collection, interview thematic analysis and reporting. Results were coordinated via cross-case synthesis.

SETTING

Australia and New Zealand, Netherlands, Nordic countries, Poland, Spain and UK.

SUBJECTS

Twenty-one interviews were conducted in six case studies.

RESULTS

Transparency of process was not universally observed across countries or areas of the recommendation setting process. Transparency practices were most commonly seen surrounding the request to develop reference values (e.g. access to risk manager/assessor problem formulation discussions) and evidence evaluation (e.g. disclosure of risk assessor data sourcing/evaluation protocols). Fewer transparency practices were observed to assist with handling uncertainty in the evidence base during the development of quantitative reference values.

CONCLUSIONS

Implementation of transparency policies may be limited by a lack of dedicated resources and best practice procedures, particularly to assist with the latter stages of reference value development. Challenges remain regarding the best practice for transparently communicating the influence of uncertain evidence on the final reference values. Resolving this issue may assist the evolution of nutrition risk assessment and better inform the recommendation setting process.