Limiting trans Fats in Foods: Use of Partially Hydrogenated Vegetable Oils in Prepacked Foods in Slovenia

Association between plasma trans fatty acids and serum α-klotho levels in adults in the United States of America: an analysis of the NHANES 2009-2010 datasets

BACKGROUND

This study aimed to explore the potential associations between trans fatty acid (TFA) and α-klotho levels.

METHODS

Datasets from the 2009-2010 National Health and Nutrition Examination Survey (NHANES) were analysed for this study. Multivariable linear regression and restricted cubic spline (RCS) analyses were performed to examine the relationships between plasma TFA and serum α-klotho levels.

RESULTS

A total of 1,205 participants were included, with a geometric mean (GM) of 803.60 (95% CI: 787.45, 820.00) pg/mL for serum α-klotho levels. RCS analysis revealed L-shaped relationships between TFA and α-klotho levels. The inflection points for palmitelaidic acid (PA), vaccinic acid (VA), elaidic acid (EA), and total TFA levels were 4.55, 20.50, 18.70, and 46.40 µmol/L, respectively. Before reaching the inflection point, serum α-klotho levels were negatively correlated with plasma PA, VA, EA and total TFA levels, with β values (95% CI) of -0.15 (-0.24, -0.06), -0.16 (-0.23, -0.09), -0.14 (-0.22, -0.05) and - 0.19 (-0.27, -0.11), respectively. Linolelaidic acid (LA) levels exhibited an inverse and linear association with α-klotho levels ( Pnonlinearity=0.167, Poverall<0.001). L-shaped relationships between TFA and α-klotho levels were also observed in the subgroups of participants who were aged < 65 years, were male, did not exercise, were ex-smokers, and were overweight/obese.

CONCLUSIONS

L-shaped correlations between plasma PA, VA, EA, and total TFA levels and serum α-klotho levels were observed among adults in the United States.

Lipid-based ayurvedic formulations of a single herb-Yashtimadhu (Glycyrrhiza glabra): Pharmaceutical standardization, shelf-life estimation and comparative characterization

BACKGROUND

Single herb Ayurvedic lipid-based formulations of Glycyrrhiza glabra are used as oral, nasal and topical applications for reducing radiotherapy induced side effects in oral cavity cancer patients. These formulations are reported to be de-glycyrrhized, thus minimizing adverse effects of glycyrrhizin on longer consumption. Being a proprietary formulation with specific ratio of herb, lipid and liquid media, there is a need of pharmaceutical standardization and stability study to be conducted for quality control and quality assurance.

OBJECTIVE

Standardization of Yashtimadhu Ghrut (YG) and Yashtimadhu Taila (YT) based on pharmaceutical characters, safety tests, chromatographic analysis and stability study.

MATERIAL AND METHODS

Two formulations viz., YG and YT were prepared using cow's ghee and sesame oil, respectively. Basic physicochemical analysis, Thin Layer Chromatography, High Pressure Liquid Chromatography of glabridin and 18-β glycyrrhetinic acid, microbial load and heavy metal analysis were performed. Long term (0,3,6,9,12 months) as well as accelerated (0,3,6 months) stability study was conducted and extrapolated shelf-life was calculated for both the drugs.

RESULT

Organoleptic and basic physicochemical characters were comparable for both the products while safety parameters were within permissible limits. Extrapolated shelf-life was deduced as 1.74 and 0.67 years for YG and YT, respectively.

CONCLUSION

Single herb- G. glabra based lipid formulations were standardized and monographs were established. Shelf-life, though complying with classical Ayurvedic texts, indicates further research work with respect to pre-treatment of lipids and packaging systems for its enhancement.

Trans-Fat Labeling in Packaged Foods Sold in Brazil Before and After Changes in Regulatory Criteria for Trans-Fat-Free Claims on Food Labels

Consumption of industrially produced trans-fat acids (TFA) is a public health concern. Therefore, it is important that information on TFA in packaged foods be clearly informed to consumers. This study aimed to assess the evolution of TFA information presented in packaged foods sold in Brazil in 2010 and 2013, before and after the introduction of stricter regulatory requirements for TFA-free claims on food labels. A repeated cross-sectional study was performed through food label censuses of all packaged foods available for sale in two stores from the same supermarket chain, totaling 2,327 foods products in 2010 and 3,176 in 2013. TFA-free claims and information indicating TFA in the ingredients list and nutrition facts label were analyzed by descriptive statistics and Pearson's chi-square test. There was a 14% decrease in the use of ingredients containing or potentially containing industrially produced TFA (i-TFA), according to analysis of the ingredients list. However, when analyzing foods by groups, it was found that this decrease was significant only for group A (bakery goods, bread, cereals, and related products; from 59 to 35%, p < 0.001). By contrast, food group F (gravies, sauces, ready-made seasonings, broths, soups, and ready-to-eat dishes) showed a 5% increase in i-TFA. The use of specific terms for i-TFA decreased between 2010 and 2013, but there was an increase in the use of alternative terms, such as vegetable fat and margarine, which do not allow consumers to reliably identify whether a food product is a possible source of i-TFA. There was an 18% decrease in the use of TFA-free claims in products containing or potentially containing i-TFA. However, almost one-third of foods sold in 2013 were false negatives, that is, foods reported to contain 0 g of TFA in the nutrition facts label or with TFA-free claims but displaying specific or alternative terms for i-TFA in the ingredients list. The results indicate that adoption of stricter requirements for TFA-free claims on food labels in Brazil helped reduce the prevalence of such claims but was not sufficient to decrease i-TFA in industrialized foods sold in supermarkets.

Trans fatty acids in frequently consumed products from Serbian and Slovenian market

OBJECTIVES

Industrially produced trans fatty acid (iTFA) have adverse health effects and thus their consumption should be limited. The aim of this study was to determine and compare the iTFA content in frequently consumed food products by young adults from the Serbian and Slovenian market with supposedly elevated iTFA content in 2015. At the time of this study, there was no recommended limit of iTFA in both countries, and reduction of iTFA in foods was on voluntary basis.

METHODS

We determined iTFA content in food products, 19 from the Serbian and 22 from the Slovenian market, blinded and analysed in the same analytical run. Contents of fatty acids (FA) methyl esters were analysed by capillary gas chromatography with a flame ionisation detector. Heptadecanoic acid was used as internal standard. Individual FA along with TFA were expressed as percentages of total measured FA. The amount of each FA in the sample was then calculated from the response factor and the transformation factor of the FA from the FA methyl ester content.

RESULTS

Elaidic acid (C18:1t) was found as the most abundant TFA in analysed products, ranging from 0.52 g/100 g of total FA in chocolate candy up to 60.4 g/100 g in a salami from Serbian market. In Slovenian products, the values for elaidic acid were lower, 0.04-3.95 g/100 g of total FA, except in one type of wafers (24.3 g/100 g).

CONCLUSIONS

The majority of analysed products from the Serbian and three from Slovenian market exceeded the recommended WHO and EU limit of 2% iTFA of total fat in foods. Samples of frequently consumed salami, wafers, tea biscuits, and snacks were identified as products with potentially higher burden of iTFA in diets of young adults in Serbia.

Use of Branded Food Composition Databases for the Exploitation of Food Fortification Practices: A Case Study on Vitamin D in the Slovenian Food Supply

Vitamin D deficiency is a worldwide public health concern, which can be addressed with voluntary or mandatory food fortification. The aim of this study was to determine if branded food composition databases can be used to investigate voluntary fortification practices. A case study was conducted using two nationally representative cross-sectional datasets of branded foods in Slovenia, collected in 2017 and 2020, and yearly sales data. Using food labeling data we investigated prevalence of fortification and average vitamin D content, while nutrient profiling was used to investigate overall nutritional quality of the foods. In both datasets, the highest prevalence of vitamin D fortification was observed in meal replacements (78% in 2017; 100% in 2020) and in margarine, corresponding to high market share. Other food categories commonly fortified with vitamin D are breakfast cereals (5% in 2017; 6% in 2020), yogurts and their imitates (5% in 2017; 4% in 2020), and baby foods (18% in both years). The highest declared average content of vitamin D was observed in margarine and foods for specific dietary use (7-8 μg/100g), followed by breakfast cereals (4 μg/100g), while the average content in other foods was below 2 μg/100g. Only minor differences were observed between 2017 and 2020. Major food-category differences were also observed in comparison of the overall nutritional quality of the fortified foods; higher overall nutritional quality was only observed in fortified margarine. Our study showed that branded food composition databases are extremely useful resources for the investigation and monitoring of fortification practices, particularly if sales data can also be used. In the absence of mandatory or recommended fortification in Slovenia, very few manufacturers decide to add vitamin D, and even when this is the case, such products are commonly niche foods with lower market shares. We observed exceptions in imported foods, which can be subject to fortification policies introduced in other countries.

Branded Foods Databases as a Tool to Support Nutrition Research and Monitoring of the Food Supply: Insights From the Slovenian Composition and Labeling Information System

Branded foods databases are becoming very valuable not only in nutrition research but also for clinical practice, policymakers, businesses, and general population. In contrast to generic foods, branded foods are marked by rapid changes in the food supply because of reformulations, the introduction of new foods, and the removal of existing ones from the market. Also, different branded foods are available in different countries. This not only complicates the compilation of branded foods datasets but also causes such datasets to become out of date quickly. In this review, we present different approaches to the compilation of branded foods datasets, describe the history and progress of building and updating such datasets in Slovenia, and present data to support nutrition research and monitoring of the food supply. Manufacturers are key sources of information for the compilation of branded foods databases, most commonly through food labels. In Slovenia, the branded food dataset is compiled using standard food monitoring studies conducted at all major retailers. Cross-sectional studies are conducted every few years, in which the food labels of all available branded foods are photographed. Studies are conducted using the Composition and Labeling Information System (CLAS) infrastructure, composed of a smartphone application for data collection and online data extraction and management tool. We reviewed various uses of branded foods datasets. Datasets can be used to assess the nutritional composition of food in the food supply (i.e., salt, sugar content), the use of specific ingredients, for example, food additives, for nutrient profiling, and assessment of marketing techniques on food labels. Such datasets are also valuable for other studies, for example, assessing nutrient intakes in dietary surveys. Additional approaches are also being tested to keep datasets updated between food monitoring studies. A promising approach is the exploitation of crowdsourcing through the mobile application VešKajJeš, which was launched in Slovenia to support consumers in making healthier dietary choices.

Dietary Sources of Plasma trans Fatty Acids among Adults in the United States: NHANES 2009-2010

BACKGROUND

Intake of trans fatty acids (TFAs) increases LDL cholesterol, decreases HDL cholesterol, and increases the risk of heart disease morbidity and mortality. Many food products potentially contain industrially produced or ruminant TFAs. However, little is known about the dietary sources of plasma TFA concentrations.

OBJECTIVE

The objective of this study was to examine associations between foods consumed and plasma TFA concentrations using 24-h dietary recall data and plasma TFA measures among adults aged ≥20 y who participated in the NHANES 2009-2010 in the United States.

METHODS

Over 4400 food products in the dietary interview data were categorized into 32 food and beverage groups/subgroups. Four major plasma TFAs (palmitelaidic acid, elaidic acid, vaccenic acid, linolelaidic acid) and the sum of the 4 TFAs (sumTFAs) were analyzed using GC-MS. Multivariable linear regression analyses were conducted to identify associations of plasma TFAs with all 32 food and beverage groups/subgroups, controlling for the potential confounding effects of 11 demographic, socioeconomic, behavioral, lifestyle, and health-related variables.

RESULTS

Consumption of the following food groups/subgroups was significantly associated with elevated plasma TFA concentrations: cream substitutes (P < 0.001 for palmitelaidic acid, elaidic acid, vaccenic acid, and sumTFAs); cakes, cookies, pastries, and pies (P < 0.001 for elaidic acid, vaccenic acid, and sumTFAs; P < 0.05 for linolelaidic acid); milk and milk desserts (P < 0.01 for palmitelaidic acid and vaccenic acid; P < 0.05 for linolelaidic acid and sumTFAs); beef/veal, lamb/goat, and venison/deer (P < 0.01 for vaccenic acid; P < 0.05 for sumTFAs); and butters (P < 0.001 for palmitelaidic acid and vaccenic acid; P < 0.05 for sumTFAs).

CONCLUSIONS

The findings suggest that the above 5 food groups/subgroups could be the main dietary sources of plasma TFAs among adults in the United States in 2009-2010.

What is the impact of food reformulation on individuals' behaviour, nutrient intakes and health status? A systematic review of empirical evidence

Food reformulation aimed at improving the nutritional properties of food products has long been viewed as a promising public health strategy to tackle poor nutrition and obesity. This paper presents a review of the empirical evidence (i.e., modelling studies were excluded) on the impact of food reformulation on food choices, nutrient intakes and health status, based on a systematic search of Medline, Embase, Global Health and sources of grey literature. Fifty-nine studies (in 35 papers) were included in the review. Most studies examined food choices (n = 27) and dietary intakes (n = 26). The nutrients most frequently studied were sodium (n = 32) and trans fatty acids (TFA, n = 13). Reformulated products were generally accepted and purchased by consumers, which led to improved nutrient intakes in 73% of studies. We also conducted two meta-analyses showing, respectively, a -0.57 g/day (95%CI, -0.89 to -0.25) reduction in salt intake and an effect size for TFA intake reduction of -1.2 (95% CI, -1.79 to -0.61). Only six studies examined effects on health outcomes, with studies on TFA reformulation showing overall improvement in cardiovascular risk factors. For other nutrients, it remains unclear whether observed improvements in food choices or nutrient intakes may have led to an improvement in health outcomes.

Dietary Intake of trans Fatty Acids in the Slovenian Population

Consumption of trans fatty acids (TFAs) has been unequivocally linked to several adverse health effects, with the increased risk of cardiovascular disease being one of the most well understood. To reduce TFA-related morbidity and mortality, several countries have imposed voluntary or mandatory measures to minimize the content of industrial TFAs (iTFAs) in the food supply. In 2018, Slovenia introduced a ban on iTFAs on top of preceding voluntary calls to industry to reduce its use of partially hydrogenated oils (PHOs) as the main source of iTFAs. To investigate the consumption of TFAs, data available from the nationally representative dietary survey SI.Menu were analyzed. The survey consisted of two 24-h non-consecutive day recalls from 1248 study participants from three age groups (10–17, 18–64, 65–74 years old), combined with socio-demographic, socio-economic, and lifestyle parameters. The analyses demonstrated that, on average, TFAs accounted for 0.38–0.50% of total energy intake (TEI). However, 13% of adolescents, 29.4% of adults, and 41.8% of the elderly population still consumed more than 0.50% TEI with TFAs. The main sources of TFAs in the diet were naturally present TFAs from butter, meat dishes, and meat products, regardless of the age group. Results indicate that following the reformulation activities, the major sources of TFAs in the diets of the Slovenian population now represent foods which are natural sources of TFAs.

Assessment of trans-fatty acid content in a sample of foods from the Slovenian food supply using a sales-weighting approach

OBJECTIVE

Consumption of trans-fatty acids (TFA) is a well-established risk factor for CVD morbidity and mortality. Our objective was to investigate TFA levels in Slovenian food supply.

DESIGN

Cross-sectional study.

SETTING

Selected foods (n 282) were purchased in Slovenia (2016), and the TFA content was determined. The sample included pre-packed foods with/without declared partially hydrogenated vegetable oils (PHO), as well as non-pre-packed foods. A sales-weighting approach was used to ponder different market shares of the products.

RESULTS

While the majority of the investigated samples had low levels of TFA, up to 6·8 g of TFA per 100 g of food was observed in certain foods. Within pre-packed foods (n 207), the highest proportion of samples with high TFA levels was found among cookies with labelled PHO: 69 % (n 18) would exceed European Union regulatory TFA limit (2 g industrial TFA per 100 g of fats), which will be implemented in April 2021. Among the investigated non-pre-packed foods (n 75), only croissants contained notable TFA levels (mean 0·90 (sd 0·97); maximum 3·3 g/100 g), with about half of the samples exceeding 2 g TFA per 100 g of fats.

CONCLUSIONS

In 2016, some foods in Slovenian food supply still contained notable amounts of TFA. Foods with listed PHO as an ingredient were usually higher in TFA as compared with foods not labelled to contain PHO. Biscuits were identified as the most concerning category of pre-packed foods, while croissants contained highest levels of TFA within non-pre-packed foods.

Sweet, Fat and Salty: Snacks in Vending Machines in Health and Social Care Institutions in Slovenia

Vending machines in health and social care facilities are often the only possible choice for a quick snack for workers and visitors, in many cases providing unhealthy dietary choices. Our study aimed to analyse the variety and nutritional quality of foods available in vending machines placed in social and health care institution in Slovenia. The available snacks were quantitatively assessed, using traffic light profiling. The model used for nutrient profiling was that of the Food Standards Australia New Zealand (FSANZ). Vending machines in 188 institutions were surveyed, resulting in 5625 food-items consisting of 267 unique product labels. Sweet products dominate in vending machines offers (about 70%), while nuts and seeds (8.4%), yoghurts (2.1%), fruits (1.4%) and milk (0.3%) are present in a very small proportion or are not available at all. According to FSANZ, 88.5% of all displayed food items in vending machines can be considered as lower nutritional quality or less healthy products. The authors' future activities will be focused on ensuring wider availability of healthy dietary choices and on including official guidelines in tender conditions for vending machines in health and social care institutions in Slovenia.

Progress towards eliminating industrially produced trans-fatty acids in the Canadian marketplace, 2013-2017

OBJECTIVE

To assess the prevalence of partially hydrogenated oils (PHO), hydrogenated oils (HO) and/or both in Canadian packaged foods in 2013 and 2017 and to determine the mean trans-fatty acid (TFA) content of products declaring such oils.

DESIGN

Repeated cross-sectional study of the Food Label Information Program.

SETTING

Food labels (n 32 875) were collected from top Canadian grocery retailers in 2013 and 2017. Proportions of products declaring PHO, HO and/or both in the Ingredients List were calculated by year and food category. The percentage contribution of TFA (g) to total fat (g) was calculated and compared against the voluntary TFA limits, defined as <2 % of total fat content for fats and oils, and <5 % for all other foods. Foods exceeding limits were identified. The mean TFA content (in g/serving and per 100 g) was calculated for products with these oils.

RESULTS

The use of PHO, HO and/or both significantly decreased in Canadian foods from 2013 to 2017 (0·8 to 0·2 %, 5 to 2·4 % and 5·7 to 2·6 %, respectively, for PHO, HO and/or both). The mean TFA content of products containing PHO increased (0·34 to 0·57 g TFA/serving); although it was not statistically significant, it is still concerning that TFA content increased. The TFA content significantly decreased in foods with HO (0·24 to 0·16 g TFA/serving, P < 0·05) during 2013-2017.

CONCLUSIONS

Products with PHO continue to be present in the Canadian marketplace, despite voluntary efforts to eliminate them. Products with HO should also be monitored, as they can also contribute to TFA content in foods.

Nutrient and Food Intake of Participants in a Whole-Food Plant-Based Lifestyle Program

OBJECTIVE

We evaluated the nutrient adequacy of a well-planned supplemented whole-food plant-based (WFPB) diet as a component of an ongoing community lifestyle optimization program. We investigated the contributions of nutrients from foods and supplements and plant-based meal replacement (SMR) separately (foods, SMR) and combined (vs recommendations) as well as food group intake, both according to sex.

METHOD

Our cross-sectional study included 151 healthy, active participants (aged 39.6 years) who were on a Western-type diet when they voluntarily joined our WFPB lifestyle program (0.5-10 years ago). We assessed diet using 3-day weighed dietary records (foods, S, and MR). After we standardized nutrient intake to 2000 kcal/d, we calculated the contribution of macro- and micronutrients from foods and SMR separately and combined (foods + SMR) (vs central European Recommendations), as well as food group intake, both according to sex.

RESULTS

All macro- and micronutrient intake (total: from foods plus SMR) exceeded the reference values, except for calcium (95% and 82% in females and males) and vitamin D (both sexes, in summertime). Compared with male participants, female participants consumed (i.e., from foods and SMR together) significantly larger amounts of 23 (/25) micronutrients (8 [/25] from foods and 22 [/25] from SMR). The diet was primarily composed of the following (by mass in descending order): unprocessed vegetables/fruits, whole grains, legumes, potatoes, nuts/seeds, MR, and spices/herbs.

CONCLUSIONS

Participants in our WFPB lifestyle program ingested a nutrient-rich WFPB diet and targeted supplementation. The presented ongoing community WFPB lifestyle program ensures a healthy, balanced, and environment-friendly dietary pattern for participants who are compliant.

Mechanisms of Action of trans Fatty Acids

Human studies have established a positive association between the intake of industrial trans fatty acids and the development of cardiovascular diseases, leading several countries to enact laws that restrict the presence of industrial trans fatty acids in food products. However, trans fatty acids cannot be completely eliminated from the human diet since they are also naturally present in meat and dairy products of ruminant animals. Moreover, bans on industrial trans fatty acids have not yet been instituted in all countries. The epidemiological evidence against trans fatty acids by far overshadows mechanistic insights that may explain how trans fatty acids achieve their damaging effects. This review focuses on the mechanisms that underlie the deleterious effects of trans fatty acids by juxtaposing effects of trans fatty acids against those of cis-unsaturated fatty acids and saturated fatty acids (SFAs). This review also carefully explores the argument that ruminant trans fatty acids have differential effects from industrial trans fatty acids. Overall, in vivo and in vitro studies demonstrate that industrial trans fatty acids promote inflammation and endoplasmic reticulum (ER) stress, although to a lesser degree than SFAs, whereas cis-unsaturated fatty acids are protective against ER stress and inflammation. Additionally, industrial trans fatty acids promote fat storage in the liver at the expense of adipose tissue compared with cis-unsaturated fatty acids and SFAs. In cultured hepatocytes and adipocytes, industrial trans fatty acids, but not cis-unsaturated fatty acids or SFAs, stimulate the cholesterol synthesis pathway by activating sterol regulatory element binding protein (SREBP) 2-mediated gene regulation. Interestingly, although industrial and ruminant trans fatty acids show similar effects on human plasma lipoproteins, in preclinical models, only industrial trans fatty acids promote inflammation, ER stress, and cholesterol synthesis. Overall, clearer insight into the molecular mechanisms of action of trans fatty acids may create new therapeutic windows for the treatment of diseases characterized by disrupted lipid metabolism.

Assessing diet in European populations using national dietary surveys

The WHO encourages countries to conduct national dietary surveys (NDS) to inform preventative policies targeting malnutrition and noncommunicable diseases. Previous reviews have found inadequate nutrient intakes and survey provision across Europe. This research is the first to provide an updated review of NDS provision within the whole WHO European Region, across the lifecourse, with reference to disadvantaged groups, obesity and nutrients of concern. Over a third of WHO European countries, mainly Central and Eastern European countries (CEEC), had no identifiable NDS. Where countries reported nutrient intakes, poor WHO recommended nutrient intake attainment was Europe-wide across the lifecourse, particularly in CEEC. Lower educated individuals had poorer diet quality. However, heterogeneity in age group sampled, dietary assessment method, nutrient composition database and under-reporting hindered inter-country comparisons. Average population trans fatty acid intakes below WHO recommended limits may hide inequalities in disadvantaged groups; legislative bans may help alleviate this. There were few associations between NDS-derived consumed food portion size (FPS) and BMI. However, consumed FPS was greater than on-pack serving-size in the majority of foods studied. This review illustrates how NDS can generate information on diet, nutrient intakes and the food environment. However, to enable valid inter-country comparisons, countries should be encouraged to conduct and report harmonised NDS, particularly in the age groups sampled, dietary assessment methodology, nutrient range, underpinning food composition database and treatment of under-reporters. This will aid effective, coordinated policy development that can have a real impact on dietary improvement, on a population and subgroup level, throughout Europe.

Nutrient Profiling Is Needed to Improve the Nutritional Quality of the Foods Labelled with Health-Related Claims

Health-related claims on food products influence consumers and their food preferences. None of the European countries have restricted the use of health claims to foods of high nutritional quality despite the regulatory background provided by the European Union in 2006. We evaluated the nutritional quality of foods labelled with claims available in the Slovenian market using two nutrient profile models—Food Standards Australia New Zealand (FSANZ) and European World Health Organization Regional office for Europe model (WHOE)—and compared the results to the nutritional quality of all available foods. Data for prepacked foods in the Slovenian food supply were collected in 2015 on a representative sample (n = 6619) and supplemented with 12-month product sales data for more accurate assessments of the food supply. A considerable proportion of foods labelled with any type of health-related claim was found to have poor nutritional quality. About 68% of the foods labelled with health-related claims passed FSANZ criterion (75% when considering sales data) and 33% passed the WHOE model (56% when considering sales data). Our results highlight the need for stricter regulations for the use of health-related claims and to build upon available nutrient profiling knowledge to improve nutrition quality of foods labeled with health-related claims.