Criterion validation of nutrient profiling systems: a systematic review and meta-analysis

BACKGROUND

Nutrient profiling systems (NPSs) use algorithms to evaluate the nutritional quality of foods and beverages. Criterion validation, which assesses the relationship between consuming foods rated as healthier by the NPS and objective measures of health, is essential to ensure the accuracy of NPSs.

OBJECTIVE

We examined and compared NPSs that have undergone criterion validity testing in relation to diet-related disease risk and risk markers.

METHODS

Academic databases were searched for prospective cohort and cross-sectional studies published before November, 2022. NPSs were eligible if they incorporated multiple nutrients or food components using an algorithm to determine an overall summary indicator (e.g., a score or rank) for individual foods. Studies were included if they assessed the criterion validity of an eligible NPS. Validation evidence was first summarized in narrative form by NPS, with random effects meta-analysis where ≥2 prospective cohort studies assessed the same NPS and outcomes.

RESULTS

Of 4519 publications identified, 29 describing 9 NPSs were included in the review. The Nutri-Score NPS was assessed as having substantial criterion validation evidence. Highest compared with lowest diet quality as defined by the Nutri-Score was associated with significantly lower risk of cardiovascular disease (hazard ratio [HR]: 0.74; 95% confidence interval [CI]: 0.59, 0.93; n = 6), cancer (HR: 0.75; 95% CI: 0.59, 0.94; n = 5), all-cause mortality (HR: 0.74; 95% CI; 0.59, 0.91; n = 4) and change in body mass index (HR: 0.68; 95% CI: 0.50, 0.92; n = 3). The Food Standards Agency NPS, Health Star Rating, Nutrient Profiling Scoring Criterion, Food Compass, Overall Nutrition Quality Index, and the Nutrient-Rich Food Index were determined as having intermediate criterion validation evidence. Two other NPSs were determined as having limited criterion validation evidence.

CONCLUSIONS

We found limited criterion validation studies compared with the number of NPSs estimated to exist. Greater emphasis on conducting and reporting on criterion validation studies across varied contexts may improve the confidence in existing NPSs.

Healthy choices in New South Wales health facilities for staff and visitors: a policy evaluation

Issue

Obesity and its determinants are risk factors for most leading causes of chronic diseases. In New South Wales (NSW), Australia, 1 in 2 adults and more than 1 in 5 children are above a healthy weight. As a key symbolic part of a suite of health eating policies, the NSW Ministry of Health implemented a Healthy Food and Drink in NSW Health facilities for Staff and Visitors Framework (Framework) across 18 Local Health Districts (LHDs). Many countries are grappling to understand the effectiveness of obesity prevention policies. Description 2: This policy evaluation synthesised evaluation study findings and internal records to assess the effectiveness of the Framework in achieving implementation targets: a) the removal of sugar-sweetened drinks (SSDs) from sale (Dec 2017), b) implementation of 12 food-based practices (Dec 2018).

Results

The overall implementation package was appropriate for the large, geographically dispersed, decentralised health system (160 health facilities; 927 food outlets;76 retailers) and variable retail arrangements. The Ministry provided LHDs with overall direction, phasing, and monitoring; the LHDs had local leadership, governance, cross-functional support and autonomy to implement in a way to suit them. Accountability and pace of implementation was driven most notably by monitoring and reporting using an electronic tool (PHIMS-N), and a 'network of practice' that was pivotal to problem solving. SSDs were removed from 96% (n = 606) of applicable food outlets; overall average achievement of all practices was high at 82% (22.4 SD). Nine in 10 (92%) consumers support the Framework, and retailers are accepting of its targets. Lessons: This was the right policy at the right time, with well-orchestrated implementation. Annual monitoring and reporting enabled by PHIMS-N is unique in this type of policy implementation and essential for tracking progress, informing decision making, and ensuring accountability.

Key messages

Implementation of the Framework has resulted in the removal of SSDs from sale, increased availability of healthier foods and decreased unhealthy foods as measured by 12 food-based practices. The Framework is feasible and effective in influencing retail practices in health facilities, has high consumer support for its goals, and overall acceptability and adoption amongst retailers.

Atopic dermatitis complicated by severe impetigo in a Syrian refugee infant

We present the case of a 3-month-old infant with atopic dermatitis who developed severe impetigo. The child was born to Syrian refugees shortly after they arrived in Canada. The case demonstrates the rapid and nearly complete resolution of dramatic skin findings after a course of hydrocortisone ointment and oral antibiotics with adjuvant measures. For resettled refugees, access to family physicians and local language proficiency are common barriers that negatively impact their health and healthcare. We discuss some aspects of how the healthcare model in one Canadian city addresses these issues in the context of this case. The case also raises questions about the burden of dermatological conditions in refugees while in transit and in countries of resettlement. The few reports that exist suggest that some conditions may be relatively common and that the epidemiology warrants additional investigation.

Reversed light-dark cycle and cage enrichment effects on ethanol-induced deficits in motor coordination assessed in inbred mouse strains with a compact battery of refined tests

The laboratory environment existing outside the test situation itself can have a substantial influence on results of some behavioral tests with mice, and the extent of these influences sometimes depends on genotype. For alcohol research, the principal issue is whether genotype-related ethanol effects will themselves be altered by common variations in the lab environment or instead will be essentially the same across a wide range of lab environments. Data from 20 inbred strains were used to reduce an original battery of seven tests of alcohol intoxication to a compact battery of four tests: the balance beam and grip strength with a 1.25 g/kg ethanol dose and the accelerating rotarod and open-field activation tests with 1.75 g/kg. The abbreviated battery was then used to study eight inbred strains housed under a normal or reversed light-dark cycle, or a standard or enriched home cage environment. The light-dark cycle had no discernable effects on any measure of behavior or response to alcohol. Cage enrichment markedly improved motor coordination in most strains. Ethanol-induced motor coordination deficits were robust; the well-documented strain-dependent effects of ethanol were not altered by cage enrichment.

Overview of mouse assays of ethanol intoxication

There are many behavioral assays to assess sensitivity to ethanol intoxication in mice. Most are simple to implement, and are sensitive to a particular dose range of ethanol. Most reflect genetic influences, and each test appears to reflect the contribution of a relatively distinct collection of genes. This genetic heterogeneity implies that no single test can claim to capture the construct "ethanol intoxication" completely. Depending on the test, and when measurements are made, acute functional tolerance to even a single dose of ethanol must be considered as a contributing factor. Whether or not a test is conducted in naïve mice or as part of a test battery can influence sensitivity, and do so in a strain-dependent manner. This unit reviews existing tests and recommends several.

Morphine and amphetamine sensitization in rats demonstrated under moderate- and high-dose NMDA receptor blockade with MK-801 (dizocilpine)

RATIONALE

It has been inferred from indirect tests that MK-801, an NMDA receptor antagonist, blocks sensitization to amphetamine and to morphine. These inferences were made from studies where behavioral scores were not recorded after each drug treatment in the sensitization protocol.

OBJECTIVES

We reinvestigated the role of NMDA receptors in sensitization to amphetamine or morphine more directly by taking locomotor and stereotypy scores after each of several treatments with MK-801 and amphetamine or morphine.

METHODS

Each male Long Evans rat was administered intraperitoneal injections of MK-801 (0.1 or 0.25 mg/kg) or saline followed 30 minutes later by amphetamine (0.75 mg/kg), morphine (1.25 mg/kg) or saline and placed immediately in a photocell chamber. Locomotion and stereotypy were measured simultaneously by photobeam breaks and direct observation, respectively. This procedure was repeated on days 1, 2, 3, 4, 5, 8, 11 and 27 for rats receiving amphetamine or saline as the second injection and on days 1-10, 13, 16 and 32 for rats receiving morphine or saline as their second injection (with no testing or treatment on intervening days).

RESULTS

The animals treated in the amphetamine condition and animals treated in the morphine condition all showed progressively greater locomotion and stereotypy over the first 5 (amphetamine) or 10 (morphine) test days; the sensitized response was seen regardless of whether the animals were pretreated with saline or with MK-801. Thus MK-801 failed to block the development of psychomotor sensitization seen with these treatment regimens. When, following initial sensitization, amphetamine or morphine was given in the absence of MK-801 (days 8 and 13 for amphetamine and morphine rats, respectively), there was no expression of the sensitized response; the sensitized response of animals previously treated in the MK-801 drug state was expressed only when the animal was tested in the MK-801 drug state. The sensitized response was still expressed, in animals tested in the appropriate drug condition, after a 2-week period in which no drugs were given, confirming that the changes underlying this form of sensitization were long-lasting and thus probably a consequence of some form of synaptic plasticity.

CONCLUSIONS

Our data provide evidence that behavioral sensitization to amphetamine and to morphine can occur despite the presence of NMDA receptor blockade. These and previous findings suggest that the failure of expression of sensitization seen when MK-801 is withdrawn from a given psychomotor stimulant treatment regimen reflects, at least in part, the dependency of sensitization on the various conditions of training rather than dependency on some essential function of NMDA receptor activation.

Polydrug self-administration in rats: cocaine-heroin is more rewarding than cocaine-alone

The i.v. self-administration by rats of a polydrug combination of cocaine and heroin was explored. The rewarding efficacies of a range of cocaine doses (0.25-8 mg/kg/injection) alone or in combination with heroin (12.5 or 25 microg/kg/injection) were compared using a progressive ratio (PR) schedule of reinforcement. Breaking points (BP) for one group of rats were determined at each dose of cocaine alone and for two other groups at each of the same cocaine doses plus one of the heroin doses, respectively. The cocaine-heroin combination was associated with higher BPs than cocaine alone at all doses of cocaine. These data demonstrate that cocaine-heroin combinations (speedballs) are more rewarding than the identical doses of cocaine alone. Some possible mechanisms by which heroin increases cocaine reward are discussed.

A study of general practitioners' skin surgery in Canterbury

AIMS

To evaluate skin surgery done by general practitioners in Christchurch.

METHODS

Twenty-eight general practitioners performing regular skin surgery were studied. Their clinical accuracy and completeness of excision was analysed. Skin lesions referred for specialist treatment were also studied.

RESULTS

Three hundred and three lesions were sent to the laboratory for analysis by participating practitioners. Sixty-one malignancies were present comprising 29 basal cell carcinomas, 28 squamous cell carcinomas, three malignant melanomas and one cutaneous lymphoma. Nineteen of the 61 malignant lesions were incompletely excised. Twenty eight further lesions were referred to specialists for treatment.

CONCLUSIONS

General practitioners in Canterbury perform more skin surgery and remove more malignant lesions than their British counterparts. Although the adequacy of their skin surgery is better than other groups studied overseas there is considerable room for improvement.

Withdrawal from chronic amphetamine elevates baseline intracranial self-stimulation thresholds

Intracranial self-stimulation was assessed before, within, and after a chronic amphetamine treatment regimen. Amphetamine was given twice daily 5 days per week for 6 weeks at dosages escalating from 1 to 10 mg/kg per injection. Lateral hypothalamic self-stimulation rate-frequency functions were taken 36 h after the last injection in each weekly series and weekly for 3 weeks following the last injection. Frequency thresholds increased and maximal response rates decreased progressively as a function of amphetamine withdrawal during treatment; each returned to near normal levels within 2 weeks of the last injection. When subsequently tested under amphetamine, animals previously receiving the 6-week amphetamine treatment regimen had self-stimulation thresholds and maximal response rates that did not differ significantly from those of saline-treated control animals. These data confirm that chronic amphetamine treatment results in a dependence syndrome characterized in part by a phasic depression in the brain mechanism mediating the reinforcing effects of lateral hypothalamic electrical stimulation.

Effects of repeated amphetamine injections on lateral hypothalamic brain stimulation reward and subsequent locomotion

Intracranial self-stimulation was assessed by the curve-shift method before and after D-amphetamine (1 mg/kg, i.p.) or vehicle injections given 8 times at 48-h intervals. Locomotor was assessed, in a separate test box, for the hour following the 35-min self-stimulation sessions. Amphetamine facilitated self-stimulation, shifting to the left the function relating response rate to stimulation frequency. The drug was most effective the first time it was given; the effects were weaker but unchanging across the remaining 7 days of repeated testing. When control animals that had been given vehicle for the eight initial days of testing were subsequently treated with amphetamine, it facilitated the behavior to the same extent as was seen the first time it was given in the experimental group. Amphetamine significantly increased locomotion in the period following the self-stimulation tests, and the degree of increase grew slightly but steadily with repeated testing; there was more rapid sensitization to this response in animals that were not subjected to self-stimulation testing prior to activity testing. These data do not fit well with earlier reports of sensitization to the reward-enhancing effects of amphetamine and reflect a potential dissociation between the locomotor-stimulating and reward-facilitating effects of amphetamine.

A very unusual breast lump

A 77 year old woman presenting with a malignant phyllodes tumour of of the right breast with exclusively stromal metastases to axillary lymph nodes refractory to both radiotherapy and chemotherapy.

Renal papillary necrosis following regular consumption of non-steroidal anti-inflammatory drugs

Since phenacetin was removed from the Drug Tariff in New Zealand in 1974 there has been a decrease in the number of patients with analgesic nephropathy entering dialysis-transplant programmes. Since then there has been an increase in the consumption of non-steroidal anti-inflammatory agents. Experimental work in animals has shown that these drugs can cause renal papillary necrosis. We report two men with sever osteoarthritis who regularly ingested anti-inflammatory agents and developed papillary necrosis with renal insufficiency and hypertension. One patient consumed 0.5 kg of indomethacin over 10 years and the other 3.5 kg of ibuprofen, 200 g of naproxen and an uncertain amount of ketoprofen over 13 years. The increased chronic usage of non-steroidal anti-inflammatory drugs could bring about an upsurge in the incidence of papillary necrosis.