Overpromoted and underregulated: National binding legal measures related to commercially produced complementary foods in seven Southeast Asian countries are not fully aligned with available guidance

The market for commercially produced complementary foods (CPCF) is rapidly expanding in Southeast Asia; however, the existence and content of mandatory national policies, standards and legislation (binding legal measures) for CPCF in the region is unclear. To assess the status of national binding legal measures for CPCF in Southeast Asia, a legal and policy desk review was conducted in seven countries (Cambodia, Laos People's Democratic Republic, Indonesia, Malaysia, Philippines, Thailand and Viet Nam). The alignment of the national binding legal measures relevant to CPCF was assessed against guidance on CPCF nutrient composition and labelling requirements provided by Codex Alimentarius and the World Health Organization (WHO). Each of the seven countries had at least two national binding legal measures related to the nutrient composition or labelling of CPCF; however, there was limited alignment with the guidance from Codex and WHO. No country was fully aligned with the three CPCF-specific Codex standards/guidelines and only one country was in full alignment with the recommendations related to the protection of breastfeeding from the 'WHO Guidance on ending the inappropriate promotion of foods for infants and young children'. The findings of the review indicate that the existing national binding legal measures are insufficient to ensure that the CPCF sold as suitable for older infants and young children are nutritionally adequate and labelled in a responsible manner that does not mislead caregivers. Improved and enforced national binding legal measures for CPCF, in alignment with global guidance, are required to ensure that countries protect, promote and support optimal nutrition for children 6-36 months of age.

Extended Spectrum β-Lactamase-Producing Enterobacterales of Shrimp and Salmon Available for Purchase by Consumers in Canada-A Risk Profile Using the Codex Framework

The extended-spectrum β-lactamase (ESBL)-producing Enterobacterales (ESBL-EB) encompass several important human pathogens and are found on the World Health Organization (WHO) priority pathogens list of antibiotic-resistant bacteria. They are a group of organisms which demonstrate resistance to third-generation cephalosporins (3GC) and their presence has been documented worldwide, including in aquaculture and the aquatic environment. This risk profile was developed following the Codex Guidelines for Risk Analysis of Foodborne Antimicrobial Resistance with the objectives of describing the current state of knowledge of ESBL-EB in relation to retail shrimp and salmon available to consumers in Canada, the primary aquacultured species consumed in Canada. The risk profile found that Enterobacterales and ESBL-EB have been found in multiple aquatic environments, as well as multiple host species and production levels. Although the information available did not permit the conclusion as to whether there is a human health risk related to ESBLs in Enterobacterales in salmon and shrimp available for consumption by Canadians, ESBL-EB in imported seafood available at the retail level in Canada have been found. Surveillance activities to detect ESBL-EB in seafood are needed; salmon and shrimp could be used in initial surveillance activities, representing domestic and imported products.

Measurement of Dietary Fiber: Which AOAC Official Method of Analysis to Use

A broad range of AOAC official methods of analysis (OMA) have been developed and approved for the measurement of dietary fiber (DF) and DF components since the adoption of the Prosky method (OMA 985.29). OMA 985.29 and other OMA were developed to support the Trowell definition of DF. However, these methods do not measure DF as defined by the "new", physiologically relevant, Codex Alimentarius definition. Methodology to support the Codex definition has been developed and updated in recent years. In this article, the relevance of each OMA in supporting the Codex definition of DF is described and suggestions are presented on the most appropriate method, together with proposals for changes in title and application statements for the "historic" OMA methods.

The Politics of Regulating Foods for Infants and Young Children: A Case Study on the Framing and Contestation of Codex Standard-Setting Processes on Breast-Milk Substitutes

BACKGROUND

Breastfeeding is important for the health and development of the child, and for maternal health, in all country contexts. However, global sales of breast-milk substitutes (BMS), including infant, follow-up and toddler formulas, have 'boomed' in recent decades. This raises the importance of international food standards established by the Codex Alimentarius Commission (Codex) on the safety, composition and labelling of BMS. Such standards appear to be strongly contested by governments, industry and civil society groups, yet few studies have investigated the politics of Codex standard-setting processes. The aim of this paper is to understand who participates in decision-making, and how actors frame and contest proposals to revise the Codex Standard on Follow-up Formula (FUF).

METHODS

We adopted a case study design involving two steps. First, we enumerated government, industry, civil society, and international organization stakeholders participating in standard-setting processes of the Codex Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU). Second, we conducted a framing analysis of stakeholder inputs during the FUF standard revision in CCNFSDU meetings. Publicly available online meeting reports (2015-2019) were retrieved, analyzed using a theoretical framework, and organized thematically.

RESULTS

High-income country (HIC) delegates greatly outnumbered those from other country income categories. Industry representation was higher compared with other observer categories. Member state delegations included more industry representation than civil society representation, and were occasionally the only member state delegates. Industry stakeholders framed arguments in terms of trade implications, science, and flexible standards. Civil society groups used public health, science, and pro-breastfeeding frames.

CONCLUSION

Codex BMS standard-setting procedures are dominated by HICs and industry groups. Limited representation of civil society, and of low- and middle-income countries (LMICs), suggest actions are needed to substantially increase support for their involvement at Codex. Such representation may help to counteract power asymmetries and commercial influences on food standards for infants and young children.

Carbapenem-resistant Escherichia coli from shrimp and salmon available for purchase by consumers in Canada: a risk profile using the Codex framework

Resistance to carbapenems in human pathogens is a growing clinical and public health concern. The carbapenems are in an antimicrobial class considered last-resort, they are used to treat human infections caused by multidrug-resistant Enterobacterales, and they are classified by the World Health Organization as 'High Priority Critically Important Antimicrobials'. The presence of carbapenem-resistant Enterobacterales (CREs) of animal-origin is of concern because targeted studies of Canadian retail seafood revealed the presence of carbapenem resistance in a small number of Enterobacterales isolates. To further investigate this issue, a risk profile was developed examining shrimp and salmon, the two most important seafood commodities consumed by Canadians and Escherichia coli, a member of the Enterobacterales order. Carbapenem-resistant E. coli (CREc) isolates have been identified in shrimp and other seafood products. Although carbapenem use in aquaculture has not been reported, several classes of antimicrobials are utilised globally and co-selection of antimicrobial-resistant microorganisms in an aquaculture setting is also of concern. CREs have been identified in retail seafood purchased in Canada and are currently thought to be uncommon. However, data concerning CRE or CREc occurrence and distribution in seafood are limited, and argue for implementation of ongoing or periodic surveillance.

Global patterns in anaphylaxis due to specific foods: A systematic review

BACKGROUND

There are increasing global data relating to prevalence of food allergy and food-induced anaphylaxis; however, this is often based on surrogate measures of sensitization rather than objective symptoms at food challenge. In terms of protecting food-allergic consumers from reactions, to our knowledge, there has been no global survey assessing geographic differences in the proportion of anaphylaxis triggered by specific foods.

OBJECTIVE

We sought to identify common triggers for food-induced anaphylaxis and how these vary from country to country.

METHODS

Systematic review of relevant reports published between January 2010 and November 2020. Results were reported following PRISMA guidelines. Publications were screened and data extracted by 2 independent reviewers, and the risk of bias was assessed.

RESULTS

Sixty-five studies (encompassing 41 countries and all 6 regions as defined by the Food and Agriculture Organization of the United Nations) were included. Significant regional variations in the most common triggers of food anaphylaxis were seen; however, in general, there was good agreement between local legislative requirements for allergen disclosure and the most common allergens for each region or nation.

CONCLUSIONS

Local legislation for allergen disclosure generally reflects those allergens commonly responsible for food anaphylaxis. Cow's milk and crustaceans appear to cause a higher proportion of anaphylaxis compared to peanut in some regions.

Codex Alimentarius commission on ensuring food safety and promoting fair trade: harmonization of standards between Korea and codex

Korea’s overall food safety management policies reflect the Codex guidelines in terms of risk analysis and standards. Korea’s food safety management plan, which is established every 3 years, includes the pre-emptive management of risk factors and provides food safety information on the basis of scientific evidence. Since officially joining Codex as a member country in 1971, Korea has led the establishment of six Codex standards, including those for Kimchi and Gochujang. Moreover, Korea’s food standards are harmonized with Codex’s risk assessment system. This review aims to examine the current status and trends of Codex and to summarize and compare the food safety management systems and food standards between Korea and Codex.

[Codex and MMSE: what to choose?]

The objective of this study was to compare in general practice, patients aged 65 years and over: the MMSE, screening tools for cognitive disorder recommended by the HAS and the Codex.

METHOD

53 patients were included between June and October 2017 at La Charmille general practice in Limpiville in rural areas during an observational study. Patients over 65 years of age were included following a consultation with their general practitioner. The MMSE and the Codex were compared on their results, intrinsic variables, the time of handover. Geriatric comorbidity factors are compared between groups of patients "with" and "without" cognitive disorders detected.

RESULTS

Of the 53 patients, 94% CI 95% [4.10; 20.25] had cognitive impairment, at an average age of 74.15 years. The predominance is female with 30 patients (57%). The passage time of the Codex is on average 1min 43s, significantly faster (p = 4,29*10^-26) than the time of passing the MMSE 4min 51s on average. There is a better satisfaction of the Codex compared to the MMSE (p = 1.675*10^-6) with an average digital scale score of 7.3 against 6.3 respectively. There is no significant difference between population with cognitive and non-cognitive impairment and geriatric comorbidity factor due to selection bias.

CONCLUSION

Codex appears to be a rapid, reliable, reproducible cognitive impairment screening tool adapted to the general practice consultation format. An important axis to work, awareness, education of doctors at the university and continuing education on the screening and management of dementia syndromes and fragility.

Codex (Cognitive Disorders Examination) Decision Tree Modified for the Detection of Dementia and MCI

Many cognitive screening instruments are available to assess patients with cognitive symptoms in whom a diagnosis of dementia or mild cognitive impairment is being considered. Most are quantitative scales with specified cut-off values. In contrast, the cognitive disorders examination or Codex is a two-step decision tree which incorporates components from the Mini-Mental State Examination (MMSE) (three word recall, spatial orientation) along with a simplified clock drawing test to produce categorical outcomes defining the probability of dementia diagnosis and, by implication, directing clinician response (reassurance, monitoring, further investigation, immediate treatment). Codex has been shown to have high sensitivity and specificity for dementia diagnosis but is less sensitive for the diagnosis of mild cognitive impairment (MCI). We examined minor modifications to the Codex decision tree to try to improve its sensitivity for the diagnosis of MCI, based on data extracted from studies of two other cognitive screening instruments, the Montreal Cognitive Assessment and Free-Cog, which are more stringent than MMSE in their tests of delayed recall. Neither modification proved of diagnostic value for mild cognitive impairment. Possible explanations for this failure are considered.

Benchmarking the Current Codex Alimentarius International Estimated Short-Term Intake Equations and the Proposed New Equations

The International Estimated Short-Term Intake IESTI equations are used during the establishment of Codex Maximum Residue Limits. A recent proposal to revise the equations sparked international debate regarding selection of residue inputs and the appropriate level of consumer protection. The 49th Codex Committee on Pesticide Residues meeting recommended benchmarking the IESTI equations against distributions of actual exposures. Using publicly available data and models, this work compares dietary exposures for strawberries, tomatoes, and apples at five levels of refinement to place these equations into context relative to real-world exposures. Case studies were based on availability of robust USDA PDP monitoring data, which is uniquely suited to refine dietary exposures for a population. Benchmarking dietary exposure involves several decision points. Alternate methodology choices are not expected to impact the large margins observed between the probabilistic estimates and the IESTI equations or to change the overall conclusion that existing IESTI equations are conservative and health-protective.

Antimicrobial Resistance (AMR) in the Food Chain: Trade, One Health and Codex

Strategies that take on a One Health approach to addressing antimicrobial resistance (AMR) focused on reducing human use of antimicrobials, but policy-makers now have to grapple with a different set of political, economic, and highly sensitive trade interests less amenable to government direction, to tackle AMR in the food chain. Understanding the importance and influence of the intergovernmental Codex negotiations underway on AMR in the Food Chain is very weak but essential for AMR public policy experts. National and global food producing industries are already under pressure as consumers learn about the use of antimicrobials in food production and more so when the full impact of AMR microorganisms in the food chain and on the human microbiome is better understood. Governments will be expected to respond. Trade-related negotiations on access and use made of antimicrobials is political: the relevance of AMR 'evidence' is already contested and not all food producers or users of antimicrobials in the food chain are prepared to, or capable of, moving at the same pace. In trade negotiations governments defend their interpretation of national interest. Given AMR in the global food chain threatens national interest, both AMR One Health and zoonotic disease experts should understand and participate in all trade-related AMR negotiations to protect One Health priorities. To help facilitate this an overview and analysis of Codex negotiations is provided.

Effective management tools for participants at Codex Committee on Residues of Veterinary Drugs meetings

The Codex Committee on Residues of Veterinary Drugs in Food (CCRVDF) fulfils a number of functions revolving around standard setting. The core activities of the CCRVDF include agreeing priorities for assessing veterinary drug residues, recommending maximum residue limits for veterinary drugs in foods of animal origin, considering methods of sampling and analyses, and developing codes of practice. Draft standards are developed and progress through an agreed series of steps common to all Codex Alimentarius Commission Committees. Meetings of the CCRVDF are held at approximately 18-month intervals. To ensure effective progress is made with meetings at this frequency, the CCRVDF makes use of a number of management tools. These include circular letters to interested parties, physical and electronic drafting groups between plenary sessions, meetings of interested parties immediately prior to sessions, as well as break out groups within sessions and detailed discussions within the CCRVDF plenary sessions. A range of these approaches is required to assist advances within the standards setting process and can be applied to other Codex areas and international standard setting more generally. Copyright © 2016 John Wiley & Sons, Ltd.

Beyond Effectiveness--The Adversities of Implementing a Fortification Program. A Case Study on the Quality of Iron Fortification of Fish and Soy Sauce in Cambodia

Fortification of fish and soy sauces is a cost-effective strategy to deliver and increase iron intake in the Cambodian diet, as both are widely consumed by the entire population. In order to qualify as fortified sauces recognized by international regulations, iron content must be between 230 and 460 mg/L, whilst nitrogen and salt should contain no less than 10 g/L and 200 g/L respectively. This survey aims to analyze the progress of the fortification program. Through a better understanding of its obstacles and successes, the paper will then consider approaches to strengthen the program. Two hundred and fifty two samples were collected from 186 plants and 66 markets in various provinces. They were then analyzed for iron, nitrogen and salt content. The study demonstrates that 74% of fortified fish and soy sauces comply with Cambodian regulations on iron content. 87% and 53.6% of the collected samples do not have adequate level of nitrogen and salt content, respectively. The paper will discuss additional efforts that need to be implemented to ensure the sustainability of the project, including the need to: (i) comply with International Codex; (ii) adopt mandatory legislation; and (iii) ensure enforcement.