Dietary mycotoxin exposure and human health risks: A protocol for a systematic review

BACKGROUND

Mycotoxins are toxic fungal secondary metabolites that contaminate a wide spectrum of essential foods worldwide, such as grain-based products, nuts and spices, causing adverse health effects pertaining to their carcinogenic, nephrotoxic and hepatotoxic nature, among others.

AIM

The aim of this systematic review (SR) is to systematically search for, appraise and synthesize primary research evidence to identify what is known about dietary mycotoxin-related health effects and what remains unknown, as well as the uncertainty around findings and the recommendations for the future.

SEARCH STRATEGY AND ELIGIBILITY CRITERIA

Search strategies, as well as eligibility criteria were structured according to a predefined PECO (population, exposure, comparison, and outcome) research question and developed in an iterative scoping process. Several bibliographic databases, including Embase, Cochrane Library, Pubmed, Web of Science Core Collection and Scopus, will be searched. Primary research on any measured or modelled dietary exposure to a single or multiple mycotoxins, and adverse human health outcomes (i.e. cancer, non-carcinogenic diseases, and reproductive & developmental adverse outcomes) will be included, and references will be imported into Covidence. In vitro, ex vivo, in silico, animal and review studies, as well as expert's opinions, secondary literature, conference abstracts, presentations, posters, book chapters, dissertations and studies involving non-dietary mycotoxin exposure, will be excluded.

STUDY SELECTION

Two independent reviewers will screen titles and abstracts, and review full-texts. Any disagreements will be resolved by a third reviewer based on two-third majority.

DATA EXTRACTION

Data from retained eligible studies will be extracted by the principal reviewer, and peer-checked by a second reviewer.

STUDY QUALITY ASSESSMENT

Eligible studies will be evaluated for risk of bias (Overall High-Quality Assessment Tool, OHAT) and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation, GRADE).

EVIDENCE SYNTHESIS

A detailed summary of the included studies will be provided within a tabular format and narratively discussed. Heat maps will be constructed to provide information on available knowledge (gaps), and a meta-analysis may be performed based on the variability in predefined PECO elements and depending on the heterogeneity of studies.

CONCLUSION

This protocol describes the methodology for the conduct of a SR on mycotoxin-related human health risks, that could guide future research and inform regulatory decisions, as emphasized by the European Commission within the field of regulatory risk assessment for emerging chemicals.

Vulnerable newborn types: analysis of subnational, population-based birth cohorts for 541 285 live births in 23 countries, 2000-2021

OBJECTIVE

To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021.

DESIGN

Descriptive multi-country secondary data analysis.

SETTING

Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021.

POPULATION

Liveborn infants.

METHODS

Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study.

RESULTS

Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%).

CONCLUSIONS

Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.

Associating multiple mycotoxin exposure and health outcomes: current statistical approaches and challenges

Mycotoxin contamination is a global challenge to food safety and population health. A diversity of adverse effects in human health such as organ damage, immunity disorders and carcinogenesis are attributed to acute and chronic exposure to mycotoxins. While there is a high likelihood of mycotoxin co-occurrence in the daily diet, multiple mycotoxin exposures represent a considerable challenge in understanding the accumulative effects of groups of exposures on health outcomes. Nevertheless, previous studies on mycotoxin exposure-health outcome associations have focused on a single or a limited number of exposures. To guide multi-exposure assessment, careful considerations of statistical approaches available are required. In addition, the issue of multicollinearity in high-dimensional settings of multiple exposure analysis underlies the controversy surrounding the reliability and consistency of statistical conclusions about the exposure-health outcome associations. Conventional approaches such as generalised linear regressions (GLR) in conjunction with regularisation methods, including ridge regression, lasso and elastic net, offer some clear advantages in terms of results’ interpretation and model selection. However, when highly-correlated variables are observed, these methods have shown a low specificity in variable selection. Principal component analysis (PCA) that has been widely used as a dimensionality reduction technique also has the limitation to identify important predictor variables as this approach may overlook the associations between certain components and health outcomes. Recently, some alternative approaches have been introduced to address the issues of high dimensionality and highly-correlated data in the context of epidemiological and environmental research. Two of the noticeable approaches are weighted quantile sum regression (WQSR) and Bayesian kernel machine regression (BKMR). Combining different methods of inference allows us to interpret the role of certain exposures, their interactions and the combined effects on human health under diverse statistical perspectives, which ultimately facilitate the construction of the toxicological profile of multiple mycotoxins’ exposure.

Multi-mycotoxin profiling in maize reveals prevalence of Fusarium mycotoxins in South and West Ethiopia

Multi-mycotoxin exposure data are missing to guide risk assessment and legislation in Ethiopia. This study therefore aimed to determine mycotoxin contamination levels in maize samples from 176 randomly selected household storages in three agro ecological zones of South (Sidama zone) and West (Jimma zone) Ethiopia, and to examine the post-harvest practices and household processing. Liquid chromatography coupled to tandem mass spectrometry was used to quantify 23 mycotoxins. The majority of the households regularly consumed maize (more than once per day). More (77%) samples in Sidama were contaminated with Fusarium mycotoxins deoxynivalenol than in Jimma (29%) (P<0.001); Similar distributions of fumonisin B1 (19%), fumonisin B2 (19%) and fumonisin B3 (12%, Sidama vs 13%, Jimma) contamination were observed (P>0.05). In Sidama, only one sample was contaminated with the Aspergillus mycotoxin aflatoxin B2 and another sample with aflatoxin B1. From all samples, 40% were contaminated with 3-5 types of Fusarium mycotoxins and only 4% of the samples were contaminated with 6-8 types of mycotoxins. After the harvested maize was dried on the field, the majority of respondents in Jimma reported that they removed the maize within one day, which was less practiced in Sidama. The majority of households in Sidama, and some in Jimma, reported that they dried maize before storage, mainly using the sun. Close to two third of the study participants in the two zones reported that they applied the chemical dichloro-diphenyl-trichloroethane (DDT) during maize storage. All households in both zones reported that they sorted visible mouldy maize grains before preparation of maize flour while most of them kept the mouldy maize for animal feed. Protective strategies of Fusarium mycotoxin contamination, with special focus on deoxynivalenol and zearalenone, should be well promoted in the study areas as they are possible human and animal health threats.

Epithelial to Mesenchymal Transition History: From Embryonic Development to Cancers

Epithelial to mesenchymal transition (EMT) is a process that allows epithelial cells to progressively acquire a reversible mesenchymal phenotype. Here, we recount the main events in the history of EMT. EMT was first studied during embryonic development. Nowadays, it is an important field in cancer research, studied all around the world by more and more scientists, because it was shown that EMT is involved in cancer aggressiveness in many different ways. The main features of EMT's involvement in embryonic development, fibrosis and cancers are briefly reviewed here.

EZH2 and KDM6B Expressions Are Associated with Specific Epigenetic Signatures during EMT in Non Small Cell Lung Carcinomas

The role of Epigenetics in Epithelial Mesenchymal Transition (EMT) has recently emerged. Two epigenetic enzymes with paradoxical roles have previously been associated to EMT, EZH2 (Enhancer of Zeste 2 Polycomb Repressive Complex 2 (PRC2) Subunit), a lysine methyltranserase able to add the H3K27me3 mark, and the histone demethylase KDM6B (Lysine Demethylase 6B), which can remove the H3K27me3 mark. Nevertheless, it still remains unclear how these enzymes, with apparent opposite activities, could both promote EMT. In this study, we evaluated the function of these two enzymes using an EMT-inducible model, the lung cancer A549 cell line. ChIP-seq coupled with transcriptomic analysis showed that EZH2 and KDM6B were able to target and modulate the expression of different genes during EMT. Based on this analysis, we described INHBB, WTN5B, and ADAMTS6 as new EMT markers regulated by epigenetic modifications and directly implicated in EMT induction.

Post-harvest interventions decrease aflatoxin and fumonisin contamination in maize and subsequent dietary exposure in Tanzanian infants: a cluster randomised-controlled trial

A cluster randomised controlled trial was performed in three agro-ecological zones of Tanzania to evaluate the effectiveness of locally available post-harvest mitigation strategies in preventing and reducing aflatoxin and fumonisin contamination in maize. A total of 300 children, each from one household, were randomly selected from 30 villages (intervention: n=15). The mitigation strategies focused on hand sorting (prior to storage and use), drying maize on mat/raised platforms, proper sun drying, application of storage insecticides and de-hulling before milling. Maize sample was collected from each household at harvest (baseline) and six months after harvest. Maize intake by each child, estimated using the 24 h dietary recall technique and its body weight measured using standard procedures were taken at six months after harvest. Aflatoxins and fumonisins in the maize samples were determined using HPLC. Follow-up (six month after harvest) data were available for 261 of the 300 households (intervention: n=136). Mean concentration of aflatoxins, or fumonisins was significantly (P<0.05) lower in the intervention than in the control group: intervention effects: μg/kg (95% confidence interval (CI)) -4.9 (-7.3,-2.5), and -405, (-647,-162), respectively. The difference corresponds to 83 and 70% for aflatoxins, and fumonisins, respectively. At the end of the intervention, aflatoxin and fumonisin estimated mean intakes were lower in the intervention than in the control group by 78 and 65%, respectively. Six months after harvest, prevalence of underweight in the intervention group was 6.7% lower (P=0.014) than in the control group. Mean weight-for-age Z-score difference between the groups was 0.57 (95% CI; 0.16,-0.98; P=0.007). Post-harvest practices are effective in preventing and reducing aflatoxin and fumonisin contamination in maize and subsequent dietary exposure to infants. The interventions may be applied in these and other communities with similar environmental conditions or agricultural practices that favour production of aflatoxin and fumonisins in food crops. The trial was registered at ClinicalTrials.gov identifier: NCT02438774.

Eating at restaurants, at work or at home. Is there a difference? A study among adults of 11 European countries in the context of the HECTOR* project

BACKGROUND/OBJECTIVES

To compare macronutrient intakes out of home-by location-to those at home and to investigate differences in total daily intakes between individuals consuming more than half of their daily energy out of home and those eating only at home.

SUBJECTS/METHODS

Data collected through 24-h recalls or diaries among 23 766 European adults. Participants were grouped as 'non-substantial', 'intermediate' and 'very substantial out-of-home' eaters based on energy intake out of home. Mean macronutrient intakes were estimated at home and out of home (overall, at restaurants, at work). Study/cohort-specific mean differences in total intakes between the 'very substantial out-of-home' and the 'at-home' eaters were estimated through linear regression and pooled estimates were derived.

RESULTS

At restaurants, men consumed 29% of their energy as fat, 15% as protein, 45% as carbohydrates and 11% as alcohol. Among women, fat contributed 33% of energy intake at restaurants, protein 16%, carbohydrates 45% and alcohol 6%. When eating at work, both sexes reported 30% of energy from fat and 55% from carbohydrates. Intakes at home were higher in fat and lower in carbohydrates and alcohol. Total daily intakes of the 'very substantial out-of-home' eaters were generally similar to those of individuals eating only at home, apart from lower carbohydrate and higher alcohol intakes among individuals eating at restaurants.

CONCLUSIONS

In a large population of adults from 11 European countries, eating at work was generally similar to eating at home. Alcoholic drinks were the primary contributors of higher daily energy intakes among individuals eating substantially at restaurants.

Strengthening the Reporting of Observational Studies in Epidemiology - nutritional epidemiology (STROBE-nut): An extension of the STROBE statement

Concerns have been raised about the quality of reporting in nutritional epidemiology. Research reporting guidelines such as the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement can improve quality of reporting in observational studies. Herein, we propose recommendations for reporting nutritional epidemiology and dietary assessment research by extending the STROBE statement into Strengthening the Reporting of Observational Studies in Epidemiology - Nutritional Epidemiology (STROBE-nut). Recommendations for the reporting of nutritional epidemiology and dietary assessment research were developed following a systematic and consultative process, co-ordinated by a multidisciplinary group of 21 experts. Consensus on reporting guidelines was reached through a three-round Delphi consultation process with 53 external experts. In total, 24 recommendations for nutritional epidemiology were added to the STROBE checklist. When used appropriately, reporting guidelines for nutritional epidemiology can contribute to improve reporting of observational studies with a focus on diet and health.

Using a gamified monitoring app to change adolescents' snack intake: the development of the REWARD app and evaluation design

BACKGROUND

As the snacking pattern of European adolescents is of great concern, effective interventions are necessary. Till now health promotion efforts in children and adolescents have had only limited success in changing adolescents' eating patterns and anthropometrics. Therefore, the present study proposes an innovative approach to influence dietary behaviors in youth based on new insights on effective behavior change strategies and attractive intervention channels to engage adolescents. This article describes the rationale, the development, and evaluation design of the 'Snack Track School' app. The aim of the app is to improve the snacking patterns of Flemish 14- to 16-year olds.

METHODS

The development of the app was informed by the systematic, stepwise, iterative, and collaborative principles of the Intervention Mapping protocol. A four week mHealth intervention was developed based on the dual-system model with behavioral change strategies targeting both the reflective (i.e., active learning, advance organizers, mere exposure, goal-setting, monitoring, and feedback) and automatic processes (i.e., rewards and positive reinforcement). This intervention will be evaluated via a controlled pre-post design in Flemish schools among 1400 adolescents.

DISCUSSION

When this intervention including strategies focused on both the reflective and automatic pathway proves to be effective, it will offer a new scientifically-based vision, guidelines and practical tools for public health and health promotion (i.e., incorporation of learning theories in intervention programs).

TRIAL REGISTRATION

NCT02622165 registrated November 15, 2015 on clinicaltrials.gov.

Association between aflatoxin M1 exposure through breast milk and growth impairment in infants from Northern Tanzania

Infants breastfeeding from mothers consuming aflatoxin contaminated foods may be exposed to aflatoxin M1 (AFM1), a metabolite of aflatoxin B1. This study estimated the association between AFM1 exposure levels and growth indicators, for infants under six months of age in the Rombo district in Northern Tanzania. A total of 143 infants and their mothers were involved. Breast-milk samples, infants' anthropometric data and 24 h dietary recall for mothers were taken at the 1st, 3rd and 5th months of children age. AFM1 contaminations in the samples were determined using HPLC. Aflatoxin M1 exposure by an infant was estimated by multiplying contamination in the breast milk consumed by him/her with the breast milk intake recorded by the United States Environmental Protection Agency for infants of his/her age divided by the infant's body weight. All the breast-milk samples were contaminated by AFM1 at levels ranging from 0.01 to 0.55 ng/ml. Above 90% of samples exceeded the EU limit of 0.025 ng/ml for infants' foods while over 76% exceeded the EU limit of 0.05 ng/ml for dairy milk and milk products. Only 1% of the samples exceeded the limit of 0.5 ng/ml set for dairy milk in the United States and several countries in Asia. AFM1 Exposures ranged from 1.13-66.79 ng/kg body weight per day. A small but significant (P<0.05) inverse association was observed between AFM1 exposure levels and weight for age Z-score or height for age Z-score. Appropriate strategies should be applied to minimise aflatoxin B1 exposure in lactating mothers in order to protect infants from AFM1 exposure.

Prevalence and socioeconomic differences of risk factors of cardiovascular disease in Ecuadorian adolescents

PURPOSE

The aim of this paper is to report the prevalence of cardiovascular risk factors and socioeconomic differences in school-going Ecuadorian adolescents.

METHODS

A cross-sectional study was performed from January 2008 until April 2009 in 770 adolescents aged 10 to 16 years old, who attend secondary schools in an urban (Cuenca), and rural area (Nabón) in Ecuador. Data collected for the overall sample included anthropometric variables (weight, height and waist circumference), blood pressure and socio-demographic characteristics. Fasting blood glucose and lipid profile determinations were collected in a subsample of 334 adolescents.

RESULTS

The most prevalent cardiovascular risk factors were dyslipidemia (34.2%), abdominal obesity (19.7%) and overweight (18.0%). The prevalence of the remaining cardiovascular risk factors were high levels of blood pressure (6.2%) and obesity (2.1%). Boys were 3.3 times (P < 0.001) more likely to have risk levels of blood pressure. Compared to their peers from lower socioeconomic groups, children from better off socioeconomic strata were 1.5 times (P = 0.048) more likely to be overweight/obese and 1.5 times (P = 0.046) more likely to have abdominal obesity. Overweight and obese children were 4.4 times more likely to have dyslipidemia (P < 0.001). Children living in the rural area were 2.8 times (P = 0.002) more likely to have dyslipidemia than those from the urban area.

CONCLUSIONS

Our results demonstrate the advanced levels of the nutrition transition in this Ecuadorian adolescent population. Primary health care should monitor and take actions to address this public health problem in adolescents.

Eating out of home and its association with dietary intake: a systematic review of the evidence

During the last decades, eating out of home (OH) has gained importance in the diets worldwide. We document the nutritional characteristics of eating OH and its associations with energy intake, dietary quality and socioeconomic status. We carried out a systematic review of peer-reviewed studies in eight databases up to 10 March 2011. Of the 7,319 studies retrieved, 29 met the inclusion criteria and were analysed in this review. The quality of the data was assessed and a sensitivity analysis was conducted by isolating nationally representative or large cohort data from 6 and 11 countries, respectively. OH foods were important sources of energy in all age groups and their energy contribution increased in adolescents and young adults. Eating OH was associated with a higher total energy intake, energy contribution from fat in the daily diet and higher socioeconomic status. Two large studies showed how eating OH was also associated with a lower intake of micronutrients, particularly vitamin C, Ca and Fe. Although the studies were cross-sectional and heterogeneous in the way they classified eating OH, we conclude that eating OH is a risk factor for higher energy and fat intake and lower micronutrient intake.

Validity of photographs for food portion estimation in a rural West African setting

Objective

To validate food photographs for food portion size estimation of frequently consumed dishes, to be used in a 24-hour recall food consumption study of pregnant women in a rural environment in Burkina Faso. This food intake study is part of an intervention evaluating the efficacy of prenatal micronutrient supplementation on birth outcomes.

Subjects

Women of childbearing age (15–45 years).

Design

A food photograph album containing four photographs of food portions per food item was compiled for eight selected food items. Subjects were presented two food items each in the morning and two in the afternoon. These foods were weighed to the exact weight of a food depicted in one of the photographs and were in the same receptacles. The next day another fieldworker presented the food photographs to the subjects to test their ability to choose the correct photograph.

Results

The correct photograph out of the four proposed was chosen in 55% of 1028 estimations. For each food, proportions of underestimating and overestimating participants were balanced, except for rice and couscous. On a group level, mean differences between served and estimated portion sizes were between −8.4% and 6.3%. Subjects who attended school were almost twice as likely to choose the correct photograph. The portion size served (small vs. largest sizes) had a significant influence on the portion estimation ability.

Conclusions

The results from this study indicate that in a West African rural setting, food photographs can be a valuable tool for the quantification of food portion size on group level.

[A review of the nutritional management plans in the member states of the European Union]

Obesity has reached epidemiological proportions in Europe and the burden of diseases attributable to nutrition is substantial. Under the impetus of the World Health Organisation (WHO), member states have been urged to develop national action plans for nutrition and physical activity. This study describes what has been done in terms of nutrition policy at national level in the member states of the European Union right before its enlargement in 2004. It is a critical review of publicly available policy documents on nutrition and physical activity. The background idea was to assist the initiative of the Belgian food industry to play a proactive role in the development of a Belgian nutrition action plan. At the time of writing, in total six out of the fifteen EU member states namely Sweden, Finland, Denmark, France, the Netherlands and the United Kingdom, reported to have an operational national nutrition plan. By the end of the year 2004, another four countries are expected to have their plan finalised. In line with WHO guidelines, all nutrition plans in this study acknowledge the importance of a multidisciplinary approach and promote stakeholder involvement at some point. Most of the plans however, do not elaborate on their specific role and strategies that will be used to do so. It seems that stakeholder mobilisation is largely restricted to the implementation phases. All operational nutrition plans envisage reducing social disparities. Long-established vulnerable groups in society such as pregnant women, children and elderly are targeted. Considerable variability was observed for nutritional objectives and dietary recommendations between the different countries. Nutrition surveillance and monitoring activities seem to vary considerably between the different action plans. None of the countries except Denmark documents the theoretical foundations and development process of their nutritional surveillance system. National nutrition policy in Europe is clearly in a state of flux and the centre of gravity seems to move away from Scandinavia. Although the importance of nutritional surveillance, comprehensive approach to nutritional problems and stakeholder involvement is recognised by the action plans, the rationale, justification and mechanisms for it is vaguely described. Our findings call for increased efforts to strengthen the evidence base of public health nutrition policy. To achieve this however, systematic evaluations and proper reporting of which health and nutrition promotion strategies work in the different countries in the EU are urgently needed.