Impact of climate change on food systems – the One Health approach

In recent decades, changes in climate have caused impacts on natural and human systems on all continents and across the oceans. Climate change has become one of the most critical issues for the sustainable development of human societies and the functioning of ecosystems on Earth. In one hand, climate change threatens our ability to ensure global food security, eradicate poverty and achieve sustainable development. Agriculture and animal production are affected by changing rainfall patterns, drought, flooding and the geographical redistribution of pests and diseases, with consequent implications in the food availability, a key requirement for food security. On the other hand, despite less debated, climate change could also affect food safety, impacting the occurrence of food safety hazards at various stages of food chain, from “farm to fork”. The tendency to increase the use of agrochemicals to balance the effects of more frequent extreme weather events and water scarcity in some regions could become more frequent. In addition to pesticide residues, both chemical and microbiological risks are expected to impair food and feed safety as a consequence of climate change: in particular mycotoxins, marine biotoxins (phycotoxins), trace metals, among others. Humans, animals and the environment are/will be affected by the consequences of climate change, with an expected impact on the food systems. Thus, a One Health perspective, representing a holistic view of the problems, defining and establishing adequate strategies to tackle these challenges, is more than needed. On this presentation, main issues relating the impact of climate change on health of humans, animals and environment and how a One Health perspective, as a holistic approach, represent a key contribution to the definition of proper policies to ensure the public health will be approached and debated.

Exposure to PM2.5 and cardiovascular diseases in Portugal – the contribute of PMCardImpact project

 

Particulate matter with a diameter of 2.5 μm or less (PM2.5) are one of the air pollutants more detrimental to human health, being responsible for around 400 000 premature deaths in Europe every year. The cardiovascular diseases (CVD) and air pollution are linked, with existing evidence of a causal relationship between exposure to particulate matter and cardiovascular morbidity and mortality. Under the scope of PMCardImpact, a national funded project, data collected from Portuguese air monitoring platform (2005-2021) (>60 stations) was used to estimate the attributable number of cases of acute myocardial infarction. The air monitoring data and parameters such as exposure-response factors will support the risk assessment in AirQ+ software (WHO Regional Office for Europe). Preliminary results showed that exceedances of Air Quality Directive in Portugal ranged between 0.1 % and 10.2% for PM10 and PM2.5 in 2019. Results obtained will include the number of cases of CVD attributable to exposure to PM2.5 in the Portuguese population. Four scenarios of exposure will be considered for presenting the results: current scenario of exposure, new WHO Air Quality guidelines, European Commission Air Quality Directive and lastly, a worst-case scenario. This assessment will be the starting point for calculation of the burden of disease of CVD that exposure to PM2.5 represent in Portugal. With a view to promote the science to policy interface, PMCardImpact project will make available to policy makers the needed supporting information to act, including actionable knowledge on air pollution trends and related health effects, to implement reducing air pollution policies.

This work is funded by FCT/MCTES through national funds to PMCardImpact (EXPL/SAU-PUB/0944/2021) and CESAM (UIDP/50017/2020 + UIDB/50017/2020 + LA/P/0094/2020).

Key messages

• PMCardImpact will make available to policy makers the needed supporting information to act to implement reducing air pollution policies.

• Risk assessment will allow to determine the number of CVD cases attributable to air pollution.

Reporting guidelines for burden of disease studies: why and how?

Background

The Disability Adjusted Life Year (DALY) is a frequently used metric to assess burden of disease (BoD). Many independent BoD studies have been performed across Europe, showing wide variations and inconsistencies in the application and reporting of DALY specific methods. The European Burden of Disease Network (burden-eu) aims to develop guidelines for reporting DALY calculation studies which may enhance transparency and comparability of BoD estimates across Europe and beyond.

Methods

A burden-eu working group of experts generated a list of potential reporting items based on existing literature, guidance for developing guidelines and consultations with BoD experts. To pilot the drafted product, we asked BoD experts and non-experts to apply it to existing BoD studies. We received feedback and we revised the guidelines accordingly.

Results

The guide for DALY calculation studies comprises about 25 items that should be reported in BoD studies. We included information about the study setting, data input sources including methods for data corrections, DALY-specific methods (e.g., YLL life table, YLD approach, disability weights etc), data analyses, and data limitations. We also included information on how users can compare their new estimates with previously available BoD estimates.

Conclusions

We introduced a reporting instrument for DALY calculations that can be used to document input data and methodological design choices in BoD studies. The application of such guidelines will enhance usability of BoD estimates for decision-makers as well as global, regional, and national health experts.

Key messages

Climate change and health impact: is food missing in the equation?

It has been generally recognized by researchers and regulators that climate change constitutes an important driver affecting the food sector, representing a public health issue that deserves particular attention. Climate change is associated with increasing temperatures and more extreme rainfall; it alters relationships among crops, pests, pathogens, and weeds; and it exacerbates several trends including declines in pollinating insects, increasing water scarcity, increasing ground-level ozone concentrations, and fishery declines. In one hand, climate change threatens our ability to ensure global food security, eradicate poverty and achieve sustainable development. Agricultural productivity is affected by changing rainfall patterns, drought, flooding and the geographical redistribution of pests and diseases, with consequent implications in food availability, a key requirement for food security. On the other hand, despite less debated, climate change could also affect food safety, namely through the occurrence of food safety hazards at various stages of the food chain, from “farm to fork”. The tendency to increase the use of agrochemicals to balance the effects of more frequent extreme weather events and water scarcity in some regions could become more frequent. In addition to pesticide residues, both chemical and microbiological risks are expected to impair food and feed safety as a consequence of climate change: in particular mycotoxins, marine biotoxins (phycotoxins), trace metals, among others. Here, all these concepts will be discussed and integrated, to highlight the potential impact of climate change in food systems, focusing particularly on the contribution to human health especially in what concerns food safety.

Health impact assessment of a voluntary protocol to decrease salt in bread: what can we learn?

Issue

Hypertension (HT) is a major and modifiable risk factor for cardiovascular diseases (CVD), which can be caused by excessive salt intake. Portugal has one of the highest mortality rate due to CVD in Europe, mainly due to HT. Thus, reduction of salt intake from food products is one of major strategies advocated to modify blood pressure (BP) and its impact on HT.

Description of the problem

The Portuguese population has excessive daily salt intake mainly due to bread consumption. Thus, in 2017 a voluntary ‘Protocol' was signed between stakeholders with the goal to reduce salt content in bread by 2021. Herein, using a Health Impact Assessment (HIA) approach we aimed to estimate the potential effect in BP from the implementation of this ‘Protocol'. Thus, two national surveys were used to find average values of salt intake and BP on population, while estimates of BP reduction were calculated based upon meta-analysis data.

Results

It was expected that the implementation of the ‘Protocol' could reduce salt ingestion and have a higher BP effect, mostly in more vulnerable populations. In fact, results showed that individuals with low educational level, men, aged and residents in the South region of Portugal were the ones that could more benefit from the ‘Protocol' implementation. However, this study found that the effects were be very low for all groups analysed, suggesting that only slight health gains can occur.

Lessons

The ‘Protocol' as a voluntary agreement is not sufficient to attain the public health targets devised. Following the HIA framework, further complementary and intersectoral integrated measures, through the use of compulsory food and fiscal policies preferably extended to other highly consumed food products, were thus recommended. HIA could be used as a comprehensive tool to assess health impacts, supporting at each national context the design and implementation of effective strategies to promote salt intake reduction and effectively prevent hypertension.

Key messages

The systematic use of HIA to design the appropriate policy framework and to inform adequately political decision-making is crucial to promote health and prevent Non-Communicable Diseases. Voluntary agreements should be complemented by other integrated measures to improve the efficacy of policies aiming to reduce salt intake and prevent hypertension.

Burden of disease of dietary exposure to aflatoxins in European countries

Aflatoxins (AFTs) are genotoxic and carcinogenic food contaminants causing hepatocellular carcinoma, the third leading cause of cancer deaths worldwide. In 2015, WHO estimated the burden of disease associated with exposure to AFTs and concluded that this exposure corresponds to 636,869 Disability-adjusted Life Years (DALYs) at global level. Particularly for Portugal and recently, there were estimated 0.08-0.30 DALYs/100,000 considering consumption and occurrence in food data, and 1.7 DALYs/100,000 based on human biomonitoring data. The present study considered the exposure data presented in the EFSA scientific opinion “Risk assessment of aflatoxins in food” where data from occurrence of AFTs in food and from food consumption were gathered to estimate the exposure to AFTs in 19 European countries. A deterministic and a bottom-up approach was developed to estimate the health impact of the exposure to AFTs for adult population through the calculation of DALYs associated to the number of estimated extra-cases of hepatocellular carcinoma (HCC). Results showed similar values for all the 19 European countries considered. For adult population and considering the data provided by EFSA using the upper-bound approach (worst-case scenario), the estimated number of DALYs ranged from 0.32 (Spain) to 1.10 (United Kingdom) DALYs/100,000. A total of 11.76 DALYs/100,000 was globally estimated for the considered European countries. The highest burden was estimated for the United Kingdom, that together with The Netherlands, Ireland, Czech Republic, and Austria were the highest contributors to the global estimated European burden associated to the exposure to AFTs. The present study generated reliable and crucial data to characterize the burden associated to exposure to AFTs in the European population. The obtained results constitute an important contribution to define priorities and support the need for further policy actions to protect European citizen's health.

A study of commercially available complementary foods for infants and young children under 36 months

Background

Commercially available complementary foods (CACFs) have been assuming an important proportion of infants and toddlers' diets in high-income countries, despite the concerns regarding their nutritional content and potential problematic marketing strategies used to promote these products. In 2016, the WHO guidance on ending the inappropriate promotion of foods for infants and young children (IYC) was approved (1) to support countries to take action on this issue. To implement this Guidance, a draft Nutrient Profile Model (NPM) (2) was developed to drive decisions regarding the identification of foods which are inappropriate for promotion.

Aim

To support the implementation of the NPM at National Level, studying the availability, composition, and marketing of CACFs for IYC in Portugal.

Methods

Three phases were considered: 1) collect data on CACFs products targeted at IYC (0-36 months); 2) compare composition of these products with WHO guidance; 3) compare methods used to promote these products with WHO Guidance.

Results

A total of 209 products were sampled. The most common products were soft-wet spoonable, ready-to-eat foods (n = 129), dry, powdered and instant cereal/starchy foods (n = 61) and dry finger foods and snacks (n = 16). Twenty-five products (11%) were marketed as being suitable for infants under the age of 6 months. For infants between 6-8 months 78% of the products were marketed as being suitable. For the age group 12 months and over, 11% of the products were marketed as being suitable.

Conclusions

This study provides valuable insights into the CACFs at the national level and reinforces that action is needed to improve the implementation and operationalization of WHO guidance on ending the inappropriate promotion of foods for IYC.

Key messages

NPM can support countries identifying products that can/cannot be promoted for IYC. It is a key opportunity to build policy measures, ensuring children healthy growth and development.

Unscattering the burden of disease landscape: supporting interaction between existing burden of disease efforts

The burden of disease landscape in Europe is currently scattered with experts from diverse professional backgrounds, ranging from experts in infectious diseases, non-communicable diseases, injuries and risk factors, to experts in more comprehensive national, regional and global burden of disease studies. Currently there is little interaction between these experts and existing burden of disease efforts. The European burden of disease network (burden-eu) COST Action aims to bring together expertise across different domains and professional backgrounds. During the course of the burden-eu COST Action, several steps will be taken to facilitate interaction between existing burden of disease efforts. First, a survey has been sent around to all members of the EU burden of disease network to map burden of disease studies that have been carried out in their country. Apart from general details about the year of the study and cause of disease categories, items of the survey included data sources, methodological approach and collaborations with institutes of other countries. In the first month, the survey has been completed for over 70 studies that have been carried out in twelve countries. Second, comparison of existing burden of disease initiatives allows for the identification of the various domains for which burden of disease has been assessed, highlight methodological differences as well as similarities, and

facilitate improvements and harmonization of methods and approaches. Furthermore, the data collected from the survey will be included in a continuously updated burden of disease database that lists all past and current burden of disease activities. Lastly, burden-eu will facilitate regular meetings and workshops. Each of these steps will make it possible to move beyond the currently scattered burden of disease landscape and increase interaction between professionals and burden of disease efforts.

Baby foods available in the Portuguese marketplace and the application of nutrient profile models

Background

An investment in nutrition at the earliest possible stage, providing appropriate complementary feeding, is critical to ensure proper growth and to prevent noncommunicable diseases (NCDs). Food and drinks high in fats, free sugars and salt are being marketed for consumption by young children and represent particular concern.

Aim

This study aims to determine the compliance of complementary foods (CACFs) for infants and young children sold in the Portuguese marketplace according to WHO draft Nutrient Profile model (NPM) for infants and young children between 6 and 36 months (1).

Methods

A sample of 128 CACFs was collected. Using nutritional food label information, products were divided into four food categories: dry, powdered and instant cereals; dry finger foods and snacks; meals with chunky pieces; and soft-wet spoonable, ready-to-eat foods. Packaging information was used to determine sodium, fat and sugar content per 100 g and percentage energy from total sugar by food category.

Results

Twenty-eight products (22%) comply with all the criteria established in the NPM. All the evaluated dry, powdered, and instant cereals, dry finger foods and snacks and meals with chunky pieces (n = 55) comply with recommendations proposed for total fat (≤4.5 g/100 kcal). Analysis of energy contribution from total sugars reveals 9 % (n = 5) of dry finger foods and snacks comply with the proposed criteria < 15% total energy from total sugars. The 73 soft-wet spoonable, ready-to-eat foods assessed, 74 % (n = 54) comply with the sodium thresholds of 50 mg/100 kcal, 64 % (n = 47) had a content ≥ 60 Kcal/100 g and 74 % (n = 54) contained over 20% of energy derived from sugar.

Conclusions

CACFs available in the Portuguese marketplace are characterised by products with high proportion of calories derived from sugar, promoting an environment that encourages development of sweet-taste preferences and adverse health outcomes resultant from the overconsumption of sugar in early life.

Key messages

There is an urgent need for updated regulations to support and guide product reformulation. A nutrient profile model for CACFs will establishes compositional thresholds and provides guidance on product-labelling and promotions.

Risk-Benefit Assessment of Foods

Food is an elementary requirement for human life, providing nutrients and essential energy needed for optimal health. But at the same time, food can also be a vehicle of hazardous substances or pathogens that could affect human health negatively. Risk‐benefit assessment (RBA) of foods, a relatively new methodology for decision support, integrates nutrition, toxicology, microbiology, chemistry and human epidemiology for a comprehensive health impact assessment. By integrating health risks and benefits related to food consumption, RBA facilitates science‐based decision‐making in food‐related areas and the development of policies and consumer advice. The present work programme aimed to allow the fellow to become acquainted with the process of RBA and the associated tools needed to assess quantitatively the risks and the benefits through three main activities (i) to learn the different methodologies used for RBA; (ii) to apply these methodologies to a specific case‐study – RBA of raw milk consumption; and (iii) to participate in the main activities of the Risk‐Benefit research group at DTU Food regarding risk‐benefit issues. For the RBA of raw milk consumption, microbiological pathogens (Listeria monocytogenes, Salmonella spp., Campylobacter jejuni and Shiga toxin‐producing Escherichia coli), probiotic bacteria and nutritional components (vitamins B2 and A) were considered, as well as the potential impact of raw milk consumption in the reduction of the allergies’ prevalence. Two major approaches were applied: the bottom‐up (estimating the disease incidence due to the exposure) and the top‐down (using epidemiological and incidence data to the estimate the number of cases attributable to a certain exposure). Through all the training and hands‐on activities performed, the present work programme enabled the fellow to extend the knowledge on the quantitative RBA, specifically in the context of raw milk consumption. EU‐FORA programme also provided an exceptional opportunity of networking and establishment of future research lines of collaboration.

Burden of disease associated with dietary exposure to carcinogenic aflatoxins in Portugal using human biomonitoring approach

Human biomonitoring is an important tool to assess human exposure to chemicals, contributing to describe trends of exposure over time and to identify population groups that could be under risk. Aflatoxins are genotoxic and carcinogenic food contaminants causing hepatocellular carcinoma, the third leading cause of cancer deaths worldwide. In Portugal, scarce data are available regarding exposure to aflatoxins and no previous study used human biomonitoring data to comprehensively characterize the associated burden of disease. 24 h urine and first-morning urine paired samples were collected by 94 participants and were analyzed by liquid chromatography-tandem mass spectrometry for the quantitative determination of aflatoxins (B₁, B₂, G₁, G₂ and M₁). Deterministic and probabilistic models were developed to assess the Portuguese exposure to aflatoxins and to estimate the health impact of this exposure, estimating the attributed Disability-Adjusted Life Years (DALYs). Aflatoxins were detected in a maximum of 13% (AFB₁), 16% (AFB₂), 1% (AFG₁), 2% (AFG₂) and 19% (AFM₁) of the urine samples. Data obtained through the probabilistic approach revealed an estimated mean probable daily intake of 13.43 ng/kg body weight per day resulting in 0.13 extra cases of hepatocellular carcinoma, corresponding to mean annual DALYs of 172.8 for the Portuguese population (10291027 inhabitants). The present study generated for the first time and within a human biomonitoring study, reliable and crucial data to characterize the burden associated to the exposure to aflatoxins of the Portuguese population. The obtained results constitute an imperative support to risk managers in the establishment of preventive policy measures that contribute to ensure public health protection.

Burden of disease attributable to exposure to aflatoxins in Portugal using Human biomonitoring data

Key messages

Portuguese population is exposed to aflatoxins, chemical food contaminants that may be harmful (carcinogenic, immunotoxic, mutagenic, teratogenic, hepatotoxic) to humans. Human biomonitoring studies provide realistic data on internal exposure at individual level, contributing to a more accurate estimation of the burden derived from this exposure.

Risk assessment of Portuguese population to multiple mycotoxins: the human biomonitoring approach

Key messages

Portuguese population is exposed to mycotoxins, chemical food contaminants that may be harmful (carcinogenic, immunotoxic, mutagenic, teratogenic, hepatotoxic) for human health. Human biomonitoring studies provide realistic data on internal exposure at individual level, allowing a more accurate knowledge of the determinants of exposure to these contaminants.

Challenges in risk assessment of multiple mycotoxins in food

Most fungi are able to produce several mycotoxins simultaneously and, consequently, to contaminate a wide variety of foodstuffs. Therefore, the risk of human co-exposure to multiple mycotoxins is real, raising a growing concern about their potential impact on human health. Besides, government and industry regulations are usually based on individual toxicities, and do not take into account the complex dynamics associated with interactions between co-occurring groups of mycotoxins. The present work assembles, for the first time, the challenges posed by the likelihood of human co-exposure to these toxins and the possibility of interactive effects occurring after absorption, towards knowledge generation to support a more accurate human risk assessment. Regarding hazard assessment, a physiologically-based framework is proposed in order to infer the health effects from exposure to multiple mycotoxins in food, including knowledge on the bioaccessibility, toxicokinetics and toxicodynamics of single and combined toxins. The prioritisation of the most relevant mixtures to be tested under experimental conditions that attempt to mimic human exposure and the use of adequate mathematical approaches to evaluate interactions, particularly concerning the combined genotoxicity, were identified as the main challenges for hazard assessment. Regarding exposure assessment, the need of harmonised food consumption data, availability of multianalyte methods for mycotoxin quantification, management of left-censored data, use of probabilistic models and multibiomarker approaches are highlighted, in order to develop a more precise and realistic exposure assessment. To conclude, further studies on hazard and exposure assessment of multiple mycotoxins, using harmonised methodologies, are crucial towards an improvement of data quality and a more reliable and robust risk characterisation, which is central for risk management and, consequently, to prevent mycotoxins-associated adverse effects. A deep understanding of the nature of interactions between multiple mycotoxins will contribute to draw real conclusions on the health impact of human exposure to mycotoxin mixtures.

Fast detection of arbitrarily shaped disease clusters

Disease cluster detection and evaluation have commonly used spatial statistics methods that scan the map with a fixed circular window to locate candidate clusters. Recently, there has been interest in searching for clusters with arbitrary shape. The circular scan test retains high power of detecting a cluster, but does not necessarily identify the exact regions contained in a non-circular cluster particularly well. We propose, implement and evaluate a new procedure that is fast and produces clusters estimates of arbitrary shape in a rich class of possible cluster candidates. We showed that our methods contain the so-called upper level set method as a particular case. We present a power study of our method and, among other results, the main conclusion is that the likelihood-based arbitrarily shaped scan method is not appropriate to find a cluster estimate. When the parameter space includes the set of all possible spatial clusters in a map, a large and discrete parameter space, maximum likely cluster estimates tend to overestimate the true cluster by a large extent. This calls for a new approach different from the maximum likelihood method for this important public health problem.

American cutaneous leishmaniasis in Southeast Brazil: space-time clustering

BACKGROUND

American cutaneous leishmaniasis (ACL) is endemic in many rural areas of Brazil where different transmission patterns of the disease have been described. This ecological study was carried out in a municipality located in Southeast Brazil and aimed to investigate the space-temporal patterns of the disease and environmental risk factors from 1966 to 1996.

METHODS

Incident ACL cases were defined by clinical diagnosis, confirmed by a positive skin test and/or parasitological examination. Age-adjusted morbidity rate of ACL was calculated by year for this municipality and their different census enumeration districts. The homogeneity chi2 test, Moran and empirical Bayes index and Knox procedure were employed for testing the significance of clusters in time, space and in time-space, respectively. A Poisson regression model was used to identify environmental factors related to rate variability.

RESULTS

A total of 1712 new ACL cases were reported with a yearly incidence rate of 48/100000 inhabitants. Higher incidence rates were detected in 1968, 1974, and 1988 (100, 160, and 190 cases/100000, respectively) with evidence of spatial clustering from 1986 to 1993. Significant space-time clustering with epidemic peaks followed by low incidence in subsequent periods was observed. The incidence rates of ACL were independently associated with rural areas; areas lacking sanitary installations and with higher proportion of exposed garbage (P < 0.01).

CONCLUSIONS

This study suggests that ACL rates vary across space and time. Rural areas and some environmental factors could explain part of this variation. Environmental modifications in the vicinity of households over time and accumulation of susceptible individuals are discussed as possible factors responsible for variability.

[Management of AIDS during traditional hospitalization and at outpatient clinics in Recife (Brazil)]

The management of 50 AIDS patients by traditional hospital admission (25 cases) and outpatient clinics (25 cases) was studied between August and November 1995 in the Department of Infectious and Parasitic Diseases of the Federal University Hospital. The most costly items of expenditure were hospital services and consumable materials. Comparison of costs was complicated by differences in clinical status of the patients in the two groups. The choice of treatment was much more dependent on clinical status than on sociodemographic factors. Traditional hospital admission tended to be associated with the poorest patients. The rationalization of care based on cost-benefit analysis requires much future work.