The future of environmental sustainability labelling on food products.

If each of us were to consider the food we had for lunch, we can probably estimate whether it was relatively healthy (e.g., did we go hungry, did it add to the variety of our diet, or consumption of five fruits and vegetables a day?). How easy is to make a similar judgement on whether our lunch contributed to a sustainable diet? For example, the carbon emissions associated with a simple sandwich can more than double, depending on the filling, where it is made, the packaging used and many more factors.1 Drawing on the past experiences of nutrition labelling on food products, we consider whether sustainability labelling can provide a practical route to encourage sustainable food choices, sustainable market changes, and a move towards sustainable and healthy food systems. Sustainability labelling on food products is most commonly associated with social and ecological certification schemes (e.g., USDA Organic Seal; Fairtrade mark; Friend of the Sea).2 More recently, an increasing number of labels have emerged which estimate the impact of a product on one or more environmental factor e.g., carbon foot-printing as a marker of greenhouse gas emissions or climate change.3 Research suggests there is a demand for these different types of sustainability labels; yet, it is uncertain if these labels will affect our everyday selections and purchases of food.4 Price, taste, brand, appearance, product familiarity and habits are still dominant reasons for our food choices; however, over 20 years’ of research indicates nutrition labelling can drive healthy food choices and incentivise product reformulation.5 In 2019, a meta-analysis investigated the impact of nutrition labels on food products and menus (including a variety of nutrient content labels, claims, logos, or indices, such as warning labels and traffic light labels). They concluded a small impact of labels, which can reduce total energy and total fat consumption, increase vegetable intake, and positively impact industry reformulation for sodium and trans fat content.5 Further research is on-going regarding whether these impacts follow a social gradient and compound diet-related health inequalities (e.g., reformulated ‘healthier’ products are added to a range at a higher price point/available only in higher income countries; or numeracy skills are required to interpret health indicating labels).6 Food labelling has become part of the food system infrastructure, yet there are challenges with governing this sector. Voluntary recommendations and mandatory regulations are used to facilitate inter-/national trade (e.g., country of origin requirements by the FAO/WHO Codex Alimentarius food labelling standards), and signify quality assurance, safety and traceability standards (e.g., declaration of trans fatty acids content). Ensuring compliance with regulation requires considerable resources from those responsible for governing the food system. For example, the European Food Safety Authority (EFSA) has been harmonising and adapting food labelling regulation since 2006 to keep pace with a proliferation of food labels in the market. EFSA now require a portfolio of evidence from each manufacturer to authorise the use of a health or nutrient claim on their food product. This is to protect fair competition within the food industry and also to monitor the validity of claims to protect the public from being misled. Producing and reviewing these portfolios has taken considerable resources for both EFSA and the food industry. It is worthwhile to consider whether existing regulation and regulatory resources are sufficient to monitor sustainability claims if they were to become more widespread. Trust and transparency in any labelling scheme is essential for it to be meaningful and motivate change in individuals or industries. We have seen confusion surrounding the use of the term ‘organic’ on food products. These products can be ascribed a ‘health halo’, yet there are limitations in the evidence indicating a superior nutrition quality of organic products and health benefits may be more associated with the social values attributed to organic production. The use of certification schemes can encourage transparent standards; however, this is less clear with schemes (e.g., Fair Trade) which have been brought in-house: where products are self-certified rather than part of an ‘independent’ certification scheme. It is difficult to discern the sustainability of a product at point of purchase and maintaining the trust and transparency of different sustainability indices or metrics, across inconsistent product categories, will be paramount to ensuring accountability for food fraud or the use of exploitative marketing techniques.7 A major challenge with sustainability labelling of food products is the complexity of the sustainability concept itself, as well as the food system within which it operates. Sustainability is multi-faceted and sustainable food systems represent not only environmental factors (ecology), they are also sensitive to the health of the population today and in the future (nutrition, food security), and society as a whole (ethics and social welfare). Food systems themselves are also dynamic and complex: involving a multitude of changeable and inter-related activities, actors, and infrastructure from the production to the consumption, recycling and/or disposal of food. At every point there can be multiple environmental impacts, related to biodiversity, green house gas emissions (carbon dioxide, methane etc.), land, water or other resource use (e.g., nitrogen or phosphorous management). All these factors complicate the ability to create a metric or index that can trace a product as it journeys through the food system in order to assess its environmental, health or social impacts. Creating food systems that provide healthy food to everyone today and in future generations without exploiting human or planetary resources is one of the greatest challenges of this century. The development and use of sustainability labelling has the potential to play a role in moving towards sustainable and healthy food systems and a sustainable future, as outlined in the aims of the United Nations Sustainable Development Goals. The reach of food labelling is considerable and could increase public awareness of how food is produced and consumed. Nutrient labelling remains a popular public health intervention, with mandatory nutrition labelling in at least 50 countries worldwide, with highly processed and packaged foods making an ever greater contribution to the global diet (e.g., in a sample of sixteen countries approximately 85 % of packaged food carried a nutrient label, health/nutrition claim, or a health/nutrition marketing claim).8 9 Past experiences of nutrition labelling provide a number of cautions to the rise in sustainability labelling. First, sustainability labelling is unlikely to be a panacea for behaviour change in consumers. Instead it can target small incremental changes at different levels and actors in the food system, within both individuals and organisations. Second, there is the potential for confusion with sustainability concepts, which can be exploited for commercial or political use, particularly where competing interests are present. The media and public attention on climate change and rise in sustainability labelling of food products provides an opportunity to develop food system analytics and sustainability metrics. Using these metrics, actors within the food system will be better equipped to communicate the nuances and evaluate the risks and trade-offs of system-wide interventions, and ultimately contribute to the evolution of sustainable and healthy food systems. The authors declare no competing interests. KAB, FH, CK contributed substantially to the conception and drafting of this work; KAB, FH, FH, CK, CP revised the work critically for important intellectual content; all authors approved the final version to be published and agree to be accountable for the work. All authors receive funding from the Wellcome Trust’s Our Planet, Our Health programme: KAB, FH, CK via the Sustainable and Healthy Food Systems (SHEFS) programme [grant number 205200/Z/16/Z], and CP via the Livestock, Environment and People (LEAP) project [grant number 205212/Z/16/Z]. This commentary does not necessarily reflect the views of the Wellcome Trust or its future policy in this area

A Photovoice Study to Reveal Community Perceptions of Highly Processed Packaged Foods in India.

India is experiencing a nutrition transition, with sales of packaged and processed foods rapidly increasing in recent years. This study sought to understand the views and experiences of self-help groups about highly processed, packaged food in Visakhapatnam, India, using the Photovoice method. Participants were able to record, reflect on and critique their environments through participatory analysis, identifying key themes, and offering a critical lens on their food environment and experiences. On an average eight and 14 members participated in the Photovoice workshops held in urban and rural Visakhapatnam respectively. The key themes emerging from the photos and text data are that participants experienced highly processed packaged foods as being: 1) democratic (easily available and consumed by all, affordable and accessible; 2) convenient (easy to prepare) and 3) unhealthy (for human consumption and for environmental sustainability). These data demonstrate the challenges facing public health nutritionists in wishing to shift dietary behaviors to healthy habits: on the surface participants acknowledged their unhealthy characteristics, however these products may now be embedded in dietary culture. Traditional methods for changing dietary habits may not be able to capture the complexity and systems approach is required to explore the most effective entry points for affecting change

Prediction of winter vitamin D status and requirements in the UK population based on 25(OH) vitamin D half-life and dietary intake data

On a population basis, there is a gradual decline in vitamin D status (plasma 25(OH)D) throughout winter. We developed a mathematical model to predict the population winter plasma 25(OH)D concentration longitudinally, using age-specific values for 25(OH)D expenditure (25(OH)D3t1/2), cross-sectional plasma 25(OH)D concentration and vitamin D intake (VDI) data from older (70+ years; n=492) and younger adults (18-69 years; n=448) participating in the UK National Diet and Nutrition Survey. From this model, the population VDI required to maintain the mean plasma 25(OH)D at a set concentration can be derived. As expected, both predicted and measured population 25(OH)D (mean (95%CI)) progressively declined from September to March (from 51 (40-61) to 38 (36-41)nmol/L (predicted) vs 38 (27-48)nmol/L (measured) in older people and from 59 (54-65) to 34 (31-37)nmol/L (predicted) vs 37 (31-44)nmol/L (measured) in younger people). The predicted and measured mean values closely matched. The predicted VDIs required to maintain mean winter plasma 25(OH)D at 50nmol/L at the population level were 10 (0-20) to 11 (9-14) and 11 (6-16) to 13(11-16)μg/d for older and younger adults, respectively dependent on the month. In conclusion, a prediction model accounting for 25(OH)D3t1/2, VDI and scaling factor for the 25(OH)D response to VDI, closely predicts measured population winter values. Refinements of this model may include specific scaling factors accounting for the 25(OH)D response at different VDIs and as influenced by body composition and specific values for 25(OH)D3 t1/2 dependent on host factors such as kidney function. This model may help to reduce the need for longitudinal measurements

Changes in take-home aerated soft drink purchases in urban India after the implementation of Goods and Services Tax (GST): An interrupted time series analysis.

OBJECTIVES: Taxes on sugar-sweetened beverages (SSB) are increasingly being implemented as public health interventions to limit the consumption of sugar and reduce associated health risks. In July 2017, India imposed a new tax rate on aerated (carbonated) drinks as part of the Goods and Services Tax (GST) reform. This study investigates the post-GST changes in the purchase of aerated drinks in urban India. METHODS: An interrupted time series analysis was conducted on state-level monthly take-home purchases of aerated drinks in urban India from January 2013 to June 2018. We assessed changes in the year-on-year growth rate (i.e. percentage change) in aerated drink purchases with controls for contextual variables. RESULTS: We found no evidence of a reduction in state-level monthly take-home aerated drink purchases in urban India following the implementation of GST. Further analysis showed that the year-on-year growth rate in aerated drink purchases increased slightly (0.1 percentage point per month, 95%CI = 0.018, 0.181) after the implementation of GST; however, this trend was temporary and decreased over time (0.008 percentage point per month, 95%CI = -0.015, -0.001). CONCLUSIONS: In India, a country currently with low aerated drink consumption, the implementation of GST was not associated with a reduction in aerated drink purchase in urban settings. Due to the lack of accurate and sufficiently detailed price data, it is not possible to say whether this finding is driven by prices not changing sufficiently. Furthermore, the impact of GST reform on industry practice (reformulation, marketing) and individual behaviour choices (substitution) is unknown and warrants further investigation to understand how such taxes could be implemented to deliver public health benefits

Core Outcomes for Colorectal Cancer Surgery: A Consensus Study

Background: Colorectal cancer (CRC) is a major cause of worldwide morbidity and mortality. Surgical treatment is common, and there is a great need to improve the delivery of such care. The gold standard for evaluating surgery is within well-designed randomized controlled trials (RCTs); however, the impact of RCTs is diminished by a lack of coordinated outcome measurement and reporting. A solution to these issues is to develop an agreed standard “core” set of outcomes to be measured in all trials to facilitate cross-study comparisons, meta-analysis, and minimize outcome reporting bias. This study defines a core outcome set for CRC surgery. Methods and Findings: The scope of this COS includes clinical effectiveness trials of surgical interventions for colorectal cancer. Excluded were nonsurgical oncological interventions. Potential outcomes of importance to patients and professionals were identified through systematic literature reviews and patient interviews. All outcomes were transcribed verbatim and categorized into domains by two independent researchers. This informed a questionnaire survey that asked stakeholders (patients and professionals) from United Kingdom CRC centers to rate the importance of each domain. Respondents were resurveyed following group feedback (Delphi methods). Outcomes rated as less important were discarded after each survey round according to predefined criteria, and remaining outcomes were considered at three consensus meetings; two involving international professionals and a separate one with patients. A modified nominal group technique was used to gain the final consensus. Data sources identified 1,216 outcomes of CRC surgery that informed a 91 domain questionnaire. First round questionnaires were returned from 63 out of 81 (78%) centers, including 90 professionals, and 97 out of 267 (35%) patients. Second round response rates were high for all stakeholders (>80%). Analysis of responses lead to 45 and 23 outcome domains being retained after the first and second surveys, respectively. Consensus meetings generated agreement on a 12 domain COS. This constituted five perioperative outcome domains (including anastomotic leak), four quality of life outcome domains (including fecal urgency and incontinence), and three oncological outcome domains (including long-term survival). Conclusion: This study used robust consensus methodology to develop a core outcome set for use in colorectal cancer surgical trials. It is now necessary to validate the use of this set in research practice

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Electronic self-reporting of adverse events for patients undergoing cancer treatment: the eRAPID research programme including two RCTs

Abstract Background Cancer is treated using multiple modalities (e.g. surgery, radiotherapy and systemic therapies) and is frequently associated with adverse events that affect treatment delivery and quality of life. Regular adverse event reporting could improve care and safety through timely detection and management. Information technology provides a feasible monitoring model, but applied research is needed. This research programme developed and evaluated an electronic system, called eRAPID, for cancer patients to remotely self-report adverse events. Objectives The objectives were to address the following research questions: is it feasible to collect adverse event data from patients’ homes and in clinics during cancer treatment? Can eRAPID be implemented in different hospitals and treatment settings? Will oncology health-care professionals review eRAPID reports for decision-making? When added to usual care, will the eRAPID intervention (i.e. self-reporting with tailored advice) lead to clinical benefits (e.g. better adverse event control, improved patient safety and experiences)? Will eRAPID be cost-effective? Design Five mixed-methods work packages were conducted, incorporating co-design with patients and health-care professionals: work package 1 – development and implementation of the electronic platform across hospital centres; work package 2 – development of patient-reported adverse event items and advice (systematic and scoping reviews, patient interviews, Delphi exercise); work package 3 – mapping health-care professionals and care pathways; work package 4 – feasibility pilot studies to assess patient and clinician acceptability; and work package 5 – a single-centre randomised controlled trial of systemic treatment with a full health economic assessment. Setting The setting was three UK cancer centres (in Leeds, Manchester and Bristol). Participants The intervention was developed and evaluated with patients and clinicians. The systemic randomised controlled trial included 508 participants who were starting treatment for breast, colorectal or gynaecological cancer and 55 health-care professionals. The radiotherapy feasibility pilot recruited 167 patients undergoing treatment for pelvic cancers. The surgical feasibility pilot included 40 gastrointestinal cancer patients. Intervention eRAPID is an online system that allows patients to complete adverse event/symptom reports from home or hospital. The system provides immediate severity-graded advice based on clinical algorithms to guide self-management or hospital contact. Adverse event data are transferred to electronic patient records for review by clinical teams. Patients complete an online symptom report every week and whenever they experience symptoms. Main outcome measures In systemic treatment, the primary outcome was Functional Assessment of Cancer Therapy – General, Physical Well-Being score assessed at 6, 12 and 18 weeks (primary end point). Secondary outcomes included cost-effectiveness assessed through the comparison of health-care costs and quality-adjusted life-years. Patient self-efficacy was measured (using the Self-Efficacy for Managing Chronic Diseases 6-item Scale). The radiotherapy pilot studied feasibility (recruitment and attrition rates) and selection of outcome measures. The surgical pilot examined symptom report completeness, system actions, barriers to using eRAPID and technical performance. Results eRAPID was successfully developed and introduced across the treatments and centres. The systemic randomised controlled trial found no statistically significant effect of eRAPID on the primary end point at 18 weeks. There was a significant effect at 6 weeks (adjusted difference least square means 1.08, 95% confidence interval 0.12 to 2.05; p = 0.028) and 12 weeks (adjusted difference least square means 1.01, 95% confidence interval 0.05 to 1.98; p = 0.0395). No between-arm differences were found for admissions or calls/visits to acute oncology or chemotherapy delivery. Health economic analyses over 18 weeks indicated no statistically significant difference between the cost of the eRAPID information technology system and the cost of usual care (£12.28, 95% confidence interval –£1240.91 to £1167.69; p > 0.05). Mean differences were small, with eRAPID having a 55% probability of being cost-effective at the National Institute for Health and Care Excellence-recommended cost-effectiveness threshold of £20,000 per quality-adjusted life-year gained. Patient self-efficacy was greater in the intervention arm (0.48, 95% confidence interval 0.13 to 0.83; p = 0.0073). Qualitative interviews indicated that many participants found eRAPID useful for support and guidance. Patient adherence to adverse-event symptom reporting was good (median compliance 72.2%). In the radiotherapy pilot, high levels of consent (73.2%) and low attrition rates (10%) were observed. Patient quality-of-life outcomes indicated a potential intervention benefit in chemoradiotherapy arms. In the surgical pilot, 40 out of 91 approached patients (44%) consented. Symptom report completion rates were high. Across the studies, clinician intervention engagement was varied. Both patient and staff feedback on the value of eRAPID was positive. Limitations The randomised controlled trial methodology led to small numbers of patients simultaneously using the intervention, thus reducing overall clinician exposure to and engagement with eRAPID. Furthermore, staff saw patients across both arms, introducing a contamination bias and potentially reducing the intervention effect. The health economic results were limited by numbers of missing data (e.g. for use of resources and EuroQol-5 Dimensions). Conclusions This research provides evidence that online symptom monitoring with inbuilt patient advice is acceptable to patients and clinical teams. Evidence of patient benefit was found, particularly during the early phases of treatment and in relation to self-efficacy. The findings will help improve the intervention and guide future trial designs. Future work Definitive trials in radiotherapy and surgical settings are suggested. Future research during systemic treatments could study self-report online interventions to replace elements of traditional follow-up care in the curative setting. Further research during modern targeted treatments (e.g. immunotherapy and small-molecule oral therapy) and in metastatic disease is recommended. Trial registration The systemic randomised controlled trial is registered as ISRCTN88520246. The radiotherapy trial is registered as ClinicalTrials.gov NCT02747264. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 1. See the NIHR Journals Library website for further project information