Nutrition challenges ahead

The breakout session ‘Nutrition challenges ahead’ was held at the EFSA 2nd Scientific Conference ‘Shaping the Future of Food Safety, Together’ (Milan, Italy, 14–16 October 2015) to address the main problems in the area of nutrition to be faced in the 21st Century, both at a global and individual level. The nutrition challenges ahead are diverse and depend on agricultural, socioeconomic and individual factors. At a global level, food security, food sustainability and decreasing the impact of food production on climate change are of paramount importance. Decreasing the prevalence of obesity and related disorders, which may coexist with selected micronutrient deficiencies, is a major challenge for wealthy countries; for developing countries and rural food systems, fighting protein–energy malnutrition and micronutrient deficiencies is a priority. Diets based on a wide variety of nutrient-rich local plant foods (e.g. fruits, vegetables, whole grain cereals, vegetable oils, nuts) that contain moderate amounts of animal protein (preferably in the form of fish) and are low in saturated and trans-fatty acids, added sugars and sodium, are healthy, nutritious, sustainable and climate friendly. Creating an environment where such diets are also economically advantageous and convenient may be a part of a global solution to these nutritional challenges. Individuals, however, are unique regarding their genetic background, gut microbiota and health status. In addition, nutrition may already play a role in the development (and prevention) of disease very early in life. Thus, additional health benefits could be achieved by tailoring nutritional strategies to particular population subgroups or even individuals on the basis of current and future knowledge about the relationship between nutrients, genes, the microbiome and health. New technologies and food innovation may help in finding novel foods fit for purpose

Cadmium exposure and breast cancer risk: a systematic review and dose-response meta-analysis of cohort studies

Background and aim: Cadmium is a heavy metal which has been implicated in breast cancer etiology because of its toxic properties such as endocrine disruption. The general population is exposed to cadmium through dietary intake, cigarette smoking, emissions of motorized traffic and industrial facilities. We carried out a systematic review and dose-response meta-analysis of the cohort studies investigating the association between cadmium exposure and breast cancer risk, for which inconsistent results have been reported in the literature. Methods: Following online database search up to January 2019, we carried out a dose-response meta-analysis to identify the relation between cadmium exposure and disease risk. We used a restricted cubic spline model and the \u2018one-stage\u2019 approach, stratifying for exposure assessment method and menopausal status. Results: We identified 12 studies, 9 using breast cancer incidence and 3 mortality as an outcome. In six studies cadmium exposure was assessed through dietary questionnaires, in five through urinary excretion levels, and in one based on environmental air levels. Seven studies included post-menopausal women only. Overall, we observed a positive linear relation between breast cancer risk and dietary cadmium intake (relative risk (RR) 1.04, 95% confidence interval (CI) 0.81-1.33 at 10 \ub5g/day, and RR 1.12, 95% CI 0.80-1.56 at 20 \ub5g/day). On the converse, risk was not associated with urinary excretion. Analysis restricted to post-menopausal women showed a positive association between cadmium exposure assessed through either dietary intake and urinary excretion, for levels higher than 20 \ub5g/day and 1.65 \ub5g/g creatinine, respectively

Insights into the association of potassium intake with blood pressure: results of a dose-response meta-analysis of randomized controlled trials

Introduction: Observational studies provide evidence for an association between potassium intake and BP levels. However, uncertainties still exist about the size and the shape of this relation. Conversely, experimental studies have not been used to estimate dose-response curves, since standard methods can only be applied in trials including at least three exposure groups. Materials and Methods: We carried out a systematic review of the evidence concerning the effect of potassium supplementation on blood pressure in epidemiologic experimental studies. Following a PubMed search up to June 20, 2019, we included randomized controlled trials (RCTs) encompassing potassium supplementation as the only intervention for at least four weeks. We used a restricted cubic spline model and the ‘one-stage’ approach to perform a dose-response meta-analysis, a newly-developed statistical procedure which allows inclusion of studies with as few as two categories of exposure (Stat Methods Med Res. 2019;28:1579-1596). Finally, we repeated the analyses stratifying for hypertensive status and use of anti-hypertensive medication. Results: Overall, we included 33 studies carried out in adult population, with potassium supplementation ranging from 30 to 140 mmol/day. RCTs’ duration ranged from 4 up to 26 weeks. Most of the studies have a cross-over design (N=24), include hypertensive individuals (N=27) and subjects not under anti-hypertensive medication (N=27). Overall, an increase of 40, 80 and 120 mmol/day of potassium resulted in reductions of SBP by -5.64 (95% CI - 8.78, -2.50), -4.62 (-6.41, -2.84) and -2.54 mmHg (95% CI -5.14, +0.06), respectively. Higher potassium intakes also resulted in reduced DBP levels by -3.57 (95% CI -5.55, -1.59), -3.07 (95% CI -5.07, -1.08), and -1.92 mmHg (95% CI -5.65, 1.81). The effect of increasing potassium intake on BP was larger among hypertensives than normotensives, and among pharmacologically untreated hypertensives compared to their treated counterparts. Subgroup analyses according to study design (parallel vs. crossover) yielded similar results. Discussion: With the application of advanced dose-response modeling on RCT results, we found a U-shaped relation between potassium intake and blood pressure. A low to moderate increase in potassium intake resulted in a progressive reduction in blood pressure, which was reversed at higher levels of potassium supplementation. The effect was stronger among untreated hypertensives. Supported by grant GP-EFSA-AFSCO-2017-01 GA09 of the European Food Safety Authority - EFSA. The text reflects only the authors' view; and EFSA is not responsible for any use that may be made of the information it contains. Conflict of Interest: There is no conflict of interes

Potassium Intake and Blood Pressure: A Dose-Response Meta-Analysis of Randomized Controlled Trials

BACKGROUND: Epidemiologic studies, including trials, suggest an association between potassium intake and blood pressure (BP). However, the strength and shape of this relationship is uncertain. METHODS AND RESULTS: We performed a meta-analysis to explore the dose-response relationship between potassium supplementation and BP in randomized-controlled trials with a duration >= 4 weeks using the recently developed 1-stage cubic spline regression model. This model allows use of trials with at least 2 exposure categories. We identified 32 eligible trials. Most were conducted in adults with hypertension using a crossover design and potassium supplementation doses that ranged from 30 to 140 mmol/d. We observed a U-shaped relationship between 24-hour active and control arm differences in potassium excretion and BP levels, with weakening of the BP reduction effect above differences of 30 mmol/d and a BP increase above differences similar to 80 mmol/d. Achieved potassium excretion analysis also identified a U-shaped relationship. The BP-lowering effects of potassium supplementation were stronger in participants with hypertension and at higher levels of sodium intake. The BP increase with high potassium excretion was noted in participants with antihypertensive drug-treated hypertension but not in their untreated counterparts. CONCLUSIONS: We identified a nonlinear relationship between potassium intake and both systolic and diastolic BP, although estimates for BP effects of high potassium intakes should be interpreted with caution because of limited availability of trials. Our findings indicate an adequate intake of potassium is desirable to achieve a lower BP level but suggest excessive potassium supplementation should be avoided, particularly in specific subgroups

Choline and contribution to normal liver function of the foetus and exclusively breastfed infants: evaluation of a health claim pursuant to Article 14 of Regulation (EC) No 1924/2006

Following an application from Procter & Gamble BV pursuant to Article 14 of Regulation (EC) No 1924/2006 via the Competent Authority of Belgium, the Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver an opinion on the scientific substantiation of a health claim related to choline and contribution to normal liver function of the foetus and exclusively breastfed infant. The scope of the application was proposed to fall under a health claim referring to children's development and health. The Panel considers that choline is sufficiently characterised. The claimed effect proposed by the applicant is contribution ‘to normal foetal and infant development, especially liver’. The proposed target population is ‘unborn fetuses and breastfed infants’. Choline is involved in the structure of cell membranes, cell signalling, metabolism and transport of lipids and cholesterol and neurotransmitter synthesis. Although choline can be synthesised de novo by the human body, depletion-repletion studies in humans show that low choline intake leads to liver dysfunction and muscle damage, which are reverted by the administration of dietary choline. For these functions, de novo synthesis of choline by the human body is insufficient and choline must be obtained from dietary sources. No human studies have addressed the effect of low maternal dietary choline intake on liver function in the fetus or exclusively breastfed infants. However, the Panel considers that the biological role of choline in normal liver function and dietary choline being essential for the function applies to all ages, including fetus and infants. The Panel concludes that a cause and effect relationship has been established between the intake of choline by pregnant and lactating women and contribution to normal liver function of the fetus and exclusively breastfed infants

Appethyl® and reduction of body weight: evaluation of a health claim pursuant to Article 13(5) of Regulation (EC) No 1924/2006

Following an application from Greenleaf Medical AB, submitted for authorisation of a health claim pursuant to Article 13(5) of Regulation (EC) No 1924/2006 via the Competent Authority of Sweden, the EFSA Panel on Nutrition, Novel Foods and Food allergens (NDA) was asked to deliver an opinion on the scientific substantiation of a health claim related to Appethyl® and reduction of body weight. Appethyl® is an aqueous extract from spinach leaves standardised by the manufacturing process and its lipase/colipase inhibition capacity in vitro. The Panel considers that the food is sufficiently characterised. A reduction in body weight is a beneficial physiological effect for overweight/obese individuals. The applicant identified a total of three human intervention studies that investigated the effects of Appethyl® on body weight as being pertinent to the claim. In weighing the evidence, the Panel took into account that Appethyl® (5 g/day for 12 weeks) had no effect on body weight as compared to placebo under minimal dietary counselling and moderate physical activity, and that no beneficial physiological effects are to be expected for the target population of overweight/obese individuals from the weight loss that could be attributed to the intervention with Appethyl® under predefined energy restriction and moderate physical activity. The Panel also considered that the effect of Appethyl® (5 g/day for 24 weeks) on body weight maintenance after initial weight loss shown in one study has not been replicated in different settings, which questions the external validity of the results, and that no evidence was provided for a plausible mechanism by which daily consumption of Appethyl® could exert a sustained effect on body weight in humans. The Panel concludes that a cause-and-effect relationship has not been established between the consumption of Appethyl® and a reduction of body weight under the conditions of use proposed by the applicant

Determinants of Test Variability in Scotopic Microperimetry: Effects of Dark Adaptation and Test Indices

Purpose: To test the effect of different dark adaptation conditions and reliability indices on the variability of two color scotopic microperimetry. Methods: We analyzed data from 22 consecutive visually healthy adults. Scotopic microperimetry was performed (Macular Integrity Assessment microperimeter, CenterVue, Padua, Italy) with two wavelength stimuli, cyan (505 nm) and red (627 nm), after a dark adaptation time of 10, 20, or 30 minutes. All tests were repeated twice to measure test-retest variability with Bland-Altman plots. We also provide a method to more accurately quantify the false-positive (FP) responses based on response data (button pressing) from the device, similar to FP responses used in standard static perimetry. Data on fixation stability (95% bivariate contour ellipse area) and blind spot responses were also extracted. Their relationship with measured sensitivity (in decibels) and test-retest variability was quantified through linear mixed effect models. Results: Dark adaptation had a significant effect on the sensitivity (dB) measured with the cyan stimulus (P < 0.001), but no effect on the red stimulus. Of the three metrics, the novel FP responses showed the best association with test-retest variability and was the only predictor consistently significant for all tests (P < 0.01). Conclusions: Dark adaptation protocols should be carefully standardized for scotopic testing, especially if a cyan stimulus is used. The proposed FP responses should be used to assess reliability of microperimetry examinations instead of other metrics. Translational Relevance: We developed a method to calculate a more accurate estimate of the FP responses using data available to all researchers, generalizable to all Macular Integrity Assessment microperimeter tests

Scientific advice related to nutrient profiling for the development of harmonised mandatory front-of-pack nutrition labelling and the setting of nutrient profiles for restricting nutrition and health claims on foods

Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver scientific advice related to nutrient profiling for the development of harmonised mandatory front-of-pack nutrition labelling and the setting of nutrient profiles for restricting nutrition and health claims on foods. This Opinion is based on systematic reviews and meta-analyses of human studies on nutritionally adequate diets, data from the Global Burden of Disease framework, clinical practice guidelines, previous EFSA opinions and the priorities set by EU Member States in the context of their Food-Based Dietary Guidelines and associated nutrient/food intake recommendations. Relevant publications were retrieved through comprehensive searches in PubMed. The nutrients included in the assessment are those likely to be consumed in excess or in inadequate amounts in a majority of European countries. Food groups with important roles in European diets have been considered. The Panel concludes that dietary intakes of saturated fatty acids (SFA), sodium and added/free sugars are above, and intakes of dietary fibre and potassium below, current dietary recommendations in a majority of European populations. As excess intakes of SFAs, sodium and added/free sugars and inadequate intakes of dietary fibre and potassium are associated with adverse health effects, they could be included in nutrient profiling models. Energy could be included because a reduction in energy intake is of public health importance for European populations. In food group/category-based nutrient profiling models, total fat could replace energy in most food groups owing to its high-energy density, while the energy density of food groups with low or no fat content may be well accounted for by the inclusion of (added/free) sugars. Some nutrients may be included in nutrient profiling models for reasons other than their public health importance, e.g. as a proxy for other nutrients of public health importance, or to allow for a better discrimination of foods within the same food category

Isomaltulose and normal energy-yielding metabolism: evaluation of a health claim pursuant to Article 13(5) of Regulation (EC) No 1924/2006

Following an application from BENEO GmbH submitted for authorisation of a health claim pursuant to Article 13(5) of Regulation (EC) No 1924/2006 via the Competent Authority of Germany, the EFSA Panel&nbsp;on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver an opinion on the scientific substantiation of a health claim related to isomaltulose and normal energy-yielding metabolism. The scope of the application was proposed to fall under a health claim based on newly developed scientific evidence. The food proposed by the applicant as the subject of the health claim is isomaltulose. The Panel&nbsp;considers that isomaltulose is sufficiently characterised. The claimed effect proposed by the applicant is ‘normal energy-yielding metabolism’. The Panel&nbsp;considers that contribution to normal energy-yielding metabolism is a beneficial physiological effect. A number of human studies applying indirect calorimetry measurements or stable isotope methodologies have shown the postprandial metabolic utilisation of isomaltulose as energy source. However, all energy-containing macronutrients (i.e. carbohydrates, proteins, and lipids) supply the body with energy and this property is not specific to isomaltulose. The Panel&nbsp;concludes that a cause and effect relationship has been established between the intake of isomaltulose and contribution to energy-yielding metabolism. The following wording reflects the scientific evidence: ‘isomaltulose contributes to normal energy-yielding metabolism’. Since the contribution to energy-yielding metabolism is not specific to isomaltulose but applies to all energy containing macronutrients (i.e. carbohydrates, proteins, and lipids) that supply the body with metabolisable energy and any amount would contribute to the claimed effect, the Panel&nbsp;cannot set conditions of use for this claim. The applicant proposes that isomaltulose should replace other sugars in foods and/or beverages. The target population is the general population

Organic foods and contribution to the protection of body cells and molecules (lipids and DNA) from oxidative damage: evaluation of a health claim pursuant to Article 14 of Regulation (EC) No 1924/2006

Following an application from Cyprus International Institute for Environmental and Public Health, Cyprus University of Technology, submitted for authorisation of a health claim pursuant to Article 14 of Regulation (EC) No&nbsp;1924/2006 via the Competent Authority of Cyprus, the EFSA Panel&nbsp;on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver an opinion on the scientific substantiation of a health claim related to organic foods and contribution to the protection of body cells and molecules (lipids and DNA) from oxidative damage. The scope of the application was proposed to fall under a health claim referring to children's development and health. The food proposed by the applicant as the subject of the health claim is ‘organic foods’. The applicant claimed that organic foods are characterised by their lower level of pesticides residues compared with foods not labelled as organic. The Panel&nbsp;notes, however, that in the application and the human studies submitted the nutritional composition and the pesticide concentration in ‘organic food’ are not reported. The Panel&nbsp;considers that organic foods which are the subject of the health claim, and the foods that they are intended to replace are not sufficiently characterised. Therefore, the Panel&nbsp;concludes that a cause and effect relationship cannot be established between the consumption of organic foods and contribution to the protection of body cells and molecules (lipids and DNA) from oxidative damage