Application of the BRAFO tiered approach for benefit-risk assessment to case studies on dietary interventions

Risk–Benefit assessment of foods: Development of a methodological framework for the harmonized selection of nutritional, microbiological, and toxicological components

Investigating the impact of diet on public health using risk–benefit assessment (RBA) methods that simultaneously consider both beneficial and adverse health outcomes could be useful for shaping dietary policies and guidelines. In the field of food safety and nutrition, RBA is a relatively new approach facing methodological challenges and being subject to further developments. One of the methodological aspects calling for improvement is the selection of components to be considered in the assessment, currently based mainly on non-harmonized unstandardized experts’ judgment. Our aim was to develop a harmonized, transparent, and documented methodological framework for selecting nutritional, microbiological, and toxicological RBA components. The approach was developed under the Novel foods as red meat replacers—an insight using Risk-Benefit Assessment methods (NovRBA) case study, which attempted to estimate the overall health impact of replacing red meat with an edible insect species, Acheta domesticus. Starting from the compositional profiles of both food items, we created a “long list” of food components. By subsequently applying a series of predefined criteria, we proceeded from the “long” to the “short list.” These criteria were established based on the occurrence and severity of health outcomes related to these components. For nutrition and microbiology, the occurrence of health outcomes was evaluated considering the presence of a component in the raw material, as well as the effect of processing on the respective component. Regarding toxicology, the presence and exposure relative to reference doses and the contribution to total exposure were considered. Severity was graded with the potential contribution to the background diet alongside bioavailability aspects (nutrition), the disability-adjusted life years per case of illness of each hazard (microbiology), and disease incidence in the population, potential fatality, and lifelong disability (toxicology). To develop the “final list” of components, the “short list” was refined by considering the availability and quality of data for a feasible inclusion in the RBA model. The methodology developed can be broadly used in food RBA, to guide and reinforce a harmonized selection of nutritional, microbiological, and toxicological components and will contribute to facilitating RBA implementation, enabling the generation of transparent, robust, and comparable outcomes.

Approaches for Health Effect Characterization in Risk-Benefit Assessment of Foods: A Comparative Case Study

One of the challenges in quantitative risk-benefit assessment (RBA) of foods is the choice of approach for health effect characterization to estimate the health impact of dietary changes. The purpose of health effect characterization is to describe an association between intake of a food or food component and a health effect in terms of a dose-response relationship. We assessed the impact of the choice of approach for health effect characterization in RBA in two case studies based on substitution of (i) white rice by brown rice and (ii) unprocessed red meat by vegetables. We explored this by comparing the dose-response relations linking a health effect with (i) a food component present in the food, (ii) a food based on non-specified substitution analyses, and (iii) a food based on specified substitution analyses. We found that the choice of approach for health effect characterization in RBA may largely impact the results of the health impact estimates. Conducting the calculations only for a food component may neglect potential effects of the food matrix and of the whole food on the diet-disease association. Furthermore, calculations based on associations for non-specified substitutions include underlying food substitutions without specifying these. Data on relevant specified substitutions, which could reduce this type of bias, are unfortunately rarely available. Assumptions and limitations of the health effect characterization approaches taken in RBA should be documented and discussed, and scenario analysis is encouraged when multiple options are available.

The Potential Contribution of Fortified Maize Flour, Oil, Rice, Salt, and Wheat Flour to Estimated Average Requirements and Tolerable Upper Intake Levels for 15 Nutrients in 153 Countries

Food fortification is designed to improve the nutritional profile of diets. The purpose of this research was to estimate the potential nutrient contribution of fortified maize flour, oil, rice, salt, and wheat flour in 153 countries, using the national intake (or availability) of the food and the nutrient levels required for fortification. This was done under two scenarios—maximum, where 100% of the food is assumed to be industrially processed and fortified, and realistic, where the maximum value is adjusted based on the percent of the food that is industrially processed and fortified. Under the maximum scenario, the median Estimated Average Requirements (EARs) met ranged from 22–75% for 14 nutrients (vitamins A, B1, B2, B3, B6, B12, D, E, folic acid and calcium, fluoride, iron, selenium and zinc), and 338% for iodine. In the realistic scenario, the median EARs met were 181% for iodine and <35% for the other nutrients. In both scenarios, the median Tolerable Upper Intake Levels (ULs) met were <55% for all nutrients. Under the realistic scenario, no country exceeded 100% of the UL for any nutrient. Current fortification practices of the five foods of interest have the global potential to contribute up to 15 nutrients to the diets of people, with minimal risk of exceeding ULs.

Drinking Green Tea: Despite the Risks Due to Mycotoxins, Is It Possible to Increase the Associated Health Benefits?

Tea has been consumed for thousands of years. Despite the different varieties, particular emphasis has been placed on green tea (GT), considering the associated health benefits following its regular consumption, some of which are due to its polyphenol constituents, such as epigallocatechin-3-gallate (EGCG). Tea is not prone to the growth of microorganisms, except fungus, when proper storage, handling, and packing conditions are compromised. Consequently, mycotoxins, secondary metabolites of fungi, could contaminate tea samples, affecting human health. In the present study, we aimed to assess the balance between risks (due to mycotoxins and high levels of EGCG) and benefits (due to moderate intake of EGCG) associated with the consumption of GT. For this, 20 GT samples (10 in bulk and 10 in bags) available in different markets in Lisbon were analyzed through a LC–MS/MS method, evaluating 38 different mycotoxins. Six samples revealed detectable values of the considered toxins. Current levels of mycotoxins and EGCG intake were not associated with health concerns. Scenarios considering an increasing consumption of GT in Portugal showed that drinking up to seven cups of GT per day should maximize the associated health benefits. The present study contributes to the future establishment of GT consumption recommendations in Portugal.

Risk-benefit in food safety and nutrition - Outcome of the 2019 Parma Summer School

Risk-benefit assessment is the comparison of the risk of a situation to its related benefits, i.e. a comparison of scenarios estimating the overall health impact. The risk-benefit analysis paradigm mirrors the classical risk analysis one: risk-benefit assessment goes hand-in-hand with risk-benefit management and risk-benefit communication. The various health effects associated with food consumption, together with the increasing demand for advice on healthy and safe diets, have led to the development of different research disciplines in food safety and nutrition. In this sense, there is a clear need for a holistic approach, including and comparing all of the relevant health risks and benefits. The risk-benefit assessment of foods is a valuable approach to estimate the overall impact of food on health. It aims to assess together the negative and positive health effects associated with food intake by integrating chemical and microbiological risk assessment with risk and benefit assessment in food safety and nutrition. The 2019 Parma Summer School on risk-benefit in food safety and nutrition had the objective was to provide an opportunity to learn from experts in the field of risk-benefit approach in food safety and nutrition, including theory, case studies, and communication of risk-benefit assessments plus identify challenges for the future. It was evident that whereas tools and approaches have been developed, more and more case studies have been performed which can form an inherent validation of the risk-benefit approach. Executed risk-benefit assessment case studies apply the steps and characteristics developed: a problem formulation (with at least 2 scenarios), a tiered approach until a decision can be made, one common currency to describe both beneficial and adverse effects (DALYs in most instances). It was concluded that risk-benefit assessment in food safety and nutrition is gaining more and more momentum, while also many challenges remain for the future. Risk-benefit is on the verge of really enrolling into the risk assessment and risk analysis paradigm. The interaction between risk-benefit assessors and risk-benefit managers is pivotal in this, as is the interaction with risk-benefit communicators.

Estimation of the burden of disease attributable to red meat consumption in France: Influence on colorectal cancer and cardiovascular diseases

The consumption of red meat has been associated with colorectal cancer (CRC) and cardiovascular disease (CVD) worldwide. The objective of this study was to assess quantitatively the burden of disease of CRC and CVD due to the consumption of red meat in France. A probabilistic risk assessment model quantifying the risk, deaths and disability adjusted life years (DALY) of both outcomes was built. In the model, uncertainty and variability were propagated separately. The model used data on current CRC and CVD incidence and red meat consumption in France, as well as dose-response from epidemiological studies. Results were given by age class and gender. A total of 19 [95% CI = 8-33] DALY per 100,000 people per year for CRC associated with red meat consumption was estimated. For CVD, 21 [95% CI = 12-32] DALY per 100,000 people per year was estimated. The uncertainty was mainly due to the dose-response, as revealed by a sensitivity analysis. A scenario analysis, performed on red meat intake, highlighted that consumption of less than 65 g per day could limit the risk of CRC and CVD in the most affected sub-populations.

A probabilistic approach for risk-benefit assessment of food substitutions: A case study on substituting meat by fish

Accounting for substitution of foods is inevitable when evaluating health impact of dietary changes. But substitution behavior and the associated health impact may vary between individuals. We therefore propose the use of probabilistic methods to model substitution and assess health impact distributions in risk-benefit assessment (RBA) of foods. We investigated the health impact of substituting red and processed meat with fish in the Danish adult population and the variability in health impact. We applied probabilistic approaches in modeling the substitution to reflect variability between individual substitution behaviors. Furthermore, when multiple intake scenarios are compared, we propose a method for adjusting intake differences for individual day-to-day variability. We estimated that 134 (95% UI: 102; 169) Disability-Adjusted Life Years/100,000 were averted per year by the substitution. The health impact varied considerably by age and sex, with the largest health benefit of the substitution observed for young women in the child-bearing age and for the older generation, mainly men. This study provides further insight in how the health impact of substituting meat by fish varies between individuals and suggests a framework to be applied in RBAs of other food substitutions. Our results are relevant for policy makers in defining targeted public health strategies.

Risk Benefit Assessment of foods: Key findings from an international workshop

Whilst risk management measures, including food policy, are developed for the protection of public health and the environment, they may also lead to a reduction in health benefits. Policy decisions require then consideration of these necessary trade-offs, which leads to an increasing need to apply formal risk-benefit assessment (RBA) of foods. In this context, the European Food Safety Authority sponsored a Risk-Benefit Assessment Workshop on "past, current and future developments within the risk-benefit assessment of foods (RBA)" held in May 2017. The overall aims of the RBA Workshop were to discuss existing methods, challenges and needs within RBA, and to draft a roadmap for future development of RBA. The specific objectives were to i) identify RBA activities in Europe and globally; ii) discuss how to further develop and optimize RBA methodology; iii) identify challenges and opportunities within RBA; and iv) increase collaboration internationally. The two-day workshop gathered 28 participants from 16 institutions in 11 countries. It included technical presentations of RBA methods and case studies, and two break-out sessions for group discussions. All participants agreed that RBA has substantial potential to inform risk-management decisions in the areas of food safety, nutrition and public health. Several activities to optimize further developments within RBA were suggested. This paper provides a summary of workshop presentations, a discussion of challenges that limit progress in this area, and suggestions of next steps for this promising approach supporting a science-based decision process in the area of risk-benefit management of foods.

Development and Application of a Probabilistic Risk-Benefit Assessment Model for Infant Feeding Integrating Microbiological, Nutritional, and Chemical Components

A probabilistic and interdisciplinary risk-benefit assessment (RBA) model integrating microbiological, nutritional, and chemical components was developed for infant milk, with the objective of predicting the health impact of different scenarios of consumption. Infant feeding is a particular concern of interest in RBA as breast milk and powder infant formula have both been associated with risks and benefits related to chemicals, bacteria, and nutrients, hence the model considers these three facets. Cronobacter sakazakii, dioxin-like polychlorinated biphenyls (dl-PCB), and docosahexaenoic acid (DHA) were three risk/benefit factors selected as key issues in microbiology, chemistry, and nutrition, respectively. The present model was probabilistic with variability and uncertainty separated using a second-order Monte Carlo simulation process. In this study, advantages and limitations of undertaking probabilistic and interdisciplinary RBA are discussed. In particular, the probabilistic technique was found to be powerful in dealing with missing data and to translate assumptions into quantitative inputs while taking uncertainty into account. In addition, separation of variability and uncertainty strengthened the interpretation of the model outputs by enabling better consideration and distinction of natural heterogeneity from lack of knowledge. Interdisciplinary RBA is necessary to give more structured conclusions and avoid contradictory messages to policymakers and also to consumers, leading to more decisive food recommendations. This assessment provides a conceptual development of the RBA methodology and is a robust basis on which to build upon.

The potential application of a biomarker approach for the investigation of low-calorie sweetener exposure

Low-calorie sweeteners (LCS) are commonly used as sugar substitutes in the diet to provide a desired sweet taste without increased energy intake. The number of LCS available on the market has increased considerably over the years and despite extensive evaluation of their safety prior to approval, debate continues around the effects of consumption on health. In Europe, Member States are obligated to monitor exposure to LCS and methods currently used tend to rely on self-reported dietary intake data alongside LCS concentrations in products. However, the acquisition of accurate data can be costly in terms of resources and time and are inherently imprecise. Although LCS are intensely sweet, they are chemically diverse and a limitation of many studies investigating the health effects of consumption is that they often fail to discern intakes of individual LCS. An approach which objectively assesses intakes of individual LCS would therefore allow robust investigations of their possible effects on health. Biomarker approaches have been utilised for the objective investigation of intakes of a range of dietary components and the feasibility of any such approach depends upon its validity as well as its applicability within the target population. This review aims to provide an overview of current understanding of LCS intake and explore the possibility of implementing a biomarker approach to enhance such understanding. Several commonly used LCS, once absorbed into the body, are excreted via the kidneys; therefore a urinary biomarker approach may be possible for the investigation of short-term exposure to these compounds.

Vitamin D and risk of CVD: a review of the evidence

This review summarises evidence for an association between vitamin D status and CVD and the mechanisms involved. Vitamin D3 is predominantly provided by the action of UVB from sunlight on skin. Average UK diets supply 2-3 μg/d vitamin D but diets containing at least one portion of oily fish per week supply about 7 μg/d. Pharmacological doses of vitamin D2 (bolus injection of 7500 μg or intakes >50 μg/d) result in a smaller increase in plasma 25(OH)D than those of D3 but physiological doses 5-25 μg/d seem equivalent. Plasma 25(OH)D concentrations are also influenced by clothing, obesity and skin pigmentation. Up to 40 % of the population have plasma 25(OH)D concentrations <25 nmol/l in the winter compared with <10 % in the summer. The relative risk of CVD death is 1·41 (95 % CI 1·18, 1·68) greater in the lowest quintile of plasma 25(OH)D according to meta-analysis of prospective cohort studies. Acute deficiency may inhibit insulin secretion and promote inflammation thus increasing the risk of plaque rupture and arterial thrombosis. Chronic insufficiency may increase arterial stiffness. There is no evidence to support claims of reduced CVD from existing trials with bone-related health outcomes where vitamin D was usually co-administered with calcium. Although several trials with cardiovascular endpoints are in progress, these are using pharmacological doses. In view of the potential toxicity of pharmacological doses, there remains a need for long-term trials of physiological doses of D2 and D3 with CVD incidence as the primary outcome.

Addressing the risk of inadequate and excessive micronutrient intakes: traditional versus new approaches to setting adequate and safe micronutrient levels in foods

Fortification of foods consumed by the general population or specific food products or supplements designed to be consumed by vulnerable target groups is amongst the strategies in developing countries to address micronutrient deficiencies. Any strategy aimed at dietary change needs careful consideration, ensuring the needs of at-risk subgroups are met whilst ensuring safety within the general population. This paper reviews the key principles of two main assessment approaches that may assist developing countries in deciding on effective and safe micronutrient levels in foods or special products designed to address micronutrient deficiencies, that is, the cut-point method and the stepwise approach to risk-benefit assessment. In the first approach, the goal is to shift population intake distributions such that intake prevalences below the Estimated Average Requirement (EAR) and above the Tolerable Upper Intake Level (UL) are both minimized. However, for some micronutrients like vitamin A and zinc, a narrow margin between the EAR and UL exists. Increasing their intakes through mass fortification may pose a dilemma; not permitting the UL to be exceeded provides assurance about the safety within the population but can potentially leave a proportion of the target population with unmet needs, or vice versa. Risk-benefit approaches assist in decision making at different micronutrient intake scenarios by balancing the magnitude of potential health benefits of reducing inadequate intakes against health risks of excessive intakes. Risk-benefit approaches consider different aspects of health risk including severity and number of people affected. This approach reduces the uncertainty for policy makers as compared to classic cut-point methods.

Critical appraisal of the assessment of benefits and risks for foods, 'BRAFO Consensus Working Group'

BRAFO, Benefit-Risk Analysis for Foods, was a European Commission project funded within Framework Six as a Specific Support Action and coordinated by ILSI Europe. BRAFO developed a tiered methodology for assessing the benefits and risks of foods and food components, utilising a quantitative, common scale for health assessment in higher tiers. This manuscript reports on the implications of the experience gained during the development of the project for the further improvement of benefit-risk assessment methodology. It was concluded that the methodology proposed is applicable to a range of situations and that it does help in optimising resource utilisation through early identification of those benefit-risk questions where benefit clearly outweighs risk or vice versa. However, higher tier assessments are complex and demanding of time and resources, emphasising the need for prioritisation. Areas identified as requiring further development to improve the utility of benefit-risk assessment include health weights for different populations and endpoints where they do not currently exist, extrapolation of effects from studies in animals to humans, use of in vitro data in benefit-risk assessments, and biomarkers of early effect and how these would be used in a quantitative assessment.