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

Approaches to risk-benefit assessment of seafood consumption: lessons learned from an evidence scan

Qualitative and quantitative risk-benefit assessments (RBA) can be used to support public health decisions in food safety. We conducted an evidence scan to understand the state of the science regarding RBA in seafood to help inform seafood dietary advice in the United States. We collected published RBA studies assessing seafood consumption, designed inclusion and exclusion criteria to screen these studies, and conducted systematic data extraction for the relevant studies published since 2019. Our findings indicate the selection of health risks and benefits does not generally follow a systematic approach. Uncertainty and variability in RBAs is often not addressed, and quantitative RBAs making use of a single health metric generally have not been leveraged to directly support published regulatory decisions or dietary guidance. To elevate the role of RBA in supporting regulatory decision-making, risk assessors and risk managers must work together to set expectations and goals. We identified the need for a prioritization phase (e.g., multicriteria decision analysis model) to determine the risks and benefits of greatest public health impact to inform the RBA design. This prioritization would consider not only the degree of public health impact of each risk and benefit, but also the potential for risks and benefits to converge on common health outcomes and their importance to subpopulations. Including a prioritization could improve the utility of the RBAs to better inform risk management decisions and advance public health. Our work serves to guide the United States Food and Drug Administration's approaches to RBA in foods.

Quantitative risk-benefit assessment of Portuguese fish and other seafood species consumption scenarios

Portugal has high fish/seafood consumption, which may have both risks and benefits. This study aims to quantify the net health impact of hypothetical scenarios of fish/seafood consumption in the Portuguese population using a risk-benefit assessment methodology. Consumption data from the National Food, Nutrition and Physical Activity Survey 2015-2016 (n 5811) were used to estimate the mean exposure to methylmercury and EPA + DHA in the current and the alternative scenarios considered. Alternative scenarios (alt) were modelled using probabilistic approaches to reflect substitutions from the current consumption in the type of fish/seafood (alt1: excluding predatory fishes; alt2: including only methylmercury low-level fishes) or in the frequency of weekly fish/seafood consumption (alt3 to alt6: 1, 3, 5 or 7 times a week, replacing fish/seafood meals with meat or others). The overall health impact of these scenarios was quantified using disability-adjusted life years (DALY). In the Portuguese population, about 11 450 DALY could be prevented each year if the fish/seafood consumption increased to a daily basis. However, such a scenario would result in 1398 extra DALY considering the consumption by pregnant women and the respective risk on fetal neurodevelopment. Our findings support a recommendation to increase fish/seafood consumption up to 7 times/week. However, for pregnant women and children, special considerations must be proposed to avoid potential risks on fetal neurodevelopment due to methylmercury exposure.

Application of BRAFO-tiered approach for health benefit-risk assessment of dark tea consumption in China

Dark tea, a unique tea fermented primarily in China, has numerous potential beneficial effects. However, harmful substances present in dark tea have provoked significant concern. To conduct a quantitative benefit-risk assessment of dark tea for Chinese residents and provide guidance on rational consumption, a framework of Benefit-Risk Analysis for Foods (BRAFO) and meta-analysis was applied to construct a disability-adjusted life year (DALY). Based on the BRAFO-tiered approach, a reference scenario (no intake) and an alternative scenario (intake of 3 cups/day) were determined. The overall health impacts of dark tea were simulated by comparing the risks of fluoride and AF with benefits of reduced-risk to coronary heart disease (CHD) and diabetes in different scenarios. Three cups of fermented tea consumed per day decreased risks of CHD and diabetes by 8.16% and 12.77% respectively. After quantitative integration of information, the ultimate net health effect was found to be -1958.827 illustrating that the benefits of drinking three cups of dark tea per day outweigh the risks. However, considering the uncertainties in the process, decision-makers should proceed with caution, consulting additional well-conducted studies and further managing harmful substances in dark tea.

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.

Human health risk-benefit assessment of fish and other seafood: a scoping review

Fish and other seafood are important sources of nutrients, but they are also sources of chemical contaminants that may cause adverse health effects. This article aimed to identify existing risk-benefit assessments (RBA) of fish, shellfish, and other seafood, compare methodologies, discuss differences and commonalities in findings, and identify limitations and ways forward for future studies. We conducted a scoping review of the scientific literature of studies in all languages published from 2000 through April 2019. We identified 106 RBA of fish and other seafood across Europe, Asia, North America, Africa, and at the global level. Studies were heterogeneous in terms of types of fish and other seafood considered, beneficial and adverse compounds assessed, and overall methodology. Collected data showed that a diet consisting of a variety of lean and fatty fish and other seafood is recommended for the overall population and that women of childbearing age and children should limit the consumption of fish and other seafood types that have a high likelihood of contamination. Our review emphasizes the need for evidence-based, up-to-date, and harmonized approaches in RBA in general.

Implementing a risk-risk analysis framework to evaluate the impact of food intake shifts on risk of illness: a case study with infant cereal

In food safety, process pathway risk assessments usually estimate the risk of illness from a single hazard and a single food and can inform food safety decisions and consumer advice. To evaluate the health impact of a potential change in diet, we need to understand not only the risk posed by the considered hazard and food but also the risk posed by the substitution food and other potential hazards. We developed a framework to provide decision-makers with a multi-faceted evaluation of the impact of dietary shifts on risk of illness. Our case study explored exposure to inorganic arsenic (iAs) and aflatoxins through consumption of infant cereals and the risk of developing lung, bladder and liver cancer over a lifetime. The estimated additional Disability-Adjusted Life Year (DALY) in the U.S. from exposure to iAs and aflatoxin based on available contamination and consumption patterns of infant rice and oat cereal is 4,921 (CI 90% 414; 9,071). If all infant cereal consumers shift intake (maintaining equivalent serving size and frequency) to only consuming infant rice cereal, the predicted DALY increases to 6,942 (CI 90% 326; 12,931). If all infant cereal consumers shift intake to only consuming infant oat cereal, the predicted DALY decreases to 1,513 (CI 90% 312; 3,356). Changes in contaminant concentrations or percent consumers, that could occur in the future, also significantly impact the predicted risk. Uncertainty in these risk predictions is primarily driven by the dose-response models. A risk-risk analysis framework provides decision-makers with a nuanced understanding of the public health impact of dietary changes and can be applied to other food safety and nutrition questions.

The burden of disease of three food-associated heavy metals in clusters in the Danish population - Towards targeted public health strategies

Lifestyle and sociodemographics are likely to influence dietary patterns, and, as a result, human exposure to chemical contaminants in foods and their associated health impact. We aimed to characterize subgroups of the Danish population based on diet and sociodemographic indicators, and identify those bearing a higher disease burden due to exposure to methylmercury (MeHg), cadmium (Cd) and inorganic arsenic (i-As). We collected dietary, lifestyle, and sociodemographic data on the occurrence of chemical contaminants in foods from Danish surveys. We grouped participants according to similarities in diet, lifestyle, and sociodemographics using Self-Organizing Maps (SOM), and estimated disease burden in disability-adjusted life years (DALY). SOM clustering resulted in 12 population groups with distinct characteristics. Exposure to contaminants varied between clusters and was largely driven by intake of fish, seafood and cereal products. Five clusters had an estimated annual burden >20 DALY/100,000. The cluster with the highest burden had a high proportion of women of childbearing age, with most of the burden attributed to MeHg. Individuals belonging to the top three clusters had higher education and physical activity, were mainly non-smokers and lived in urban areas. Our findings may facilitate the development of preventive strategies targeted to the most affected subgroups.

Public health risk-benefit assessment of red meat in France: Current consumption and alternative scenarios

Consumption of red meat has been associated with the risks of colorectal cancer (CRC), cardiovascular disease (CVD), foodborne-pathogen related diseases and with the potential benefit obtained by reduction of iron deficiency anemia (IDA). Based on probabilistic models, current risks and benefit for the French population were aggregated into a single metric, the disability adjusted life years (DALY). In France, per 100,000 people, current red meat consumption was responsible for a mean of 19 DALYs due to CRC, 21 DALYs to CVD and 7 DALYs to foodborne diseases. Current consumption of iron throughout the diet led to a mean of 15 DALYs due to IDA. To mitigate the risks, scenarios were built per sub-population of age and gender. Among adult and elderly population, the big meat eaters would benefit to adhere to the current recommendation (less than 500 g/w): the risks of CRC and CVD would decrease. Regarding IDA (scenario built with fixed ground beef amount), for young population, a consumption of 375g/w would be sufficient to eliminate the burden while for 25-44 years-old females, 455g/w would reduce IDA, but not entirely. This study highlighted the importance of assessing health risk-benefit per sub-populations and the necessity of communicating the results accordingly.

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.

Integration of various dimensions in food-based dietary guidelines via mathematical approaches: report of a DGE/FENS Workshop in Bonn, Germany, 23-24 September 2019

In the past, food-based dietary guidelines (FBDGs) were derived nearly exclusively by using systematic reviews on diet-health relationships and translating dietary reference values for nutrient intake into foods. This approach neglects many other implications that dietary recommendations have on society, the economy and environment. In view of pressing challenges, such as climate change and the rising burden of diet-related diseases, the simultaneous integration of evidence-based findings from different dimensions into FBDGs is required. Consequently, mathematical methods and data processing are evolving as powerful tools in nutritional sciences. The possibilities and reasons for the derivation of FBDGs via mathematical approaches were the subject of a joint workshop hosted by the German Nutrition Society (DGE) and the Federation of European Nutrition Societies (FENS) in September 2019 in Bonn, Germany. European scientists were invited to discuss and exchange on the topics of mathematical optimisation for the development of FBDGs and different approaches to integrate various dimensions into FBDGs. We concluded that mathematical optimisation is a suitable tool to formulate FBDGs finding trade-offs between conflicting goals and taking several dimensions into account. We identified a lack of evidence for the extent to which constraints and weights for different dimensions are set and the challenge to compile diverse data that suit the demands of optimisation models. We also found that individualisation via mathematical optimisation is one perspective of FBDGs to increase consumer acceptance, but the application of mathematical optimisation for population-based and individual FBDGs requires more experience and evaluation for further improvements.

Toxicological risk factors in the burden of malnutrition: The case of nutrition (and risk) transition in sub-Saharan Africa

Toxicant exposures may worsen the micronutrient status, especially during the womb-to-childhood development, impairing organism programming and increasing the risk for health disorders in adulthood. Growing evidence calls for an integrated risk analysis of the interplay of environment, behavior and lifestyle, where a) imbalanced diet and micronutrient deficiencies may increase the vulnerability to toxicants and alter body defence systems and b) intake of antinutrients and contaminants may increase nutritional requirements. Such scenarios are especially evident in communities undergoing a fast nutrition transition, such as in many countries of sub-Saharan Africa. Specific challenges of toxicological risk analysis in sub-Saharan Africa still need a thorough assessment, including: rapid changes of lifestyle and consumers' preferences; dumping of foods and consumer' products; risk management under weak or non-existent awareness, legislation enforcement and infrastructures. The significant and growing literature from Africa-led scientific research should be used to build quality-controlled data repositories supporting regulatory top-down actions. Meanwhile, bottom-up actions (eg consumer's empowerment) could exploit social and economic drivers toward a qualified African presence in the global and local markets. A science-based combination of top-down and bottom-up actions on preventable toxicological risk factors will contribute fighting the new forms of malnutrition and prevent multi-factorial diseases. Exposures to toxicants should be included in the integrated approach proposed by WHO to address the urgent health challenge of simultaneously reduce the risk or burden of both malnutrition (ie deficiency of one or more essential nutrients) and overweight, obesity, and diet-related NCDs.

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.