Risk-benefit assessment of foods and its role to inform policy decisions: outcome of an international workshop.

Policy decisions in public health require consideration and evaluation of trade-offs for which transparency and science-based evidence is needed. Improvement of decision-support tools is essential to help guide food policy decisions that promote healthy diets and meet the challenges of food systems without compromising food security, food safety, and sovereignty. Risk-benefit assessment of foods (RBA) is an established methodological approach designed to inform policy decisions within the area of nutrition and food safety. Despite methodological developments, translation of RBA findings into policies is still limited. In this context, a stakeholder workshop held in May 2023 gathered RBA experts and food regulators from Europe to identify the challenges, obstacles and opportunities in using evidence generated through RBAs to inform food policy decisions. A structured process was implemented to collect their views through online surveys, breakout groups, and plenary discussions. As a secondary objective, food regulators' views on other approaches for holistic risk assessment fit for food systems analysis were also explored. This paper summarizes the main findings of the workshop and discusses policy implications and future perspectives to improve the area of RBA and its role in food policymaking.

Substituting red meat with insects in burgers: Estimating the public health impact using risk-benefit assessment.

In Western societies, reducing red meat consumption gained prominence due to health, environmental, and animal welfare considerations. We estimated the public health impact of substituting beef with house cricket (Acheta domesticus) in European diets (Denmark, France, and Greece) using the risk-benefit assessment (RBA) methodology, building upon the EFSA-funded NovRBA project. The overall health impact of substituting beef patties with insect powder-containing patties was found to be impacted by the amount of cricket powder incorporated in the patties. While using high amounts of cricket powder in meat substitutes may be safe, it does not inherently offer a healthier dietary option compared to beef. Adjustment of cricket powder levels is needed to yield a positive overall health impact. The main driver of the outcome is sodium, naturally present in substantial amounts in crickets. Moreover, the way that cricket powder is hydrated before being used for the production of patties (ratio of powder to water), influences the results. Our study highlighted that any consideration for dietary substitution should be multidimensional, considering nutritional, microbiological and toxicological aspects, and that the design of new food products in the framework of dietary shifts should consider both health risks and benefits associated with the food.

The direct disease burden of COVID-19 in Belgium in 2020 and 2021.

BACKGROUND: Burden of disease estimates have become important population health metrics over the past decade to measure losses in health. In Belgium, the disease burden caused by COVID-19 has not yet been estimated, although COVID-19 has emerged as one of the most important diseases. Therefore, the current study aims to estimate the direct COVID-19 burden in Belgium, observed despite policy interventions, during 2020 and 2021, and compare it to the burden from other causes. METHODS: Disability-adjusted life years (DALYs) are the sum of Years Lived with Disability (YLDs) and Years of Life Lost (YLLs) due to disease. DALYs allow comparing the burden of disease between countries, diseases, and over time. We used the European Burden of Disease Network consensus disease model for COVID-19 to estimate DALYs related to COVID-19. Estimates of person-years for (a) acute non-fatal disease states were calculated from a compartmental model, using Belgian seroprevalence, social contact, hospital, and intensive care admission data, (b) deaths were sourced from the national COVID-19 mortality surveillance, and (c) chronic post-acute disease states were derived from a Belgian cohort study. RESULTS: In 2020, the total number of COVID-19 related DALYs was estimated at 253,577 [252,541 - 254,739], which is higher than in 2021, when it was 139,281 [136,704 - 142,306]. The observed COVID-19 burden was largely borne by the elderly, and over 90% of the burden was attributable to premature mortality (i.e., YLLs). In younger people, morbidity (i.e., YLD) contributed relatively more to the DALYs, especially in 2021, when vaccination was rolled out. Morbidity was mainly attributable to long-lasting post-acute symptoms. CONCLUSION: COVID-19 had a substantial impact on population health in Belgium, especially in 2020, when COVID-19 would have been the main cause of disease burden if all other causes had maintained their 2019 level.

Animal sources of antimicrobial-resistant bacterial infections in humans: a systematic review.

Bacterial antimicrobial resistance (AMR) is among the leading global health challenges of the century. Animals and their products are known contributors to the human AMR burden, but the extent of this contribution is not clear. This systematic literature review aimed to identify studies investigating the direct impact of animal sources, defined as livestock, aquaculture, pets, and animal-based food, on human AMR. We searched four scientific databases and identified 31 relevant publications, including 12 risk assessments, 16 source attribution studies, and three other studies. Most studies were published between 2012 and 2022, and most came from Europe and North America, but we also identified five articles from South and South-East Asia. The studies differed in their methodologies, conceptual approaches (bottom-up, top-down, and complex), definitions of the AMR hazard and outcome, the number and type of sources they addressed, and the outcome measures they reported. The most frequently addressed animal source was chicken, followed by cattle and pigs. Most studies investigated bacteria-resistance combinations. Overall, studies on the direct contribution of animal sources of AMR are rare but increasing. More recent publications tailor their methodologies increasingly towards the AMR hazard as a whole, providing grounds for future research to build on.

Burden of lung cancer and predicted costs of occupational exposure to hexavalent chromium in the EU - The impact of different occupational exposure limits.

BACKGROUND: Exposure to hexavalent chromium [Cr(VI)] occurs widely in occupational settings across the EU and is associated with lung cancer. In 2025, the occupational exposure limit is set to change to 5 µg/m3. Current exposure limits are higher, with 10 µg/m3 as a general limit and 25 µg/m3 for the welding industry. We aimed to assess the current burden of lung cancer caused by occupational exposure to Cr(VI) and to evaluate the impact of the recently established EU regulation by analysing different occupational exposure limits. METHODS: Data were extracted from the literature, the Global Burden of Disease 2019) study, and Eurostat. We estimated the cases of cancer attributable to workplace exposure to Cr(VI) by combining exposure-effect relationships with exposure data, and calculated related DALYs and health costs in scenarios with different occupational exposure limits. RESULTS: With current EU regulations, 253 cases (95%UI 250.96-255.71) of lung cancer were estimated to be caused by Cr(VI) in 2019, resulting in 4684 DALYs (95%UI 4683.57-4704.08). In case the welding industry adopted 10 µg/m3, a decrease of 43 cases and 797 DALYs from current values is expected. The predicted application of a 5 µg/m3 limit would cause a decrease of 148 cases and 2746 DALYs. Current costs are estimated to amount to 12.47 million euros/year (95%UI 10.19-453.82), corresponding to 39.97 million euros (95%UI 22.75-70.10) when considering costs per DALY. The limits implemented in 2025 would lead to a decrease of 23.35 million euros when considering DALYs, with benefits of introducing a limit value occurring after many decades. Adopting a 1 µg/m3 limit would lower costs to 1.04 million euros (95%UI 0.85-37.67) and to 3.33 million euros for DALYs (95%UI 1.89-5.84). DISCUSSION: Assessing different scenarios with different Cr(VI) occupational exposure limits allowed to understand the impact of EU regulatory actions. These findings make a strong case for adapting even stricter exposure limits to protect workers' health and avoid associated costs.

Direct impact of COVID-19 by estimating disability-adjusted life years at national level in France in 2020.

BACKGROUND: The World Health Organization declared a pandemic of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), on March 11, 2020. The standardized approach of disability-adjusted life years (DALYs) allows for quantifying the combined impact of morbidity and mortality of diseases and injuries. The main objective of this study was to estimate the direct impact of COVID-19 in France in 2020, using DALYs to combine the population health impact of infection fatalities, acute symptomatic infections and their post-acute consequences, in 28 days (baseline) up to 140 days, following the initial infection. METHODS: National mortality, COVID-19 screening, and hospital admission data were used to calculate DALYs based on the European Burden of Disease Network consensus disease model. Scenario analyses were performed by varying the number of symptomatic cases and duration of symptoms up to a maximum of 140 days, defining COVID-19 deaths using the underlying, and associated, cause of death. RESULTS: In 2020, the estimated DALYs due to COVID-19 in France were 990 710 (1472 per 100 000), with 99% of burden due to mortality (982 531 years of life lost, YLL) and 1% due to morbidity (8179 years lived with disability, YLD), following the initial infection. The contribution of YLD reached 375%, assuming the duration of 140 days of post-acute consequences of COVID-19. Post-acute consequences contributed to 49% of the total morbidity burden. The contribution of YLD due to acute symptomatic infections among people younger than 70 years was higher (67%) than among people aged 70 years and above (33%). YLL among people aged 70 years and above, contributed to 74% of the total YLL. CONCLUSIONS: COVID-19 had a substantial impact on population health in France in 2020. The majority of population health loss was due to mortality. Men had higher population health loss due to COVID-19 than women. Post-acute consequences of COVID-19 had a large contribution to the YLD component of the disease burden, even when we assume the shortest duration of 28 days, long COVID burden is large. Further research is recommended to assess the impact of health inequalities associated with these estimates.

Health and Economic Burden of Seven Foodborne Diseases in Denmark, 2019.

We ranked seven foodborne pathogens in Denmark on the basis of their health and economic impact on society in 2019. We estimated burden of disease of infections with Campylobacter spp., Salmonella spp., Shiga toxin-producing Escherichia coli (STEC), Yersinia enterocolitica, Listeria monocytogenes, norovirus, and hepatitis A virus in terms of incidence, mortality, disability-adjusted life years (DALY), and economic burden in terms of direct and indirect health costs. These seven pathogens accounted for 268,372 cases, 98 deaths, and 3121 DALYs, and led to a total expenditure of 434 million Euro in 1 year in a country with 5.8 million citizens. Foodborne infections by Campylobacter, Salmonella, and norovirus caused the most DALYs, whereas Campylobacter, and norovirus and STEC had the higher costs. A combination of disease burden and cost of illness estimates is useful to inform policymaking and establish food safety priorities at the national level.

Burden of Disease of COVID-19: Strengthening the Collaboration for National Studies.

Objectives: Quantifying the combined impact of morbidity and mortality is a key enabler to assessing the impact of COVID-19 across countries and within countries relative to other diseases, regions, or demographics. Differences in methods, data sources, and definitions of mortality due to COVID-19 may hamper comparisons. We describe efforts to support countries in estimating the national-level burden of COVID-19 using disability-adjusted life years. Methods: The European Burden of Disease Network developed a consensus methodology, as well as a range of capacity-building activities to support burden of COVID-19 studies. These activities have supported 11 national studies so far, with study periods between January 2020 and December 2021. Results: National studies dealt with various data gaps and different assumptions were made to face knowledge gaps. Still, they delivered broadly comparable results that allow for interpretation of consistencies, as well as differences in the quantified direct health impact of the pandemic. Discussion: Harmonized efforts and methodologies have allowed for comparable estimates and communication of results. Future studies should evaluate the impact of interventions, and unravel the indirect health impact of the COVID-19 crisis.

Estimating the Direct Disability-Adjusted Life Years Associated With SARS-CoV-2 (COVID-19) in the Republic of Ireland: The First Full Year.

Objectives: Burden of Disease frameworks facilitate estimation of the health impact of diseases to be translated into a single measure, such as the Disability-Adjusted-Life-Year (DALY). Methods: DALYs were calculated as the sum of Years of Life Lost (YLL) and Years Lived with Disability (YLD) directly associated with COVID-19 in the Republic of Ireland (RoI) from 01 March 2020, to 28 February 2021. Life expectancy is based on the Global Burden of Disease (GBD) Study life tables for 2019. Results: There were 220,273 confirmed cases with a total of 4,500 deaths as a direct result of COVID-19. DALYs were estimated to be 51,622.8 (95% Uncertainty Intervals [UI] 50,721.7, 52,435.8). Overall, YLL contributed to 98.5% of the DALYs. Of total symptomatic cases, 6.5% required hospitalisation and of those hospitalised 10.8% required intensive care unit treatment. COVID-19 was likely to be the second highest cause of death over our study's duration. Conclusion: Estimating the burden of a disease at national level is useful for comparing its impact with other diseases in the population and across populations. This work sets out to standardise a COVID-19 BoD methodology framework for the RoI and comparable nations in the EU.

Mathematical modelling of Toxoplasma gondii transmission: A systematic review.

BACKGROUND: Toxoplasma gondii is a ubiquitous protozoan parasite that can infect virtually all warm-blooded animals. It is the causative agent of toxoplasmosis, a significant public health issue worldwide. Mathematical models are useful to study the transmission dynamics of T. gondii infection in different settings, and may be used to compare the effectiveness of prevention measures. METHODS: To obtain an overview of existing mathematical models for transmission of T. gondii, a systematic review was undertaken. The review was conducted according to an a priori protocol and the results were reported according to the PRISMA guidelines. Specific search terms were developed and used in the search of three databases (Scopus, PubMed, and Embase). RESULTS: In total, 484 unique records were retrieved from the systematic search. Among them, 15 studies that used mathematical models to study the transmission of T. gondii. These studies were categorized into four groups based on the primary aims: dynamics of transmission (n = 8), intervention (n = 5), spatial distribution (n = 1), and outbreak investigation (n = 1). CONCLUSIONS: Considering the high disease burden caused by T. gondii, the number of studies using mathematical models to understand the transmission dynamics of this parasite and to evaluate the effectiveness of intervention measures was only 15. This systematic review provides an overview of existing mathematical models and identifies the data gaps for model building. The results from this study can be helpful for further development of mathematical models and improved understanding of the transmission dynamics of T. gondii infection.

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.

Non-typhoidal human salmonellosis in Rio Grande do Sul, Brazil: A combined source attribution study of microbial subtyping and outbreak data.

Salmonella spp. remains the most significant foodborne pathogen in south Brazil, but its epidemiology tends to change over time. Using official and surrogate data, a microbial subtyping model attributed different Salmonella serovars to laying hens, pigs, broilers, and turkeys from 2005 to 2015 in Rio Grande do Sul (RS). Additional to the subtyping model, three sub-analyses of outbreak data attributed Salmonella spp. in humans to animal and non-animal food. Laying hens/eggs was the most important source of human salmonellosis in RS, with almost 40% (159 cases; 95% credibility interval, 43-247) attribution proportion, followed by pigs reared in Santa Catarina, a neighbor state (34.5%). The Salmonella serovars Enteritidis and Typhimurium were the most common serovars involved. Source-related parameters had wide credibility intervals but showed a higher risk of illness from contaminated eggs than from the other three animal-food sources. Analysis of the outbreak data corroborated the findings and indicated signs of decreasing importance for eggs and increasing importance for pork consumption.

Attributing Human Foodborne Diseases to Food Sources and Water in Japan Using Analysis of Outbreak Surveillance Data.

ABSTRACT: In Japan, strategies for ensuring food safety have been developed without reliable scientific evidence on the relationship between foodborne diseases and food sources. This study aimed to provide information on the proportions of foodborne diseases caused by seven major causative pathogens (Campylobacter spp., Salmonella, enterohemorrhagic Escherichia coli [EHEC], Vibrio parahaemolyticus, Clostridium perfringens, Staphylococcus aureus, and norovirus) attributed to foods and to explore factors affecting changes in these source attribution proportions over time using analysis of outbreak surveillance data. For the calculation of the number of outbreaks attributed to each source, simple-food outbreaks were assigned to the single-food category in question, and complex-food outbreaks were classified under each category proportional to the estimated probability. During 2007 to 2018, 8,730 outbreaks of foodborne diseases caused by seven pathogens were reported, of which 6,690 (76.6%) were of unknown source. We estimated the following source attribution proportions of foodborne diseases: chicken products (80.3%, 95% uncertainty interval [UI] 80.1 to 80.4) for Campylobacter spp.; beef products (50.1%, UI 47.0 to 51.5) and vegetables (42.3%, UI 40.9 to 45.5) for EHEC; eggs (34.6%, UI 27.8 to 41.4) and vegetables (34.4%, UI 27.8 to 40.8) for Salmonella; finfish (50.3%, UI 33.3 to 66.7) and shellfish (49.7%, UI 33.3 to 66.7) for V. parahaemolyticus; grains and beans (57.8%, UI 49.7 to 64.9) for S. aureus; vegetables (63.6%, UI 48.5 to 74.6), chicken products (12.7%, UI 4.6 to 21.5), and beef products (11.1%, UI 8.5 to 13.1) for C. perfringens; and shellfish (75.5%, UI 74.7 to 76.2) for norovirus. In this study, we provide the best available evidence-based information to evaluate the link between foodborne diseases and foods. Our results on source attribution for Campylobacter spp. and EHEC suggest that the strict health regulations for raw beef were reflected in the proportions of these diseases attributed to this food.

Exposure to Gestational Diabetes Is a Stronger Predictor of Dysmetabolic Traits in Children Than Size at Birth.

CONTEXT AND OBJECTIVE: Being born small or large for gestational age and intrauterine exposure to gestational diabetes (GDM) increase the risk of type 2 diabetes in the offspring. However, the potential combined deleterious effects of size at birth and GDM exposure remains unknown. We examined the independent effect of size at birth and the influence of GDM exposure in utero on cardiometabolic traits, body composition, and puberty status in children. DESIGN, PARTICIPANTS, AND METHODS: The present study was a longitudinal birth cohort study. We used clinical data from 490 offspring of mothers with GDM and 527 control offspring aged 9 to 16 years, born singleton at term from the Danish National Birth Cohort with available birthweight data. RESULTS: We found no evidence of a U-shaped association between size at birth (expressed as birthweight, sex, and gestational age adjusted z-score) and cardiometabolic traits. Body size in childhood and adolescence reflected the size at birth but was not reflected in any metabolic outcome. No synergistic adverse effect of being born small or large for gestational age and exposure to GDM was shown. However, GDM was associated with an adverse metabolic profile and earlier onset of female puberty in childhood and adolescence independently of size at birth. CONCLUSION: In childhood and adolescence, we found GDM was a stronger predictor of dysmetabolic traits than size at birth. The combination of being born small or large and exposed to GDM does not exacerbate the metabolic profile in the offspring.

Investigating the risk-benefit balance of substituting red and processed meat with fish in a Danish diet.

Danish dietary guidelines recommend the Danish population to increase the consumption of fish while decreasing the consumption of red and processed meat to prevent nutrition-related diseases. However, the presence of contaminants in these foods may affect the overall risk-benefit balance of such substitution. We performed a quantitative risk-benefit assessment on substituting red and processed meat with fish in a Danish diet. We modeled the substitution among Danish adults based on data from a Danish dietary survey and compared four alternative scenarios based on varying chemical and nutrient exposures to the current consumption. We quantified the overall health impact of the substitutions in terms of Disability-Adjusted Life Years (DALYs). Approximately 150 DALYs/100,000 individuals could be averted each year if Danish adults consumed 350 g of fish/week (fatty or mix of fatty and lean) while decreasing the consumption of red and processed meat. A lower beneficial impact was observed when consumption of fish was restricted to lean fish (80 DALYs/100,000 averted), and a marked health loss (180 DALYs/100,000) was estimated when consumption was restricted to tuna. Our results show an overall beneficial effect of the substitution if the consumption of large predatory fish is low and at least half is fatty fish.

Burden of disease of dietary exposure to acrylamide in Denmark.

Acrylamide (AA) is a process-contaminant that potentially increases the risk of developing cancer in humans. AA is formed during heat treatment of starchy foods and detected in a wide range of commonly consumed products. Increased focus on risk ranking and prioritization of major causes of disease makes it relevant to estimate the impact that exposure to chemical contaminants and other hazards in food have on health. In this study, we estimated the burden of disease (BoD) caused by dietary exposure to AA, using disability adjusted life years (DALY) as health metric. We applied an exposure-based approach and proposed a model of three components: an exposure, health-outcome, and DALY-module. We estimated BoD using two approaches for estimating cancer risk based on toxicological data and two approaches for estimating DALY. In Denmark, 1.8 healthy life years per 100.000 inhabitants are lost each year due to exposure to AA through foods, as estimated by the most conservative approach. This result should be used to inform risk management decisions and for comparison with BoD of other food-borne hazards for prioritizing policies. However, our study shows that careful evaluation of methodological choices and assumptions used in BoD studies is necessary before use in policy making.

Application of Bayesian techniques to model the burden of human salmonellosis attributable to U.S. food commodities at the point of processing: adaptation of a Danish model.

Mathematical models that estimate the proportion of foodborne illnesses attributable to food commodities at specific points in the food chain may be useful to risk managers and policy makers to formulate public health goals, prioritize interventions, and document the effectiveness of mitigations aimed at reducing illness. Using human surveillance data on laboratory-confirmed Salmonella infections from the Centers for Disease Control and Prevention and Salmonella testing data from U.S. Department of Agriculture Food Safety and Inspection Service's regulatory programs, we developed a point-of-processing foodborne illness attribution model by adapting the Hald Salmonella Bayesian source attribution model. Key model outputs include estimates of the relative proportions of domestically acquired sporadic human Salmonella infections resulting from contamination of raw meat, poultry, and egg products processed in the United States from 1998 through 2003. The current model estimates the relative contribution of chicken (48%), ground beef (28%), turkey (17%), egg products (6%), intact beef (1%), and pork (<1%) across 109 Salmonella serotypes found in food commodities at point of processing. While interpretation of the attribution estimates is constrained by data inputs, the adapted model shows promise and may serve as a basis for a common approach to attribution of human salmonellosis and food safety decision-making in more than one country.

Using outbreak data for source attribution of human salmonellosis and campylobacteriosis in Europe.

Salmonella and Campylobacter are the most important bacterial causes of foodborne illness in Europe. To identify and prioritize food safety interventions, it is important to quantify the burden of human foodborne illness attributable to specific sources. Data from outbreak investigations are observed at the public health endpoint and can therefore be a direct measure of attribution at the point of exposure. An analysis or summary of outbreak investigations is useful for attributing illnesses to foods, but often the implicated foods in reported outbreaks are complex foods, containing several food items, many of which could be the specific source of the infection. We describe a method that is able to attribute human cases to specific food items contained in complex foods. The model is based on data from investigations of Salmonella and Campylobacter outbreaks in the European Union in 2005 and 2006. The reporting of the causative vehicles for the outbreaks was not harmonized between and within countries. Consequently, we organized the implicated foods in mutually exclusive food categories. We estimated that the most important food sources for salmonellosis cases were eggs (32%) and meat and poultry-meat (15%), and that the majority of the cases of campylobacteriosis were attributed to chicken (10%). For both pathogens, a large proportion of cases could not be linked to any source. Among illnesses that could be attributed to a source, 58% of salmonellosis cases were attributed to eggs, and 29% of campylobacteriosis cases were attributed to chicken. Results also revealed regional differences in the relative importance of specific sources. We assessed the method to be of limited value to attribute human campylobacteriosis due to the limited number of outbreaks. Nevertheless, the presented source attribution approach can be applied to other foodborne pathogens, and is easily adaptable to countries having an appropriate number of reported outbreaks.