Dietary mycotoxin exposure and human health risks: A protocol for a systematic review.

BACKGROUND: Mycotoxins are toxic fungal secondary metabolites that contaminate a wide spectrum of essential foods worldwide, such as grain-based products, nuts and spices, causing adverse health effects pertaining to their carcinogenic, nephrotoxic and hepatotoxic nature, among others. AIM: The aim of this systematic review (SR) is to systematically search for, appraise and synthesize primary research evidence to identify what is known about dietary mycotoxin-related health effects and what remains unknown, as well as the uncertainty around findings and the recommendations for the future. SEARCH STRATEGY AND ELIGIBILITY CRITERIA: Search strategies, as well as eligibility criteria were structured according to a predefined PECO (population, exposure, comparison, and outcome) research question and developed in an iterative scoping process. Several bibliographic databases, including Embase, Cochrane Library, Pubmed, Web of Science Core Collection and Scopus, will be searched. Primary research on any measured or modelled dietary exposure to a single or multiple mycotoxins, and adverse human health outcomes (i.e. cancer, non-carcinogenic diseases, and reproductive & developmental adverse outcomes) will be included, and references will be imported into Covidence. In vitro, ex vivo, in silico, animal and review studies, as well as expert's opinions, secondary literature, conference abstracts, presentations, posters, book chapters, dissertations and studies involving non-dietary mycotoxin exposure, will be excluded. STUDY SELECTION: Two independent reviewers will screen titles and abstracts, and review full-texts. Any disagreements will be resolved by a third reviewer based on two-third majority. DATA EXTRACTION: Data from retained eligible studies will be extracted by the principal reviewer, and peer-checked by a second reviewer. STUDY QUALITY ASSESSMENT: Eligible studies will be evaluated for risk of bias (Overall High-Quality Assessment Tool, OHAT) and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation, GRADE). EVIDENCE SYNTHESIS: A detailed summary of the included studies will be provided within a tabular format and narratively discussed. Heat maps will be constructed to provide information on available knowledge (gaps), and a meta-analysis may be performed based on the variability in predefined PECO elements and depending on the heterogeneity of studies. CONCLUSION: This protocol describes the methodology for the conduct of a SR on mycotoxin-related human health risks, that could guide future research and inform regulatory decisions, as emphasized by the European Commission within the field of regulatory risk assessment for emerging chemicals.

Vulnerable newborn types: analysis of subnational, population-based birth cohorts for 541 285 live births in 23 countries, 2000-2021.

OBJECTIVE: To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021. DESIGN: Descriptive multi-country secondary data analysis. SETTING: Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021. POPULATION: Liveborn infants. METHODS: Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study. RESULTS: Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%). CONCLUSIONS: Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.

Factors influencing the reinforcing value of fruit and unhealthy snacks.

OBJECTIVE: The present study investigated the reinforcing value of healthy and unhealthy snack food in adolescents (n = 108, aged 14-16 years). Moderation by access to different foods, sex and the personality trait reward sensitivity is tested. METHODS: In a computerized Food Reinforcement Task, adolescents could earn portions of a healthy and an unhealthy snack following an identical progressive reinforcement schedule for both food types. Reinforcing value of food was indexed by the number of button presses for each food type. Participants were allocated randomly to two-order condition: fruit-snack versus snack-fruit. Reward sensitivity was assessed with the Dutch age-downward version of Carver and White's BIS/BAS scale. RESULTS: Results showed that the reinforcing value of an unhealthy snack is higher than that of fruit, with participants making more button presses for unhealthy snacks, M = 1280.40, SD = 1203.53, than for fruit, M = 488.04, SD = 401.45, F(1,48) = 25.37, p < 0.001. This effect is stronger in boys (ß = -1367.67) than in girls (ß = -548.61). The effect is only present in the snack-fruit condition, not in the fruit-snack condition, indicating that access to food moderates the effect of food type. There is no evidence for moderation by reward sensitivity. CONCLUSIONS: Results point to the importance of simultaneously increasing barriers to obtain unhealthy food and promoting access to healthy food in order to facilitate healthy food choices.

Eating at restaurants, at work or at home. Is there a difference? A study among adults of 11 European countries in the context of the HECTOR* project.

BACKGROUND/OBJECTIVES: To compare macronutrient intakes out of home-by location-to those at home and to investigate differences in total daily intakes between individuals consuming more than half of their daily energy out of home and those eating only at home. SUBJECTS/METHODS: Data collected through 24-h recalls or diaries among 23 766 European adults. Participants were grouped as 'non-substantial', 'intermediate' and 'very substantial out-of-home' eaters based on energy intake out of home. Mean macronutrient intakes were estimated at home and out of home (overall, at restaurants, at work). Study/cohort-specific mean differences in total intakes between the 'very substantial out-of-home' and the 'at-home' eaters were estimated through linear regression and pooled estimates were derived. RESULTS: At restaurants, men consumed 29% of their energy as fat, 15% as protein, 45% as carbohydrates and 11% as alcohol. Among women, fat contributed 33% of energy intake at restaurants, protein 16%, carbohydrates 45% and alcohol 6%. When eating at work, both sexes reported 30% of energy from fat and 55% from carbohydrates. Intakes at home were higher in fat and lower in carbohydrates and alcohol. Total daily intakes of the 'very substantial out-of-home' eaters were generally similar to those of individuals eating only at home, apart from lower carbohydrate and higher alcohol intakes among individuals eating at restaurants. CONCLUSIONS: In a large population of adults from 11 European countries, eating at work was generally similar to eating at home. Alcoholic drinks were the primary contributors of higher daily energy intakes among individuals eating substantially at restaurants.

Development and validation of a quantitative snack and beverage food frequency questionnaire for adolescents.

BACKGROUND: A short, reliable and valid tool to measure snack and beverage consumption in adolescents, taking into account the correct definitions, would benefit both epidemiological and intervention research. The present study aimed to develop a short quantitative beverage and snack food frequency questionnaire (FFQ) and to assess the reliability and validity of this FFQ against three 24-h recalls. METHODS: Reliability was assessed by comparing estimates of the FFQ administered 14 days apart (FFQ1 and FFQ2) in a convenience sample of 179 adolescents [60.3% male; mean (SD) 14.7 (0.9) years]. Validity was assessed by comparing FFQ1 with three telephone-administered 24-h recalls in a convenience sample of 99 adolescents [52.5% male, mean (SD) 14.8 (0.9) years]. Reliability and validity were assessed using Bland-Altman plots, classification agreements and correlation coefficients for the amount and frequency of consumption of unhealthy snacks, healthy snacks, unhealthy beverages, healthy beverages, and for the healthy snack and beverage ratios. RESULTS: Small mean differences (FFQ1 versus FFQ2) were observed for reliability, ranking ability ranged from fair to substantial, and Spearman coefficients fell within normal ranges. For the validity, mean differences (FFQ1 versus recalls) were small for beverage intake but large for snack intake, except for the healthy snack ratio. Ranking ability ranged from slightly to moderate, and Spearman coefficients fell within normal ranges. CONCLUSIONS: Reliability and validity of the FFQ for all outcomes were found to be acceptable at a group level for epidemiological purposes, whereas for intervention purposes only the healthy snack and beverage ratios were found to be acceptable at a group level.

Strengthening the Reporting of Observational Studies in Epidemiology - nutritional epidemiology (STROBE-nut): An extension of the STROBE statement.

Concerns have been raised about the quality of reporting in nutritional epidemiology. Research reporting guidelines such as the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement can improve quality of reporting in observational studies. Herein, we propose recommendations for reporting nutritional epidemiology and dietary assessment research by extending the STROBE statement into Strengthening the Reporting of Observational Studies in Epidemiology - Nutritional Epidemiology (STROBE-nut). Recommendations for the reporting of nutritional epidemiology and dietary assessment research were developed following a systematic and consultative process, co-ordinated by a multidisciplinary group of 21 experts. Consensus on reporting guidelines was reached through a three-round Delphi consultation process with 53 external experts. In total, 24 recommendations for nutritional epidemiology were added to the STROBE checklist. When used appropriately, reporting guidelines for nutritional epidemiology can contribute to improve reporting of observational studies with a focus on diet and health.

Using a gamified monitoring app to change adolescents' snack intake: the development of the REWARD app and evaluation design.

BACKGROUND: As the snacking pattern of European adolescents is of great concern, effective interventions are necessary. Till now health promotion efforts in children and adolescents have had only limited success in changing adolescents' eating patterns and anthropometrics. Therefore, the present study proposes an innovative approach to influence dietary behaviors in youth based on new insights on effective behavior change strategies and attractive intervention channels to engage adolescents. This article describes the rationale, the development, and evaluation design of the 'Snack Track School' app. The aim of the app is to improve the snacking patterns of Flemish 14- to 16-year olds. METHODS: The development of the app was informed by the systematic, stepwise, iterative, and collaborative principles of the Intervention Mapping protocol. A four week mHealth intervention was developed based on the dual-system model with behavioral change strategies targeting both the reflective (i.e., active learning, advance organizers, mere exposure, goal-setting, monitoring, and feedback) and automatic processes (i.e., rewards and positive reinforcement). This intervention will be evaluated via a controlled pre-post design in Flemish schools among 1400 adolescents. DISCUSSION: When this intervention including strategies focused on both the reflective and automatic pathway proves to be effective, it will offer a new scientifically-based vision, guidelines and practical tools for public health and health promotion (i.e., incorporation of learning theories in intervention programs). TRIAL REGISTRATION: NCT02622165 registrated November 15, 2015 on clinicaltrials.gov.

Prevalence and socioeconomic differences of risk factors of cardiovascular disease in Ecuadorian adolescents.

PURPOSE: The aim of this paper is to report the prevalence of cardiovascular risk factors and socioeconomic differences in school-going Ecuadorian adolescents. METHODS: A cross-sectional study was performed from January 2008 until April 2009 in 770 adolescents aged 10 to 16 years old, who attend secondary schools in an urban (Cuenca), and rural area (Nabón) in Ecuador. Data collected for the overall sample included anthropometric variables (weight, height and waist circumference), blood pressure and socio-demographic characteristics. Fasting blood glucose and lipid profile determinations were collected in a subsample of 334 adolescents. RESULTS: The most prevalent cardiovascular risk factors were dyslipidemia (34.2%), abdominal obesity (19.7%) and overweight (18.0%). The prevalence of the remaining cardiovascular risk factors were high levels of blood pressure (6.2%) and obesity (2.1%). Boys were 3.3 times (P < 0.001) more likely to have risk levels of blood pressure. Compared to their peers from lower socioeconomic groups, children from better off socioeconomic strata were 1.5 times (P = 0.048) more likely to be overweight/obese and 1.5 times (P = 0.046) more likely to have abdominal obesity. Overweight and obese children were 4.4 times more likely to have dyslipidemia (P < 0.001). Children living in the rural area were 2.8 times (P = 0.002) more likely to have dyslipidemia than those from the urban area. CONCLUSIONS: Our results demonstrate the advanced levels of the nutrition transition in this Ecuadorian adolescent population. Primary health care should monitor and take actions to address this public health problem in adolescents.

Eating out of home and its association with dietary intake: a systematic review of the evidence.

During the last decades, eating out of home (OH) has gained importance in the diets worldwide. We document the nutritional characteristics of eating OH and its associations with energy intake, dietary quality and socioeconomic status. We carried out a systematic review of peer-reviewed studies in eight databases up to 10 March 2011. Of the 7,319 studies retrieved, 29 met the inclusion criteria and were analysed in this review. The quality of the data was assessed and a sensitivity analysis was conducted by isolating nationally representative or large cohort data from 6 and 11 countries, respectively. OH foods were important sources of energy in all age groups and their energy contribution increased in adolescents and young adults. Eating OH was associated with a higher total energy intake, energy contribution from fat in the daily diet and higher socioeconomic status. Two large studies showed how eating OH was also associated with a lower intake of micronutrients, particularly vitamin C, Ca and Fe. Although the studies were cross-sectional and heterogeneous in the way they classified eating OH, we conclude that eating OH is a risk factor for higher energy and fat intake and lower micronutrient intake.

Validity of photographs for food portion estimation in a rural West African setting.

OBJECTIVE: To validate food photographs for food portion size estimation of frequently consumed dishes, to be used in a 24-hour recall food consumption study of pregnant women in a rural environment in Burkina Faso. This food intake study is part of an intervention evaluating the efficacy of prenatal micronutrient supplementation on birth outcomes. SUBJECTS: Women of childbearing age (15-45 years). DESIGN: A food photograph album containing four photographs of food portions per food item was compiled for eight selected food items. Subjects were presented two food items each in the morning and two in the afternoon. These foods were weighed to the exact weight of a food depicted in one of the photographs and were in the same receptacles. The next day another fieldworker presented the food photographs to the subjects to test their ability to choose the correct photograph. RESULTS: The correct photograph out of the four proposed was chosen in 55% of 1028 estimations. For each food, proportions of underestimating and overestimating participants were balanced, except for rice and couscous. On a group level, mean differences between served and estimated portion sizes were between -8.4% and 6.3%. Subjects who attended school were almost twice as likely to choose the correct photograph. The portion size served (small vs. largest sizes) had a significant influence on the portion estimation ability. CONCLUSIONS: The results from this study indicate that in a West African rural setting, food photographs can be a valuable tool for the quantification of food portion size on group level.

[A review of the nutritional management plans in the member states of the European Union]. / Een overzicht van de nutritionele beleidsplannen in de lidstaten van de Europese Unie.

Obesity has reached epidemiological proportions in Europe and the burden of diseases attributable to nutrition is substantial. Under the impetus of the World Health Organisation (WHO), member states have been urged to develop national action plans for nutrition and physical activity. This study describes what has been done in terms of nutrition policy at national level in the member states of the European Union right before its enlargement in 2004. It is a critical review of publicly available policy documents on nutrition and physical activity. The background idea was to assist the initiative of the Belgian food industry to play a proactive role in the development of a Belgian nutrition action plan. At the time of writing, in total six out of the fifteen EU member states namely Sweden, Finland, Denmark, France, the Netherlands and the United Kingdom, reported to have an operational national nutrition plan. By the end of the year 2004, another four countries are expected to have their plan finalised. In line with WHO guidelines, all nutrition plans in this study acknowledge the importance of a multidisciplinary approach and promote stakeholder involvement at some point. Most of the plans however, do not elaborate on their specific role and strategies that will be used to do so. It seems that stakeholder mobilisation is largely restricted to the implementation phases. All operational nutrition plans envisage reducing social disparities. Long-established vulnerable groups in society such as pregnant women, children and elderly are targeted. Considerable variability was observed for nutritional objectives and dietary recommendations between the different countries. Nutrition surveillance and monitoring activities seem to vary considerably between the different action plans. None of the countries except Denmark documents the theoretical foundations and development process of their nutritional surveillance system. National nutrition policy in Europe is clearly in a state of flux and the centre of gravity seems to move away from Scandinavia. Although the importance of nutritional surveillance, comprehensive approach to nutritional problems and stakeholder involvement is recognised by the action plans, the rationale, justification and mechanisms for it is vaguely described. Our findings call for increased efforts to strengthen the evidence base of public health nutrition policy. To achieve this however, systematic evaluations and proper reporting of which health and nutrition promotion strategies work in the different countries in the EU are urgently needed.