Toward healthy and sustainable diets for the 21st century: Importance of sociocultural and economic considerations.

Four years after the EAT-Lancet landmark report, worldwide movements call for action to reorient food systems to healthy diets that respect planetary boundaries. Since dietary habits are inherently local and personal, any shift toward healthy and sustainable diets going against this identity will have an uphill road. Therefore, research should address the tension between the local and global nature of the biophysical (health, environment) and social dimensions (culture, economy). Advancing the food system transformation to healthy, sustainable diets transcends the personal control of engaging consumers. The challenge for science is to scale-up, to become more interdisciplinary, and to engage with policymakers and food system actors. This will provide the evidential basis to shift from the current narrative of price, convenience, and taste to one of health, sustainability, and equity. The breaches of planetary boundaries and the environmental and health costs of the food system can no longer be considered externalities. However, conflicting interests and traditions frustrate effective changes in the human-made food system. Public and private stakeholders must embrace social inclusiveness and include the role and accountability of all food system actors from the microlevel to the macrolevel. To achieve this food transformation, a new "social contract," led by governments, is needed to redefine the economic and regulatory power balance between consumers and (inter)national food system actors.

Senior citizens' vitamin D supplements intake: evidence from Denmark.

BACKGROUND: Several public interventions have been designed in recent years to urge the intake of vitamin D supplements among the senior population to avoid the direct and indirect consequences associated with vitamin D deficiency. However, the effectiveness of these public campaigns remains quite limited. In an online survey, the current study investigates attitudes towards vitamin D supplements intake and associated behaviours in a representative sample of Danish senior citizens (N = 554) - that is, individuals aged 55 years and above. RESULTS: Approximately half of the sample reported taking vitamin D supplements in the preceding year. Furthermore, being male and having a positive perception of individuals' own health status increased the probability of being a non-user. Increasing confidence in the information provided by health authorities (such as medical doctors and pharmacies) is particularly critical for enhancing the likelihood of non-users to purchase vitamin D supplements. However, also encouraging the uptake of vitamin D supplements in specialized supermarkets with stands and promotions seems an appealing and practical solution to increase seniors' uptake of vitamin D supplements. CONCLUSIONS: The present study outlines the characteristics of senior Danish non-users of vitamin D supplements. Additionally, the research provides information on the strategies that could be applied by public organizations to foster vitamin D supplements intake among this target segment of the population. © 2023 The Authors. Journal of The Science of Food and Agriculture published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Impact of health claims: what has been achieved and what is the future?

Using health claims on foods in the European Union and the United States for more than two decades did not have a noticeable positive impact on public health and neither on the innovation or sales of such food products. The objective was to assess the reasons for this limited impact using a narrative review approach. Consumers assess the value of health claims on foods case-by-case in a way that can be explored with the opportunity, ability, and motivation framework. Perceived relevance of a health claim seems to be an important motivational factor in consumer responses. Thus, targeted marketing of foods with health claims should be applied specifically to those consumers for which the claimed benefit is relevant. Language for the health claim should be used that is reflective for the scientific substantiation as well as credible and clearly understood by the target consumer. The food should be a credible carrier for the claimed benefit, and not be compromised on taste and other sensory properties. Finally, consumers should be made more aware of what health claims are, and what they are not, in relation to healthy eating. With these adaptations the use and impact of health claims may become more effective.

Users' Experiences With the NoHoW Web-Based Toolkit With Weight and Activity Tracking in Weight Loss Maintenance: Long-term Randomized Controlled Trial.

BACKGROUND: Digital behavior change interventions (DBCIs) offer a promising channel for providing health promotion services. However, user experience largely determines whether they are used, which is a precondition for effectiveness. OBJECTIVE: The primary aim of this study is to evaluate user experiences with the NoHoW Toolkit (TK)-a DBCI that targets weight loss maintenance-over a 12-month period by using a mixed methods approach and to identify the main strengths and weaknesses of the TK and the external factors affecting its adoption. The secondary aim is to objectively describe the measured use of the TK and its association with user experience. METHODS: An 18-month, 2×2 factorial randomized controlled trial was conducted. The trial included 3 intervention arms receiving an 18-week active intervention and a control arm. The user experience of the TK was assessed quantitatively through electronic questionnaires after 1, 3, 6, and 12 months of use. The questionnaires also included open-ended items that were thematically analyzed. Focus group interviews were conducted after 6 months of use and thematically analyzed to gain deeper insight into the user experience. Log files of the TK were used to evaluate the number of visits to the TK, the total duration of time spent in the TK, and information on intervention completion. RESULTS: The usability level of the TK was rated as satisfactory. User acceptance was rated as modest; this declined during the trial in all the arms, as did the objectively measured use of the TK. The most appreciated features were weekly emails, graphs, goal setting, and interactive exercises. The following 4 themes were identified in the qualitative data: engagement with features, decline in use, external factors affecting user experience, and suggestions for improvements. CONCLUSIONS: The long-term user experience of the TK highlighted the need to optimize the technical functioning, appearance, and content of the DBCI before and during the trial, similar to how a commercial app would be optimized. In a trial setting, the users should be made aware of how to use the intervention and what its requirements are, especially when there is more intensive intervention content. TRIAL REGISTRATION: ISRCTN Registry ISRCTN88405328; https://www.isrctn.com/ISRCTN88405328. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2019-029425.

Issues surrounding consumer trust and acceptance of existing and emerging food processing technologies.

The purpose of food processing today is to make food safer, more nutritious and tastier, and to increase storage life. Consumers have a lack of trust in the way food is produced, formulated and processed, particularly with possible contaminants or chemical residues from production. Food manufacturers are not seen as being highly trusted sources. This may partly result from manufacturers' reluctance to share all information and to protect intellectual property via patents and thus maintain a competitive edge. There is a need to inform the consumer better about what operations the involved ingredients are subjected to and why. Various ways of food processing are reviewed. New food processing technologies face challenges when introduced and factors influencing consumers' and other stakeholders' acceptance should be part of decision-making process when adopting new technologies. Consumers' perception of risks is not the same as the risk assessment made by experts. A few specific cases are being discussed to further highlight the multiplicity of factors that may contribute to the development of a certain consumer perception about a product or a class of products. This is also linked to the emergence of certain terminologies that are associated with an increasingly negative perception of the processing of foods. We recommend more transparency on food formulation and food processing to restore consumer trust, which enables to take the advantage of the benefits different processing methods offer. Food manufacturers must make an effort to let consumers know how their food is being processed within the walls of the factory and highlight the benefits vis-à-vis preparing foods in a domestic environment.

Comparison of requirements for using health claims on foods in the European Union, the USA, Canada, and Australia/New Zealand.

Nutrition is recognized as one of the leading factors influencing the growing incidence of noncommunicable diseases. Despite society experiencing a global rise in obesity, specific populations remain at risk of nutrient deficiencies. The food industry can use health claims to inform consumers about the health benefits of foods through labeling and the broader promotion of specific food products. As health claims are carefully regulated in many countries, their use is limited due to considerable investments required to fulfill the regulatory requirement. Although health claims represent a driving force for innovation in the food industry, the risk of misleading of consumers need to be avoided. The health claim scientific substantiation process must be efficient and transparent in order to meet the needs of companies in the global market, but should be based on strong scientific evidence and plausible mechanisms of actions, to ensure highest level of consumer protection. The objective of this review is to compare the possibilities for using health claims on foods in the European Union, the USA, Canada, and Australia and New Zealand. In particular, we focused on differences in the classification of claims, on the scientific substantiation processes and requirements for health claims use on foods in the selected regions. Reduction of disease risk (RDR) claims are associated with relatively similar procedures and conditions for use, whereas several notable differences were identified for other types of claims. In all cases, RDR claims must be approved prior their introduction to the market, and only a few such claims have been authorized. Much greater differences were observed concerning other types of claims.

Determinants of intention to reduce salt intake and willingness to purchase salt-reduced food products: Evidence from a web survey.

To study consumers' intention to reduce their dietary salt intake and willingness to purchase salt-reduced food products, as well as the determinants of these, this research relies on data collected through a web survey of 1030 participants in Denmark. The majority of respondents (66.8%) express no intentions to change their dietary salt intake, but 12.6% indicate such intentions, and 20.6% claim to have already implemented a change. Willingness to purchase salt-reduced food products is high but varies across product categories, ranging from 52% for olives to 72% for meat spreads. Personal and social norms reveal the strongest influences on intention to change dietary habits, whereas personal norms, knowledge, and awareness of health consequences exert the strongest influences on willingness to purchase salt-reduced food products. These results suggest that most consumers are willing to purchase salt-reduced food products, even without having a salt reduction goal. These results are relevant for stakeholders and policy makers, as evidence of how consumers respond to salt-reduced food products and their intention to lower their dietary salt intake.

How attitude towards food fortification can lead to purchase intention.

This research examines how consumers' general attitude towards food fortification can lead to their intention to purchase vitamin D fortified food. Specifically, it is argued that this effect can be mediated by the perceived personal benefit of consuming vitamin D fortified food; and that the indirect effect is moderated by problem awareness and the perceived appropriateness of vitamin D fortification in a given food product category. Perceived personal benefit and problem awareness reflect the individual versus public interest to improve health, respectively. The model is tested among a sample of 1263 adult consumers who evaluated ten mainly animal-based food products, including dairy and processed meat products. Results of moderated mediation analysis indicate that general attitude towards food fortification are associated with perceived personal benefit, especially under conditions of high problem awareness. Purchase intention of vitamin D fortified food does not only depend on consumers' assessment of their personal benefit of enriching foods with vitamin D, but also the perceived appropriateness of a given product to be fortified. Importantly, high appropriateness can offset the attenuated effect associated with low problem awareness.

Attribution of weight regain to emotional reasons amongst European adults with overweight and obesity who regained weight following a weight loss attempt.

PURPOSE: Despite the wide availability of effective weight loss programmes, maintenance of weight loss remains challenging. Difficulties in emotion regulation are associated with binge eating and may represent one barrier to long-term intervention effectiveness in obesity. The purpose of this study was to determine the relationship between emotion regulation difficulties and the extent of weight regain in a sample of adults who had lost, and then regained, weight, and to examine the characteristics associated with emotional difficulties. METHODS: 2000 adults from three European countries (UK, Portugal, and Denmark) completed an online survey assessing self-reported weight loss and regain following their most recent weight loss attempt. They also completed a binge eating disorder screening questionnaire and, if they had regained weight, were asked if they attributed it to any emotional factors (a proxy for emotion regulation difficulties). Spearman's correlations and logistic regression were used to assess the associations between emotion regulation, weight regain, and strategy use. RESULTS: Emotion regulation difficulties were associated with greater weight regain (N = 1594 who lost and regained weight). Attribution to emotional reasons was associated with younger age, female gender, loss of control and binge eating, lower perceptions of success at maintenance, using more dietary and self-regulatory strategies in weight loss, and fewer dietary strategies in maintenance. CONCLUSIONS: Weight-related emotion regulation difficulties are common amongst regainers and are associated with regaining more weight. Affected individuals are already making frequent use of behavioural strategies during weight loss, but do not apply these consistently beyond active attempts. Simply encouraging the use of more numerous strategies, without concurrently teaching emotion regulation skills, may not be an effective means to improving weight outcomes in this group. LEVEL OF EVIDENCE: Level V, descriptive (cross-sectional) study.

Foods with increased protein content: A qualitative study on European consumer preferences and perceptions.

Foods with increased protein content have rapidly become one of the fastest-growing product categories targeting image- and health-focused consumers. However, it is not clear whether consumers really understand the difference between 'inherently rich in protein' and 'artificially increased protein'. This study used a qualitative focus group approach to investigate the consumer preferences and perceptions of foods with increased protein content among mixed-age and older population in four European countries. In total fifty-two participants were involved in the study. Understanding of the concept of foods with 'increased protein' content was limited. Both older and mixed-age participants could not differentiate between natural sources of protein and foods with increased protein content, no matter whether foods with animal or plant proteins were mentioned. Older participants expressed more scepticism towards foods with increased protein content than mixed-age participants. The combination of protein type and food carrier closer to conventional foods received more acceptance among both older and mixed-age participants. Future use and acceptance of foods with increased protein content will depend on the extent to which consumer concerns about incorporating additional protein into a diet can be responded.

Determinants of consumer food waste behaviour: Two routes to food waste.

Approximately one quarter of the food supplied for human consumption is wasted across the food supply chain. In the high income countries, the food waste generated at the household level represents about half of the total food waste, making this level one of the biggest contributors to food waste. Yet, there is still little evidence regarding the determinants of consumers' food waste behaviour. The present study examines the effect of psycho-social factors, food-related routines, household perceived capabilities and socio-demographic characteristics on self-reported food waste. Survey data gathered among 1062 Danish respondents measured consumers' intentions not to waste food, planning, shopping and reuse of leftovers routines, perceived capability to deal with household food-related activities, injunctive and moral norms, attitudes towards food waste, and perceived behavioural control. Results show that perceived behavioural control and routines related to shopping and reuse of leftovers are the main drivers of food waste, while planning routines contribute indirectly. In turn, the routines are related to consumers' perceived capabilities to deal with household related activities. With regard to intentional processes, injunctive norms and attitudes towards food waste have an impact while moral norms and perceived behavioural control make no significant contribution. Implications of the study for initiatives aimed at changing consumers' food waste behaviour are discussed.

Determinants of meal satisfaction in a workplace environment.

Workplace lunches are recurrent meal occasions that can contribute to the general well-being of employees. The objective of our research was to study which factors influence consumers' satisfaction with these meals by exploring the relative role of food-related, personal, situational factors. Using a longitudinal approach, we monitored a total of 71 participants compiled and experienced 519 meals from their workplace canteen buffet during a three-month period; in addition the composed lunches were photographed. Before and after the lunch choice period respondents filled in a questionnaire on several meal-related variables. A mixed modelling approach was used to analyse the data. Meal satisfaction was directly associated with a positive ambience and a positive evaluation of both the quality of the food eaten and the buffet assortment, whereas the meal's energy content did not contribute to meal satisfaction. Additionally, meal satisfaction was associated with a more positive mood, lower hunger level as well as feeling less busy and stressed after lunch. The buffet assortment, a more positive mood before lunch and mindful eating contributed to the perceived food quality, but not associated with the hunger level before lunch. Time available, mindful eating and eating with close colleagues were positively associated with perceived ambience. The results indicate that consumers' satisfaction with workplace meals can be increased by putting emphasis on the quality of food served, but equally important is the ambience in the lunch situation. Most of the ambience factors were related to available time and mental resources of the participants and the possibility to share the meal with close colleagues. These are factors that can be facilitated by the service provider, but not directly influenced.

Are food-related perceptions associated with meal portion size decisions? A cross-sectional study.

The purpose of this study was to test a comprehensive model of meal portion size determinants consisting of sociodemographic, psychological and food-related variables, whilst controlling for hunger and thirst. Using cross-sectional nationally representative data collected in 2075 participants from the Island of Ireland (IoI) and Denmark (DK), eight separate hierarchical multiple regression analyses were conducted to examine the association between food-related variables and meal portion size (i.e. pizza, vegetable soup, chicken salad and a pork meal) within each country. Stepwise regressions were run with physiological control measures (hunger and thirst) entered in the first step, sociodemographic variables (sex, age, body mass index (BMI)) in the second step; psychological variables (cognitive restraint, uncontrolled eating, emotional eating, general health interest (GHI)) in the third step and food-related variables (expected fillingness, liking, expected healthfulness, food familiarity) in the fourth step. Sociodemographic variables accounted for 2-19% of the variance in meal portion sizes; psychological variables explained an additional 3-8%; and food-related variables explained an additional 2-12%. When all four variable groups were included in the regression models, liking and sometimes expected healthfulness was positively associated with meal portion size. The strongest association was for liking, which was statistically significant in both countries for all meal types. Whilst expected healthfulness was not associated with pizza portion size in either country, it was positively associated with meals that have a healthier image (vegetable soup; chicken salad and in IoI, the pork meal). In conclusion, after considering sociodemographic and psychological variables, and the food-related variables of liking and expected healthfulness, there may be little merit in manipulating the satiating power, at least of these type of meals, to maintain or promote weight loss.

The mediation effect of emotional eating between depression and body mass index in the two European countries Denmark and Spain.

In two European countries with a different prevalence of depression, namely Denmark (high) and Spain (low), we assessed whether the mediation effect of emotional eating between depression and Body Mass Index (BMI) as found in earlier studies can be replicated and whether this mediation effect is contingent on 1) change in appetite and 2) gender. Mediation and moderated mediation was assessed with Hayes' PROCESS macro in SPSS. Emotional eating (DEBQ: Dutch Eating Behavior Questionnaire), depressive symptoms (CES-D: Center for Epidemiologic Studies Depression Scale), change in appetite, weight and height were self-reported. In both countries, emotional eating acted as a mediator between depression and BMI (Denmark: B = 0.03 (SE = 0.01), 95% CI, [0.03, 0.05]; Spain: B = 0.03 (SE = 0.01), 95% CI, [0.02, 0.04]). In Denmark this mediation effect was stronger for participants with increased appetite and for females than for participants with decreases/no change in appetite and for males (more appetite: B = 0.08, (SE = 0.03), [0.03, 0.15]; decreased appetite/no change in appetite: B = 0.03 (SE = 0.01), [0.02, 0.04]); females: B = 0.05 (SE = 0.01), [0.03, 0.07]; males: B = 0.01 (SE = 0.01), [0.004, 0.04]. This supports depression with atypical features as an underlying mechanism in the mediation effect of emotional eating. In Spain there was no support for depression with atypical features as underlying mechanism because the mediation effect was neither moderated by change in appetite nor by gender. Instead, post-hoc analyses suggested 'stress of unemployment' as possible explanatory factor of the mediation effect, with stronger mediation effects for unemployed than for employed people (unemployed: B = 0.05 (SE = 0.01), [0.03, 0.07]; employed B = 0.02 (SE = 0.01), [0.01, 0.04]). The mediating effect of emotional eating between depressive symptoms and body mass index in both countries suggests that obesity interventions should take emotional eating into account.

Communication of scientific uncertainty: international case studies on the development of folate and vitamin D Dietary Reference Values.

OBJECTIVE: Transparent evidence-based decision making has been promoted worldwide to engender trust in science and policy making. Yet, little attention has been given to transparency implementation. The degree of transparency (focused on how uncertain evidence was handled) during the development of folate and vitamin D Dietary Reference Values was explored in three a priori defined areas: (i) value request; (ii) evidence evaluation; and (iii) final values. DESIGN: Qualitative case studies (semi-structured interviews and desk research). A common protocol was used for data collection, interview thematic analysis and reporting. Results were coordinated via cross-case synthesis. SETTING: Australia and New Zealand, Netherlands, Nordic countries, Poland, Spain and UK. SUBJECTS: Twenty-one interviews were conducted in six case studies. RESULTS: Transparency of process was not universally observed across countries or areas of the recommendation setting process. Transparency practices were most commonly seen surrounding the request to develop reference values (e.g. access to risk manager/assessor problem formulation discussions) and evidence evaluation (e.g. disclosure of risk assessor data sourcing/evaluation protocols). Fewer transparency practices were observed to assist with handling uncertainty in the evidence base during the development of quantitative reference values. CONCLUSIONS: Implementation of transparency policies may be limited by a lack of dedicated resources and best practice procedures, particularly to assist with the latter stages of reference value development. Challenges remain regarding the best practice for transparently communicating the influence of uncertain evidence on the final reference values. Resolving this issue may assist the evolution of nutrition risk assessment and better inform the recommendation setting process.

EURRECA-A framework for considering evidence in public health nutrition policy development.

A key step toward developing appropriate evidence-based public health nutrition policies is determining exactly how that evidence should be collected and assessed. Despite this the extent to which different evidence bases influence policy selection is rarely explored. This article presents an epistemological framework which offers a range of considerations affecting this process generally and with particular implications for both micronutrient requirements and the role of behavior in the policy-making process. Qualitative case study data covering 6 European countries/regions (Czech Republic, Italy, the Netherlands, Nordic countries, Poland, and Spain), and three micronutrients (folate, iodine, and vitamin D), have been presented to illustrate the relevance of the Framework.

Supporting consumers' informed food choices: Sources, channels, and use of information.

Information about food is available from several sources using a variety of communication channels. Following an overview of the different types on food information, the most important source/channel combinations are discussed. The key steps in processing the information toward making a food choice are discussed: consumer's exposure to such information, the attention the consumer pays to it, the understanding and/or liking of the information, as well as the importance of motivation, knowledge, and trust. To support consumers in making informed food choices, it is recommended to ensure that food information is easy to understand and targeted to consumers with a specific need or interest, align the information on the food label with the communication about the food elsewhere ("off label"), provide (non-expert) influencers with transparent information to enable an increase in the trustworthiness of their communications on the web in on social media. Furthermore, increase cooperation between authorities and food producers to create standards that fulfill the legal requirements and are feasible as label elements. Improving food literacy among consumers by including it in formal education would provide consumers with better nutrition knowledge and skills to interpret food-related information in a manner that supports informed choices.

Food-related consumer behaviours in times of crisis: Changes in the wake of the Ukraine war, rising prices and the aftermath of the COVID-19 pandemic.

When the COVID-19 pandemic subsided, the war in Ukraine led to further disruptions in consumers' daily behaviours, with rising prices for food and energy. We conducted a survey study on self-reported changes in food-related consumer behaviour in ten European countries and compared the results to a similar study conducted two years ago. A latent class cluster analysis distinguished five clusters and showed that different types of consumers can be distinguished based on how they react to the crisis as regards their eating habits. 19% of survey participants reported no major changes, and 32% reported changes mostly in terms of more price sensitivity. Among those that reported changes beyond reacting to higher prices, there are indications of more mindful eating and more deliberate choices. The changes already found earlier in response to the COVID-19 pandemic therefore seem to have been strengthened and supplemented by reactions to price increases. The results present a challenge to the food industry in terms of supplying healthy and sustainable food at affordable prices.

Changing micronutrient intake through (voluntary) behaviour change. The case of folate.

The objective of this study was to relate behaviour change mechanisms to nutritionally relevant behaviour and demonstrate how the different mechanisms can affect attempts to change these behaviours. Folate was used as an example to illuminate the possibilities and challenges in inducing behaviour change. The behaviours affecting folate intake were recognised and categorised. Behaviour change mechanisms from "rational model of man", behavioural economics, health psychology and social psychology were identified and aligned against folate-related behaviours. The folate example demonstrated the complexity of mechanisms influencing possible behavioural changes, even though this only targets the intake of a single micronutrient. When considering possible options to promote folate intake, the feasibility of producing the desired outcome should be related to the mechanisms of required changes in behaviour and the possible alternatives that require no or only minor changes in behaviour. Dissecting the theories provides new approaches to food-related behaviour that will aid the development of batteries of policy options when targeting nutritional problems.

A review of consumer awareness, understanding and use of food-based dietary guidelines.

Food-based dietary guidelines (FBDG) have primarily been designed for the consumer to encourage healthy, habitual food choices, decrease chronic disease risk and improve public health. However, minimal research has been conducted to evaluate whether FBDG are utilised by the public. The present review used a framework of three concepts, awareness, understanding and use, to summarise consumer evidence related to national FBDG and food guides. Searches of nine electronic databases, reference lists and Internet grey literature elicited 939 articles. Predetermined exclusion criteria selected twenty-eight studies for review. These consisted of qualitative, quantitative and mixed study designs, non-clinical participants, related to official FBDG for the general public, and involved measures of consumer awareness, understanding or use of FBDG. The three concepts of awareness, understanding and use were often discussed interchangeably. Nevertheless, a greater amount of evidence for consumer awareness and understanding was reported than consumer use of FBDG. The twenty-eight studies varied in terms of aim, design and method. Study quality also varied with raw qualitative data, and quantitative method details were often omitted. Thus, the reliability and validity of these review findings may be limited. Further research is required to evaluate the efficacy of FBDG as a public health promotion tool. If the purpose of FBDG is to evoke consumer behaviour change, then the framework of consumer awareness, understanding and use of FBDG may be useful to categorise consumer behaviour studies and complement the dietary survey and health outcome data in the process of FBDG evaluation and revision.