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Despite increased political attention, foodborne diseases still cause a substantial public health, economic, and social burden worldwide. Children younger than 5 years, people living in developing regions, and in the poorest areas of the world are disproportionally affected, bearing a large proportion of the global burden of foodborne disease. Yet, food safety is a prerequisite to ensuring food security globally: Foods that are responsible for important food safety problems are also crucial to ensure food security in some regions and are essential sources of nutrition. Moreover, together with calls for action to meeting international sustainable development goals, global efforts to promote food security and healthy diets have now highlighted the need to modify food systems globally. This article therefore explores the food safety dimensions of transitions toward food systems that promote sustainable healthy diets. The current body of evidence points to the combined health and environmental benefits of shifting toward a more plant-based diet, including vegetables and fruits, nuts, pulses, and whole grains. As a shift toward more plant-based diets may also lead to higher exposures to chemicals or pathogens present in these foods, an evaluation of food safety implications of such transitions is now imperative. We conclude that several synergies between public health, environmental, and food safety strategies can be identified to support dietary transitions.

Exposure to chemical contaminants found in foods has been associated with diverse adverse health effects. The aim of this study was to estimate the burden of disease associated with dietary exposure to four chemicals in Denmark in 2019: lead (Pb), cadmium (Cd), methylmercury (MeHg), and inorganic arsenic (i-As). We collected national food consumption and chemical food monitoring data from Danish databases, dose-response and severity data from the scientific literature, and disease incidence and population numbers from national statistics. We adopted a risk assessment approach to estimate disease burden, quantifying incidence, mortality, and Disability-Adjusted Life Years (DALYs) attributable to dietary exposure to the chemicals. In all models, we propagated uncertainty around the input parameters through the calculations using Monte Carlo simulation. We estimated that, among these chemicals, Pb and MeHg were responsible for the highest disease burden. MeHg led to the loss of nearly 600 healthy life years, or approximately 10 DALYs per 100,000 inhabitants. Dietary exposure to Pb was estimated to cause 383 to 1,261 DALYs, corresponding to 6.6 (lower bound) to 22 (upper bound) DALYs/100,000 per year. The foods contributing most to disease burden were fish (MeHg) and sweets, fruit, and bread and cereals (Pb). The burden attributed to dietary exposure to i-As (5 DALYs) and Cd (0.04 DALY) was substantially lower. Interpretation of estimates needs to consider all underlying uncertainties, linked with data and knowledge gaps. These estimates are useful supplements to traditional risk assessment to guide food safety interventions and inform dietary guidelines for different population groups.

This article belongs to the Section Pediatric Nutrition. Cereal-based foods, including breakfast (BC) and infant cereals (IC), are among the first solid foods introduced to infants. BC and IC are sources of macro and micronutrients that have bene ficial effects on health, but can also be sources of harmful chemical and microbiological contaminants and nutrients that may lead to adverse health effects at high consumption levels. This study was performed under the RiskBenefit4EU project with the aim of assessing the health impact associated with consumption of BC and IC by Portuguese children under 35 months. Adverse effects associated with the presence of aflatoxins, Bacillus cereus, sodium and free sugars were assessed against the benefits of fiber intake. We applied a risk–benefit assessment approach, and quantified the health impact of changes in consumption of BC and IC from current to various alternative consumption scenarios. Health impact was assessed in terms of disability-adjusted life years. Results showed that moving from the current consumption scenario to considered alternative scenarios results in a gain of healthy life years. Portuguese children can benefit from exchanging intake of IC to BC, if the BC consumed has an adequate nutritional profile in terms of fiber, sodium and free sugars, with levels of aflatoxins reduced as much as possible. This research was funded by European Food Safety Authority (EFSA) (Grant Agreement Number–GA/EFSA/AFSCO/2017/01–GA02) (The authors declare that this manuscript reflects only the authors’ view and EFSA is not responsible for any use that may be made of the information it contains.). R.A., P.A. and C.M. also thanks FCT/MCTES for the financial support to CESAM (UIDP/50017/2020 + UIDB/50017/2020), through national funds. R.A. was supported by FCT Individual CEEC 2018 Assistant Researcher Grant CEECIND/01570/2018. info:eu-repo/semantics/publishedVersion

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.

Objective: To evaluate the health impact of current and alternative patterns of rice consumption in Chinese adult men (40–79 years of age).Methods: We applied a risk–benefit assessment (RBA) model that took into account the health effects of selenium (Se), cadmium (Cd), and inorganic arsenic (i-As). The health effects included the prevention of prostate cancer associated with exposure to Se, and an increased risk of lung, bladder, and skin cancer for i-As and chronic kidney disease (CKD) for Cd. We defined the baseline scenario (BS) as the current individual mean daily consumption of rice in the population of interest and two alternative scenarios (AS): AS1 = 50 g/day and AS2 = 200 g/day. We estimated the health impact for different age groups in terms of change in Disability-Adjusted Life Years (ΔDALY).Results: The BS of rice consumption was 71.5–105.4 g/day in different age groups of adult men in China. We estimated that for AS1, the mean ΔDALY was −2.76 to 46.2/100,000 adult men of 40–79 years old. For AS2, the mean ΔDALY was 41.3 to 130.8/100,000 individuals in this population group.Conclusion: Our results showed that, based on associated exposure to selenium, cadmium, and i-As in rice, the current consumption of rice does not pose a risk to adult men in China. Also, a lower (50 g/day) or higher (200 g/day) rice consumption will not bring larger beneficial effects.

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. Highlights: - Risk-benefit assessment goes hand-in-hand with RB-management and RB-communication; - Holistic approach in food safety and nutrition, comparing health risks and benefits; - Risk-benefit assessment estimates the overall impact of food on health; - Risk-benefit characteristics: problem formulation, tiered approach, common currency. info:eu-repo/semantics/publishedVersion

A key goal of most Burden of Disease (BoD) studies is to support public health policies. However, while the concepts of BoD and Disability Adjusted Life years have been introduced more than 25 years, BoD researchers are still struggling to find better ways to translate their findings and communicate them to the relevant decision makers and other stakeholders. To address this gap, the burden-eu COST Action aims to generate better guidance of the use of BoD metrics in policy-making processes. In collaboration with experts in knowledge translation and risk communication, the Action will compile good practices in knowledge translation and develop a roadmap to integrate knowledge translation in national BOD studies. To support these objectives, collaborations have been established with knowledge translation experts from the European Observatory on Health Systems and Policies, the WHO Regional Office for Europe, and the European Public Health Association. During an initial meeting of the “knowledge translation” working group, 29 participants identified elements in the pathway from evidence generation to practice that need to be addressed. Building on the outcomes of this meeting and the inputs from the knowledge translation experts, this presentation will introduce the knowledge translation framework, and address some of the challenges in identifying best routes to reach out to the public and policy-makers. Specific emphasis will be placed in profiling the context, actors and processes of each country within the policy triangle, and drawing on best and worst example case studies. Additionally, the process will be discussed to co-create a toolkit or guide for using BoD evidence in policy and practice. The session will conclude with an interaction with the audience to learn about the perceived barriers for implementing knowledge translation within the BoD framework.

Diets consisting of high amounts of animal-based protein have been associated with adverse public health effects and are often deemed environmentally unsustainable. Therefore, replacing red meat by pulses has been proposed to reduce the adverse impact on human health and environment. However, unprocessed red meat is an important source of nutrients, such as vitamin B12, iron, zinc and selenium, and the substitution may have negative impact on nutrient adequacy. Using a risk-benefit assessment (RBA) approach, we, therefore, estimated the health impact of substituting unprocessed red meat by pulses on the burden of non-communicable diseases in Denmark, using Disability-Adjusted Life Years (DALY). Furthermore, we assessed the impact of the substitution on nutrient adequacy. We found that 187 (95% UI: 209; 168) healthy years of life could be gained per 100,000 individuals per year by substituting 100% of unprocessed red meat by pulses in the Danish diet. We found a decrease in the intake of vitamin B12, zinc and selenium due to the substitution. An additional 10% of the Danish population will become at risk of vitamin B12 and selenium inadequacy, and an additional 20% will be at risk of zinc inadequacy due to the substitution. For iron, a small decrease in the proportion at risk of inadequacy was found. Substitution of unprocessed red meat by pulses was estimated to provide a beneficial health impact on the burden of non-communicable disease, expressed in DALY. Additionally, it was found that the complete substitution will lead to a higher risk of nutrient inadequacies.

Following publication of the original article [1], the authors identified an error in the author name of Brecht Devleesschauwer. The incorrect author name is: Brecht Devleeschauwer The correct author name is: Brecht Devleesschauwer The author group has been updated above and the original article [1] has been corrected.

Background: Evidence has emerged showing that elderly people and those with pre-existing chronic health conditions may be at higher risk of developing severe health consequences from COVID-19. In Europe, this is of particular relevance with ageing populations living with non-communicable diseases, multi-morbidity and frailty. Published estimates of Years Lived with Disability (YLD) from the Global Burden of Disease (GBD) study help to characterise the extent of these effects. Our aim was to identify the countries across Europe that have populations at highest risk from COVID-19 by using estimates of population age structure and YLD for health conditions linked to severe illness from COVID-19. Methods: Population and YLD estimates from GBD 2017 were extracted for 45 countries in Europe. YLD was restricted to a list of specific health conditions associated with being at risk of developing severe consequences from COVID-19 based on guidance from the United Kingdom Government. This guidance also identified individuals aged 70 years and above as being at higher risk of developing severe health consequences. Study outcomes were defined as: (i) proportion of population aged 70 years and above; and (ii) rate of YLD for COVID-19 vulnerable health conditions across all ages. Bivariate groupings were established for each outcome and combined to establish overall population-level vulnerability. Results: Countries with the highest proportions of elderly residents were Italy, Greece, Germany, Portugal and Finland. When assessments of population-level YLD rates for COVID-19 vulnerable health conditions were made, the highest rates were observed for Bulgaria, Czechia, Croatia, Hungary and Bosnia and Herzegovina. A bivariate analysis indicated that the countries at high-risk across both measures of vulnerability were: Bulgaria; Portugal; Latvia; Lithuania; Greece; Germany; Estonia; and Sweden. Conclusion: Routine estimates of population structures and non-fatal burden of disease measures can be usefully combined to create composite indicators of vulnerability for rapid assessments, in this case to severe health consequences from COVID-19. Countries with available results for sub-national regions within their country, or national burden of disease studies that also use sub-national levels for burden quantifications, should consider using non-fatal burden of disease estimates to estimate geographical vulnerability to COVID-19., peer-reviewed

“RiskBenefit4EU ‐ Partnering to strengthen the risk‐benefit assessment within EU using a holistic approach” was a knowledge transfer project funded by the European Food Safety Authority (EFSA) that integrated a multidisciplinary team from Portugal, Denmark and France. This project aimed to strengthen the EU capacity to assess risks and benefits associated with human food consumption, considering the fields of toxicology, microbiology and nutrition. To train the recipient partners from Portugal on Risk‐Benefit Assessment (RBA), a capacity‐building program was implemented, including three main activities: theoretical training on RBA concepts; hands‐on training applying concepts to a case‐study using methods and tools displayed; and scientific missions to provide advanced training in specific domains of RBA. The developed RBA strategy was applied to a case study focusing on the RBAof the consumption of cereal‐based products by Portuguese young children. Risks due to aflatoxins, Bacillus cereus, sodium and free sugars, were evaluated, as well as the benefit of fibreintake. Five different scenarios of infant cereals and/or breakfast cereals consumption were considered, and the assessment showed that moving from the current consumption to the considered alternative scenarios wouldresult in a gain of healthy‐life years. The RiskBenefit4EU project applied a collaborative method to train a new team to perform RBAs of foods and face the challenge of cooperation between experts from different disciplines. During the process of capacity building, a movement from conceptual knowledge towards action was an essential step to effectively increase performance. The developed framework facilitated the case‐study accomplishment and contributed to build a shared and harmonized RBA approach and culture. The suggested strategy can now be re‐used to capacitate other teams in RBA,and can be considered as a basis to build upon.

Background Humans are exposed to heavy metals from certain foods, thus specific dietary patterns may lead to high burden of disease (BoD). By identifying diet, lifestyle and socio-demographic characteristics of population groups with highest BoD, targeted preventive strategies can be developed. We aimed at identifying clusters and characteristics of Danish individuals with highest BoD due to food exposure to three heavy metals: methylmercury (MeHg), cadmium and inorganic arsenic. Methods We collected diet, lifestyle and socio-demographic information of 3,946 individuals in the Danish National Survey of Diet and Physical Activity. Occurrence of heavy metals in food was obtained from Danish food monitoring. We applied machine learning self-organizing maps to group individuals according to similarities in diet, lifestyle and socio-demographics, and estimated BoD due to metal exposure in terms of Disease-Adjusted Life Years (DALY). We will present calculation steps of our approach in a tutorial-like way and demonstrate its applicability to other cases. Results We identified 13 population subgroups with distinct dietary and lifestyle characteristics. The estimated BoD varied largely between subgroups, with five subgroups experiencing a BoD > 10 DALY/100,000. The cluster bearing the highest BoD (26.2 (95% uncertainty interval (UI): 10.3, 50.6) DALY/100,000) was significantly different from the cluster with the lowest BoD (5.1 (95% UI: 2.5, 9.2) DALY/100,000) (preliminary). BoD was higher in subgroups with diet and lifestyle considered healthy. Most of the BoD was due to MeHg, particularly in female-dominant subgroups. Conclusions Linking machine learning, exposure assessment and burden of disease metrics, this novel approach identified population subgroups with higher BoD due to exposure to three heavy metals. It can be expanded to estimate BoD of other chemicals, and used to develop targeted preventive strategies to reduce BoD in more affected subgroups.

Background: Human diet may present both risks and benefits to consumers’ health. Risk-benefit assessment of foods (RBA) intends to estimate the overall health impact associated with exposure (or lack of exposure) to a particular food or food component. Scope and approach: “RiskBenefit4EU – Partnering to strengthen the risk-benefit assessment within EU using a holistic approach” (RB4EU) is a project funded by the European Food Safety Authority (EFSA) that integrates a multidisciplinary team from Portugal, Denmark and France. This project aims to strengthen the EU capacity to assess and integrate food risks and benefits regarding toxicology, microbiology and nutrition. One of the specific objectives of RB4EU was to build capacity in RBA among the recipient partners from Portugal. In order to achieve this objective, a capacity building strategy including theoretical and hands-on training and the development of a case-study were established. This paper aims to present the strategy used in the RB4EU project to build capacity within RBA, including the main training approaches and the lessons learned. Key findings and conclusions: The capacity-building program included three main activities: theoretical training, focusing on RBA concepts; hands-on training, applying the acquired concepts to a concrete case-study, using the methods and tools displayed; and scientific missions, intending to provide advanced training in specific domains of RBA. The developed strategy can be used in the future to build capacity within RBA. Highlights: Risk-benefit assessment (RBA) aims to estimate health benefits and risks of foods; Capacity building actions contribute to acquire scientific foundation on RBA; RiskBenefit4EU project aims to strengthen the EU capacity to perform RBA; A capacity building strategy was developed and implemented under RiskBenefit4EU; Lessons learned through this capacity building process were reviewed and discussed. This work was supported by the “RiskBenefit4EU – Partnering to strengthen the risk-benefit assessment within EU using a holistic approach” funded by EFSA Partnering Grants (Grant Agreement Number – GA/EFSA/AFSCO/2017/01 – GA02). 1 Ricardo Assunção, Paula Alvito and Carla Martins are grateful to the support of CESAM funded by the Portuguese Foundation for Science and Technology (UID/AMB/50017/2013), through national funds, and the co-funding by the FEDER (POCI-01-0145-FEDER-00763), within the PT2020 Partnership Agreement and Compete 2020. info:eu-repo/semantics/publishedVersion

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

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

Background Sufficient intake of fish and limited red meat intake is commonly encouraged by national dietary guidelines to prevent various lifestyle diseases. One way to fulfill these guidelines would be to substitute red meat by fish. However, quantitative evidence of the public health gain of such substitution is lacking. Moreover, contaminants in these foods may compromise nutritional benefits. We aimed to estimate the health impact of substituting red meat by fish in the Danish diet in a risk-benefit assessment (RBA). Our study can support policy makers in defining evidence-based public health strategies. Methods We quantified the health impact of substituting red meat by fish among Danish adults in terms of Disability-Adjusted Life Years (DALY) using data from a national dietary survey and food monitoring. We investigated the use of probabilistic methods to model variability in individual substitution behaviors and to assess health impact distributions in RBA of food. Results Health impact of the substitution varied largely by the type of fish consumed and by age and sex of the consumer. We estimated that 134 (95% uncertainty interval: 102; 169) DALYs/100,000 could be averted per year if a mix of lean and fatty fish is consumed in the Danish recommended amounts and intake of red meat decreased among Danish adults. The highest benefit was estimated for women in the childbearing age and for men above 50 years of age. However, a small fraction of women were assigned an overall health loss due to methylmercury exposure during pregnancy and the associated adverse effects in unborn children. Conclusions Our study estimated an overall health gain of substituting red meat by fish in the general Danish adult population, while providing insight in the variability in health impact at the level of individual consumers. Our approach can be applied in other RBAs and the results support the need for targeted public health strategies to ensure consumer health and safety. Key messages The health impact of substituting red meat by fish in Danish adults was quantified in terms of disability-adjusted life years (DALYs), while accounting for variability between individuals. We estimated that young women and men above 50 years of age will experience the largest health gain while a small fraction of the women were assigned a health loss due to chemical exposure.

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.

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.