The health benefits of fruit, vegetables and dietary fibre have been promoted for many years. Much of the supporting evidence is circumstantial or even contradictory and mechanisms underlying health benefits of specific foods are poorly understood. Colorectal cancer shows marked geographical differences in incidence, probably linked with diet, and explanations for this require knowledge of the complex interactions between diet, microbiota and the gut epithelium. Dietary fibres can act as prebiotics, encouraging growth of saccharolytic bacteria, but other mechanisms are also important. Some but not all soluble fibres have a ‘contrabiotic’ effect inhibiting bacterial adherence to the epithelium. This is particularly a property of pectins (galacturonans) whereas dietary fructans, previously regarded as beneficial prebiotics, can have a proinflammatory effect mediated via toxic effects of high butyrate concentrations. This also suggests that ulcerative colitis could in part result from potentially toxic faecal butyrate concentrations in the presence of a damaged mucus layer. Epithelial adherence of lectins, either dietary lectins as found in legumes, or bacterial lectins such as the galactose-binding lectin expressed by colon cancer-associated Fusobacterium nucleatum, may also be important and could be inhibitable by specific dietary glycans. Conversely, emulsifiers in processed foods may increase bacterial translocation and alter the microbiota thus promoting inflammation or cancer. Focusing on one condition is of limited value although in developing public health messages and growing evidence for impacts of dietary components on all-cause mortality is gaining more attention. We are only just starting to understand the complex interactions between food, the microbiota and health.

The WHO encourages countries to conduct national dietary surveys (NDS) to inform preventative policies targeting malnutrition and noncommunicable diseases. Previous reviews have found inadequate nutrient intakes and survey provision across Europe. This research is the first to provide an updated review of NDS provision within the whole WHO European Region, across the lifecourse, with reference to disadvantaged groups, obesity and nutrients of concern. Over a third of WHO European countries, mainly Central and Eastern European countries (CEEC), had no identifiable NDS. Where countries reported nutrient intakes, poor WHO recommended nutrient intake attainment was Europe-wide across the lifecourse, particularly in CEEC. Lower educated individuals had poorer diet quality. However, heterogeneity in age group sampled, dietary assessment method, nutrient composition database and under-reporting hindered inter-country comparisons. Average population trans fatty acid intakes below WHO recommended limits may hide inequalities in disadvantaged groups; legislative bans may help alleviate this. There were few associations between NDS-derived consumed food portion size (FPS) and BMI. However, consumed FPS was greater than on-pack serving-size in the majority of foods studied. This review illustrates how NDS can generate information on diet, nutrient intakes and the food environment. However, to enable valid inter-country comparisons, countries should be encouraged to conduct and report harmonised NDS, particularly in the age groups sampled, dietary assessment methodology, nutrient range, underpinning food composition database and treatment of under-reporters. This will aid effective, coordinated policy development that can have a real impact on dietary improvement, on a population and subgroup level, throughout Europe.

The concept of food addiction is currently a highly debated subject within both the general public and the scientific communities. The term food addiction suggests that individuals may experience addictive-like responses to food, similar to those seen with classic substances of abuse. An increasing number of studies have established the prevalence and correlates of food addiction. Moreover, food addiction may be associated with obesity and disordered eating. Thus, intervening on food addiction may be helpful in the prevention and therapy of obesity and eating disorders. However, controversy exists about if this phenomenon is best defined through paradigms reflective of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) substance-related disorders (e.g. food addiction) or non-substance-related disorders (e.g. eating addiction) criteria. This review paper will give a brief summarisation of the current state of research on food addiction, a more precise definition of its classification, its differentiation from eating addiction and an overview on potential overlaps with eating disorders. Based on this review, there is evidence that food addiction may represent a distinct phenomenon from established eating disorders such as bulimia nervosa or binge-eating disorder. Future studies are needed to further examine and establish orthogonal diagnostic criteria specific to food addiction. Such criteria must differentiate the patterns of eating and symptoms that may be similar to those of eating disorders to further characterise food addiction and develop therapy options. To date, it is too premature to draw conclusions about the clinical significance of the concept of food addiction.

Knowing who eats what, understanding the various eating habits of different population groups, according to the geographical area, is critical to develop evidence-based policies for nutrition and food safety. The FAO/WHO Global Individual Food consumption data Tool (FAO/WHO GIFT) is a novel open-access online platform, hosted by FAO and supported by WHO, providing access to harmonised individual quantitative food consumption (IQFC) data, especially in low- and middle-income countries (LMIC). FAO/WHO GIFT is a growing repository, which will serve as the global FAO/WHO hub to disseminate IQFC microdata. Currently five datasets from LMIC are available for dissemination, and an additional fifty datasets will be made available by 2022. To facilitate the use of these data by policy makers, ready-to-use food-based indicators are provided for an overview of key data according to population segments and food groups. FAO/WHO GIFT also provides an inventory of existing IQFC data worldwide, which currently contains detailed information on 188 surveys conducted in seventy-two countries. In order for end-users to be able to aggregate the available data, all datasets are harmonised with the European Food Safety Authority's food classification and description system FoodEx2 (modified for global use). This harmonisation is aimed at enhancing the consistency and reliability of nutrient intake and dietary exposure assessments. FAO/WHO GIFT is developed in synergy with other global initiatives aimed at increasing the quality, availability and use of IQFC data in LMIC to enable evidence-based decision-making and policy development for better nutrition and food safety.

Africa is experiencing a sharp rise in non-communicable diseases (NCD) related to rapid globalisation and urbanisation leading to shifts in dietary and lifestyle patterns characterised by increased energy intake and physical inactivity. However, unlike more resource-endowed regions, Africa has a double burden of disease: NCD co-exist with infectious diseases including lower respiratory tract infections, HIV/AIDS and diarrhoeal diseases. The African economy is also relatively weaker, making it difficult to cope with this burden. It is postulated that NCD will soon overtake infectious diseases as the number one cause of death in the African region. The recognition of NCD as diseases and obesity as a related risk factor is weak in Africa, compounded by stigma associated with wasting in HIV/AIDS and obesity being perceived as a sign of wealth, achievement and care. There is also a dearth of data on overweight and obesity in the region and little knowledge that infant feeding practices, such as breast-feeding, are linked to reduced risk of NCD in both children and mothers. While complex multi-sectoral approaches to address this NCD menace are needed, Africa may benefit from taking simple initial steps to address NCD risk factors including: (1) behaviour change communication to challenge perceptions on NCD; (2) promoting and protecting breast-feeding; (3) formulating policies and regulations limiting wide availability of unhealthy foods; (4) mainstream nutrition education in school curricula and (5) collection of accurate data based on indicators that can reflect the double burden of disease and malnutrition; and fostering multi-sectoral actions against NCD.

Multiple forms of malnutrition co-exist (the double burden) in low- and middle-income countries, but most interventions and policies target only one form. Identifying shared drivers of the double burden of malnutrition is a first step towards establishing effective interventions that simultaneously address the double burden of malnutrition (known as double-duty actions). We identified shared drivers for the double burden of malnutrition, to assess which double-duty actions are likely to have the greatest reach in preventing all forms of malnutrition, in the context of the sustainable development goals. We reviewed existing conceptual frameworks of the drivers of undernutrition, obesity and environmental sustainability. Shared drivers affecting all forms of malnutrition and environmental sustainability were captured using a socio-ecological approach. The extent to which drivers were addressed by the five double-duty actions proposed by the WHO was assessed. Overall, eighty-three shared drivers for the double burden of malnutrition were identified. A substantial proportion (75·0%) could be addressed by the five WHO double-duty actions. ‘Regulations on marketing’ and ‘promotion of appropriate early and complementary feeding in infants’ addressed the highest proportion of shared drivers (65·1% and 53·0%, respectively). Twenty-four drivers were likely to be sensitive to environmental sustainability, with ‘regulations on marketing’ and ‘school food programmes and policies’ likely to have the greatest environmental reach. A quarter of the shared drivers remained unaddressed by the five WHO double-duty actions. Substantially more drivers could be addressed with minor modifications to the WHO double-duty actions and the addition of de novo actions.

Offering large portions of high-energy-dense (HED) foods increases overall intake in children and adults. This is known as the portion size effect (PSE). It is robust, reliable and enduring. Over time, the PSE may facilitate overeating and ultimately positive energy balance. Therefore, it is important to understand what drives the PSE and what might be done to counter the effects of an environment promoting large portions, especially in children. Explanations for the PSE are many and diverse, ranging from consumer error in estimating portion size to simple heuristics such as cleaning the plate or eating in accordance with consumption norms. However, individual characteristics and hedonic processes influence the PSE, suggesting a more complex explanation than error or heuristics. Here PSE studies are reviewed to identify interventions that can be used to downsize portions of HED foods, with a focus on children who are still learning about social norms for portion size. Although the scientific evidence for the PSE is robust, there is still a need for creative downsizing solutions to facilitate portion control as children and adolescents establish their eating habits.

A major advantage of analyses on the food group level is that the results are better interpretable compared with nutrients or complex dietary patterns. Such results are also easier to transfer into recommendations on primary prevention of non-communicable diseases. As a consequence, food-based dietary guidelines (FBDG) are now the preferred approach to guide the population regarding their dietary habits. However, such guidelines should be based on a high grade of evidence as requested in many other areas of public health practice. The most straightforward approach to generate evidence is meta-analysing published data based on a careful definition of the research question. Explicit definitions of study questions should include participants, interventions/exposure, comparisons, outcomes and study design. Such type of meta-analyses should not only focus on categorical comparisons, but also on linear and non-linear dose–response associations. Risk of bias of the individual studies of the meta-analysis should be assessed, rated and the overall credibility of the results scored (e.g. using NutriGrade). Tools such as a measurement tool to assess systematic reviews or ROBIS are available to evaluate the methodological quality/risk of bias of meta-analyses. To further evaluate the complete picture of evidence, we propose conducting network meta-analyses (NMA) of intervention trials, mostly on intermediate disease markers. To rank food groups according to their impact, disability-adjusted life years can be used for the various clinical outcomes and the overall results can be compared across the food groups. For future FBDG, we recommend to implement evidence from pairwise and NMA and to quantify the health impact of diet–disease relationships.

Effective pharmaceutical treatments for age-related cognitive decline have proved elusive. There is, however, compelling evidence that nutritional status and supplementation could play crucial roles in modifying the expression of cognitive change through the lifespan. Subjective memory impairment and mild cognitive impairment can be harbingers of dementia but this is by no means inevitable. Neurocognitive change is influenced by a variety of processes, many of which are involved in other aspects of systemic health, including cardiovascular function. Importantly, many of these processes are governed by mechanisms which may be modified by specific classes of bioactive nutrients. There is increasing, converging evidence from controlled trials that nutritional interventions can improve mood and cognitive function in both clinical and healthy populations. Specific examples include selected botanical extracts such as the flavonoids. Some nutritional supplements (e.g. broad-spectrum micronutrient supplementation) appear to support improved cognitive function, possibly through redressing insufficient nutrient status (i.e. suboptimal but above the threshold for frank deficiency). Recent mechanistic research has unveiled physiologically plausible, modifiable, cognition-relevant targets for nutrition and nutraceuticals. These include processes involved in both systemic and central vascular function, inflammation, metabolism, central activation, improved neural efficiency and angiogenesis. The advent and development of human neuroimaging methodology have greatly aided our understanding of the core central mechanisms of cognitive change. Different imaging modalities can provide insights into modifiable central mechanisms which may be targeted by bioactive nutrients. The latter may contribute to slowing age-related decline through supporting neurocognitive scaffolding mechanisms.

The ability to synthesise sufficient vitamin D through sunlight in human subjects can be limited. Thus, diet has become an important contributor to vitamin D intake and status; however, there are only a few foods (e.g. egg yolk, oily fish) naturally rich in vitamin D. Therefore, vitamin D-enriched foods via supplementing the animals’ diet with vitamin D or vitamin D fortification of foods have been proposed as strategies to increase vitamin D intake. Evidence that cholecalciferol (vitamin D3) and calcifediol (25(OH)D3) content of eggs, fish and milk increased in response to vitamin D3 supplementation of hens, fish or cows’ diets was identified when vitamin D-enrichment studies were reviewed. However, evidence from supplementation studies with hens showed only dietary 25(OH)D3, not vitamin D3 supplementation, resulted in a pronounced increase of 25(OH)D3 in the eggs. Furthermore, evidence from randomised controlled trials indicated that a 25(OH)D3 oral supplement could be absorbed faster and more efficiently raise serum 25(OH)D concentration compared with vitamin D3 supplementation. Moreover, evidence showed the relative effectiveness of increasing vitamin D status using 25(OH)D3 varied between 3·13 and 7·14 times that of vitamin D3, probably due to the different characteristics of the investigated subjects or study design. Therefore, vitamin D-enrichment or fortified foods using 25(OH)D3 would appear to have advantages over vitamin D3. Further well-controlled studies are needed to assess the effects of 25(OH)D3 enriched or fortified foods in the general population and clinical patients.

The food industry holds great potential for driving consumers to adopt healthy food choices as (re)formulation of foods can improve the nutritional quality of these foods. Reformulation has been identified as a cost-effective intervention in addressing non-communicable diseases as it does not require significant alterations of consumer behaviour and dietary habits. Nutrient profiling (NP), the science of categorizing foods based on their nutrient composition, has emerged as an essential tool and is implemented through many different profiling systems to guide reformulation and other nutrition policies. NP systems should be adapted to their specific purposes as it is not possible to design one system that can equally address all policies and purposes, e.g. reformulation and labelling. The present paper discusses some of the key principles and specificities that underlie a NP system designed for reformulation with the example of the Nestlé nutritional profiling system. Furthermore, the impact of reformulation at the level of the food product, dietary intakes and public health are reviewed. Several studies showed that food and beverage reformulation, guided by a NP system, may be effective in improving population nutritional intakes and thereby its health status. In order to achieve its maximum potential and modify the food environment in a beneficial manner, reformulation should be implemented by the entire food sector. Multi-stakeholder partnerships including governments, food industry, retailers and consumer associations that will state concrete time-bound objectives accompanied by an independent monitoring system are the potential solution.

Stable isotopes are non-radioactive, safe and are applied for various purposes in human health assessment in trace amounts that minimally disturb normal physiology. The International Atomic Energy Agency supports the use of stable isotope techniques to design and evaluate interventions addressing malnutrition in all its forms with focus on infant and young child feeding; maternal and adolescent nutrition; diet quality; prevention and control of non-communicable diseases; healthy ageing and gut function. These techniques can be used to objectively measure: (1) amount of human milk consumed and whether an infant is exclusively breastfed; (2) body composition in the context of re-feeding programmes for moderate and severe acute malnutrition and as an indicator of the risk for obesity; (3) bioavailability and bioconversion of pro-vitamin A and vitamin A body stores following vitamin A intervention programmes; (4) absorption and retention of iron, zinc and protein; (5) total energy expenditure for validation of physical activity measurement and dietary assessment tools and (6) diagnosis of Helicobacter pylori. Stable isotope techniques will be invaluable in the tracking of global targets on exclusive breast-feeding childhood obesity and anaemia among women. Efforts are underway to make nuclear techniques more affordable, field-friendly and less invasive, and to develop less sophisticated but precise equipment. Advocacy for the wide adoption of the techniques is needed.

Although the literature on the contribution of DHA and arachidonic acid (ARA) to fundamental metabolic functions in brain, immune and cardiovascular systems is extensive, there is a lack of consensus on the need for explicit recommendations on dietary intake for both DHA and ARA during the early years of life. This review takes a public health perspective with the objective of ensuring that recommendations protect the most vulnerable children worldwide. Most studies on the effects of DHA and ARA in early life have been undertaken in high-income countries and this is reflected in policy recommendations. Although breast milk is considered the gold standard and always contains DHA and ARA, there are proposals that infant formulas, especially follow-on formulas, do not need to be supplemented with these fatty acids. Complementary foods frequently have low concentrations of ARA and DHA and this is most significant in low-income countries where availability is also limited. Recent evidence shows that in developing countries, intakes of DHA and ARA during the age period 6–36 months are low and this relates to low national income. It is concluded that a continuum of DHA and ARA intake needs to be maintained during early life, a critical period of infant growth and development. For both infant and follow-on formulas, DHA and ARA should be mandatory at levels that are equivalent to breast milk. An optional recommendation may be limited to countries that can demonstrate evidence of adequate intakes of DHA and ARA during early life.

Metabolomic and microbiome profiling are promising tools to identify biomarkers of food intake and health status. The individual's genetic makeup plays a significant role on health, metabolism, gut microbes and diet and twin studies provide unique opportunities to untangle gene–environment effects on complex phenotypes. This brief review discusses the value of twin studies in nutrition research with a particular focus on metabolomics and the gut microbiome. Although, the twin model is a powerful tool to segregate the genetic component, to date, very few studies combine the twin design and metabolomics/microbiome in nutritional sciences. Moreover, since the individual's diet has a strong influence on the microbiome composition and the gut microbiome is modifiable (60 % of microbiome diversity is due to the environment), future studies should target the microbiome via dietary interventions.

The globalisation of agrifood systems is a mega-trend with potentially profound nutritional implications. This paper describes various facets of this globalisation process and reviews studies on nutritional effects with a particular focus on developing countries. Results show that global trade and technological change in agriculture have substantially improved food security in recent decades, although intensified production systems have also contributed to environmental problems in some regions. New agricultural technologies and policies need to place more emphasis on promoting dietary diversity and reducing environmental externalities. Globalising agrifood systems also involve changing supply-chain structures, with a rapid rise of modern retailing, new food safety and food quality standards, and higher levels of vertical integration. Studies show that emerging high-value supply chains can contribute to income growth in the small farm sector and improved access to food for rural and urban populations. However, there is also evidence that the retail revolution in developing countries, with its growing role of supermarkets and processed foods, can contribute to overweight and obesity among consumers. The multi-faceted linkages between changing agrifood systems and nutrition are a new field of interdisciplinary research, combining agricultural, nutritional, economics and social sciences perspectives. The number of studies on specific aspects is still limited, so the evidence is not yet conclusive. A review at this early stage can help to better understand important relationships and encourage follow-up work.

The Bath Breakfast Project is a series of randomised controlled trials exploring the effects of extended morning fasting on energy balance and health. These trials were categorically not designed to answer whether or not breakfast is the most important meal of the day. However, this review will philosophise about the meaning of that question and about what questions we should be asking to better understand the effects of breakfast, before summarising how individual components of energy balance and health respond to breakfast v. fasting in lean and obese adults. Current evidence does not support a clear effect of regularly consuming or skipping breakfast on body mass/composition, metabolic rate or diet-induced thermogenesis. Findings regarding energy intake are variable, although the balance of evidence indicates some degree of compensatory feeding later in the day such that overall energy intake is either unaffected or slightly lower when breakfast is omitted from the diet. However, even if net energy intake is reduced, extended morning fasting may not result in expected weight loss due to compensatory adjustments in physical activity thermogenesis. Specifically, we report that both lean and obese adults expended less energy during the morning when remaining in the fasted state than when consuming a prescribed breakfast. Further research is required to examine whether particular health markers may be responsive to breakfast-induced responses of individual components of energy balance irrespective of their net effect on energy balance and therefore body mass.

Red and processed meat (RPM) intake varies widely globally. In some high-income countries (HIC) the last decade has witnessed an overall decline or stabilisation in the consumption of RPM, in contrast to emerging economies where its consumption continues to increase with rising income and rapid urbanisation. The production and consumption of RPM have become major concerns regarding the environmental impacts of livestock in particular, but also because of associations between high RPM consumption and diet-related non-communicable disease. Therefore, it is important to identify socioeconomic and demographic drivers of the consumption of RPM. This paper explores how consumption of RPM differs with age, gender, socioeconomic status and in different global contexts. There are some key socioeconomic and demographic patterns in RPM consumption. Men tend to consume RPM more often and in higher quantities, and there is evidence of a social gradient in HIC, with lower socioeconomic groups consuming RPM more often and in larger quantities. Patterns for consumption with age are less clear cut. It is apparent that consumers in HIC are still consuming high levels of RPM, although the downward shifts in some socioeconomic and demographic groups is encouraging and suggests that strategies could be developed to engage those consumers identified as high RPM consumers. In low- and middle-income countries, RPM consumption is rising, especially in China and Brazil, and in urban areas. Ways of encouraging populations to maintain their traditional healthy eating patterns need to be found in low- and middle-income countries, which will have health, environmental and economic co-benefits.

The WHO's Ottawa Charter highlights five priority areas for taking action in public health. Only one of them is at the individual level as action at more upstream intervention levels, such as community or policy levels, is critical for enabling individuals to succeed. The objective of the present paper is to give insight into the many complex processes involved in public health nutrition by describing the Ottawa Charter's five priority areas for taking action using public health nutrition initiatives I have been involved in. Evidence-based guidelines for healthy eating and infant feeding provide an essential basis for individuals to ‘develop personal skills’ (Action Area 1). ‘Re-orienting health services’ (Action Area 2) can address the needs of vulnerable population subgroups, such as the culturally sensitive diabetes prevention programme established for an Indo-Asian community in Canada. Identifying geographic areas at high risk of childhood obesity enables better strategic planning and targeting of resources to ‘strengthen community action’ (Action Area 3). Calorie menu labelling can ‘create supportive environments’ (Action Area 4) through encouraging a demand for less energy-dense, healthier food options. ‘Building healthy public policy’ (Action Area 5) to implement mandatory folic acid food fortification for prevention of birth defects has many advantages over a voluntary approach. In conclusion, evaluation and evidence-based decision-making needs to take account of different strategies used to take action in each of these priority areas. For this, the randomised control trial needs adaptation to determine the best practice in public health nutrition where interventions play out in real life with all its confounding factors.

The prevalence of osteoporosis and the incidence of age-related fragility fracture vary by ethnicity. There is greater than 10-fold variation in fracture probabilities between countries across the world. Mineral and bone metabolism are intimately interlinked, and both are known to exhibit patterns of daily variation, known as the diurnal rhythm (DR). Ethnic differences are described for Ca and P metabolism. The importance of these differences is described in detail between select ethnic groups, within the USA between African-Americans and White-Americans, between the Gambia and the UK and between China and the UK. Dietary Ca intake is higher in White-Americans compared with African-Americans, and is higher in White-British compared with Gambian and Chinese adults. Differences are observed also for plasma 25-hydroxy vitamin D, related to lifestyle differences, skin pigmentation and skin exposure to UVB-containing sunshine. Higher plasma 1,25-dihydroxy vitamin D and parathyroid hormone are observed in African-American compared with White-American adults. Plasma parathyroid hormone is also higher in Gambian adults and, in winter, in Chinese compared with White-British adults. There may be ethnic differences in the bone resorptive effects of parathyroid hormone, with a relative skeletal resistance to parathyroid hormone observed in some, but not all ethnic groups. Renal mineral excretion is also influenced by ethnicity; urinary Ca (uCa) and urinary P (uP) excretions are lower in African-Americans compared with White-Americans, and in Gambians compared with their White-British counterparts. Little is known about ethnic differences in the DR of Ca and P metabolism, but differences may be expected due to known differences in lifestyle factors, such as dietary intake and sleep/wake pattern. The ethnic-specific DR of Ca and P metabolism may influence the net balance of Ca and P conservation and bone remodelling. These ethnic differences in Ca, P and the bone metabolism may be important factors in the variation in skeletal health.