It is well known that food has a considerable environmental impact. Less attention has been given to mapping and analysing the emergence of policy responses. This paper contributes to that process. It summarises emerging policy development on nutrition and sustainability, and explores difficulties in their integration. The paper describes some policy thinking at national, European and international levels of governance. It points to the existence of particular policy hotspots such as meat and dairy, sustainable diets and waste. Understanding the environmental impact of food systems challenges nutrition science to draw upon traditions of thinking which have recently been fragmented. These perspectives (life sciences, social and environmental) are all required if policy engagement and clarification is to occur. Sustainability issues offer opportunities for nutrition science and scientists to play a more central role in the policy analysis of future food systems. The task of revising current nutrition policy advice to become sustainable diet advice needs to begin at national and international levels.

The concept of a healthy and environmentally sustainable diet is not new, but with increasing concern about future global food security and climate change there is a renewed interest in this topic. Dietary intakes in UK accounts for approximately 20–30% of total annual greenhouse gas emissions (GHGE), with the greatest contributions coming from high intakes of meat and dairy products. Dietary proposals to help mitigate climate change (i.e. reduce GHGE) have focused on reducing consumption of meat and dairy products, but this must be considered in the context of the whole diet, alongside any possible nutritional consequences for health. Bringing together health and environmental impact of the diet raises the question of whether a healthy diet can also be an environmentally sustainable diet. While recent research showed that it is possible to achieve a realistic diet that meets dietary requirement for health and has lower GHGE, it cannot be assumed that a healthy diet will always have lower GHGE. With different combinations of food it is possible to consume a diet that meets dietary requirements for health, but has high GHGE. It is important to understand what constitutes a sustainable diet, but this then needs to be communicated effectively to try and change well-established dietary intakes of the population. Studies show that understanding of sustainable diets is poor and there are many misconceptions (e.g. the overestimation of the protein requirements for a healthy diet), which could contribute to the barriers towards changing dietary intakes.

One of the greatest challenges we face in the twenty-first century is to sustainably feed nine to ten billion people by 2050 while at the same time reducing environmental impact (e.g. greenhouse gas (GHG) emissions, biodiversity loss, land use change and loss of ecosystem services). To this end, food security must be delivered. According to the United Nations definition, ‘food security exists when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life’. At the same time as delivering food security, we must also reduce the environmental impact of food production. Future climate change will make an impact upon food production. On the other hand, agriculture contributes up to about 30% of the anthropogenic GHG emissions that drive climate change. The aim of this review is to outline some of the likely impacts of climate change on agriculture, the mitigation measures available within agriculture to reduce GHG emissions and outlines the very significant challenge of feeding nine to ten billion people sustainably under a future climate, with reduced emissions of GHG. Each challenge is in itself enormous, requiring solutions that co-deliver on all aspects. We conclude that the status quo is not an option, and tinkering with the current production systems is unlikely to deliver the food and ecosystems services we need in the future; radical changes in production and consumption are likely to be required over the coming decades.

The global food system makes a significant contribution to climate changing greenhouse gas emissions with all stages in the supply chain, from agricultural production through processing, distribution, retailing, home food preparation and waste, playing a part. It also gives rise to other major environmental impacts, including biodiversity loss and water extraction and pollution. Policy makers are increasingly aware of the need to address these concerns, but at the same time they are faced with a growing burden of food security and nutrition-related problems, and tasked with ensuring that there is enough food to meet the needs of a growing global population. In short, more people need to be fed better, with less environmental impact. How might this be achieved? Broadly, three main ‘takes’ or perspectives, on the issues and their interactions, appear to be emerging. Depending on one's view point, the problem can be conceptualised as a production challenge, in which case there is a need to change how food is produced by improving the unit efficiency of food production; a consumption challenge, which requires changes to the dietary drivers that determine food production; or a socio-economic challenge, which requires changes in how the food system is governed. This paper considers these perspectives in turn, their implications for nutrition and climate change, and their strengths and weaknesses. Finally, an argument is made for a reorientation of policy thinking which uses the insights provided by all three perspectives, rather than, as is the situation today, privileging one over the other.

Ten years ago, it was assumed that disease risk prediction and personalised nutrition based on genetic information would now be in widespread use. However, this has not (yet) transpired. The interaction of genetic make-up, diet and health is far more complex and subtle than originally thought. With a few notable exceptions, the impact of identified common genetic variants on phenotype is relatively small and variable in their penetrance. Furthermore, the known variants account for only a fraction of what we believe to be the total genetic contribution to disease risk and heterogeneity in response to environmental change. Here, the question ‘how far have we progressed and are we likely to get there’ (Rimbach and Minihane, 2009) is revisited with regard to the translation of genetic knowledge into public health benefit. It is concluded that progress to date has been modest. It is hoped that recent technological developments allowing the detection of rarer variants and future use of more hypothesis-driven targeted data analysis will reveal most of the currently ‘hidden’ significant genetic variability.

The efficacy by which dietary interventions influence risk markers of multi-factorial diseases is mainly determined by taking population-based approaches. However, there exists considerable inter-individual variation in response to dietary interventions, and some interventions may benefit certain individuals or population subgroups more than others. This review evaluates the application of nutrigenomic technologies to further the concept of personalised nutrition, as well as the process to take personalised nutrition to the marketplace. The modulation of an individual's response is influenced by both genetic and environmental factors. Many nutrigenetics studies have attempted to explain variability in responses based on a single or a few genotypes so that a genotype may be used to define personalised dietary advice. It has, however, proven very challenging to define an individual's responsiveness to complex diets based on common genetic variations. In addition, there is a limited understanding of what constitutes an optimal response because we lack key health biomarkers and signatures. In conclusion, advances in nutrigenomics will undoubtedly further the understanding of the complex interplay between genotype, phenotype and environment, which are required to enhance the development of personalised nutrition in the future. At the same time, however, issues relating to consumer acceptance, privacy protection as well as marketing and distribution of personalised products need to be addressed before personalised nutrition can become commercially viable.

Direct-to-consumer (DTC) genetic tests have aroused controversy. Critics have argued many of the tests are not backed by scientific evidence, misguide their customers and should be regulated more stringently. Proponents suggest that finding out genetic susceptibilities for diseases could encourage healthier behaviours and makes the results of genetics research available to the public. This paper reviews the state of play in DTC genetic testing, focusing on tests identifying susceptibilities for lifestyle-related diseases. It will start with mapping the market for the tests. The paper will review (1) research on the content of the online marketing of DTC tests, (2) studies on the effects of DTC genetic tests on customers and (3) academic and policy proposals on how to regulate the tests. Current studies suggest that the marketing of DTC genetic tests often exaggerates their predictive powers, which could misguide consumers. However, research indicates that the tests do not seem to have major negative effects (worry and confusion) but neither do they engender positive effects (lifestyle change) on current users. Research on regulation of the tests has most commonly suggested regulating the marketing claims of the companies. In conclusion, the risks and benefits of DTC genetic tests are less significant than what has been predicted by critics and proponents, which will be argued reflects broader historical trends transforming health and medicine.

The role of the food industry (retailers, manufacturers and food service) in helping consumers eat healthily and sustainably has been receiving considerable attention in recent years. This paper focuses on the challenges facing the food industry and the role of food reformulation in meeting these challenges, through the lens of a public health nutritionist. Attention has been heightened by the Government's Responsibility Deal, launched in early 2011 by the Department of Health (England), by the UK's engagement with the global food security and food supply sustainability agendas and by the Government Office of Science's Foresight report. The Responsibility Deal's food network has to date focused on reduction of trans fatty acids, salt and calories and out-of-home calorie labelling (in food service settings). New pledges are expected soon on increasing fruit and vegetable intakes. Reformulation is a major feature of the Responsibility Deal's approach, and along with other approaches such as portion control, choice editing and information provision, there is potential to increase the breadth of healthier choices available to the public. With the exception of fruit and vegetables, the emphasis has been almost exclusively on aspects of the diet that are in excess for many of the population (e.g. energy and salt). Evidence of low consumption of some key micronutrients by some groups of the population, particularly adolescents and young adults, often alongside excess energy intake compared with expenditure, is all too often overlooked. This paper summarises the progress made to date, the challenges faced and the opportunities that exist, with particular focus on reformulation. One of the biggest challenges is the relatively poor understanding of how to effect positive and long-term dietary behaviour change. The paper concludes that, in isolation, reformulation is unlikely to provide a complete solution to the challenge of improving eating patterns and nutrient provision, although it is a contributor.

Methods for conducting dietary assessment in the United States date back to the early twentieth century. Methods of assessment encompassed dietary records, written and spoken dietary recalls, FFQ using pencil and paper and more recently computer and internet applications. Emerging innovations involve camera and mobile telephone technology to capture food and meal images. This paper describes six projects sponsored by the United States National Institutes of Health that use digital methods to improve food records and two mobile phone applications using crowdsourcing. The techniques under development show promise for improving accuracy of food records.

The aim of this paper is to describe innovations taking place in national nutrition surveys in the UK and the challenges of undertaking innovations in such settings. National nutrition surveys must be representative of the overall population in characteristics such as socio-economic circumstances, age, sex and region. High response rates are critical. Dietary assessment innovations must therefore be suitable for all types of individuals, from the very young to the very old, for variable literacy and/or technical skills, different ethnic backgrounds and life circumstances, such as multiple carers and frequent travel. At the same time, national surveys need details on foods consumed. Current advances in dietary assessment use either technological innovations or simplified methods; neither lend themselves to national surveys. The National Diet and Nutrition Survey (NDNS) rolling programme, and the Diet and Nutrition Survey of Infants and Young Children (DNSIYC), currently use the 4-d estimated diary, a compromise for detail and respondent burden. Collection of food packaging enables identification of specific products. Providing space for location of eating, others eating, the television being on and eating at a table, adds to eating context information. Disaggregation of mixed dishes enables determination of true intakes of meat and fruit and vegetables. Measurement of nutritional status requires blood sampling and processing in DNSIYC clinics throughout the country and mobile units were used to optimise response. Hence, innovations in national surveys can and are being made but must take into account the paramount concerns of detail and response rate.

Vitamin D status may influence the risk of developing metabolic diseases such as Type 2 diabetes (T2D), metabolic syndrome (MetS) and insulin resistance (IR). Several studies have assessed vitamin D in relationship with metabolic outcomes; however, results remain inconsistent. A systematic review and meta-analysis using multiple databases (MEDLINE, Web of Science and EMBASE), was performed up to 10 August 2012. Prospective studies reporting association of circulating or dietary vitamin D with incident T2D, MetS and IR outcomes were included. Relative risks (RR) were pooled using random effects and subgroup analysis by pertinent study-level characteristics was performed. A total of seventeen articles based on eighteen unique prospective studies, and comprising 210 107 participants with 15 899 metabolic events, collected during a median follow up of 10 years (range 3–22 years), were included. RR for individuals in top v. bottom thirds of baseline vitamin D were 0·81 (95% CI 0·71, 0·92); 0·86 (95% CI 0·80, 0·92); and 0·84 (95% CI 0·64, 1·12) for T2D, MetS and IR outcomes, respectively. Moderate heterogeneity was found between fourteen studies (I2 = 67%, P < 0·001) reporting on T2D. Findings were generally consistent across various study-level characteristics. In conclusion, vitamin D status at baseline in apparently healthy adults is inversely associated with future risks of T2D and MetS. Interventions aimed at maintaining adequate levels of vitamin D in addition to preventing deficiency may be a useful preventive measure for metabolic diseases. However, reliable evidence from carefully designed intervention studies, particularly those based on healthy populations, is needed to confirm observational findings.

Cardiovascular prevention, including emphasising healthy diet and physical activity patterns for weight loss and diabetes prevention, is an important focus of primary care medicine, yet provision of intensive lifestyle counselling in the primary care setting remains uncommon. Online approaches for providing lifestyle counselling are emerging as a new avenue for bringing support to outpatient patient populations. Features of successful programmes include the use of a structured behavioural programme, electronic counselling support and feedback, and uncomplicated user interfaces. Online tools may be used independently or to complement in-person approaches. Limited data also suggest that the internet can be used to support the maintenance of weight loss. In addition, the internet may help overcome various clinical barriers to lifestyle support, including significant time limitations, a need to prioritise acute care and maintain clinical workflow, and the high cost of counselling. Furthermore, the continuity of the primary care patient–provider(s) relationship provides an established source of long-term support which has been difficult to create in other community settings. As the field of online lifestyle counselling matures, nutrition and physical activity experts will face new challenges in providing asynchronous counselling without the assistance of traditional non-verbal communication cues. However, the potential for reaching a wider population in a convenient and accessible manner also creates unique opportunities for providing lifestyle support.

Food additives have been used throughout history to perform specific functions in foods. A comprehensive framework of legislation is in place within Europe to control the use of additives in the food supply and ensure they pose no risk to human health. Further to this, exposure assessments are regularly carried out to monitor population intakes and verify that intakes are not above acceptable levels (acceptable daily intakes). Young children may have a higher dietary exposure to chemicals than adults due to a combination of rapid growth rates and distinct food intake patterns. For this reason, exposure assessments are particularly important in this age group. The paper will review the use of additives and exposure assessment methods and examine factors that affect dietary exposure by young children. One of the most widely investigated unfavourable health effects associated with food additive intake in preschool-aged children are suggested adverse behavioural effects. Research that has examined this relationship has reported a variety of responses, with many noting an increase in hyperactivity as reported by parents but not when assessed using objective examiners. This review has examined the experimental approaches used in such studies and suggests that efforts are needed to standardise objective methods of measuring behaviour in preschool children. Further to this, a more holistic approach to examining food additive intakes by preschool children is advisable, where overall exposure is considered rather than focusing solely on behavioural effects and possibly examining intakes of food additives other than food colours.

Brewers’ spent grain (BSG) is a low-value co-product of the brewing industry produced in large quantities annually. This paper reviews the existing evidence regarding the phenolic component of BSG, focusing on composition, extraction and biofunctions such as antioxidant, anti-atherogenic, anti-inflammatory and anti-carcinogenic activities. Furthermore, the incorporation of BSG in foodstuffs will be discussed, including the use of BSG as an animal feed supplement and the potential of BSG to be incorporated into foods for human consumption. BSG contains hydroxycinnamic acids including ferulic acid, p-coumaric acid and caffeic acid; which have shown bioactivity in the pure form (antioxidant, anti-inflammatory, anti-atherogenic and anti-cancer). Phenolic extracts from BSG have also shown antioxidant potential, by protecting against oxidant-induced DNA damage, possibly by Fe chelation. Studies show that BSG has many benefits when used as a supplement in animal feed, such as increasing milk yield, milkfat content and in providing essential dietary amino acids. The incorporation of BSG in human foods such as cookies and ready-to-eat snacks has resulted in increased protein and fibre contents of the products, where the changes in organoleptic properties are controllable. It can be concluded that the phenolic component of BSG has potential bioactive effects, which are worth pursuing given that the inclusion of BSG into human foodstuffs is viable and beneficial.

Childhood obesity is a growing problem worldwide. In recent years, out-of-home (OH) eating has been highlighted as one of the many factors contributing to the obesogenic environment. This review seeks to identify a range of existing guidelines for the provision of healthy food options for families who eat OH frequently. Nationally available nutrition policies were identified using targeted and untargeted searches of the internet to identify established strategies for providing food for children in the family eating out sector in America (US), Australia, Canada and the WHO's European Region (EUR). These were categorised on the basis of eleven pre-defined criteria including: family eating out sector included as stakeholder; inclusion of children's food OH; cost strategies for healthier food choices; provision of nutrition information for customers; nutrition training of catering staff; and monitoring and evaluation structures. Fifty-five policies were reviewed, of which 71% addressed children's food served OH, but principally only for food available in schools. Two voluntary programmes, from Colorado and Slovenia, were identified as possible best practice models as they met a majority of the evaluation criteria. The most frequently used strategy by policies to promote healthier eating OH was the provision of nutrition information on menus, while monitoring and evaluation plans were poorly incorporated into any OH strategies, thus raising issues about their effectiveness. This review has identified a range of initiatives that could be employed to make healthier eating OH more accessible for families. However, to establish best practice guidelines for healthier OH food choices further investigations are required.

The purpose of this review was to update available knowledge on the relationship between adherence to the Mediterranean diet (MeDi) and cognitive decline, risk of dementia or Alzheimer's Disease (AD), and to analyse the reasons for some inconsistent results across studies. The traditional MeDi has been recognised by the United Nations Educational Scientific and Cultural Organisation as an Intangible Cultural Heritage of Humanity. This dietary pattern is characterised by a high consumption of plant foods (i.e. vegetables, fruits, legumes and cereals), a high intake of olive oil as the main source of fat, a moderate intake of fish, low-to-moderate intake of dairy products and low consumption of meat and poultry, with wine consumed in low-to-moderate amounts during meals. Beyond the well-known association between higher adherence to the MeDi and lower risk of mortality, in particular from CVD and cancer, new data from large epidemiological studies suggest a relationship between MeDi adherence and cognitive decline or risk of dementia. However, some inconsistent results have been found as well, even in Mediterranean countries. In this review, we analyse the reasons likely to explain these discrepancies, and propose that most of these differences are due to variations in the methodology used to assess MeDi adherence. We also discuss the possibility of residual confounding by lifestyle, that is, greater adherents to the MeDi also have a healthier lifestyle in general, which can favourably affect cognition. In conclusion, large-scale studies in various populations with common methodology are required before considering the MeDi as an optimal dietary strategy to prevent cognitive decline or dementia.

Genetic susceptibility testing for common complex disease is a practice that is currently in clinical use. There are two types of gene mutations, and therefore, two varieties of genotype testing: deterministic and susceptibility. As the term suggests, deterministic genes determine whether or not a person will develop a given trait in Mendelian fashion, such as Huntington's disease. Genotype screening for such deterministic mutations has existed for decades, and is commonly used in routine medical practice. In recent years, the sequencing of the human genome has identified several ‘susceptibility genes’ or genes with incomplete penetrance. Mutations in these genes may increase disease susceptibility, but are not causative for disease. Genetic susceptibility testing allows unaffected individuals to obtain risk information for a variety of common complex diseases and health conditions including Alzheimer's disease (AD), CVD, cancer and diabetes. The availability of genetic susceptibility testing has increased over the past decade, and several studies are now focusing on the impact that genetic testing has on health and other lifestyle behaviours related to nutrition. The aim of this paper is to review the literature and evaluate what, if any, impact genetic risk assessment has on behaviours related to nutrition and physical activity. This paper summarises seven clinical studies that evaluated the impact of disclosing genetic risk information for disease on nutrition-related health behaviour changes. Of these seven studies, only three studies reported that health behaviour change was influenced by genotype disclosure.

The intermediate and advanced stages of Alzheimer's disease (AD) are frequently associated with weight loss (WL), but WL may even precede the onset of cognitive symptoms. This review focuses on the possible aetiologic and temporal relationships between AD and WL. When WL occurs some years before any signs of cognitive impairment, it may be a risk factor for dementia due to deficiency of several micronutrients, such as vitamins and essential fatty acids, and consequent oxidative tissue damage. The leptin reduction associated with WL may also facilitate cognitive decline. The mechanisms potentially inducing WL in AD include lower energy intake, higher resting energy expenditure, exaggerated physical activity, or combinations of these factors. A hypermetabolic state has been observed in animals with AD, but has not been confirmed in human subjects. This latter mechanism could involve amyloid assemblies that apparently increase the circulating cytokine levels and proton leakage in mitochondria. WL may be caused by patients’ increased physical activity as they develop abnormal motor behaviour (restlessness and agitation) and waste energy while trying to perform daily activities. During the course of AD, patients usually find it increasingly difficult to eat, so they ingest less food. AD-related neurodegeneration also affects brain regions involved in regulating appetite. The caregiver has an important role in ensuring an adequate food intake and controlling behavioural disturbances. In conclusion, WL is closely linked to AD, making periodic nutritional assessments and appropriate dietary measures important aspects of an AD patient's treatment.

It is estimated that by 2050 there will be 2 billion people aged 60 years and older in the world. The evidence base for the health benefits of good nutrition and physical activity, as well as weight loss among overweight and obese adults, is growing and a number of policies and guidelines are available to guide health professionals in serving older people at various stages of the lifecycle. There are many potential influences on dietary habits including individual factors, families and friends, community characteristics, the food and supplement industry, and public policy. This review focuses on the evidence base for factors influencing diet in older adults, food insecurity, Na, vitamin D, vitamin B12, protein, obesity and the benefits of energy restriction in overweight and obese older adults. Research is needed to continue to increase the evidence base for appropriate ways to improve diet and health in older people. Also, much of the available information is from the US, so there is a need to conduct research in other areas of the world.

The goal of this brief review is to address the role of the ageing gut in the genesis of malnutrition in the elderly. We assess the burden of malnutrition in the elderly, exploring the role of comorbid conditions and neurohumoral changes that take place to contribute towards the process of anorexia associated with ageing. Following this, the review assesses physiological changes that occur in each part of the gastrointestinal (GI) tract and what implication they may have in clinical practice. In the oropharynx and the oesophagus, changes in swallowing and oesophageal motility associated with ageing can be demonstrated using physiological testing. However, in the absence of comorbid disease, they often have little, if any, clinical significance. In the stomach, reduced fundal compliance may contribute to early satiety; however, the primary change is hypochlorhydria, which may predispose to malabsorption or bacterial overgrowth further along the GI tract. Almost uniquely, the small bowel, particularly its absorptive function, is unaffected by age and we review the literature demonstrating this. In the colon, there is evidence of a prolonged transit time related to a reduction in both neurotransmitters and receptors. Although this may cause symptoms, this aspect is unlikely to contribute to malnutrition. In addition, we assess the potential changes in the gut microbiome and how this may interact with the immune system in the process of ‘inflamm-ageing’. We conclude by summarising the main changes and their impact for the clinician along with recommendations for future areas of research.