The introduction of evidence-based programs and practices into healthcare settings has been the subject of an increasing amount of research in recent years. While a number of studies have examined initial implementation efforts, less research has been conducted to determine what happens beyond that point. There is increasing recognition that the extent to which new programs are sustained is influenced by many different factors and that more needs to be known about just what these factors are and how they interact. To understand the current state of the research literature on sustainability, our team took stock of what is currently known in this area and identified areas in which further research would be particularly helpful. This paper reviews the methods that have been used, the types of outcomes that have been measured and reported, findings from studies that reported long-term implementation outcomes, and factors that have been identified as potential influences on the sustained use of new practices, programs, or interventions. We conclude with recommendations and considerations for future research.Two coders identified 125 studies on sustainability that met eligibility criteria. An initial coding scheme was developed based on constructs identified in previous literature on implementation. Additional codes were generated deductively. Related constructs among factors were identified by consensus and collapsed under the general categories. Studies that described the extent to which programs or innovations were sustained were also categorized and summarized.Although "sustainability" was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation . Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves.Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment. All systems and organizations are faced with the challenge of implementing new practices at one time or another, yet many of the innovations that are initially successful fail to become part of the habits and routines of the host organizations and communities. Why do some take root and flourish while others languish? Recognizing the need to promote the use of best practices to achieve better outcomes in healthcare, many government agencies and community organizations have devoted significant resources to promoting research on evidence-based practices (EBPs), clinical guideline implementation, and quality-improvement programs ,2. The NThe results of program evaluation and research to date suggest that sustainability must be studied as a distinct and dynamic phenomenon ,5. AlthoMany factors make it difficult to study sustainability and draw conclusions in the current literature. A fundamental challenge is the tension that exists between the continuation of interventions as originally designed and the need to adapt them for use in contexts that may differ in important ways from those in which they were originally developed and tested ,16,17. ATo better understand the state of research on sustainability to date, we reviewed studies that investigated whether or to what extent programs or interventions that had previously been implemented were sustained, and those that sought to understand factors that influence their sustainment. We present an overview of the ways that some key research considerations have been addressed from this perspective in a variety of fields, and we allow what we found using this approach to guide our synthesis of the results and recommendations. For the purposes of this review, we consider relevant studies to be those that identified interventions, procedures, or programs that were implemented to achieve specific program-, patient-, or population-level benefits. We reviewed studies that examined (1) sustainability outcomes   and alternative spellings were included in the search. We also employed a snowballing strategy, in which we searched the reference sections of reviews and theoretical papers on implementation and sustainability ,25,28,29nability ,25,30-32Our inclusion criteria included peer-reviewed studies that addressed sustainability of specific interventions or programs, were written in English, and were published or in press by July 2011. Because sustainability has been defined in numerous ways, we included all studies in which the authors used one of the terms described above or in which an effort was made to determine the extent to which a program or intervention continued after an initial period of training, implementation, or study. Studies were coded only if they included a methodology or procedure designed to identify (1) the status of the program after the initial implementation effort or funding has ended ; (2) the program-, service-, or recipient-level outcomes measured after external support or funding was withdrawn; or (3) the influences on the persistence of the implementation, whether or not the primary focus of the article was sustainability. Articles were excluded if they (1) reported only on initial implementation efforts, (2) were purely narrative accounts or papers on "lessons learned" that did not examine sustainability using qualitative or quantitative research methodologies, (3) reported only long-term follow-up of individuals after a clinical trial or intervention study, or (4) contained insufficient information to determine whether inclusion or exclusion criteria were met . Studies were considered to focus on initial implementation efforts if the original training, supervision, monitoring, or funding support was ongoing throughout the time period of the research .All titles and abstracts retrieved by electronic searching were reviewed by one reviewer, who screened out papers that were not related to implementation . Where it was not possible to exclude articles based on title and abstract, full text versions were obtained and their eligibility was assessed. Full text versions of all potentially relevant articles identified from the reference lists of included articles were obtained. Papers related to implementation were screened independently by two reviewers, and those studies that did not meet the inclusion criteria were excluded. Raters agreed on 95% of the papers that were excluded and agreed on the reasons for exclusion for 91% of the articles. Disagreements were resolved through discussion and consensus.Figure An initial coding scheme was developed based on constructs identified in previous conceptualizations of implementation ,9,34,35 Our search procedure identified studies from a variety of fields. Forty-one (33%) of the studies reported on medical interventions or healthcare programs, 42 (34%) on public health or health promotion programs, 33 (27%) on mental or behavioral health interventions, and 9 (7%) on educational interventions. Eighty-eight (72%) of the studies examined either programs or multicomponent interventions as opposed to a single procedure or intervention, such as a discrete medical procedure.The majority of the studies  reported on sustainability at multiple implementation sites or settings, followed by studies that reported on sustainability at the individual or provider level . The remainder of the studies reported on sustainability within single systems or communities , at a single site , among individual providers within sites , or at the team level .Studies were coded for the last post-implementation timeframe reported. Most studies  occurred two years or more past the initial implementation. Seven (6%) reported outcomes at less than 12 months post-implementation, 20 (16%) at 12 months, and 15 (12%) between 12 and 24 months post-implementation.Sustainability was defined in a number of ways, and different terms were used to refer to the continuation of an innovation within an organization or community. Table Almost half of the studies reviewed employed self-report measures  or interviews  to assess sustainability or its influences. Fifty-four (43%) included some form of observation, 35 (28%) involved record review, and 23 (19%) included assessment of the fidelity/integrity of an intervention or practice. Eight (7%) of the studies reported on sustainability after an intervention had been implemented in a clinical trial. Solely quantitative approaches were used in 68 (54%) of the studies, qualitative approaches alone were used in 27 (22%), and 28 (23%) of the studies employed both qualitative and quantitative strategies. Nearly all examinations of sustainability were naturalistic rather than experimental. However, seven studies (6%) involved experimental manipulation of training or implementation strategies and assessed self-reported use, skill, or fidelity at a follow-up.Studies discussed or reported on a variety of outcomes, and some reported multiple outcomes. Fifty-seven health-related studies (45% of the studies reviewed) reported outcomes such as the proportion of sites or providers sustaining, or the proportion of eligible patients receiving an intervention. The remaining studies did not report sustainability outcomes or reported data in such a way that it was not possible to determine the extent to which an intervention or practice was continued. For example, some reported on factors related to sustainability, without describing sustainability outcomes. Among the 57 studies that reported outcomes, 51 reported the proportion of sites or providers sustaining or discontinuing an intervention or program. The remaining studies reported the percent of patients or communities that received an intervention during a follow-up period. Seventy-five (60%) of the reviewed studies reported changes in the rate of program implementation and/or recipient outcomes, and two studies reported changes in both. Twenty-seven (22%) of the studies reported some form of health outcome (sustained impact or increases/decreases in desired outcomes), 14 of which were published in or after 2010.Figure Of the 75 studies that reported on changes in implementation or recipient-level outcomes after initial implementation efforts or funding had ended, 56 studies reported on the intervention or program implementation. Of these, 19 reported lower levels of implementation after initial implementation efforts had ended, 17 reported an increase, and 3 reported no change or a similar level of implementation. Seventeen studies reported varying changes in rates across different intervention or program components. Twenty-one studies assessed changes in outcomes: 5 reported a decrease in desired outcomes, 10 reported an increase, and 1 reported no change. The remaining five studies reported multiple outcomes or indicators that varied in the extent to which they sustained.Thirty studies employed quantitative methodologies to identify predictors, correlates, or associated factors of sustainability. Thirty-six studies employed qualitative or mixed methodologies to identify influences on or processes associated with sustainability. Twenty of these studies specified that they were guided by a conceptual framework. Four broad categories of potential influences emerged in our coding process: influences related to the innovation, organizational context, capacity , and processes. These four categories were common among each of the health-related fields we examined. However, only eight of the quantitative studies that examined elements related to sustainability included all four areas in their analyses, and 12 examined factors related to both the organization and capacity . Twelve of the studies, all of which employed qualitative or mixed methodologies, found that elements in all four categories were associated with sustainability.Table We examined 125 published papers to identify the different methodologies, types of innovations studied, timeframes examined, definitions used, outcomes examined, and factors examined in research on sustainability to date. Discussions in the literature over the past two decades  regardinBecause of the variety of results reported in the studies we reviewed, it is difficult to quantify or generalize about the extent to which new programs and practices are sustained. However, three findings are notable. First, similar to findings from a previous review , we founOur review found that although terminologies and areas of emphasis differ somewhat across fields, influences on sustainability relate to the context , the innovation itself , processes , and the capacity to sustain . Some qualitative findings also supported the conceptual literature that suggests an interrelation and interaction between these factors . The broFindings related to capacity were relatively common in both quantitative and qualitative research. For example, both qualitative and quantitative methodologies identified influences related to the workforce as associated with sustainability. These included the stability of the workforce and attributes of the workforce, such as their skills and attitudes. Additionally, qualitative studies identified the support or participation of key stakeholders and funding as important influences. Funding was rarely measured or included in the analyses, perhaps because studies took place after the initially allocated funding and resources had been removed. While some studies explicitly assessed or discussed the availability of new funds to support the programs that were being studied, most did not indicate whether additional funding had been obtained or allocated. However, influences such as sufficient resources and staffing that were identified in qualitative studies may be indicators of the adequacy of funds.Other elements that are included in conceptualizations of sustainability  rarely eProcesses and interactions were associated with sustainability in nearly three-quarters of the qualitative studies. Integration of the program into policies, collaboration among stakeholders, and ongoing support were commonly identified processes. Findings related to processes that emerged in qualitative studies may explain why factors such as culture and climate were rarely identified in the studies we reviewed, despite their prominence in the implementation literature. Those who were interviewed in qualitative studies may have been more likely to describe noticeable processes and interactions that are evidence of a particular culture or leadership style than to characterize the culture of an organization. For example, some processes identified in our review, such as integration into policies or standards, may serve as "culture-embedding mechanisms" ,68. SimiIn summary, the findings that we presented above illustrate the variability in methods, outcomes, and potential influences that have been studied to date. Based on the empirical literature that we reviewed, it is difficult to generalize about influences on sustainability and the long-term impact of implementation efforts. As research develops further, refinements in conceptualizations and study designs will lead to results that are more easily interpreted. Below, we discuss some considerations and recommendations for such research.An important limitation to the body of research on sustainability that we reviewed is the high proportion of studies that did not present a working definition or demonstrate evidence of guidance by a model of sustainability. The way that the concept is defined and conceptualized has important implications for how it is investigated. At a basic level, the studies that we reviewed focused on the continuation of the programs and practices that were implemented within organizations, systems, or communities after initial implementation efforts or funding ended . While simpact may be considered sustained if desired health benefits remain at or above the level achieved during implementation and this increase can be attributed to continuation of the program. A program or intervention may be considered to be sustained at a given point in time if, after initial implementation support has been withdrawn, core elements are maintained  whether, and to what extent, the core elements  ,32,64 argnizable  or delivgnizable ,62,71) aAs our discussion of elements of sustainability above indicates, the desired impact and benefits of the program or intervention should be identified. Additionally, stakeholder goals for sustainability  should be considered in the interpretation of findings. The type of innovation and setting will drive some of these considerations. For specific interventions identified to improve patient-level outcomes , these health benefits may be considered to be the "bottom line." For programs formed to identify and implement multiple interventions to achieve health-related goals, outcomes such as indicators that programs are being implemented, the existence and functioning of a decision-making body, and coordination between multiple agencies or stakeholders may be critical outcomes in addition to population-level outcomes such as reduced rates of disease or infection.When studying the sustainment of a program or intervention, a timeframe that is sufficiently beyond an initial implementation effort to provide meaningful information must be chosen. Although there may be no obvious indicator for determining when initial implementation efforts have "ended," it can be useful conceptually to separate the period of initial implementation from a post-implementation phase. Most of the studies we reviewed examined sustainability two or more years after implementation, consistent with suggestions in the literature . Althougprevent further innovation or adoption of more effective practices [Consistent with discussions of sustainability that suggest that adaptation and evolution of the practices and innovations are to be expected ,32,72,73ractices ,31,32, iractices ,74, withractices . In the ractices . Evidencractices ,62,74. Iractices ,76 and mractices . This tyractices -80. Theoractices ,82.Simply measuring fidelity and characterizing modifications as deviations may obscure the very refinements that facilitate the continued use of some innovations. A period of mutual adaptation  is probaIdentifying core elements, or components that are critical for the achievement of desired outcomes, is also a critical area for future study. Developers of many complex interventions have not yet pursued these questions. Isolating elements of innovative practices and examining their relative contributions to the overall impact of the practice can be challenging and may not be feasible or desirable in some situations. However, when available, this information can facilitate a streamlined or pragmatic implementation effort that retains the aspects found to be most effective and successful in everyday practice . As a poFindings from our review suggest that the study of influences on sustainability is nascent. Fewer studies than we expected identified influences that are found in existing conceptualizations of sustainability. It is possible that these findings result from a lack of guidance by a theoretical framework, given that fewer than one-third of the studies that we reviewed were guided by an explicit model. To advance research in this area, we recommend that researchers identify models or frameworks of sustainability  that areThere is also room for improvement in methods employed to characterize intervention sustainability and its influences. Beyond fidelity measures used in clinical trials, there are few procedures or benchmarks to guide researchers in efforts to identify the extent to which interventions and programs were continued as implemented. Pluye and colleagues operationalized definitions of three degrees of sustainability for public health programs  but did not develop a formal assessment instrument. However, they did develop a 15-question interview to assess degrees of sustainability . The LevTypically, in research that employs surveys to measure influences on sustainment, the instruments were developed for the specific projects or implementation efforts , and psyQualitative and mixed methodologies that assess potential influences across multiple levels will continue to be necessary to refine hypotheses, explore results, understand the relationships between sustainability drivers, and facilitate the development of interventions to promote the sustainability of effective programs and practices. Our review indicates that qualitative studies yielded a wider variety of findings and have highlighted processes and constructs that warrant further study. However, the vast majority did not provide interview guides to clarify how they assessed activities, processes, or influences associated with sustainability. This step will improve the interpretability and replicability of future research. Furthermore, prospective research on sustainability and efforts to identify influences and interventions that lead to sustainable implementation efforts will be of critical importance . ElucidaSome limitations to our review are important to acknowledge. In this project, we reviewed studies that identified specific programs or interventions and investigated either the extent to which those interventions and/or the desired benefits were sustained or factors that influenced their sustainability. Information generated from this review can inform researchers about what has not yet been sufficiently explored and stakeholders about what may be important to consider when monitoring specific programs or interventions that they have chosen to implement. We did not specifically seek studies that examined the adaptive capacity of systems, and we did not take an ecological or developmental perspective in our review ,97. SuchAlthough we attempted to identify studies from a variety of fields using a number of search strategies, the diffuse nature of the literature on sustainability and the variety of terms used may have limited our ability to complete an exhaustive review. Additionally, we sought to look broadly across literatures from a number of fields, but the applicability of some findings to any one innovation may be somewhat limited. We sought to learn what the available findings could tell us about the extent to which specific practices or programs have become rooted and sustained within organizations and communities, in order to conduct the most comprehensive review possible. By "casting a broad net" in terms of the fields and methodologies that were represented in our review, we intended to identify methods, strategies, constructs, and findings that may not have been considered within some individual fields. In these studies, the extent to which a program or intervention had continued was generally assessed at a single point in time, limiting conclusions that could be drawn about changes over time. Thus, we chose to present ranges of sustainment that had been found within particular fields in lieu of a definitive statement about whether or to what extent sustainment could be expected for particular innovations.post hoc research [In the early efforts to study the sustainability of specific programs and interventions that we reviewed, we have identified a body of literature that is fragmented and underdeveloped. In addition to previously noted challenges, limited funding for monitoring programs after initial implementation, challenges to observation in real-time, and the lack of validated measures have complicated the study of sustainability, and much of what is known to date has been determined through research . The curEach of our recommendations to advance what is known about sustainability will require time, resources, and funding, all of which have been relatively limited across the fields that we reviewed. With prospective studies of implementation efforts underway, investigators could make a substantial contribution to the field by planning follow-up studies that assess the degree to which the programs or practices are maintained and the nature and implications of changes that are made once implemented. Furthermore, researchers and policy makers should be encouraged to consider the question of sustainability when developing implementation programs and research. Appropriate planning, assessment, and allocation of funds would result in much better understanding of why and how some interventions and programs last and others do not. In an era of increasing budget pressures and greater scrutiny of new investments, nothing could be more desirable as a practical matter as well.The authors declare that they have no competing interests.SWS conceptualized the study, contributed to the data collection and coding, and was the predominant contributor to this article. NC and AC assisted with the coding of articles and compilation and interpretation of results. MC, JK, and FC made significant contributions to the conceptual framework and the interpretation of results. All authors read and modified drafts and approved the final manuscript.Articles Included in the Review [e Review ,98-220.Click here for file


The intense sweeteners currently authorised in Europe comprise ten compounds of various chemical natures. Their overall use has sharply risen in the last 20 years. These compounds are mainly used to formulate reduced-calorie products while maintaining sweetness.This extensive analysis of the literature reviews the data currently available on the potential nutritional benefits and risks related to the consumption of products containing intense sweeteners.Regarding nutritional benefits, the available studies, while numerous, do not provide proof that the consumption of artificial sweeteners as sugar substitutes is beneficial in terms of weight management, blood glucose regulation in diabetic subjects or the incidence of type 2 diabetes. Regarding nutritional risks , it is not possible based on the available data to establish a link between the occurrence of these risks and the consumption of artificial sweeteners. However, some studies underline the need to improve knowledge of the links between intense sweeteners consumption and certain risks. The term 'Intense sweeteners' (IS) refers to various substances of plant origin or obtained by chemical synthesis, used in the food industry for their high sweetening power and their low caloric value. The intense sweeteners currently authorised in Europe comprise ten compounds of various chemical natures.They are used in the formulation of foods and beverages, essentially for their sweetening role but also for their technological properties . Their sweetening power is a hundred  to several thousand (e.g. neotame) times higher than that of sucrose. Their overall use has sharply risen in the last 20 years. These compounds are mainly used to formulate reduced-calorie products while maintaining sweetness. Their lower calorie content suggests a direct link to weight management for consumers. However, no claim- related to the effects of IS on weight management have been authorised.This extensive analysis of the literature reviews the data currently available on the potential nutritional benefits and risks related to the consumption of products containing IS, particularly since nutritional benefits were not examined in the context of the initial authorisation issued under Regulation (EU) No 257/2010.The substances covered in this assessment are the IS currently authorised in Europe, after scientific review: aspartame , acesulfThe search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilised in this review. An initial search of Medline Table , CochranIn vitro, ex vivo, and animals studies have been excluded.Types of studies were broad and unrestrictive to capture as much data as possible. Meta-analysis, randomised controlled, quasi experimental, cohort, case-control and cross-sectional studies were accepted. Whatever its design and quality, a single study is never able to establish the causality between the exposure and the disease, in this case between IS consumption and its effects on health. In our review, we used part of Hill’s criteria of causation to assist in the assessment of the causal relationships. Indeed, a modified version of the Bradford Hill criteria was used to evaluate the evidence of a causal relationship between IS consumption and health outcomes. As a matter of fact, the following eight criteria, considered as the most important to answer our questions, were used in our review: strength, consistency, temporality, coherence, experiment, plausibility, analogy and biological gradient. One criterion, the specificity, was omitted because considered as nonspecific to our various outcomes. It should be pointed that none of these criteria alone is sufficient to establish causality and that no systematic algorithm was used. The final interpretation of the causality was based on experts’ judgment based on all analysed data.The exhaustive review included 10,989 manuscripts . Out of them, 9,373 were excluded after a reading of the title and the abstract. Consequently, 1,616 full-text manuscripts have been extensively reviewed of which 383  have been considered of interest for the topic of benefits and risks related to IS. For this review however, only the most relevant ones have been quoted, mainly based on their methodology, novelty and originality. Among these studies, 30.1 % were funded by the industry, 56.3 % by non-profit organisations, and the others did not report funding sources. However, we did not consider differently studies based the funding source.IS are often consumed as sugar substitutes, particularly in beverages, in order to satisfy a desire for sweetness while avoiding energy intake from sugars. The expert appraisal assessed whether there were metabolic consequences of this separation of sweetness and calorie intake, particularly in terms of body's ability to associate a taste with an energy value and therefore regulate its energy balance, and also in terms of consequences of IS consumption on appetite for sweetness and the consumption of sweet products.A meta-analysis covering studies undertaken before 2006 along with around ten randomised experimental studies were identified to address these points. The meta-analysis of 15 randomised experimental studies  assessedOverall, based on studies dealing with occasional exposure to an IS before a meal, it is not possible to infer the effect of regular IS consumption on sweetness habituation or increased cravings for sweetened products. Most experimental studies show that the occasional consumption of IS before or during a meal has no effect on food intake or energy intake during the next meal. Occasional IS consumption before a meal reduces the sensation of hunger and the desire to eat, just like caloric sweeteners, but this effect is temporary and disappears before the start of the meal. In most cases, the use of IS as sugar substitutes results in a decrease in short-term energy intake due to their low calorie content and the lack of compensation. However, the available data cover insufficient time periods to guarantee the maintenance of this effect over the medium or long term.vs sugar-sweetened beverages on the satiety and desire to eat of children aged seven to 11 years for 18 months ,, 16,9, 1la Hunty ,32. Thesla Hunty , 27, 29 position ; four stposition ,28; and position , 26.TablIn conclusion, observational and intervention studies report contradictory associations between IS consumption and weight loss. Therefore, no conclusion can be drawn as to the long-term effect of replacing caloric sweeteners with IS on the weight of regular adult consumers of sweet products.Four RCT studies focusing on the relationship between IS consumption and body composition were identified. In three of these studies, changes in weight and BMI did not differ between IS consumers and non-consumers –35. ThesMost of the prospective observational studies undertaken in children show that IS use is paradoxically associated with weight gain, although the causality of this relationship has not been established. The four available controlled trials showed conflicting results but none reported weight gain. No conclusions can be drawn from all of these studies as to the significance of IS for weight management in children and adolescents.This section presents data on the effects of IS consumption on glucose homeostasis and risk of diabetes, in healthy subjects, type 1 diabetics and type 2 diabetics Thirty-one clinical trials and two reviews assessed the short-term effects (less than one week) of IS consumption on glucose homeostasis. To date, the data on the long-term risk of developing diabetes are still limited and have been taken from seven observational epidemiological studies.Regarding the acute effects (i.e. less than 24 hrs.), the available studies did not show any effects related to the consumption of aspartame on an empty stomach –44, saccWhen considering short- and medium-term effects, several studies assessed the effect of regular IS intake , in capsule form or in beverages, on maintaining blood sugar control . For type 2 diabetics, the consumption of sucralose  or asparOverall, the vast majority of studies do not show any acute effects of IS intake on blood glucose or insulin concentrations measured on an empty stomach or after a test meal, in healthy subjects or in diabetics. Some studies reported a modest increase in GLP-1 secretion, but with no repercussions on insulin secretion or blood glucose concentrations. IS consumption has no effect on short- and medium-term blood glucose parameters in healthy subjects or in diabetics.The seven observational studies dealing with IS consumption and the incidence of T2D showed diverging results. Four cohort studies of good quality (three undertaken in North American populations and one in a European population), over periods of nine to 24 years, did not show any relationship between the consumption of artificially sweetened beverages and the risk of developing T2D after adjustment for BMI and energy intake of subjects –63, 26. In conclusion, the long-term epidemiological studies on the risk of developing T2D show heterogeneous results, but the most robust studies do not report any effects.Of the 20 randomised controlled experimental studies analysed, the majority focused on aspartame or stevia extracts. Compared to a placebo, aspartame consumption had no effects on triglycerides or cholesterol concentrations  in various populations  for periods ranging from 13 to 28 weeks. Compared to a caloric sweetener , of the five identified studies, two showed a modest significant improvement in lipid profile  in the group that received aspartame, still with no differences compared to the placebo. Three studies, two in T2D patients, assessed the effect of stevia extracts on lipid parameters and showed no differences compared to a placebo. Studies using other types of IS  also showed no effects on the assessed lipid parameters. Of the four identified cohort studies, most showed no effects on lipid parameters related to the consumption of artificially sweetened beverages. A single study reported a positive association between the consumption of these beverages and an increase in TG concentrations associated with a lowering of HDLc .In conclusion, the majority of observational studies showed no effects on lipid profile related to IS. Two studies reported that replacing sugars with aspartame reduced plasma triglyceride concentrations but the data are too limited to conclude that IS have a beneficial effect on lipid profile.Two epidemiological studies are available. In the first , a dose-Based on the available data, it is not possible to identify any benefits or draw any conclusions regarding the risk related to the consumption of intense sweeteners during pregnancy, in terms of maternal health, obstetrical parameters or newborn health.The relationship between IS consumption and cancer in humans was assessed in 55 scientific studies. Thirty-nine of these studies involved the urinary tract and 32 focused exclusively on bladder cancer. The other studies assessed the relationship between IS consumption and the risk of brain cancer (four studies), digestive system cancer (six studies) or other cancers (five studies). Except in the studies focusing on bladder cancer, the IS in question were not identified by the authors. The relationship between saccharine consumption and bladder cancer was the most commonly studied, given that data were available in rodents . The resOn the whole, the epidemiological studies do not show any effects of IS consumption on cancer risk. Only one recent study suggested a relationship between the consumption of beverages containing IS and the occurrence of non-Hodgkin lymphomas and myelomas, and additional studies are required.Regarding the potential neurological effects of IS, only aspartame has been studied. There are two studies in healthy adults , 73. No Some studies with significant methodological limitations suggested that aspartame consumption may be involved in triggering epileptic seizures and migraines but no conclusions can be drawn regarding the occurrence of such a risk from the data as a whole.The use and consumption of intense sweeteners have risen sharply over the last twenty years, probably due to concerns linked to the doubling of prevalence of overweight and obesity. While the potential risks of each intense sweetener are assessed before their authorisation, no general assessment of the overall nutritional risks and benefits of these products has been conducted at the European level up to now –83.th percentile intakes are lower than the ADIs.After an analysis of all of the scientific literature, it appears that, despite a large number of studies, the data are insufficient to determine any long-term nutritional benefits related to the consumption of products containing IS as sugar substitutes. The available data do not show any risks related to IS consumption. However, due to the limited number of studies, it is not possible to rule out potential long-term risks related to IS consumption in specific populations, particularly adult daily consumers and children. It is important to note that before their authorization to be on the market, the potential risks of each intense sweetener are assessed and an acceptable Daily Intake (ADI) is set for each IS. Based on several food surveys, an estimate of the dietary intakes of the ISs currently used in various countries shows that in all study populations  and irrespective of the IS taken into consideration, the mean and 95The use of intense sweeteners as a substitute for sugar in most cases engenders a short term reduction in caloric intake due to the low calorie levels of these substances and the lack of compensation. However, the available data cover insufficient time periods for guaranteeing that this effect is maintained in the long term. Moreover, studies of weight control in adults and children have reported conflicting associations. Certain observational studies show that intense sweetener use is paradoxically associated with weight gain, although the causality of this relationship has not been established.The consumption of intense sweeteners was not shown to have any beneficial effects on prevention of type 2 diabetes; similarly, their regular consumption as a sugar substitute does not appear to have any beneficial effect on regulating blood glucose concentrations. For the risks of developing cancer, type 2 diabetes, or premature births, the data available to date do not enable a link to be established between onset of these risks and the consumption of intense sweeteners. A few studies do however highlight the need to obtain further knowledge on the link between intense sweeteners and certain risks and in specific populations, particularly adults daily consumers and children.This review of the scientific literature revealed some gaps that should be filled and areas of research that should be explored. There were differences between the results of randomised controlled trials and the results of observational studies. Furthermore, the studies assessing the effects of replacing sugars with IS on eating behaviour or energy intake were undertaken over the short term and should be supplemented with long-term studies. Two types of additional studies seem necessary to clear up these differences. On the one hand, longer-term (at least one year) blind, placebo-controlled intervention studies would shed further light on the metabolic and physiological effects of IS. On the other hand, intervention studies in which IS are consciously consumed would help to understand potential changes in eating behaviour related to the replacement of sugars with IS in near-real-life conditions. There are also very few data on the long-term impact of IS on food preferences. Therefore, it appears necessary to study the effects of IS consumption on dietary choices. In most of the cohort studies, the consumption of artificially sweetened beverages was reported only when the subjects were first included, and subsequent consumption was not taken into account. These studies assessed only the consumption of artificially sweetened beverages, and not the total consumption of artificial sweeteners. It is also difficult to distinguish between the effects of the various IS consumed alone and their effects when combined with other IS. Future cohort studies should be capable of taking into account qualitative and quantitative changes in the consumption of artificially sweetened products and adapted dietary questionnaires, to accurately and specifically assess IS consumption. Specific populations such as pregnant women, children, diabetic subjects and regular IS consumers have not been adequately studied. It appears necessary to further study the effects of IS in these populations. Likewise, it appears necessary to determine the repercussions of IS consumption during the peri-natal phase on offspring . Some data suggested that the potential effects of IS on changes in weight or the incidence of diabetes may vary depending on initial corpulence. Due to the increasing prevalence of obesity, it appears necessary to study potential interactions between corpulence and IS consumption in terms of the risk of weight gain or diabetes. At last, the literature on steviol glycosides is still sparse and should be enhanced, particularly given the recent growth in their use in beverages and foods.No beneficial effects have been shown that provide grounds to recommend regular IS consumption for adults or children. Moreover, the available data do not show the occurrence of risk in occasional consumers. However, based on the epidemiological data currently available, it is not possible to completely rule out certain risks in the event of regular, prolonged consumption. Therefore, for the general population, the overall assessment of potential risks and benefits does not justify the long-term use of IS as sugar substitutes, particularly in beverages, which are their main vector. Lastly, in a nutritional policy context in which one of the main objectives is the reduction of sugar intake in the general public, as pointed out by the 2015 WHO guidelines on sugar intake, this review points out that no meaningful data exist that justify encouraging the substitution of sugars by intense sweeteners. This objective of reduction of sugar intake levels should be reached through a reduction in sweet tasting foods in general at an early age. It should therefore be recommended that artificially-sweetened and sugar-sweetened soft drinks shall not be consumed as a replacement for water.


Harmful alcohol consumption has long been recognized as being the major determinant of male premature mortality in the European countries of the former USSR. Our focus here is on Belarus and Russia, two Slavic countries which continue to suffer enormously from the burden of the harmful consumption of alcohol. However, after a long period of deterioration, mortality trends in these countries have been improving over the past decade. We aim to investigate to what extent the recent declines in adult mortality in Belarus and Russia are attributable to the anti-alcohol measures introduced in these two countries in the 2000s.We rely on the detailed cause-specific mortality series for the period 1980–2013. Our analysis focuses on the male population, and considers only a limited number of causes of death which we label as being alcohol-related: accidental poisoning by alcohol, liver cirrhosis, ischemic heart diseases, stroke, transportation accidents, and other external causes. For each of these causes we computed age-standardized death rates. The life table decomposition method was used to determine the age groups and the causes of death responsible for changes in life expectancy over time.Our results do not lead us to conclude that the schedule of anti-alcohol measures corresponds to the schedule of mortality changes. The continuous reduction in adult male mortality seen in Belarus and Russia cannot be fully explained by the anti-alcohol policies implemented in these countries, although these policies likely contributed to the large mortality reductions observed in Belarus and Russia in 2005–2006 and in Belarus in 2012. Thus, the effects of these policies appear to have been modest. We argue that the anti-alcohol measures implemented in Belarus and Russia simply coincided with fluctuations in alcohol-related mortality which originated in the past. If these trends had not been underway already, these huge mortality effects would not have occurred. Excessive alcohol consumption has long been recognized as being the major determinant of male premature mortality in the European countries of the former USSR (FSU). The results of a large number of national-level studies have repeatedly suggested the existence of the strong correlation between changes in alcohol consumption and fluctuations in mortality.–10 A numyears of life lost due to alcohol. In both countries, the average male aged 15 or older consumes more than 30 liters of pure alcohol a year. Together with Ukraine, Russia has the most risky patterns of drinking in the world.[We focus on Belarus and Russia, two Slavic countries which currently suffer enormously from the burden of harmful alcohol consumption. According to the most recent WHO report on alcohol consumption, Belarus had the world’s highest total (recorded and unrecorded) level of alcohol consumption, of 17.5 liters consumed per capita in 2010. Accordinhe world. The WHO he world.. There ahe world. However,he world. Meanwhilhe world.If we consider the long-term evolution of adult mortality and trends in alcohol-related causes of death, the situation in Belarus looks even more unfavorable than the situation in Russia. While it was a republic of the USSR, Belarus had one of the lowest mortality levels across the Soviet Union. Prior toHowever, since 2003–2004 positive changes in mortality dynamics have been observed in both countries. Between 2003 and 2013 male life expectancy increased by 6.6 years in Russia  and by 4In this paper we investigate to what extent the recent declines in adult mortality in Belarus and Russia are attributable to the anti-alcohol measures implemented in these countries. The study is organized as follows. First, as background information we provide an overview of the anti-alcohol measures adopted in Belarus and Russia during the Soviet and the post-Soviet periods. We then conduct a comparative demographic analysis of the observed mortality declines in the two countries, linking these decreases to anti-alcohol measures. Finally, we discuss the potential mechanisms underlying these rapid and somewhat unexpected mortality changes.Even though excessive alcohol consumption is widely recognized as constituting a major threat to public health, the anti-alcohol policies of Belarus and Russia have generally been irregular and lacking in consistency. In the past, little was done to curb the levels of alcohol consumption in these countries. Excessive drinking was even encouraged, as alcohol production was a very profitable industry for the Soviet government.. There wVytrezvitel (drunk tank). There was also an absolute ban on alcohol consumption in public places and institutions, including in sports venues and on public transportation. In addition, the government developed a network of LTPs. The campaign resulted in a rapid reduction in mortality, especially among adult males.[Gorbachev’s anti-alcohol campaign appears to have been far more effective than previous efforts by the Soviet government to limit alcohol consumption. The campaign included a number of extreme administrative measures, such as rationing , restricted hours of sale of alcohol (from 2 pm to 7 pm), and the detainment of publicly intoxicated individuals in a lt males. However,lt males.,27In the years immediately following the dissolution of the USSR, there were almost no anti-alcohol policies in the republics, and the power of the newly independent states to control the production and circulation of alcohol was very weak. These factors contributed to sharp rise in alcohol consumption, and particularly of illegal forms of alcohol, including of beverages which were manufactured locally or imported from abroad. The situation was particularly severe in Russia, where the state alcohol monopoly was abolished in 1991 and a portion of the alcohol industry was privatized. MeanwhilIn July 1998, Belarus approved a law regulating the production and circulation of ethyl alcohol and alcohol products. Under the law, the state was given the authority to regulate not just the production, sale, and import and export of alcohol; but also alcohol prices. In August 1999, excise stamps for marking alcohol beverages were introduced in Belarus. In 2000, the Belarusian government adopted the concept of a state anti-alcohol policy, as well as a national program of actions to prevent alcoholism for 2001–2005. Presidential decrees issued in 2002 and 2005 mandated the further strengthening of state control over the production, circulation, and advertising of alcohol. In 2006, a second national program of actions to prevent alcoholism for 2006–2010 was announced. In 2008, a new law on the state regulation of the production and circulation of ethanol-containing beverages went into force, replacing the analogous law of 1998.In 2011, a third state program of actions to prevent alcoholism for 2011–2015 was adopted in Belarus. This most recent program has several features that distinguish it from the two previous campaigns. The current program puts more emphasis on the prevention of alcoholism through the reduction of major risk factors, and has two main targets. The first target is to reduce alcohol-related mortality, and especially accidental poisoning by alcohol. The Ministry of Health is responsible for the monitoring of the progress made in reaching this target, and for improving narcology services across the country, including both the treatment and the prevention of alcoholism. The second target is the prevention of alcohol-related crimes, which is the responsibility of the Ministry of Internal Affairs. In addition to the measures undertaken in the previous programs, the 2011 anti-alcohol campaign included a number of new initiatives, such as increases in the excise duties on specific alcohol products, increases in the policing of and financial penalties on home producers, and a strengthening of laws on driving while intoxicated. The WHO has called the Belarusian anti-alcohol campaign of 2011 “an example of leadership and commitment to reducing harmful use of alcohol”.The alcohol policies implemented in Russia have been described in detail by a number of authors. ,28–31 ThIn early 2010 the Russian government approved a national program of actions to reduce alcohol-related harm and prevent alcoholism among the Russian population for the period 2010–2020. This initiative has, however, so far been purely symbolic. As the initial estimates of alcohol consumption in Russia were significantly overstated, the Minister of Health was able to claim to claim that the main tasks of the concept had been quickly implemented.Measures to limit the consumption of non-beverage alcohol appear to be the most successful of the anti-alcohol initiatives implemented in Russia. Leon and colleagues  showed tFor Belarus, we rely on the mortality series by sex, five-year age group, and cause of death; harmonized using the uniform method of a posteriori reconstruction of continuous mortality series.,35 MortaWe focus on males aged 20–64 years. This population group has been identified as the main one in terms of the impact of alcohol consumption on mortality . Our anaalcohol-related: namely, accidental poisoning by alcohol (corresponds to item X45 in the ICD–10), cirrhosis of the liver , ischemic heart diseases (I20–I25), stroke (I60–I67), transportation accidents (V02–V99), and other external causes . Although there are many more causes of death which can be linked to alcohol, we do not consider them in the analysis due their very small contributions to mortality.In our analysis we consider only a limited number of causes of death which we label as being To ensure the comparability of mortality trends, we calculated age-standardized death rates (SDRs) on the basis of the European population standard. To deterIt can been seen that there was a substantial difference in the overall mortality rates between Belarus and Russia in the yearly 1980s. It is interesting to note that higher mortality observed in Russia at that time corresponds to a much lower level of recorded alcohol consumption. The mortality gap between the two countries narrowed after the launch of the anti-alcohol campaign in 1985 but increased again after the collapse of the USSR in 1991. After quite different developments in the 1990s and early 2000s the trends have finally converged so that the difference between Belarus and Russia in adult male mortality reached its historic minimum.The trends in mortality from selected alcohol-related causes appear in As it is directly associated with the most hazardous forms of alcohol consumption, mortality from accidental poisoning by alcohol is a very sensitive correlate of overall alcohol consumption. Unlike tThe trends in mortality from liver cirrhosis look similar in the two countries. However, in Russia there was a very large increase in the early 1990s, followed by a subsequent decline of about the same magnitude; and, since 1998, by an increase that has been steeper than that of Belarus. In Belarus, mortality from liver cirrhosis increased without interruptions until 2011, when it reached its peak. But in 2012, mortality from liver cirrhosis in Belarus dropped dramatically; by about one-third.The trends in mortality from ischemic heart diseases are very much in line with those of mortality from accidental poisoning by alcohol, particularly for Russia. Whereas in Russia mortality has been declining rapidly since 2003, in Belarus progress was made starting in 2005, but was quickly interrupted, and did not resume until 2011. Despite a huge decline in 2012, mortality from ischemic heart diseases among adult Belarusian males is currently higher than among their Russian counterparts. While the trends in mortality from stroke have been similar, the pace of the reduction in mortality from stroke has been more impressive and sustainable than the speed of the reduction in mortality from ischemic heart diseases. In both countries, progress has been ongoing since the beginning of the 2000s. In Belarus, it accelerated after 2011. Currently, in both Belarus and Russia mortality from stroke among adult males is at historic lows. The trends in mortality from transportation accidents have also improved, particularly in Belarus, where mortality has been declining steadily since 1990. As was the case with other alcohol-related causes, there was a notable decline in 2012, although by this point in time mortality from transportation accidents had already reached relatively low levels in Belarus.Between 2011 and 2012 male life expectancy in Belarus increased by two years.. As suchThe increase in male life expectancy was almost exclusively attributable to rising life expectancy in the population aged 20–64. The reduction in adult mortality from causes which are closely linked to alcohol explains about two-thirds of the improvements. The pattern of mortality reduction observed in Belarus is very similar to the pattern seen in this country and in Russia during Gorbachev’s anti-alcohol campaign. However, unlike in the 1980s, these recent improvements are also linked to reductions in mortality from ischemic heart diseases and from liver cirrhosis. This is largely because these causes of death contribute to mortality levels to a much greater extent currently than they did in the 1980s.Can the recent decline in adult male mortality in Belarus and Russia be directly attributed to the anti-alcohol policies in these countries, or there is a more complex mechanism behind this phenomenon? If we consider the experience of Gorbachev’s anti-alcohol campaign, we would expect to find that the implementation of anti-alcohol measures would have an immediate impact on mortality. samogon” and the spread of alcohol surrogates led to a substantial decline in the consumption of illegal alcohol. [The results show that in both countries there were major reductions in mortality in 2006–2007 and in 2012–2013. Russia had more significant declines in 2006–2007, while Belarus saw greater decreases in 2012–2013. The mortality reduction observed in Russia in 2006 can be attributed to the anti-alcohol measures implemented in 2005–2006. But given its magnitude, it is unlikely that the subsequent reduction seen in 2007 is attributable to this factor alone. The 2006–2007 decrease in alcohol-related mortality in Belarus can be linked to the 2006 anti-alcohol campaign. Razvodovsky  has provalcohol.  This decBy contrast, a huge decline in mortality from this cause was recorded in Belarus in 2012. There were also marked improvements in mortality from the other alcohol-related causes, such as ischemic heart diseases, stroke, and external causes. This sharp drop in mortality rates can be linked to the most recent anti-alcohol campaign.Several limitations of this study have to be mentioned. First of all, using a statistical technique such as an Autoregressive Integrated Moving Average (ARIMA) would be an appropriate way to examine statistically the effects of alcohol policies on mortality. –48 HowevSecondly, an important aspect which this study omits is examining the association between alcohol policies and changes in per capita alcohol consumption. Unfortunately, in the countries considered in the analysis, especially in Russia, official statistics on alcohol consumption are unreliable due to the under-registration of the consumption of illegal alcohol and surrogates . AccordiFinally, the quality of death registration has to be taken into account while analyzing mortality data by cause. Generally, cause-of-death statistics of adult male population are considered to be reliable and comparable across the FSU countries.  ComparedThe recent reduction in mortality among adult males in Belarus and Russia is substantial, and shows signs of having lasting effects. Until 2003–2004, there were large fluctuations in these countries in both overall adult mortality and alcohol-related mortality in particular. Gorbachev’s anti-alcohol campaign generated a massive “mortality wave” which seems to still be affecting mortality dynamics. Thus, it is very difficult to assess the impact of policy interventions, and to disentangle their pure mortality effects.Our results do not lead us to conclude that the schedule of anti-alcohol measures corresponds to the schedule of mortality changes seen in Belarus and Russia. First, in both countries alcohol-related mortality started declining before the major anti-alcohol measures went into effect. Furthermore, given the magnitude of the reductions in alcohol-related mortality observed in Russia in, for example, 2007 and 2010, it is difficult to attribute these declines to anti-alcohol measures. Finally, despite the implementation of anti-alcohol measures, mortality from liver cirrhosis continued to increase in Russia until very recently. In Russia, there was a lag between the decline in mortality from accidental poisoning and the decrease in mortality from liver cirrhosis. In Belarus, mortality from liver cirrhosis continued to increase after the decline in mortality from accidental poisoning had started. This might be explained by the shift in the composition of alcohol consumption towards ‘lighter’ drinks  as well as changes in drinking habits such as reduction in the prevalence of the most hazardous forms of drinking associated with immediate death. Meanwhile, all these changes could result in increasing damages to the liver among individuals who had already been suffering from chronic liver diseases. On the other hand, the acceleration of the mortality decline in 2006 can indeed be linked to anti-alcohol policies. It has, however, been suggested that this acceleration made only a small contribution to the overall decline.,30To understand the underlying mechanisms of the recent changes in alcohol-related mortality, it is important to recognize the role of past dynamics. Generally, alcohol-related mortality is unstable, and tends to change over time. In the fsubbotniks,” collective trips to the park, or walks in nature. It is likely that the very strict measures imposed by the anti-alcohol campaign of 1985 limited drinking to the third type listed above. As a result of the ban on drunkenness at work and on public drinking near shops and at outdoor events, people began to drink less. The amount of alcohol consumed in a single session of drinking was also reduced as it was difficult to get large quantities at one time. As a result, the incidence of hazardous drinking declined. An analysis of causes of death during the anti-alcohol campaign showed that the decline in mortality observed in this period was attributable primarily to a reduction in deaths due to causes common among the group of individuals who engage in hazardous drinking. [zapoi,” a Russian term used to describe a period of two or more days of continuous drunkenness during which the person withdraws from normal social life. According to Nemtsov, [zapoi during the anti-alcohol campaign led to a decrease in the number of cases of alcohol dependency and abuse, and generally resulted in a decline in alcohol-related mortality.We argue that there are two major pathways through which anti-alcohol measures can influence alcohol-related mortality. On one hand, these measures can reduce the overall risk of mortality from spontaneous (unsystematic) drinking, predominantly due to trauma; and from the adverse consequences of a disease not related to alcohol. On the other hand, the anti-alcohol policies can directly influence the dynamics and mortality of the high-risk group. The anti-alcohol measures implemented in the USSR in 1972 are examples of the first pathway. These campaigns did little to reduce mortality, except for having a barely discernible effect on mortality from external causes among young adults. It can be assumed that mortality from spontaneous drinking decreased. At the same time, however, people who drank alcohol regularly expanded the list of liquids they were willing to consume to include items such as cleaning agents. Anecdotal evidence suggests that, until 1985, the following types of daily drinking patterns were prevalent in the USSR: 1) drinking at work, usually at lunchtime, but possibly continuing into the second half of the day; 2) drinking on the way home from work, often near the store where the alcohol was purchased in the "for three" mode; 3) drinking at home after work during lunch/dinner, and later in the evening outside of the house, often in the company of neighbors; and 4) drinking at public events, such as during demonstrations, “Nemtsov,  the reduHowever, in the early 1990s all types of drinking re-emerged. In 1992–1994 in Russia (and in 1992–1995 in Belarus and Ukraine) there was an explosion in alcohol-related mortality. AfterwarThe anti-alcohol measures implemented in Russia in 2005 and subsequent years did not result in any real declines in the availability of alcohol, except during a short period in the summer of 2006.  In all oIn sum, we believe that the continuous reduction in adult mortality which has been observed in Belarus and Russia over the past decade cannot be explained by the anti-alcohol policies implemented in these countries. Nemtsov and Shelygin  who analS1 Appendix(DOC)Click here for additional data file.


Ugba is an alkaline fermented African oil bean cotyledon (Pentaclethra macrophylla) produced by the Ibos and other ethnic groups in southern Nigeria. Seen as a family business in many homes, its preparation is in accordance with handed-down tradition from previous generations and serves as a cheap source of plant protein. Its consumption as a native salad is made possible by fermentation of the cotyledon for 2–5 days, but could also serve as a soup flavoring agent when fermentation last for 6–10 days. The fermentation process involved is usually natural with an attendant issue of product safety, quality and inconsistency. The production of this condiment is on a small scale and the equipment used are very rudimentary, devoid of good manufacturing procedures that call to question the issue of microbial safety. This paper therefore reviews the production process and the spectrum of microbial composition involved during fermentation. In addition, potential spoilage agents, nutritional and biochemical changes during production are examined. Furthermore, information that can support development of starter cultures for controlled fermentation process in order to guarantee microbiological safety, quality and improved shelf life are also discussed.Legumes and oil bean seeds used for the production of condiments in Africa are inedible in their natural state; they contain some anti-nutritional factors especially undigestible oligosaccharides and phytate. Fermentation impact desirable changes by reducing anti-nutritional factors and increasing digestibility.  Ugba, a product of alkaline fermentation of oil bean seeds (Pentaclethra macrophylla) is very popular among the Ibos and other ethnic groups in southern Nigeria. The product serves both as a delicacy and a food flavoring agent. As an important nutritional item, ugba is very rich in protein. It similarly plays an economic, social and cultural role among the Ibos in the eastern part of Nigeria. The production of ugba is usually pursued as a family business that has become an art that is handed over from one generation to another.ugba is usually by natural fermentation, a process that involves microbiological and biochemical changes, caused by hydrolysis and desirable changes. This process is usually influenced by the raw materials and the processing method with variations observed from one production batch or producer to another  and sanitation  Odunfa, , the antUgba is usually wrapped in leaves (in most cases banana leaf), and nylon bags and sold to the public. These packaging materials could be the source of contamination of the product.Recently, Oguntoyinbo  reportedkawal production, through the fermentation of the leaves of Cassia obtusitfolia in Sudan has been shown to improve safety quality and acceptability  and later wrapped (about 40–50 g of slices per wrap) using another leaf  and incubated for 72 h at room temperature.The production process of ugba flavor and the product is consumed as native salad. However, fermentation for a longer period of time (6–10 days) produces very soft ugba which is used as soup flavoring , B. licheniformis, B. megaterium, B. macerans, and B. circulans , pyrazine and antimicrobial such as subtiliosin production  especially at the early stages of production , lipids (43–47%) and carbohydrates  reduced the phosphorus and iron contents of the seeds while processing generally raised the calcium and magnesium contents , lipolytic activity is reported to be low during the fermentation of the oil bean seeds  have centered on the isolation and characterizations of organisms involved in the fermentation processes. Not much effort seems to have been made toward the occurrence and growth of possible pathogens in the product. However, Adewunmi et al. (iru microbiota and reported bacterial species with both spoilage and pathogenic history. In addition, genome typing of Bacillus species isolated from okpehe and soumbala identified species of Bacillus cereus with enterotoxin production potential (Ouaba et al., ugba, in order to guarantee its microbial safety. Furthermore, because of the stress associated with the food processing, it would be important to use culture dependent and independent methods in order to find/detect non-culturable or not yet cultured microorganisms. Available information in literature shows that organisms such as E. coli, Staphylococcus aureus and other members of the Enterobacteriaceae have been isolated from condiments in West Africa (Isu and Njoku, Most works on African fermented foods (i et al.  used a cugba involves natural solid state fermentation of the African oil bean seeds. This chanced inoculation method has the inherent drawback of possible growth and occurrence of pathogens in the final product. Although, microbiota that best adapted brings about the final product, variation in final product due to fermentation time and unhygienic handling does affect the product and its consistency.The traditional method of production of ugba in Nigeria. Oguntoyinbo et al. (okpehe, a fermented Prosopis africana cotyledon. Isu and Ofuya (Bacillus subtilis attached to cowpea and maize granules in the fermentation process of ugba. They monitored changes in pH, amino-nitrogen and protease activity as fermentation indicators, carried out with the immobilized cells. Protease activity increased from 4.5 to 27.65 mg N/min for the immobilized cells with respect to 10.5 mg N/min produced by the natural fermentation, and there was a reduction in the fermentation time to 48 h as compared to 96 h for the natural fermentation process.Selection and application of starter cultures in the production process has been identified as critical to the elimination of pathogens and spoilage microbes (Holzapfel, o et al.  used a cnd Ofuya  studied ugba using B. subtilis and B. lichenformis singly and as mixed cultures fermentation. The process fermentation time was reduced from 96 to 48 h. Ugba produced with the starters were similar in terms of color, taste and nutritional content to those produced by natural fermentation.Okorie and Olasupo  developeSeveral other attempts have been made to control the fermentation of this product with similar results as stated above (Ogueke and Aririatu, Ugba is an important part of the diet of the Ibos and other ethnic groups in the eastern and southeastern parts of Nigeria. It is produced through a natural solid state fermentation of the oil bean seeds. The major microorganisms involved in the process are Bacillus species. These microorganisms metabolize the protein content of the seeds into free amino acids and ammonia, having undergone a biochemical reaction during the fermentation process known as proteolysis.Fermentation of the oil bean seeds leads to increase in the nutritional values of the product. The natural process of its production, and the subsistent level at which the condiment is being produced leaves the safety of this product in doubt and makes its quality inconsistent. Efforts at controlled fermentation of the product have shown that some of these observed drawbacks could be overcome by the application of starter cultures in the production process. There is therefore a need to make the local processors of this product realize the potential benefits derivable from the application of starter cultures in their process line.NO: Participated in conception, literature search, design and write up. CO: Participate in literature search, design and write up. FO: Participated in literature search, design and write up.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A medium- and long-term perspective is required in human resource development to ensure that future needs and demands for oral healthcare are met by the most appropriate health professionals. This paper presents a case study of the Sultanate of Oman, one of the Gulf States with a current population of 3.8 million, which has initiated dental training through the creation of a dental college.The objectives of this paper are first to describe trends in the dental workforce in Oman from 1990 to date and compare the dental workforce with its medical counterparts in Oman and with other countries, and second, to consider future dental workforce in the Sultanate.Data were collected from published sources, including the Ministry of Health (MoH), Ministry of Manpower (MoM), and Ministry of National Economy (MoNE)-Sultanate of Oman; the World Health Organization (WHO); World Bank; and the Central Intelligence Agency (CIA). Dentist-to-population ratios were compared nationally, regionally and globally for medicine and dentistry. Dental graduate outputs were mapped onto the local supply. Future trends were examined using population growth predictions, exploring the expected impact in relation to global, regional and European workforce densities.n = 160). Subsequent to Oman Dental College (ODC) starting to qualify dental (BDS) graduates in 2012, there is an increase in the annual growth of the dentist workforce. On the assumption that all future dental graduates from ODC have an opportunity to practise in Oman, ODC graduates will boost the annual Omani dentist growth rate starting at 28% per annum from 2012 onwards, building capacity towards global (n = 1711) and regional levels (Gulf State: n = 2167) in the medium term.Population growth in Oman is increasing at a rate of over 2% per year. Oman has historically been dependent upon an expatriate dental workforce with only 24% of the dentist workforce Omani in 2010 (The output of dental graduates from Oman Dental College is improving the dentist-to-population ratio and helping the Sultanate to realize its aim of developing an Omani-majority dental workforce. The implications for retention of dentists and team training are discussed. Dental professionals play a vital role in meeting the oral health needs and demands of individuals in society. It therefore is important to ensure that the workforce resource is appropriate to the population, particularly given the cost of training and a working life that can span four decades. This paper presents the case study of the Sultanate of Oman, one of the Gulf States in the Middle East, which forms part of the Gulf Cooperation Council (GCC).Globally, there is a health workforce shortage ,2 and inAs countries recognize the importance of oral health for overall health and well-being, and the need for oral health care, so the education and training of dentists is facilitated. Oman, with a population approaching 4 million and a growth rate of over 2%, is one such case . Dental Oman has made a rapid transition to become a high-income country. This is reflected in improved population life expectancy, together with year-on-year increases in the prevalence of chronic non-communicable diseases, including diabetes and cardiovascular disease . PopulatImportant dental public health developments have included the introduction of water fluoridation in the Muscat area, together with school oral health preventative programmes involving fissure sealants, tooth brushing and the application of fluoride . FurtherAs a developed country, Oman has placed great emphasis on developing its medical workforce and healthcare system ,25. The Until recently, Omanis who wished to study dentistry had to train abroad, there having been no dental education available in the Sultanate. Thus, traditionally, Oman relied on expatriate dentists to form its dental workforce, together with a minority of overseas-qualified Omanis. With new policy encouraging the participation of the private sector in higher education, and the determination of its founding figures, Oman Dental College (ODC)  was estaGallagher and Wilson  advocateThe aggregate number of dentists in any country and their contribution to the workforce is vital to meet the need, and demand, for oral healthcare services within high-income countries with an established healthcare system. The purpose of the present study was to investigate the dentist workforce in Oman and to compare Oman’s dentist workforce data with global and regional norms. It is important to elucidate the future requirements of dentists in Oman, the Sultanate not yet having embraced the concept of the dental team, and to explore the extent to which these requirements can be met by ODC.The objectives of this paper are to describe trends in the dentist workforce in Oman from 1990 to date and compare workforce supply density with medicine nationally and dentistry regionally and globally, as well as examine dentist workforce requirements until 2020 based on population estimates.Dental workforce analysis, to inform planning, is an important strategic healthcare activity that takes account of, and seeks to reflect, changes and pressures appropriately . The litAt their most basic, integrated models may be presented as supply density . It is aThis paper has adopted a basic integrated model using dentist-to-population ratios, benchmarking supply to provide comparisons with other countries. This approach is straightforward, transparent and most appropriate based on locally available data on the population and the dental supply. Oman publishes annual data on its health workforce numbers including the numbers of Omani and expatriate dentists . Its sinOption 1: dentist: population density equivalent to the level considered appropriate to meet future oral health needs across Europe [s Europe .Option 2: dentist: population density to match the current GCC average [ average .Option 3: dentist: population density to match the current global average [ average .Population projections form the backbone of any workforce analysis as the main aim of the workforce is to serve the population , and popThe following assumptions underpin these scenarios. First, the addition of dental (BDS) graduates from ODC to the Omani dental workforce remains constant at circa 50, given that a number of ODC graduates will go abroad to work or study each year. Second, the current level of expatriates will be maintained by inflow to account for outflow, death and retirement. Third, population growth continues on its upward trajectory. Fourth, and finally, selection of dentistry as a career remains popular amongst prospective students and student numbers remain unchanged in the medium term.Only 24% of the dentist workforce was Omani in 2010; this ranged from 53% Ministry of Health, 68% in non-MoH government sector which includes the military services and only 1% in the private sector .WHO data provide comparisons of physician- and dentist-to-population ratios across the globe . First, Looking at trends in the Oman dental workforce, there has been a moderate increase in the number of dentists observed during the 2000s Figs.  and 4, aOption 1: dentist: population density equivalent to the level considered appropriate to meet future oral health needs across the WHO European region (1:2000 or 5 per 10 000) will require 1900 dentists currently as presented in Fig. Option 2: dentist: population density to match the current GCC average (1:3000 or 3.2 per 10 000) will require circa 1500 dentists currently as presented in Fig. Option 3: dentist: population density to match the current global average (1:3800 or 2.6 per 10 000) will require circa 1000 dentists currently as presented in Fig. Considering the recent rise in the number of dentists in Oman bringing the dentist-to-population ratio closer to the global average of 1:3800, it is important to consider the short- to medium-term perspective, namely 2012–2020, in more detail. The expected increase in the number of Omani dentists should contribute to the total required number of dentists in Oman and bring down the expatriate growth rate to pave the way for further Omanisation.With reference to the original feasibility study conducted by ODC prior to it being established, it is important to note several points. First, a reduction in the shortfall in dentists was expected, and second, that the shortfall would not be eliminated by the initial student intake and graduate output. Based on the latest published data, this feasibility study projection has been shown to be realistic. The model suggests that the projected increase in dental graduates from ODC from 2018 onwards will help to narrow the gap between the Omani dentist-to-population ratio and that of local GCC as well as moving towards high-income regions such as Europe. This is of course assumes that most ODC graduates are encouraged, and have the opportunity, to practice in Oman, and the number of expatriate dentists remains relatively constant.The findings suggest that there is a need for more dentists to enter into the workforce locally to match global capacity and work towards the GCC dentist-to-population ratio of 1:3000, or 3.2 per 10 000. In 2010, Omanisation of the dentist workforce was just around one quarter (24%). To achieve the two local dental workforce goals, the retention in Oman of an annual graduate output of about 50 dentists from ODC will be vital, assuming population growth remains moderate to high. It is interesting to note that ODC’s 2003 feasibility study estimated that with an output of 39 graduates, there would be 213 Omani dentists available in the country by 2011 . However, MoH data suggest that as of 2011 there were only 168 Omani dentists , emphasiIt is clear, in terms of the physician: population ratio, that Oman is well above the global average , and aheIt is firmly acknowledged, by the authors, that a growth in dentists is not the ‘answer’ to meeting the needs of the population of Oman. There is an unquestionable need for primary prevention of oral and dental disease ,21,22, dIt is well accepted that population and dental workforce projections depend on multiple factors, not all of which can be accounted for, as some influences are unexpected. Population projections depend on assumptions about mortality, fertility, base life expectancy and migration. Dental and dentist workforce projections are influenced by additional factors such as the economy, population demand for oral healthcare, government policy and the contribution of health professionals to workforce capacity. Naturally, any changes in these assumptions may affect these projections.The tremendous decline in the infant mortality rate in Oman is contributing to population growth, and there is a large expatriate population of a potentially highly variable size working on a range of projects and developments . FurtherAnalysis of dentist-to-population ratios is a crude measure, because it does not take account of the needs of different sections of the population. Neither does it consider the complexity of supply issues including professional working patterns, particularly for younger dentists and females. In the United Kingdom and the United Arab Emirates, there is some evidence that graduates, both male and female, do not necessarily plan to work full time and some, irrespective of opportunities locally, will plan to travel and work or study overseas ,54. ThusGiven the current emphasis on training mid-level providers globally -57, suchThe data used for this analysis highlight the need for ongoing research to inform dental workforce planning; this must include consideration of the changing health needs of the population, a regular census of the workforce population , understA further aspect of the development of the dentist workforce which is beyond the scope of this paper is the need to develop a workforce of dental specialists. Oman presently only supports specialty training in oral and maxillofacial surgery (OMFS) locally, thus, as alluded to above, existing graduates seeking to train in dental specialties must do so abroad, joining a general drift in healthcare workforce personnel with no, or limited, career development opportunities nationally towards countries which offer specialization and postgraduate education. Early consideration should be given to developing postgraduate and specialist training programmes in Oman. According to international practice, such training programmes are best based in a dental school and hospital, thus providing a clinical academic environment.Finally, it must be stressed that for an existing and future dental workforce to be effective, consideration needs to be given to the development of additional members of the team involving team training and care delivery . As outlThis case study illustrates the benefits of workforce analysis to inform workforce development. The present analysis suggests that consideration should be given in Oman to embracing the output of dental graduates from the Sultanate’s new, and only, dental school to bring the dentist-to-population ration closer to the global (1:3800) or GCC ratio (1:3000), if not the level considered appropriate to meet future oral health needs across Europe (1:2000) and realize the Oman Ministry of Health aim to develop an Omani-majority, dental workforce. The discussion highlights the need for consideration to be given to dental workforce expansion through the adoption of a dental team approach to future oral healthcare provision and the introduction of postgraduate and specialty training programmes in Oman, all of which should be informed by further workforce development research. There is a pressing need in Oman to establish a dental nurse training programme to ensure that there are sufficient numbers of suitably trained dental nurses to support the safe, effective practice of dentistry in the Sultanate, followed by wider team development.