The Satiety Index Each of the following foods is rated by how much food people ate after consuming them to satisfy their hunger. All are compared to white bread, ranked as "100" Bakery Products Carbohydrate-Rich Foods Croissant 47% White bread 100% Cake 65% French fries 116% Doughnuts 68% White pasta 119% Cookies 120% Brown Rice 132% Crackers 127% White rice 138% Snacks and Confectionary Grain bread 154% Mars candy bar 70% Wholemeal bread 157% Peanuts 84% Brown pasta 188% Yogurt 88% Potatoes, boiled 323% Crisps 91% Protein-Rich Foods Ice cream 96% Lentils 133% Jellybeans 118% Cheese 146% Popcorn 154% Eggs 150% Breakfast Cereals with Milk Baked beans 168% Muesli 100% Beef 176% Sustain 112% Ling fish 225% Special K 116% Fruits Cornflakes 118% Bananas 118% Honeysmacks 132% Grapes 162% All-Bran 151% Apples 197% Porridge/Oatmeal 209% Oranges 202%

Holt is concerned that there may be some confusion in the interpretation of her study's findings. "The Satiety Index scores reflect the total amount of fullness produced by the set portions of the test foods over two hours—i.e. short-term satiety. Although most foods with high Satiety Index scores kept fullness relatively high for the whole two hours, there were a few exceptions," Holt notes. "The fruits were served in very large portions, but fullness dropped off quickly towards the end of the second hour, reflecting the rapid rate of gastric emptying (oranges and apples and grapes are mainly sugar and water)," she adds. "Many 'health-conscious' dieters," she continues, "will eat a meal based on several pieces of fruit and some rice cakes (in Australia anyway) and then wonder why they feel ravenous a few hours later. These kinds of extremely low-fat, high-carb meals do not keep hunger at bay because they are not based on slowly-digested carbs and probably don't contain enough protein. A dieter would be better off eating a wholesome salad sandwich on wholegrain bread with some lean protein like tuna or beef and an apple. This kind of meal can keep hunger at bay for a very long time."

"You can't just say that vegetables are satisfying or that bakery products aren't, because there can be a two-fold difference between two similar foods," says Holt. "We found that bananas are much less satisfying than oranges or apples, and that wholemeal bread is half again as satisfying as white bread [157 compared to 100 respectively]."

"You can eat an awful lot of popcorn without taking in a lot of calories," says Holt. "It may not weigh much, but it makes your stomach feel full just because it takes up so much space. Oranges come out very high on the index for the same reason—but orange juice probably wouldn't, even though it has the same number of calories."

The chemical components of a food is one of the factors that determines how it ranks on the index. "Beans and lentils, for example, contain anti-nutrients which delay their absorption so they make you feel full for longer," says Holt. "Roughly speaking, the more fiber, protein and water a food contains, the longer it will satisfy. But you have to look at each foodstuff individually—and that is why we think our index will be so useful."

Holt drew up the Satiety Index by feeding 240-calorie portions of 38 different foods to volunteers. The foods were served from under a hood to minimize the influence of appearance, and, if possible, they were served at the same temperature and in the same size chunks. After eating, the volunteers told the scientists what their appetite ratings were, but they were not allowed anything else for the next two hours. Then, after two hours, they were then allowed to eat from a small buffet, where the scientists measured how much they nibbled from a variety of other foods. Their consumption was closely monitored, and every 15 minutes they were questioned about their hunger to see if their subjective impression of satisfaction matched their eating behavior. Using white bread as the baseline of 100, 38 different foods were ranked. In other words, foods scoring higher than 100 are more satisfying than white bread and those under 100 are less satisfying.

"Satiety Index," Holt's tool ranks different foods on their ability to satisfy hunger.

Table. 4—

Table. 3—

Table. 2—

Table. 1—

RESULTS

Analysis

Immunological assessment Skin-prick tests were performed to cat dander, grass pollen and Dermatophadoides pteronyssinus (Allergopharma, Reinbek, Germany) and considered positive if they produced a mean weal diameter of ≥3 mm. Participants with one or more positive tests were considered atopic. Wheat flour (five Canadian and English wheat flours provided by the Flour Milling Bakers' Research Association) and fungal α-amylase (Novo Nordisk, Dagsvaerd, Denmark) were extracted in 0.1 M ammonium hydrogen carbonate (BDH, Merck, West Drayton, UK) overnight by shaking. The extracts were dialysed against distilled deionised water for 16 h and freeze-dried. The level of serum specific immunoglobulin (Ig)E to both allergens were measured by radioallergosorbent assay, and considered positive if binding was ≥2%. Exposure assessment Employees from the first 10 stores visited wore personal dust samplers to estimate whole-shift measurements of inhalable dust and fungal α-amylase (Cassella IOM sampling head (Cassella Group Ltd, Kempton, UK) and a Millipore glass microfibre). Samplers were set at a flow rate of 2 L·min−1. Gravimetric analysis was undertaken using before and after sample weights of dust with a lower limit of detection of 0.01 mg. The samples were analysed by the Health and Safety Laboratories, Sheffield, UK, for fungal α-amylase using a monoclonal enzyme-linked immunoassay 11. Inhibition assays demonstrated that the assay was specific to fungal α-amylase and was not affected by cereal α-amylases, which occur naturally in flour. The lower limit of detection for fungal α-amylase was 1 ng·mL−1.

Questionnaire

An independent workplace cross-sectional survey of all bakery employees in 20 in-store bakeries was undertaken. All individual results were confidential. For logistical reasons, stores were selected from a limited geographical area; 25 with an in-store bakery fell within this area and 20 were randomly selected for survey. These bakeries did not differ in baking process, size or number of employees from company bakeries in the rest of the country. Due to employees' variable shift and work-hour patterns, multiple visits by the investigator (A. Brant) to each store were necessary to attain good coverage.

In 2001, the company had over 300 stores where bread was produced from raw ingredients. Within each supermarket bakery, four main job categories could be distinguished: baker, manager, confectioner and assistant. The tasks of a baker include the emptying of 20 kg bags of flour and other essential ingredients, including powdered enzymes, into mixing bowls, the dusting of loaves with flour, and the cleaning of equipment and the bakery. Managers perform several tasks, but are commonly themselves also bakers. Confectioners finish and decorate pastries and produce doughnuts. Bakery assistants may be packers, counter staff or bakers not involved in the mixing of raw ingredients. Batch baking starts in the early morning and the baker's shift is usually finished by midday. Confectioners often start their work shift not long after the bakers; managers and assistants have shifts that are spread throughout the opening hours of the store and may extend into the early evening.

This population of bakery workers has important levels of sensitisation and work-related respiratory symptoms, despite low levels of dust exposure. Changes in the location and process of bread manufacture have led to a change in the distribution of bakers' asthma in the UK.

Asthma arising from workplace exposure to cereal flour or baking enzymes (bakers' asthma) is one of the commonest causes of occupational asthma in Europe 3, 4 with, in the UK, an estimated annual incidence of 951 per million bakery workers 4. Most investigations of the disease have been within large industrial bakery or milling settings. There are only limited studies in small or craft bakeries 5, 6. Work-related respiratory symptoms and sensitisation to both flour and fungal α-amylase have been related to inhalable dust or allergen concentrations 7–9, with atopy probably the most important modifier in these relationships.

but their employees have not previously been investigated for occupational asthma.

A cross-sectional survey was undertaken involving 239 (71%) employees from 20 different supermarket bakeries. The work-related symptoms were investigated by using questionnaires and measuring the radioallergosorbent test serum-specific immunoglobulin (Ig)E to flour and fungal α-amylase. A total of 89 employees underwent whole-shift personal measurement of dust exposure.

Table 4 Adjusted prevalence of dietary behaviours and mean daily dietary intakes, with their standard errors, by continuity of overall value for sustainable diet practices (≥2 practices were ‘somewhat’ or ‘very important’) from adolescence or emerging adulthood (2003–2004) to young adulthood (2015–2016) reported in the 2015–2016 Project EAT survey*,† Project EAT, Project Eating and Activity among Teens and Young Adults.a,b,c Mean values within a row with unlike superscript letters were significantly different (P < 0·05).* Models included sex, ethnicity/race, educational attainment, age group, parental status and vegetarian status as covariates. The independent variable was represented as four trajectory groups defined by indicating the practice was ‘not at all’ or only ‘a little’ important at both time points (never important), important only in 2003–2004 (early importance), important only in 2015–2016 (late importance) and important at both time points (long-term importance).† The overall sample was limited to participants who completed survey items regarding sustainable practices in both 2003–2004 and 2015–2016, and also completed an FFQ in 2015–2016 (n 1396). The sample size for analysis of meal behaviours was further restricted as a result of skip patterns in the survey. Meal preparation frequency was reported only by participants who did not live alone (n 1150) and family meal behaviours were reported only by participants who were parents (n 666).‡ Details of the foods included within each food group are detailed in Table 3.§ Model showed statistically significant differences (P = 0·014) across trajectory categories when adjusted for energy intake using the density method (i.e. modelled as mg Na/4184 kJ (1000 kcal) daily total energy).

Table 3 Adjusted prevalence of dietary behaviours and daily dietary intakes, with their standard errors, by young adult report of an overall value for sustainable diet practices (≥2 practices were ‘somewhat’ or ‘very important’) in the 2015–2016 Project EAT survey*,† Project EAT, Project Eating and Activity among Teens and Young Adults.* Models included sex, ethnicity/race, educational attainment, age group, parental status and vegetarian status as covariates.† The sample was limited to participants who completed surveys in both 2003–2004 and 2015–2016 as well as an FFQ in 2015–2016 (n 1396). The sample size for analysis of meal behaviours was further restricted as a result of skip patterns in the survey. Meal preparation frequency was reported only by participants who did not live alone (n 1150) and family meal behaviours were reported only by participants who were parents (n 666).‡ Whole fruit servings were defined by reported intake of raisins/grapes, prunes/dried plums, bananas, cantaloupe, fresh apples/pears, oranges, grapefruit, strawberries, blueberries, peaches/plums and apricots. Dark green vegetable servings were defined by reported intake of broccoli, kale/mustard greens/chard, spinach (cooked, raw) and romaine/leaf lettuce. Red and orange vegetable servings were defined by intake of tomatoes, tomato/spaghetti sauce, tomato juice, carrots (cooked, raw), yams/sweet potatoes and dark orange (winter) squash. Total vegetable servings included intake of all dark green, red and orange vegetables along with intake of string beans, beans/lentils, peas/lima beans, cauliflower, corn, mixed/stir-fry vegetables, eggplant/zucchini/other squash, iceberg/head lettuce, celery and onions. Whole grain servings were defined by grams of whole grains (1 serving = 16 g) coming from cereals, breads, crackers, rice, popcorn and other grain foods. Sugar-sweetened drink servings were defined by reported intake of carbonated beverages with caffeine and sugar, other carbonated beverages with sugar, and other sugared beverages such as lemonade and sports drinks.§ Model showed statistically significant differences (P = 0.004) between young adults who indicated sustainable practices were important v. not important when adjusted for energy intake using the density method (i.e. modelled as mg Na/4184 kJ (1000 kcal) daily total energy).

The percentage of the 1620 young adults (aged 25–36 years) who indicated in 2015–2016 that it was somewhat or very important for their food to be produced according to a specific practice ranged from 38·9 % for organic to 54·3 % for not processed (Table 2). Just over half (52·9 %) of these young adults reported valuing two or more practices by indicating their importance. Table 2 Percentages of young adults (n 1620), by sociodemographic characteristics, who reported it was ‘somewhat’ or ‘very important’ that their food is produced according to sustainable nutrition practices in the 2015–2016 Project EAT survey* Project EAT, Project Eating and Activity among Teens and Young Adults.* All percentages are weighted to reflect the probability of responding to follow-up surveys in 2003–2004 and 2015–2016; sample numbers reflect the unweighted size of the participant group. The subgroup sample numbers for each characteristic do not all add to 1620 due to missing responses.† P values represent testing for independence of sociodemographic categorization and value for a sustainable practice by the χ 2 test.

Table 1 Trajectories of values for sustainable nutrition practices among young people who participated in the 2003–2004 and 2015–2016 Project EAT surveys as members of the cohort enrolled at public schools in Minneapolis–St. Paul, MN, USA in 1998–1999 (n 1620)* , † Project EAT, Project Eating and Activity among Teens and Young Adults.* All percentages are weighted to reflect the probability of responding to the follow-up Project EAT surveys in 2003–2004 and 2015–2016.† The four value trajectory groups were defined by indicating the practice was ‘not at all’ or only ‘a little’ important at both time points (never important), ‘somewhat’ or ‘very important’ only in 2003–2004 (early importance), ‘somewhat’ or ‘very important’ only in 2015–2016 (late importance) and ‘somewhat’ or ‘very important’ at both time points (long-term importance).

Results

Statistical analysis

Participant characteristics

Frequency of at-home meal preparation was determined by asking the question: ‘During the past month, how often have you prepared a meal that included vegetables?’; the inclusion of vegetables was specified as an indicator of meal quality( Reference Laska, Larson and Neumark-Sztainer 35 ). Six response categories were combined for analysis to represent infrequent (‘never’, ‘one time’, ‘a few times’, ‘weekly’) v. frequent (‘a few times a week’, ‘most days of the week’) preparation of a meal (test–retest agreement = 87 %). Frequency of eating family meals was assessed with the question: ‘In the past week, how many times did all, or most, of the people living in your household eat a meal together?’ Seven response categories were combined for analysis to represent 0–4 times or ≥5 times in a given week (test–retest agreement = 87 %). Frequency of purchasing fast food for family meals was assessed with the question: ‘During the past week, how many times was a family meal purchased from a fast-food restaurant and eaten together either at the restaurant or at home? (pizza counts)’( Reference Boutelle, Fulkerson and Neumark-Sztainer 36 ). Four response categories were combined for analysis to represent 0–1 purchases or ≥2 purchases of fast food in a given week (test–retest agreement = 79 %).

‘How important is it to you that your food is…?’ ‘produced as organic’, ‘not processed’, ‘locally grown’ and ‘not genetically modified’( Reference Robinson-O’Brien, Larson and Neumark-Sztainer 5 ).

Survey development

Data for the analysis reported here were drawn from the follow-up survey conducted in 2003–2004 and the most recent follow-up survey in 2015–2016. In 2003–2004, current contact information was identified for 3672 of the original 4746 participants and 2516 complete surveys were returned in response to a mailed invitation (response rate: 68·4 %). In 2015–2016, follow-up EAT-IV survey invitations were again mailed to participants in the original 1998–1999 assessment but only to those who had responded to at least one previous follow-up survey wave. EAT-IV survey and FFQ data were collected online, by mail or by telephone from 66·1 % of those for whom contact information was available at the time (n 2770), resulting in the completion of surveys by 1830 young adults with a mean age of 31·0 (sd 1·6) years( Reference Christoph, Larson and Laska 30 – Reference Larson, Chen and Wall 33 ). Most respondents (95·4 %) completed the online survey and completers took an average of 40 min to answer the questions. More than 88 % of the EAT-IV sample had also completed the mailed survey wave in 2003–2004 (n 1620, mean age 19·4 (sd 1·7) years) and formed the analytic sample for analyses reported here( Reference Neumark-Sztainer, Wall and Eisenberg 24 , Reference Neumark-Sztainer, Wall and Guo 28 ).

Project EAT is a large, population-based cohort study of eating and weight-related outcomes that has followed young people from adolescence to adulthood. The original assessment was designed as a cross-sectional study of students enrolled at public middle schools and senior high schools in the Minneapolis–St. Paul metropolitan area of MN, USA, in 1998–1999( Reference Neumark-Sztainer, Story and Hannan 22 , Reference Neumark-Sztainer, Croll and Story 23 ).

strong need for research to inform the identification of relevant and effective nutrition education messaging for young adults and the optimal timing of message delivery.

National survey data show that intakes of whole fruit, non-starchy vegetables and whole grains are lower than recommended, while nearly all US young adults exceed the recommended Na intake and maximum energy intake from added sugars and solid fats( 9 , Reference Krebs-Smith, Guenther and Subar 17 , Reference Jackson, King and Zhao 20 , Reference Bailey, Fulgoni and Cowan 21 ).

Although the importance of dietary intake quality during this life stage is well established, most young adults do not meet recommendations for healthy eating such as those within the Dietary Guidelines for Americans( Reference Krebs-Smith, Guenther and Subar 17 – Reference Lipsky, Nansel and Haynie 19 ).

Consuming a nutrient-dense diet during the transition from adolescence into the young adult years (18–35 years) may protect against future chronic disease, promote optimal reproductive outcomes, support psychological resilience and help to prevent excess weight gain( Reference VanKim, Larson and Laska 8 – Reference Xiao, Simas and Person 16 ).

selected aspects of sustainable diets (e.g. eating food that is organic, minimally processed, locally grown and not GM) has found evidence that individuals who are more aware of where and how food is produced tend to select more nutrient-dense food choices( Reference Auestad and Fulgoni 1 , Reference von Koerber, Bader and Leitzmann 3 , Reference Burlingame and Dernini 4 ).

Sustainable diets have a minimal impact on the environment, contribute to food security, and promote a healthy life for present and future generations( Reference Auestad and Fulgoni 1 , Reference Rose, Heller and Roberto 2 ). More specifically, the principles that define sustainable diets include optimizing natural and human resources along with being protective and respectful of biodiversity and ecosystems, culturally acceptable, accessible, economically fair and affordable, nutritionally adequate, safe and healthy( Reference Auestad and Fulgoni 1 ).

Addressing the sustainability of food choices as part of public health messaging may be relevant for many young adults.

One-third (36·1 %) of participants reported valuing <2 practices at both assessments; 11·1 and 34·5 % respectively reported valuing ≥2 practices in 2003–2004 only and in 2015–2016 only; 18·3 % reported valuing ≥2 practices at both assessments. Regression models including demographics, parental status and vegetarian status showed that valuing ≥2 practices was associated with preparation of meals with vegetables at least a few times/week, less frequent purchase of family meals from fast-food restaurants, and higher diet quality in 2015–2016. For example, those who valued ≥2 practices consumed nearly one full vegetable serving more than other young adults on an average day and part of this difference was specifically associated with intake of dark green and red/orange vegetables.

Young adults (n 1620; 58 % female, mean age 31 (sd 1·6) years) who were participating in Project EAT (Eating and Activity among Teens and Young Adults) and responded to follow-up surveys in 2003–2004 and 2015–2016.

Observational study. Participant ratings of how important it is for food to be produced as organic, not processed, locally grown and not GM were categorized to represent whether they valued (very/somewhat important) or did not value (a little/not at all important) each practice. Diet quality markers (e.g. fruit servings) were based on an FFQ.

Inclusion of baked milk and egg into the diets of milk- and egg-allergic patients appears to be well tolerated and beneficial as a potential form of immunotherapy to help children outgrow their milk and egg allergy. It is unlikely that tolerance of baked milk and egg simply represents a milder or transient form of milk or egg allergy, because baseline reactivity to regular milk and egg and diagnostic testing have had limited ability to predict baked milk or egg tolerance.

Conversely, one could make the argument that since diagnostic testing does not appear to correlate as well with baked milk and egg reactivity as it does with regular milk and egg reactivity, that tolerance of baked milk and egg does not simply represent a milder, transient form of milk or egg allergy. If it did, then only patients with small SPT wheals or low IgE levels to cow's milk and egg white would be expected to tolerate baked milk or egg.

Due to the inconsistencies in diagnostic testing for predicting baked milk and egg reactivity, OFC remains the most useful method for determining tolerability. Since a majority of milk- and egg-allergic children tolerate baked forms, there is debate over whether baked milk and egg can be introduced at home or if a physician-supervised OFC should be performed first.

Table 3. Predictability of Baked Milk Tolerance by TestingEmpty CellSPT whealSpecific IgE (kUA/L)Suggested cut-off for OFCsNowak-Wegrzyn et al. [20]CM < 5 mm = 100 % NPV [poor specificity]CM IgE ≥35 = >50 % PPVCM IgE 5.0 kU/LCM 15 mm = 50 % PPVCaubet et al. [21]N/ACM IgE 24.5 = 69 % PPV [poor sensitivity]Casein IgE 5 kUA/LCasein IgE 20.2 = 69 % PPV [poor sensitivity]CM IgE 10 kUA/LCasein IgE 4.95 = 89 % NPVBartnikas et al. [22]CM <7 mm = 100 % NPVCM IgE >20.6 = 100 % PPVN/ACasein >15 mm = 100 % PPVCasein IgE >10.3 = 100 % PPVCasein IgE 0.9 = 90 % NPV [poor sensitivity and specificity]SPT skin prick test, CM cow’s milk, PPV positive predictive value, NPV negative predictive value, OFC oral food challengeTable 4. Predictability of Baked Egg Tolerance by TestingEmpty CellSPT WhealSpecific IgE (kUA/L)Suggested cut-offs for OFCsLemon-Mule et al. [19]EW 15 mm = 60 % PPVEW IgE 75 = >50 % PPVN/AOM IgE 50 = 90 % PPVAndo et al. [41]N/AEW IgE 30.7 = 84 % PPV [moderate sensitivity]EW IgE 7.38 kUA/LOM IgE 10.8 = 88 % PPV [moderate sensitivity]OM IgE 4.40 kUA/LOM IgE 1.16 = 97 % NPV [moderate specificity]Cortot et al. [26]EW < 10 mm = 100 % NPVEW IgE not significantN/ALieberman et al. [25]EW not significantEW IgE 10 = 60 % PPV [poor sensitivity]N/ACaubet et al. [42]N/AEW IgE 26.2 = 43 % PPV [poor sensitivity]EW IgE 2.6 kUA/LEW 0.78 = 97 % NPV [poor sensitivity]OM IgE 3.3 kUA/LOM IgE 12.8 = 64 % PPV [poor sensitivity]Tan et al. [27]OM ≥ 11 mm = 100 % PPV [poor sensitivity]N/AMuffin <2 mm = 88 % NPV [poor specificity]Bartnikas et al. [28]EW <3 mm = 100 % NPVEW IgE 9.65 = 59 % PPV [poor sensitivity]OM IgE 0.35 kUA/LEW < 11 mm = >90 %NPV [moderate sensitivity and specificity]OM IgE 3.38 = 42 % PPV [poor sensitivity]EW IgE 6.00 kUA/LEW SPT 11 mmTurner et al. [29]EW ≥ 12 mm = LR 9.1 [poor sensitivity]N/ARaw egg ≥25 mm = LR 5.8 [very poor sensitivity]Peters et al. [43]EW > 11 mm = 82 % PPVN/ASPT skin prick test, EW egg white, OM ovomucoid, PPV positive predictive value, NPV negative predictive value, LR likelihood ratio, OFC oral food challenge

(Tables 3 and 4).

About 68 % of parents appeared motivated to include baked milk and egg in the diet based on the possibility that it may help their child outgrow their milk or egg allergy. A majority of parents also reported that performing the muffin challenge helped to relieve concerns about their child’s allergy (82 %) and helped with dietary management (77 %).

Without a repeat baked milk or egg OFC, it is difficult to know if baked milk or egg products at home were sufficiently baked or if these subjects subsequently developed sensitivity.

Symptoms to baked milk and egg at home after passing a baked milk or egg OFC have been reported in other studies, however it is not possible to verify whether the foods were properly baked.

One baked milk-tolerant subject subsequently reported oral pruritus to insufficiently baked milk items (homemade bread and waffles), but tolerated a repeat baked milk OFC and resumed sufficiently baked milk products at home [20]. One baked egg-tolerant subject developed delayed vomiting and diarrhea after accidental ingestion of regular egg consistent with food protein-induced enterocolitis syndrome, and subsequently returned to avoiding all forms of egg [31]. No subject ingesting baked milk or egg developed eosinophilic esophagitis determined to be due to milk or egg [32].

In two prospective cohort studies at a large tertiary care center, Nowak et al. and Lemon-Mule et al. demonstrated that the ingestion of baked milk and egg, respectively, was well tolerated [19, 20]. There was no difference in weight, height and body mass index for age and z score at baseline compared to after 12 months of ingesting baked milk or egg.

Table 1. Tolerance of baked milk and resolution of milk allergyEmpty CellType of studyBM tolerantResolution of milk allergyWood et al. [39] (n = 155)Observational without OFC21 % by 5 yearsRelative hazard after 5 years:4.1 in those who reported BM tolerance0.28 in those who reported BM reactivityNowak-Wegrzyn et al. [20] (n = 91) and Kim et al. [32] (n = 88; follow-on study)Prospective with OFC75 % initially, 80 % by end of follow-on study59 % of those ingesting BM (followed for median 37 months)22 % of control group (followed for median 40 months)Caubet et al. [21] (n = 121)*Prospective with OFC69 %N/ABartnikas et al. [22] (n = 35)Retrospective with OFC83 %N/AMehr et al. [23] (n = 70)Prospective with OFC73 %N/AOFC oral food challenge, BM baked milk*only second cohort; first cohort include subjects from Nowak et alTable 2. Tolerance of baked egg and resolution of egg allergyEmpty CellType of studyBE tolerantResolution of egg allergySicherer et al. [40] (n = 113)Observational without OFC38 % by 6 yearsAfter 6 years:71 % in those who reported BE tolerance45 % in those not ingesting BE57 % in those who reported BE reactivityDes Roches et al. [30]Prospective with OFC73 %Lemon-Mule et al. [19] (n = 91) and Leonard et al. [31] (n = 79; follow-on study)Prospective with OFC70 % initially,53 % of those ingesting BE (followed for median 37.8 months)89 % by end of follow-on study28 % of control group (followed for median 67.3 months)Clark et al. [24] (n = 95)Longitudinal with OFC66 %N/ALieberman et al. [25] (n = 100)Retrospective with OFC66 %N/ACortot et al. [26] (n = 52)Retrospective with OFC83 %N/ATurner et al. [18] (n = 236)Prospective with OFC64 %N/ATan et al. [27] (n = 143)Prospective with OFC63 %N/ABartnikas et al. [28] (n = 169)Retrospective with OFC84 %N/ATurner et al. [29] (n = 186)Retrospective with OFC66 %N/APeters et al. [37] (n = 158)Prospective with OFC or by report80 % by OFCBy age 2 years of age:72 % by report49 % of those ingesting BE after OFC at 1 year74 % of those ingesting BE by report at 1 year13 % of those with positive BE OFC at 1 yearOFC oral food challenge, BE baked egg

Studies show that a majority of milk- and egg-allergic children can tolerate baked milk or egg. In cohort studies, between 69 and 83 % of milk-allergic subjects tolerated baked milk (Table 1) [20., 21., 22.–23]. Similarly, between 63 and 84 % of egg-allergic subjects tolerated baked egg (Table 2) [18, 19, 24., 25., 26., 27., 28., 29.–30].

Studies have shown that subjects can tolerate a larger amount of milk or egg protein in baked goods compared to regular milk or egg alone. Turner et al. noted that tolerance of baked egg was not simply due to smaller amounts of egg ingested since a number of patients tolerated over 1 gram of baked egg protein in a muffin, yet remained reactive to under 300 mg of regular (unbaked) egg protein [18]. Likewise, Lemon-Mule et al. reported subjects who tolerated 2.2 g of baked egg protein during a muffin challenge, yet reacted to a median dose of 1.5 g of regular egg protein, with 75 % reacting to less than 2.2 g [19]. Nowak et al. had similar findings in baked milk, reporting subjects who tolerated 1.3 g of baked milk protein during a muffin challenge yet reacted to a median dose of 0.4 g regular (unbaked) milk protein [20]. This supports the theory that IgE recognition of milk and egg proteins in baked goods is altered and less allergenic.

Besides alterations due to heating, the interaction of milk and egg proteins with a food matrix, such as wheat, has also been shown to decrease IgE recognition.

Studies have shown that milk- and egg-allergic patients with predominant IgE binding to linear epitopes of casein and ovomucoid are more likely to have persistent milk and egg allergy [15, 16]. Using serum from milk- and egg-allergic patients, Bloom et al. demonstrated that heating decreased IgE binding to milk and egg proteins, and that all baked milk-reactive patients retained IgE binding to casein, regardless of heating time [14].

Milk and egg are common food ingredients, as well as important sources of protein in young children. The ability to add safer, less allergenic forms of milk and egg protein, such as in baked goods, into the diets of milk- and egg-allergic children has several benefits. First, it broadens the diet and decreases the risk of nutritional deficiencies or feeding issues in young children. Second, it improves quality of life by increasing dietary options and allowing children to feel more included in social situations, such as birthday parties [12]. And lastly, it can decrease the time to development of tolerance to regular milk and egg. This article will show that baked milk and egg is well tolerated and can help children outgrow their milk or egg allergy.

Oral immunotherapy to mitigate food allergy is not available in routine clinical practice in most countries. The primary management of food allergy remains strict avoidance of food allergens and prompt treatment of accidental ingestions and reactions. Strategies that could help children outgrow milk and egg allergies would be invaluable.

Up to 80 % of children may outgrow milk and egg allergy, however, while it was previously thought that tolerance developed in a majority by school age, recent data suggests that it is taking longer to outgrow these allergies [8., 9.–10].

Unfortunately, milk and egg allergies are also some of the most common food allergies in childhood. Less allergenic forms of milk and egg due to heating and interactions with a food matrix, as in baked goods, are tolerated by a majority of milk- and egg-allergic patients. Adding baked milk and egg into the diets of milk- and egg-allergic children can broaden diets, increase nutrition, and improve quality of life. Most important, regular ingestion of baked milk and egg can help children outgrow their allergies to milk and egg.

Some researchers have evaluated the acceptance of baked goods containing PSL.Marques et al. (2016)MARQUES, GA; SÃO JOSÉ, JFB; SILVA, DA; SILVA, EMM Whey protein as a substitute for wheat in the development of no added sugar cookies. Lebensmittel-Wissenschaft + Technologie, v. 67, p. 118-126, 2016. http://dx.doi.org/10.1016/j.lwt.2015.11.044. http://dx.doi.org/10.1016/j.lwt.2015.11.... , when inserting PSL in the formulation of cookies without added sugar, noticed similar acceptance rates for the sensory attributes, especially for texture.Silva et al. (2011)SILVA, CA; GOMES, JP; SILVA, FLH; MELO, ESRL; CALDAS, MCS Use of whey in bread making: study of sensory quality. Brazilian Journal of Agroindustrial Products, v. 13, no. 4, p. 355-362, 2011. http://dx.doi.org/10.15871/1517-8595/rbpa.v13n4p355-362. http://dx.doi.org/10.15871/1517-8595/rbp... , in a study with breads made with cow's milk whey, obtained results that, when compared to those obtained in the present study, are inferior. However, breads made with goat's milk whey obtained averages very close to those shown here. Similar results were obtained byGurgel et al. (2011)GURGEL, CSS; MACIEL, JF; FARIAS, LRG; COSTA, MJC; MOREIRA, RT Consumer acceptance and purchase intention of bread enriched with milk serum and calcium carbonate. Revista do Instituto Adolfo Lutz, v. 70, no. 3, p. 283-289, 2011., when formulating bread containing whey powder and calcium carbonate, as well as byFerrari et al. (2013)FERRARI, AS; BALDONI, NR; AZEREDO, EMC Sensory and physical-chemical analysis of products made from whey. Journal of the Vale do Rio Verde University, v. 11, no. 1, p. 216-223, 2013., after formulation of cakes containing in natura whey .

3.2 Sensory analysis

3.1 Measurements of the cakes

The response surface graphs were designed only for the significant responses, using the mathematical model proposed in the real (decoded) levels of the variables, keeping the response as a function of the Z axis, with the X and Y axes representing the independent variables , while the other variables were kept constant at the central point (corresponding to the coded level zero). For significant responses, a second-order polynomial equation was generated (Equation 2 ), through applied regression: ²²Y=β0+β1X1+β2X2+β11X1²+β22X2²+β12X1X2+ξ<math display="block" id="m2"> <mrow> <mi>Y</mi> <mo>=</mo> <msub> <mi>β</mi> <mn>0</mn> </msub> <mo>+</mo> <msub> <mi>β</mi> <mn>1</mn> </msub> <msub> <mi>X</mi> <mn>1</mn> </msub> <mo>+</mo> <msub> <mi>β</mi> <mn>2</mn> </msub> <msub> <mi>X</mi> <mn>2</mn> </msub> <mo>+</mo> <msub> <mi>β</mi> <mrow> <mn>11</mn> </mrow> </msub> <msub> <mi>X</mi> <mn>1</mn> </msub> <mo>²</mo> <mtext> </mtext> <mo>+</mo> <msub> <mi>β</mi> <mrow> <mn>22</mn> </mrow> </msub> <msub> <mi>X</mi> <mn>2</mn> </msub> <mo>²</mo> <mtext> </mtext> <mo>+</mo> <msub> <mi>β</mi> <mrow> <mn>12</mn> </mrow> </msub> <msub> <mi>X</mi> <mn>1</mn> </msub> <msub> <mi>X</mi> <mn>2</mn> </msub> <mo>+</mo> <mi>ξ</mi> </mrow> </math> (two) where: Y = response function; X 1 , X 2 = values ​​of independent variables; β 0 = coefficient related to the interpretation of the plane with the response axis; β 1 , β 2 = linear coefficients estimated by the least squares method; β 11 , β 22 = coefficients of the quadratic variables; β 12 = coefficient of interaction between independent variables; ε = experimental error. Sensory analysis results were submitted to analysis of variance ( oneway ANOVA ), followed by the Tukey test . The results of the proximate composition were submitted to Student's t test . For all evaluations, a probability of 5% was considered. All statistical analyzes were performed using the Statistica 10.0 software .

To calculate the acceptance index (AI) of the product, the expression1 : IA(%)=A×100/B<math display="block" id="m1"> <mrow> <mtext>I</mtext> <mi>A</mi> <mtext> </mtext> <mrow> <mo>(</mo> <mi>%</mi> <mo>)</mo> </mrow> <mo>=</mo> <mi>A</mi> <mo>×</mo> <mn>100</mn> <mo>/</mo> <mi>B</mi> </mrow> </math> (1) where A= average grade obtained for the product and B= maximum grade given to the product. The AI ​​with good repercussion has been considered ≥ 70% (DUTCOSKY, 2007DUTCOSKY, SD Sensory analysis of foods. 2nd ed. Curitiba: Champagnat, 2007. 239 p.).

Table 1 Results of measurements of cakes made with different proportions of whey protein (PSL) and margarine.

. The variables were established in five coded levels with four repetitions at the central point, four variables at the axial point and four factorials, totaling 12 trials (Table 1 ).

According to the study ofEster (2004)ESTELLER, MS Manufacture of breads with reduced calorie content and rheological changes that occur during storage. 2004. 248 f. Dissertation (Master in Food Technology)-Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo, 2004., in bakery products, such as cake, whey protein concentrate may have applicability as a fat substitute in products with reduced fat content.

Whey protein is an economically important cheese-making product, which is used as an ingredient in the food industry due to its high nutritional value and functional attributes. In addition, it has a high biological potential, resulting from its content of essential amino acids, in particular leucine and lysine, being also a good source of methionine and cysteine ​​(OLIVEIRA et al., 2012OLIVEIRA, DF; BRAVO, CEC; TONIAL, IB Whey: a valuable by-product. Magazine of the Instituto de Laticínios Cândido Tostes, v. 67, no. 385, p. 64-71, 2012. http://dx.doi.org/10.5935/2238-6416.20120025. http://dx.doi.org/10.5935/2238-6416.2012... ).

Following the current trend, there is a growing concern with health and body aesthetics, making the consumer seek, in the market, products that are nutritionally healthy, as well as sensorially pleasant. With this, the need and interest of the industry arise in inserting and/or replacing certain ingredients, aiming to increase the added value of processed food products (SILVA, 2011SILVA, JV Development of cakes, with and without added sugar, from the partial replacement of wheat flour by pumpkin husk and seed flour (Curcubita moschata). 2011. 111 f. Dissertation (Master's in Food Science and Technology) - Federal University of Sergipe, São Cristóvão, 2011.;VOORPOSTEL et al., 2014VOORPOSTEL, CR; DUTRA, MBL; BOLINI, HMA Sensory profile and drivers of liking for grape nectar among smoker and nonsmoker consumers. Food Science and Technology, v. 34, no. 1, p. 164-173, 2014.).

The effect of adding PSL and margarine to cakes was evaluated using a second-order central composite rotational design. The selected treatments were evaluated by means of sensorial analysis and characterized as to the proximate composition, in addition to proceeding to the microbiological evaluation after 15 days of storage. The addition of up to 11, 98 g/100 g of margarine significantly influenced the reduction of the height of the cakes. The treatment with intermediate PSL content (30 g/100 g) and lower margarine content (6.72 g/100 g) had better acceptability and, when compared to the control, higher protein content. The microbiological conditions were satisfactory, in compliance with current legislation, even after 15 days of storage.

Bakery import shipments in United States from Canada are 472, imported by 96 Buyers.Top 3 Product Categories of Bakery Imports in United States areHSN Code 230800 : 230800HSN Code 230910 : 230910HSN Code 190590 : HS : other:United States imports most of its Bakery from Canada.The top 1 import markets for Bakery are United States. United States is the largest importer of Bakery and accounts for 472 shipments.These facts are updated till 6 Oct 2021, and are based on Volza's United States Import data of Bakery sourced from 70 countries export import shipments with names of buyers, suppliers, top decision maker's contact information like phone, email and LinkedIn profiles.