Development of healthy and sustainable food-based dietary guidelines for the Netherlands

Can micronutrient requirements be met by diets from sustainable sources: outcomes of dietary modelling studies using diet optimization

BACKGROUND

Consumption of diets from sustainable sources is required for planetary health, however, large sections of the population, including females of reproductive age and children, will be at risk of not meeting their micronutrient (MN) requirements in a complete transition to plant-based foods. Constrained diet optimization methods use mathematical programming to construct diets that meet predefined parameters and may contribute towards modelling dietary solutions that meet nutritional and planetary targets.

OBJECTIVE

Review the evidence from diet optimization studies proposing solutions to ensure MN availability in the context of a transition to diets from sustainable sources.

APPROACH

Narrative review focusing on literature published over the last five years.

RESULTS

Dietary modelling using diet optimization can design a range of omnivorous and plant-based diets that meet individual MN requirements, have reduced environmental impacts, and minimize deviation from culturally acceptable dietary practices. Using data from large-scale dietary surveys, diet optimization can support development of food-based dietary guidelines; identify limiting MNs in a particular context or a conflict between constraints e.g. nutrition and environment; explore food-based strategies to increase nutrient supply, such as fortification; and support trial design. Methods used and outcomes reported are sources of variability. Individual-level dietary data and MN requirements for population sub-groups such as females of reproductive age and children are important requirements. Although maintaining iron and zinc intakes are regularly reported to present challenges in diets from sustainable sources, few studies have considered bioavailability, which reduces with increased dietary phytate. These and other data gaps including acceptability and affordability must be addressed to improve the applicability of modelling outcomes in population recommendations.

CONCLUSIONS

Dietary modelling using diet optimization can be useful in the design of more sustainable diets that meet MN requirements, however, translation of outcomes into dietary intervention studies is required to test real-world application and adoption into dietary guidelines.

Low-carbon diets across diverse dietary patterns: Addressing population heterogeneity under constrained optimization

Mathematical optimization is a useful tool for modeling diets that fulfill requirements for health and environmental sustainability, however, population-based optimization approaches fail to account for underlying dietary diversity in populations. This study proposes a methodological approach to consider diverse dietary intake patterns in mathematical optimization of nutritionally adequate low-carbon diets and investigates the differences between different population groups, along with trade-offs between greenhouse gas emission (GHGE) reduction and the inconvenience of dietary changes required to achieve optimized diets. A k-means clustering analysis was applied to individual dietary intake data from Denmark, which resulted in four clusters with different dietary patterns. This was followed by quadratic programming, wherein the total dietary changes required from the observed diet within each cluster were used as a proxy for consumer inconvenience (i.e., "inconvenience index") and were minimized while fulfilling nutrient constraints and incrementally tightened GHGE constraints. Across clusters, a steep increase of the inconvenience index was observed at GHGE levels below approximately 3 kg CO2e/10 MJ, corresponding to GHGE reductions of 24-36 % in different clusters. In all clusters, the optimized diets with nutritional and GHGE constraints showed common traits of increased content of cereals and starches, eggs, and fish and decreased amounts of beef and lamb, cheese, animal-based fats, and alcoholic beverages, but differences across clusters were also observed, maintaining characteristics of the clusters' baselines. When additional health-based targets for food amounts were applied as constraints, the optimized diets converged towards the same type of diet. The total inconvenience of dietary changes required to fulfill constraints differed between clusters, indicating that specific sub-populations may be more effective targets for dietary transition. The method has potential for future integration of more sustainability aspects and different consumer preferences.

Targeting persistent fatigue with tailored versus generic self-management strategies in adolescents and young adults with a fatigue syndrome or rheumatic condition: A randomized crossover trial

OBJECTIVES

To evaluate the use of two self-management intervention strategies for persistent fatigue in adolescents and young adults with a fatigue syndrome or rheumatic condition.

DESIGN

A randomized crossover trial administering tailored lifestyle advice and generic dietary advice, each 12 weeks, with a four-week washout period between.

METHODS

Sixty participants (aged 12-29) were included. Tailoring was achieved through the PROfeel method. Dietary guidelines were conceptualized by the Netherlands Nutrition Centre. Questionnaires were used pre-post-interventions to measure primary outcome 'fatigue severity' (Checklist Individual Strength-8) and secondary outcomes 'self-efficacy' (Self-Efficacy Scale-28) and 'quality of life' (QoL) (Paediatric Quality of Life Inventory 4.0). Feasibility and adherence were self-rated on a scale of 1 to 10 (low to high). Linear mixed modelling was used to assess change over time, compare strategy effectiveness and study the impact of intervention order.

RESULTS

Fatigue severity, self-efficacy and QoL regarding 'physical' and 'emotional' functioning improved significantly over time (all p < .015). The average improvement of the two QoL subscales was clinically relevant, as was the fatigue improvement in 20 out of 46 participants who completed the trial and 5 dropouts. The interventions were equally effective, and intervention order did not impact the improvement level (prange = .242-.984). The self-management strategies received similar feasibility (M = 6.45, SD = 1.91) and adherence (M = 7.67, SD = 1.67) ratings.

CONCLUSIONS

As small to clinically relevant improvements were observed, self-management strategies might be particularly useful to bridge waiting time for guided treatments such as Cognitive Behavioural Therapy.

Individual outcomes after tailored versus generic self-management strategies for persistent fatigue in youth with a fatigue syndrome or rheumatic condition: A multiple single-case study

OBJECTIVE

To examine individual outcomes after tailored lifestyle (PROfeel) or generic dietary advice as self-management intervention for persistent fatigue in adolescents and young adults with a chronic condition, to compare participants who did and did not benefit and to explore changes to factors in the biopsychosocial model of fatigue after PROfeel.

METHOD

A multiple single-case AB-phase design was embedded in a randomized crossover trial (N = 45). Intensive longitudinal data (ILD) on outcomes 'fatigue severity', 'self-efficacy' and 'quality of life' (QoL) were collected through weekly smartphone measurement for 20 weeks. ILD on biopsychosocial factors were collected through experience sampling methodology for 28 days pre-post first intervention. Baseline characteristics were compared with t-tests and chi-square tests. Permutation distancing tests were used to assess change over time in all ILD.

RESULTS

Regarding weekly measurements, nineteen participants (42.22%) showed small to large positive outcomes (drange = .05 to 2.59), mostly after PROfeel. Eleven participants (24.44%) showed small to moderate negative outcomes (drange = -.02 to -2.46), mostly after dietary advice. Fatigue severity improved most, followed by self-efficacy. Participants who benefitted showed higher QoL levels and lower fatigue and pain levels compared with others at baseline (all p < .02). When positive outcomes were observed after PROfeel, typically ≥1 biopsychosocial factor had been targeted successfully.

CONCLUSION

Self-management advice has more potential when tailored to individual characteristics, including the biopsychosocial model of fatigue. PROfeel appears particularly useful as fatigue intervention for individuals with relatively less severe symptoms.

A systematic review and meta-analysis of randomized trials of substituting soymilk for cow's milk and intermediate cardiometabolic outcomes: understanding the impact of dairy alternatives in the transition to plant-based diets on cardiometabolic health

BACKGROUND

Dietary guidelines recommend a shift to plant-based diets. Fortified soymilk, a prototypical plant protein food used in the transition to plant-based diets, usually contains added sugars to match the sweetness of cow's milk and is classified as an ultra-processed food. Whether soymilk can replace minimally processed cow's milk without the adverse cardiometabolic effects attributed to added sugars and ultra-processed foods remains unclear. We conducted a systematic review and meta-analysis of randomized controlled trials, to assess the effect of substituting soymilk for cow's milk and its modification by added sugars (sweetened versus unsweetened) on intermediate cardiometabolic outcomes.

METHODS

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched (through June 2024) for randomized controlled trials of ≥ 3 weeks in adults. Outcomes included established markers of blood lipids, glycemic control, blood pressure, inflammation, adiposity, renal disease, uric acid, and non-alcoholic fatty liver disease. Two independent reviewers extracted data and assessed risk of bias. The certainty of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). A sub-study of lactose versus sucrose outside of a dairy-like matrix was conducted to explore the role of sweetened soymilk which followed the same methodology.

RESULTS

Eligibility criteria were met by 17 trials (n = 504 adults with a range of health statuses), assessing the effect of a median daily dose of 500 mL of soymilk (22 g soy protein and 17.2 g or 6.9 g/250 mL added sugars) in substitution for 500 mL of cow's milk (24 g milk protein and 24 g or 12 g/250 mL total sugars as lactose) on 19 intermediate outcomes. The substitution of soymilk for cow's milk resulted in moderate reductions in non-HDL-C (mean difference, - 0.26 mmol/L [95% confidence interval, - 0.43 to - 0.10]), systolic blood pressure (- 8.00 mmHg [- 14.89 to - 1.11]), and diastolic blood pressure (- 4.74 mmHg [- 9.17 to - 0.31]); small important reductions in LDL-C (- 0.19 mmol/L [- 0.29 to - 0.09]) and c-reactive protein (CRP) (- 0.82 mg/L [- 1.26 to - 0.37]); and trivial increases in HDL-C (0.05 mmol/L [0.00 to 0.09]). No other outcomes showed differences. There was no meaningful effect modification by added sugars across outcomes. The certainty of evidence was high for LDL-C and non-HDL-C; moderate for systolic blood pressure, diastolic blood pressure, CRP, and HDL-C; and generally moderate-to-low for all other outcomes. We could not conduct the sub-study of the effect of lactose versus added sugars, as no eligible trials could be identified.

CONCLUSIONS

Current evidence provides a good indication that replacing cow's milk with soymilk (including sweetened soymilk) does not adversely affect established cardiometabolic risk factors and may result in advantages for blood lipids, blood pressure, and inflammation in adults with a mix of health statuses. The classification of plant-based dairy alternatives such as soymilk as ultra-processed may be misleading as it relates to their cardiometabolic effects and may need to be reconsidered in the transition to plant-based diets.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT05637866.

Protein Adequacy, Plant Protein Proportion, and Main Plant Protein Sources Consumed Across Vegan, Vegetarian, Pescovegetarian, and Semivegetarian Diets: A Systematic Review

BACKGROUND

There are several types of plant-based diets, with unknown differences across diets on total/plant protein intake and variety of plant protein sources consumed.

OBJECTIVES

This systematic review aimed to compare total protein intake, proportion of plant proteins, and main plant protein sources consumed across 4 primarily plant-based diets: vegan, vegetarian, pescovegetarian, and semivegetarian.

METHODS

We included observational studies reporting on protein intake and/or protein sources in generally healthy adults that were published between 2002 and 2023. We determined the following: 1) % energy from total and plant protein; 2) the proportion of plant protein relative to total protein intake; and 3) main plant protein sources (median percentage contribution of each source to total plant protein intake; interquartile range) consumed across the 4 diets. The plant protein sources were broadly classified into the following United States Department of Agriculture food groups: grains; nuts and seeds; soy products; and beans, peas, and lentils.

RESULTS

We included 13 studies reporting on protein intake/sources that were conducted in the United States, Europe, and South Korea. Of these, 7 reported on vegan, 11 on vegetarian, 7 on pescovegetarian, and 7 on semivegetarian diets with total protein intake ranging from 10% to 17.4%. Vegan diets had the highest plant protein proportion (range: 77%-98%) and semivegetarian diets the lowest (range: 37%-83%). Plant protein source contribution was the highest from grains (range: 60%-78%). Nuts and seeds were the most consumed in vegetarian diets (7.9%; 2.9%-10.3%) and least in semivegetarian diets (3.7%; 2%-14.8%). Soy products and beans, peas, and lentils were most consumed in vegan diets (17.3%; 16.3%-19.9, and 19.6%; 14.6%-21.3, respectively) and least in semivegetarian (3.7%; 1.3%-13.9%, and 8.5%; 5.2%-10.2%) diets.

CONCLUSIONS

Vegan diets has the highest plant protein proportion and a variety of plant protein sources, while semivegetarian diets has the lowest plant protein proportion and mainly relied on grains as a plant protein source.

Stress-related eating in pregnancy? An RCT examining links between prenatal stress and food choices

BACKGROUND

Diet quality during pregnancy is important for maternal health and offspring development. However, national dietary recommendations are not always met. A potential barrier for healthy food choices might be the experience of stress. Previous literature in non-pregnant populations suggests a negative effect of acute stress on diet quality. This preregistered study is the first to test whether an acute stressor leads to unhealthy food choices in pregnancy and examine the moderating role of stress, depressive and anxiety complaints in daily life.

METHOD

Pregnant women (N = 110, 3rd trimester) completed online self-reported surveys measuring stress, depressive and anxiety complaints in daily life. Hereafter, participants were invited for a laboratory visit, in which they were exposed to the Trier Social Stress Test or a control task. After this manipulation, self-reported and actual food choices and food intake were assessed. At the end of the visit, a hair sample was collected. Throughout the visit, visual analogue scales on negative affect were completed and saliva samples were collected.

RESULTS

The stress group experienced significantly more psychological stress than the control group during the experimental manipulation. Main regression analyses showed that the acute laboratory stressor did not cause unhealthy food choices in the third trimester of pregnancy. In fact, the stress group chose fewer unhealthy foods and consumed fewer kilocalories compared to the control group. Additionally, the findings point at a moderating role of depressive and stress complaints in daily life on food choices within the control group: higher scores were related to more unhealthy food choices and more kilocalories consumed.

DISCUSSION

As this was the first study to test the effect of an acute stressor on food choices in pregnant women, more research is needed to obtain a better understanding of stress-related eating in pregnancy. This knowledge may inform future interventions to support pregnant women in improving their diet quality.

Planetary Health Diet Compared to Dutch Dietary Guidelines: Nutritional Content and Adequacy

In 2019, the EAT-Lancet Commission proposed a Planetary Health Diet (PHD) to address challenges toward sustainable and healthy diets. However, its suitability within the Dutch context and a comparison with the Dutch Dietary Guidelines (DDG) needs investigation. Our study aimed to compare the PHD with DDG in terms of food groups, servings, nutritional content, and adequacy in adults. We modeled two theoretical diets, the PHD (PHD-NL) and another based on the DDG (DDG-NL), using the Dutch National Food Consumption Survey (FCS-2016) and Dutch Food Composition Database to calculate the nutritional content and compared it with the Dutch Dietary Reference Values (DRVs). The PHD included higher quantities of vegetables, fish, legumes, and nuts, while the DDG suggested more significant amounts of cereals, tubers, starchy vegetables, dairy, and red meat. We observed differences in macronutrient distribution; while both diets lacked sufficient vitamin D, calcium content was lower in the PHD-NL. The PHD-NL had higher levels of fiber, vegetable protein, unsaturated fats, and non-heme iron, while vitamins B2, B6, B12, and calcium were lower than the DDG-NL diet. The PHD-NL has nutritional adequacy in the Dutch context, except for vitamin D and calcium, although it is essential to be cautious with iron because of the bioavailability of non-heme iron in plant-based diets. These findings have implications for the adoption of a sustainable diet according to nutritional requirements, population health status, and sociocultural context, as well as compliance with specific dietary behaviors of populations.

The planet on our plates: approaches to incorporate environmental sustainability within food-based dietary guidelines

For many decades, food-based dietary guidelines (FBDGs) were only health-oriented. This changed post-2009 when gradually, an increasing number of countries began to include environmental sustainability considerations in their guidelines. International organisations such as the Food and Agriculture Organization (FAO) and the World Health Organization (WHO) have stated that governments should include environmental sustainability in future FBDGs. However, methodologies on how this should be done are lacking. Therefore, through workshops and discussions with experts, we analysed a selection of methodologies and classified them into six groups: (1) health first; (2) additional advice; (3) demonstrating synergies; (4) modelling impact; (5) combining strategies; (6) systems first. We then assessed how innovative each approach was and their potential for transformative impact. Of the 6 approaches investigated, only approaches 5 and 6 could be considered as disruptive innovations and leading to major changes. Adding environmental sustainability into FBDGs is a policy innovation and has become a debate between old and new multi-criteria guidelines for eating. With the addition of environmental sustainability in FBDGS, a new or emerging set of multi-criteria guidelines for judging food are being proposed that challenges past norms and governance. Today, there is growing scientific consensus that diets that are good for human health are also good for the environment. There is also a growing recognition that food system change is inevitable and desirable. We see this as a positive opportunity to collaborate on FBDGs that are more appropriate for the 21st century and ambitious enough to meet the environmental challenges at hand.

Higher Muscle Protein Synthesis Rates Following Ingestion of an Omnivorous Meal Compared with an Isocaloric and Isonitrogenous Vegan Meal in Healthy, Older Adults

BACKGROUND

Plant-derived proteins are considered to have fewer anabolic properties when compared with animal-derived proteins. The anabolic properties of isolated proteins do not necessarily reflect the anabolic response to the ingestion of whole foods. The presence or absence of the various components that constitute the whole-food matrix can strongly impact protein digestion and amino acid absorption and, as such, modulate postprandial muscle protein synthesis rates. So far, no study has compared the anabolic response following ingestion of an omnivorous compared with a vegan meal.

OBJECTIVES

This study aimed to compare postprandial muscle protein synthesis rates following ingestion of a whole-food omnivorous meal providing 100 g lean ground beef with an isonitrogenous, isocaloric whole-food vegan meal in healthy, older adults.

METHODS

In a randomized, counter-balanced, cross-over design, 16 older (65-85 y) adults (8 males, 8 females) underwent 2 test days. On one day, participants consumed a whole-food omnivorous meal containing beef as the primary source of protein (0.45 g protein/kg body mass; MEAT). On the other day, participants consumed an isonitrogenous and isocaloric whole-food vegan meal (PLANT). Primed continuous L-[ring-13C6]-phenylalanine infusions were applied with blood and muscle biopsies being collected frequently for 6 h to assess postprandial plasma amino acid profiles and muscle protein synthesis rates. Data are presented as means ± standard deviations and were analyzed by 2 way-repeated measures analysis of variance and paired-samples t tests.

RESULTS

MEAT increased plasma essential amino acid concentrations more than PLANT over the 6-h postprandial period (incremental area under curve 87 ± 37 compared with 38 ± 54 mmol·6 h/L, respectively; P-interaction < 0.01). Ingestion of MEAT resulted in ∼47% higher postprandial muscle protein synthesis rates when compared with the ingestion of PLANT (0.052 ± 0.023 and 0.035 ± 0.021 %/h, respectively; paired-samples t test: P = 0.037).

CONCLUSIONS

Ingestion of a whole-food omnivorous meal containing beef results in greater postprandial muscle protein synthesis rates when compared with the ingestion of an isonitrogenous whole-food vegan meal in healthy, older adults. This study was registered at clinicaltrials.gov as NCT05151887.

Dietary Intake of Adolescents and Alignment with Recommendations for Healthy and Sustainable Diets: Results of the SI.Menu Study

BACKGROUND

The SI.Menu study offers the latest data on the dietary intake of Slovenian adolescents aged 10 to 17. The purpose of this study is to comprehensively assess their dietary intake (energy and nutrients) and compare their food intakes with dietary recommendations for healthy and sustainable diets.

METHODS

The cross-sectional epidemiological dietary study SI.Menu (March 2017-April 2018) was conducted on a representative sample of Slovenian adolescents aged 10 to 17 years (n = 468) (230 males and 238 females). Data on dietary intake were gathered through two non-consecutive 24 h recalls, in line with the European Food Safety Authority (EFSA) EU Menu methodology. The repeated 24 h Dietary Recall (HDR) and Food Propensity Questionnaire (FPQ) data were combined to determine the usual intakes of nutrients and food groups, using the Multiple Source Method (MSM) program.

RESULTS

Adolescents' diets significantly deviate from dietary recommendations, lacking vegetables, milk and dairy products, nuts and seeds, legumes, and water, while containing excessive meat (especially red meat) and high-sugar foods. This results in insufficient intake of dietary fibre, and nutrients such as vitamin D, folate, and calcium.

CONCLUSIONS

The dietary intake of Slovenian adolescents does not meet healthy and sustainable diet recommendations. This study provides an important insight into the dietary habits of Slovenian adolescents that could be useful for future public health strategies.

A plant-based diet index to study the relation between diet and disease risk among adults: a narrative review

Plant-based diets (PBD) may offer various health benefits and contribute to a sustainable way of life, but, if not planned correctly, may also confer risks, e.g., by focusing on plant foods with low nutrient density, such as foods primarily consisting of refined carbohydrates. A plant-based diet index (PDI) differentiating between a healthful, unhealthful, and overall PBD, offers a promising approach to standardize and compare studies and integrate results. In this review we (1) summarize current evidence on the PDI and disease risk of relevance to public health, (2) discuss the methodology of the PDI and how it can be sensibly applied in further studies and (3) indicate areas with a lack of knowledge, such as vulnerable populations. In summary, our amalgamation shows, that adherence to a healthier plant-based diet is associated with an 8-68% lower risk for metabolic risk factors, diabetes, and cardiovascular disease, while adherence to an unhealthier plant-based diet is associated with a 10-63% higher risk. Although differences in calculation methods and underlying diet patterns between populations should be accounted for, the PDI can be a useful tool to assess adherence to different plant-based diet patterns and their association with health outcomes in cohort studies across cultures.

What factors influence sustainable and healthy diet consumption? A review and synthesis of literature within the university setting and beyond

Globally, typical dietary patterns are neither healthy nor sustainable. Recognizing the key role of dietary change in reducing noncommunicable disease risk and addressing environmental degradation, it is crucial to understand how to shift individuals toward a sustainable and healthy diet (SHD). In this literature review, we introduced the concept of a SHD and outlined the dietary behaviors necessary to transition toward SHD consumption; we reviewed the literature on factors that may influence sustainable (and unsustainable) dietary behaviors in adults; and we developed a novel scoring system to rank factors by priority for targeting in future research. Given the significant potential to promote a sustainable and healthy dietary transition on the university campus-where factors that may impact dietary behaviors can be targeted at all levels of influence (i.e., individual, interpersonal, environmental, policy)-we narrowed our focus to this setting throughout. Aided by our novel scoring system, we identified conscious habitual eating, product price, food availability/accessibility, product convenience, self-regulation skills, knowledge of animal ethics/welfare, food promotion, and eating norms as important modifiable factors that may influence university students' dietary behaviors. When scored without consideration for the university population, these factors were also ranked as highest priority, as was modified portion sizes. Our findings offer insight into factors that may warrant attention in future research aimed at promoting SHDs. In particular, the high-priority factors identified from our synthesis of the literature could help guide the development of more personalized dietary behavioral interventions within the university setting and beyond.

More than the worksite cafeteria: the workplace food environment of small and medium-sized enterprises in the Netherlands

OBJECTIVE

To characterise the food environment of Dutch small and medium-sized enterprises (SMEs), encompassing physical, sociocultural, economic and policy features and to explore variations within SMEs according to company characteristics (number of employees, location of work and presence of worksite cafeteria).

DESIGN

Online cross-sectional survey study of a representative Dutch SME sample by a panel agency.

SETTING

Dutch SMEs.

PARTICIPANTS

Three hundred and fifteen employees of Dutch SMEs responsible for food and drink in their company.

RESULTS

Most SMEs did not have a worksite cafeteria, no provision of fruits or vegetables, and did not offer discounts on food or drinks. The food environment of these SMEs varied significantly based on company characteristics. For example, SMEs with a worksite cafeteria were significantly more likely to have fruits (OR = 8·76, 95 % CI (4·50, 17·06)), vegetables (OR = 10·29, 95 % CI (5·49, 19·31)) and company food policies (OR = 5·04, 95 % CI (2·08, 12·20)) than SMEs without. Additionally, SMEs with ≥ 50 employees were more likely to have fruits (OR = 2·39, 95 % CI (1·42, 4·03)), vegetables (OR = 1·89, 95 % CI (1·04, 3·46)) and company food policies (OR = 2·82, 95 % CI (1·09, 7·29) than SMEs with < 50 employees. Moreover, having a worksite cafeteria (B = 0·23, 95 % CI (0·08, 0·38)) and employees working mostly on-site (B = 0·14, 95 % CI (0·01, 0·28)) were associated with stronger social norms of healthy and sustainable eating at work compared to SMEs without a worksite cafeteria and working mostly off-site.

CONCLUSIONS

In SMEs, an overall comprehensive picture of the food environment points to its limited active encouragement of healthy food choices, particularly so in small SMEs without a worksite cafeteria. Company characteristics strongly influence SME food environments and should be considered when developing interventions improving SME workplace food environments.

Evaluating agreement between evidence from randomised controlled trials and cohort studies in nutrition: a meta-research replication study

This meta-research study aims to evaluate the agreement of effect estimates between bodies of evidence (BoE) from RCTs and cohort studies included in the same nutrition evidence synthesis, to identify factors associated with disagreement, and to replicate the findings of a previous study. We searched Medline, Epistemonikos and the Cochrane Database of Systematic Reviews for nutrition systematic reviews that included both RCTs and cohort studies for the same patient-relevant outcome or intermediate-disease marker. We rated similarity of PI/ECO (population, intervention/exposure, comparison, outcome) between BoE from RCTs and cohort studies. Agreement of effect estimates across BoE was analysed by pooling ratio of risk ratios (RRR) for binary outcomes and difference of standardised mean differences (DSMD) for continuous outcomes. We performed subgroup and sensitivity analyses to explore determinants associated with disagreements. We included 82 BoE-pairs from 51 systematic reviews. For binary outcomes, the RRR was 1.04 (95% confidence interval (CI) 0.99 to 1.10, I2 = 59%, τ2 = 0.02, prediction interval (PI) 0.77 to 1.41). For continuous outcomes, the pooled DSMD was  - 0.09 (95% CI  - 0.26 to 0.09, PI  - 0.55 to 0.38). Subgroup analyses yielded that differences in type of intake/exposure were drivers towards disagreement. We replicated the findings of a previous study, where on average RCTs and cohort studies had similar effect estimates. Disagreement and wide prediction intervals were mainly driven by PI/ECO-dissimilarities. More research is needed to explore other potentially influencing factors (e.g. risk of bias) on the disagreement between effect estimates of both BoE.Trial registration: CRD42021278908.

Impact of consuming an environmentally protective diet on micronutrients: a systematic literature review

BACKGROUND

A global move toward consumption of diets from sustainable sources is required to protect planetary health. As this dietary transition will result in greater reliance on plant-based protein sources, the impact on micronutrient (MN) intakes and status is unknown.

OBJECTIVE

Evaluate the evidence of effects on intakes and status of selected MNs resulting from changes in dietary intakes to reduce environmental impact. Selected MNs of public health concern were vitamins A, D, and B12, folate, calcium, iron, iodine, and zinc.

METHODS

We systematically searched 7 databases from January 2011 to October 2022 and followed the PRISMA guidelines. Eligible studies had to report individual MN intake and/or status data collected in free-living individuals from the year 2000 onward and environmental outcomes.

RESULTS

From the 10,965 studies identified, 56 studies were included, mostly from high-income countries (n = 49). Iron (all 56) and iodine (n = 20) were the most and least reported MNs, respectively. There was one randomized controlled trial (RCT) that also provided the only biomarker data, 10 dietary intake studies, and 45 dietary modeling studies, including 29 diet optimization studies. Most studies sought to reduce greenhouse gas emissions or intake of animal-sourced foods. Most results suggested that intakes of zinc, calcium, iodine, and vitamins B12, A, and D would decrease, and total iron and folate would increase in a dietary transition to reduce environmental impacts. Risk of inadequate intakes of zinc, calcium, vitamins A, B12 and D were more likely to increase in the 10 studies that reported nutrient adequacy. Diet optimization (n = 29) demonstrated that meeting nutritional and environmental targets is technically feasible, although acceptability is not guaranteed.

CONCLUSIONS

Lower intakes and status of MNs of public health concern are a potential outcome of dietary changes to reduce environmental impacts. Adequate consideration of context and nutritional requirements is required to develop evidence-based recommendations. This study was registered prospectively with PROSPERO (CRD42021239713).

Developing a novel optimisation approach for keeping heterogeneous diets healthy and within planetary boundaries for climate change

BACKGROUND AND OBJECTIVES

Current dietary habits have substantial negative impacts on the health of people and the planet. This study aimed to develop a novel approach for achieving health-promoting and climate-friendly dietary recommendations for a broad range of consumers.

SUBJECTS AND METHODS

Hierarchical clustering analysis was combined with linear programming to design nutritionally adequate, health-promoting, climate-friendly and culturally acceptable diets using Swedish national dietary data (n = 1797). Diets were optimised for the average consumption of the total population as well as for the dietary clusters.

RESULTS

Three dietary clusters were identified. All optimised diets had lower shares of animal-source foods and contained higher amounts of plant-based foods. These dietary shifts reduced climate impacts by up to 53% while leaving much of the diet unchanged. The optimised diets of the three clusters differed from the optimised diet of the total population. All optimised diets differed considerably from the food-group pattern of the EAT-Lancet diet.

CONCLUSIONS

The novel cluster-based optimisation approach was able to generate alternatives that may be more acceptable and realistic for a sustainable diet across different groups in the population.

Interventions to increase circularity and reduce environmental impacts in food systems

Applying specific circularity interventions to the food system may have environmental benefits. Using an iterative linear food system optimisation model (FOODSOM), we assess how changes in human diets, imports and exports, and the utilisation of waste streams impact land use and greenhouse gas emissions (GHG). After including these circularity principles, land use and GHG emissions were on average 40% and 68% lower than in the current food system, primarily driven by a reduction in production volumes and a shift towards feeding the domestic population. Shifting from the current diet to a circular diet decreased land use with 43% and GHG emissions with 52%. Allowing up to half of each nutrient in the human diet to be imported, while balancing imports with equal exports in terms of nitrogen, phosphorus and potassium, also decreased land use (up to 34%) and GHG emissions (up to 26%) compared to no imported food. Our findings show that circularity interventions should not be implemented mutually exclusively; by combining a circular diet with imported food and fully utilising waste streams, the lowest land use and GHG emissions can be realised.

Assessment of the Dutch Healthy Diet index 2015 in the Lifelines cohort study at baseline

BACKGROUND

Dietary indices are useful measures to investigate associations between dietary intake and disease development. The Dutch Healthy Diet index 2015 (DHD2015-index), a measure of diet quality, assesses adherence to the 2015 Dutch dietary guidelines. We assessed the DHD2015-index in the Lifelines cohort study, and compared calculations from basic and detailed dietary intake data. This article replaces the retracted article that was published on 16 May 2022 [1].

METHODS

Dietary intake was assessed with a specially developed Food Frequency Questionnaire (FFQ) called Flower-FFQ, which consists of one main questionnaire (heart-FFQ), which asks for intakes of major food groups, and three complementary questionnaires (petal-FFQs), which ask for detailed information on food types within major food groups of the heart-FFQ. The DHD2015-index was assessed using data from the total Flower-FFQ (for 56,982 participants), and using data from the heart-FFQ only (for 129,030 participants). Agreement between the two indices was assessed with correlation and cross-classification.

RESULTS

The median (25th-75th percentile) DHD2015-index score was 75 (65-85) for men and 81 (70-91) for women based on the Flower-FFQ, and 68 (58-77) for men and 73 (63-82) for women based on the heart-FFQ. The Kendall's tau-b correlation coefficient between the two scores was 0.67 for men and 0.66 for women. Cross-classification into quartiles of the DHD2015-index showed that 59-60% of participants were classified in the same quartile, 36-37% in the adjacent, and 4% in the non-adjacent.

CONCLUSION

Dietary data from the Flower-FFQ provide the most optimal information to assess the DHD2015-index. However, the DHD2015-index from the heart-FFQ showed good agreement with the index from the Flower-FFQ of ranking participants according to diet quality, and can be used when the DHD2015 index from the Flower-FFQ is not available.

A Smartphone Food Record App Developed for the Dutch National Food Consumption Survey: Relative Validity Study

BACKGROUND

In the Dutch National Food Consumption Survey, dietary intake has been assessed since 2003 through 24-hour dietary recalls using the GloboDiet software. A new self-administered smartphone food record app called DitEetIk! was developed for potential use in future surveys.

OBJECTIVE

This study aims to evaluate the data collected using the DitEetIk! app and its relative validity for food group, energy, and nutrient intake compared with the previous dietary assessment method (GloboDiet 24-hour dietary recalls).

METHODS

A total of 300 participants aged 18 to 79 years were recruited from a consumer panel. Participants were asked to keep a record of their consumption using the DitEetIk! app on 3 nonconsecutive days. Trained dietitians conducted a 24-hour dietary recall interview by telephone using the GloboDiet software (International Agency for Research on Cancer) regarding 1 of 3 DitEetIk! recording days. Nutrient intake was calculated using the NEVO database (version 2021/7.0). Relative validity was studied by comparing data from GloboDiet 24-hour dietary recalls and the DitEetIk app for the same day. Participants with implausible records, defined as days with energy intake of <0.6 or >3.0 basal metabolic rate, were excluded from the analyses. For 19 food groups and 29 nutrients, differences in median intake were assessed using the Wilcoxon signed rank test, and Spearman correlation coefficients were calculated. Bland-Altman plots with mean differences and 95% limits of agreement were created for energy intake and the contribution to energy intake from fat, carbohydrates, and protein.

RESULTS

A total of 227 participants completed a combination of a DitEetIk! app recording day and a 24-hour dietary recall interview for the same day. Of this group, 211 participants (n=104, 49.3% men and n=107, 50.7% women) had plausible recording days. Of all recorded food items, 12.8% (114/894) were entered via food barcode scanning, and 18.9% (169/894) were searched at the brand level. For 31% (5/16) of the food groups, the median intake assessed using the DitEetIk! app was >10% lower than that assessed using 24-hour dietary recalls; this was the case for fruit (P=.005), added fats (P=.001), milk and milk products (P=.02), cereal products (P=.01), and sauces (P<.001). This was also the case for 14% (4/29) of the nutrients (all P<.001). Regarding mean intake, differences were generally smaller. Regarding energy intake, the mean difference and 95% limits of agreement were 14 kcal (-1096 to 1124). Spearman correlation coefficients between intake assessed using the DitEetIk! app and 24-hour dietary recalls ranged from 0.48 to 0.88 (median 0.78) for food groups and from 0.58 to 0.90 (median 0.72) for nutrients.

CONCLUSIONS

Compared with GloboDiet 24-hour dietary recalls, the DitEetIk! app assessed similar mean energy intake levels but somewhat lower median intake levels for several food groups and nutrients.

Real-world nudging, pricing, and mobile physical activity coaching was insufficient to improve lifestyle behaviours and cardiometabolic health: the Supreme Nudge parallel cluster-randomised controlled supermarket trial

BACKGROUND

Context-specific interventions may contribute to sustained behaviour change and improved health outcomes. We evaluated the real-world effects of supermarket nudging and pricing strategies and mobile physical activity coaching on diet quality, food-purchasing behaviour, walking behaviour, and cardiometabolic risk markers.

METHODS

This parallel cluster-randomised controlled trial included supermarkets in socially disadvantaged neighbourhoods across the Netherlands with regular shoppers aged 30-80 years. Supermarkets were randomised to receive co-created nudging and pricing strategies promoting healthier purchasing (N = 6) or not (N = 6). Nudges targeted 9% of supermarket products and pricing strategies 3%. Subsequently, participants were individually randomised to a control (step counter app) or intervention arm (step counter and mobile coaching app) to promote walking. The primary outcome was the average change in diet quality (low (0) to high (150)) over all follow-up time points measured with a validated 40-item food frequency questionnaire at baseline and 3, 6, and 12 months. Secondary outcomes included healthier food purchasing (loyalty card-derived), daily step count (step counter app), cardiometabolic risk markers (lipid profile and HbA1c via finger prick, and waist circumference via measuring tape), and supermarket customer satisfaction (questionnaire-based: very unsatisfied (1) to very satisfied (7)), evaluated using linear mixed-models. Healthy supermarket sales (an exploratory outcome) were analysed via controlled interrupted time series analyses.

RESULTS

Of 361 participants (162 intervention, 199 control), 73% were female, the average age was 58 (SD 11) years, and 42% were highly educated. Compared to the control arm, the intervention arm showed no statistically significant average changes over time in diet quality (β - 1.1 (95% CI - 3.8 to 1.7)), percentage healthy purchasing (β 0.7 ( - 2.7 to 4.0)), step count (β - 124.0 (- 723.1 to 475.1), or any of the cardiometabolic risk markers. Participants in the intervention arm scored 0.3 points (0.1 to 0.5) higher on customer satisfaction on average over time. Supermarket-level sales were unaffected (β - 0.0 (- 0.0 to 0.0)).

CONCLUSIONS

Co-created nudging and pricing strategies that predominantly targeted healthy products via nudges were unable to increase healthier food purchases and intake nor improve cardiometabolic health. The mobile coaching intervention did not affect step count. Governmental policy measures are needed to ensure more impactful supermarket modifications that promote healthier purchases.

TRIAL REGISTRATION

Dutch Trial Register ID NL7064, 30 May 2018, https://www.onderzoekmetmensen.nl/en/trial/20990.

Changes in nutrient composition and diet quality in the first 6 months following bariatric surgery: An observational cohort study

BACKGROUND

Bariatric surgery (BS) may result in inadequate nutrient intake and poor diet quality, which can lead to nutritional complications. The present study aimed to evaluate changes in macro- and micronutrient composition and diet quality in the first 6 months following BS.

METHODS

One hundred seven participants undergoing BS (Roux-en-Y gastric bypass: n = 87, sleeve gastrectomy: n = 20) completed 3-day food records before and 6 months after surgery. Changes in energy, macronutrient (carbohydrates, protein, fat, dietary fibre) and micronutrient intake (folate, vitamin B12, vitamin D, calcium, iron) were evaluated. Diet quality was assessed by adherence to the Dutch food-based dietary guidelines.

RESULTS

After BS, we observed a significant decrease in intake of energy and all macro- and micronutrients (p < 0.01 for all), except for calcium (-39.0 ± 404.6 mg; p = 0.32). Overall, nutrient composition slightly changed with an increase in the relative intake of protein (+1.1 ± 4.3 energy percentage [en%]; p = 0.01) and mono- and disaccharides (+4.2 ± 6.4 en%; p < 0.001) post-surgery. Consumption (median [Q1, Q3]) of vegetables (-50 [-120, 6] g day-1 ), wholegrain products (-38 [-81, -8] g day-1 ), liquid fats (-5 [-13, 2] g day-1 ), red meat (-3 [-30, 4] g day-1 ), processed meat (-32 [-55, 13] g day-1 ), sodium (-0.7 [-1.1, -0.2] g day-1 ) and unhealthy food choices (-2.4 [-5.0, 0.6] serves week-1 ) significantly decreased after BS (p < 0.01 for all).

CONCLUSIONS

Our results demonstrate both favourable and unfavourable changes in macro- and micronutrient composition and diet quality in the first 6 months following BS. Insight into these changes can improve dietary counselling in this population. Future research into underlying causes, consequences and long-term changes in dietary intake is needed.

Replacement of Milk and Dairy Products with Soy-Based Alternatives-How to Avoid Nutrient Deficiencies in a Milk-Free Diet?

BACKGROUND

In Germany, milk and dairy products are increasingly replaced by their plant-based alternatives. Although they can be used as substitutes, they differ significantly in their nutrient composition; thus, substitution could lead to nutrient deficiencies. So far, there are no food-based dietary recommendations that show which foods can replace milk and dairy products in a healthy way when switching to a plant-based substitute.

OBJECTIVES

Against this background, the question arises as to how to ensure adequate intake of critical nutrients when plant-based alternatives are consumed instead of milk and dairy products. To answer this question, this study aims to analyze what dietary changes would be required to avoid possible nutrient deficiencies and what types of foods can be consumed instead.

METHODS

To answer the research question, 3 different models are compared using the linear programming method: healthy diets with 1) milk and dairy products, 2) nonfortified plant-based alternatives, and 3) fortified plant-based alternatives. The models are applied to omnivorous, pescatarian, and vegetarian diet types.

RESULTS

The results show that when consuming nonfortified soy alternatives, an adequate supply of calcium and, in the case of a vegetarian diet, vitamin B12 can only be achieved if significant dietary changes are made compared to the average diet. This includes a significantly higher consumption of fruit and vegetables, whereby within the groups, calcium-rich varieties should be chosen (e.g., green leafy vegetables). When consuming fortified soy-based alternatives instead, the absence of milk and dairy products can be well compensated by the nutrients currently added to commercially available products.

CONCLUSIONS

Given the trend to consume less milk and dairy products or to abstain from them altogether, public health measures should point out possible nutrient deficiencies as well as necessary dietary changes, especially because in Germany, many plant-based alternatives are not fortified.

Stability of clustering of lifestyle risk factors in the Dutch adult population and the association with mental health

BACKGROUND

Lifestyle factors often co-occur in clusters. This study examines whether clusters of lifestyle risk factors, such as smoking, alcohol use, physical inactivity, poor diet, sexual risk behaviour, cannabis and other drug use, change over time in a representative sample of Dutch adults. Additionally, the association between mental health and self-reported depression of lifestyle clusters was examined.

METHODS

Each year cross-sectional data of approximately 7500 individuals of 18 years and older from the annual Dutch Health Survey of 2014-2019 were used. Clusters were determined by a two-step cluster analysis. Furthermore, regression analyses determined the association between clusters of lifestyle risk factors and mental health.

RESULTS

Results show six clusters composed of one, multiple or no lifestyle risk factors. The clusters remained relatively stable over time: in some clusters, the number of people slightly changed between 2014 and 2019. More specifically, clusters that increased in size were the cluster with no lifestyle risk factors and the cluster with multiple lifestyle risk factors. Furthermore, results show that clusters with none to a few lifestyle risk factors were associated with better mental health and a lower prevalence of self-reported depression compared with clusters with multiple lifestyle risk factors.

CONCLUSIONS

The clustering of lifestyle risk factors remained stable over time. People with multiple lifestyle risk factors had poorer mental health than those without risk factors. These findings may emphasize the need for intervention strategies targeting this subgroup with multiple lifestyle risk factors.

Dietary Inflammatory Index and Clinical Outcome Measures in Adults With Moderate-to-Severe Asthma

BACKGROUND

Diet is increasingly recognized as a modifiable factor in lung health, predominantly due to the immunomodulatory effects of nutrients. The Dietary Inflammatory Index (DII) is a score developed to express the inflammatory potential of a diet.

OBJECTIVE

We aimed to assess the association of the DII and food groups, with clinical, functional, and inflammatory asthma outcomes in adults with asthma.

METHODS

Patients with moderate-to-severe asthma were included in this cross-sectional study between June 2019 and October 2021, and completed a 3-day food diary, to calculate the DII and intake of food groups (ie, fruits, whole grains, processed meats, and sugar-sweetened beverages). Functional outcomes included pulmonary function tests and the 6-minute walking distance, whereas clinical outcomes were assessed using questionnaires on asthma control, quality of life, and health care utilization. Inflammatory markers were exhaled nitric oxide and blood leukocytes, eosinophils, and IL-6. Multivariable regression analyses were used to examine the association of DII and food groups with asthma outcomes.

RESULTS

A total of 109 patients participated (35% male, mean ± standard deviation age 51.8 ± 14.2 years, body mass index 27.4 ± 5.3 kg/m2). Overall, 62% had a DII score >0, indicating a proinflammatory diet, which was not related to asthma severity. A more proinflammatory diet was consistently associated with lower forced vital capacity (%pred), but inconsistent results were observed with respect to airway obstruction. Neither the DII nor food groups were associated with clinical outcomes. Except for higher levels of exhaled nitric oxide in relation to an anti-inflammatory diet, we found no associations between inflammatory markers and the DII.

CONCLUSION

Results from this cross-sectional study among patients with moderate-to-severe asthma do not support the hypothesis that a proinflammatory diet is associated with worse asthma outcomes, although limitations in study design and dietary intake estimation should be considered. Future well-designed experimental studies are needed to assess whether targeting the inflammatory potential of diet could lead to better outcomes in adults with asthma.

Sustainable diets among youth: Validity and reliability of a questionnaire assessing knowledge, attitudes, practices, and willingness to change

BACKGROUND

In light of the global commitment to promoting sustainable dietary choices and the pivotal role of young adults in the adoption of these choices, it is paramount to understand their perspectives of healthy and sustainable diets. The present study aimed to investigate the validity and reliability of a questionnaire examining the knowledge, attitudes, practices, and willingness to change regarding sustainable diets among young adults in the United Arab Emirates (UAE).

METHODS

Male and female students attending University of Sharjah, UAE (n = 436), completed an online questionnaire consisting of four sections: knowledge, attitudes, practices, and willingness to change with regard to sustainable diets. Of the participants, 106 completed the questionnaire a second time, 1 month later. Factor analysis (FA) (both exploratory and confirmatory), Cronbach-α, interitem correlations, and intra class correlation (ICC) coefficients were used in the data analysis.

RESULTS

Exploratory FA revealed four factors corresponding to the components of the questionnaire. Results of the confirmatory FA indicated a good fit: the χ2 df ratio was < 5 (2.3), root mean squared error of approximation was < 0.08 (0.048) and the comparative fit index was above 0.9 (0.901). Cronbach α and interitem correlations were: knowledge: 0.57 and 0.21; attitude: 0.70 and 0.28; practices: 0.76 and 0.39; willingness to change: 0.69 and 0.27. The ICC coefficients, assessing the reliability of the questionnaire, ranged between 0.48 and 0.92 for the various items.

CONCLUSIONS

The developed questionnaire is a valid and reliable tool that could be used to identify the gaps and opportunities for the development of evidence-based interventions aiming to enhance the uptake of sustainable diets among young adults.

The perceptions of food service staff in a nursing home on an upcoming transition towards a healthy and sustainable food environment: a qualitative study

BACKGROUND

Healthy and sustainable food environments are urgently needed, also in nursing and residential care homes. Malnutrition in care homes is becoming an increasing problem as populations worldwide are ageing and many older people do not consume sufficient protein, fibre, fruit, and vegetables. Nursing homes also often experience a lot of food waste. A transition in the food environment like a nursing home, involves the participation of facility management and food service staff members. This study aims to map out their perceived barriers and facilitators for this transition.

METHODS

A qualitative study using semi-structured interviews was conducted with food service staff members (n = 16), comprising of kitchen staff (n = 4), wait staff (n = 10), and facility management (n = 2) of two nursing homes in the Netherlands. Thematic analysis was used to derive content and meaning from transcribed interviews.

RESULTS

Four main themes were identified. Theme 1: 'Communication, transparency and accountability in the chain', highlighting the lack of effective communication flows and a fragmented overview of the food service chain as a whole. Theme 2: 'Understanding, knowledge and ability of the concepts healthy and sustainable', revealing the gap in staff's understanding of these abstract concepts, despite perceiving themselves as having sufficient knowledge and ability. Theme 3: 'The pampering service mind-set', highlighting the contradiction in the staff's shared goal of proving the highest quality of life for residents while also pampering them in ways that may not align with promoting healthy and sustainable food choices. Theme 4: 'Transition is important but hard to realize', describing the barriers such as existing routines and a lack of resources as challenges to implementing changes in the food service.

CONCLUSIONS

Facilitators to transitioning nursing homes towards a healthy and sustainable food environment as perceived by staff members included transparent communication, accountability in the food supply chain, staff's perceived ability and shared goal, while barriers included lack of understanding of the concepts healthy and sustainable, the current pampering mindset, and top-down decision-making. These findings provide valuable insights for nursing homes seeking to transition towards a healthier and more sustainable food environment.

Consumer attitudes and behaviors toward more sustainable diets: a scoping review

There is an urgent need to move toward more sustainable diets. Although this will require radical and systemic changes across food systems, altering consumer ideologies and practices is essential to garner support for such actions. In this scoping review, the evidence on consumers' attitudes and behaviors toward more sustainable diets is synthesized and a range of factors, considerations, and proposed strategies are presented that can contribute to building the societal-level support for urgent and systems-level changes. The findings suggest that consumers, insofar as they are interested in sustainability and have the capacity to engage with the concept, primarily approach the concept of sustainable diet from a human health perspective. However, the interconnectedness of human health and well-being with environmental health is poorly understood and under-researched in the context of consumer behaviors and attitudes toward sustainable diets. This highlights the need for (1) sustained efforts from public health professionals to encourage a realignment of the term sustainable diet with its multidimensional meaning by championing an ecological public health approach in all efforts aimed at promoting more sustainable consumption, from awareness raising to policy development; (2) a broader research lens focused on the multidimensional concept of sustainability in the literature exploring consumer attitudes and behaviors; and (3) the development of multidisciplinary, clear, and evidence-based sustainable-eating messages, including holistic sustainable dietary guidance, to address knowledge gaps, minimize conflicting narratives, and build consumer agency. The findings contribute to understanding how support can be generated for the necessary structural and system-level changes required to support behavior change.

A community focused approach toward making healthy and affordable daily diet recommendations

Introduction

Maintaining an affordable and nutritious diet can be challenging, especially for those living under the conditions of poverty. To fulfill a healthy diet, consumers must make difficult decisions within a complicated food landscape. Decisions must factor information on health and budget constraints, the food supply and pricing options at local grocery stores, and nutrition and portion guidelines provided by government services. Information to support food choice decisions is often inconsistent and challenging to find, making it difficult for consumers to make informed, optimal decisions. This is especially true for low-income and Supplemental Nutrition Assistance Program (SNAP) households which have additional time and cost constraints that impact their food purchases and ultimately leave them more susceptible to malnutrition and obesity. The goal of this paper is to demonstrate how the integration of data from local grocery stores and federal government databases can be used to assist specific communities in meeting their unique health and budget challenges.

Methods

We discuss many of the challenges of integrating multiple data sources, such as inconsistent data availability and misleading nutrition labels. We conduct a case study using linear programming to identify a healthy meal plan that stays within a limited SNAP budget and also adheres to the Dietary Guidelines for Americans. Finally, we explore the main drivers of cost of local food products with emphasis on the nutrients determined by the USDA as areas of focus: added sugars, saturated fat, and sodium.

Results and discussion

Our case study results suggest that such an optimization model can be used to facilitate food purchasing decisions within a given community. By focusing on the community level, our results will inform future work navigating the complex networks of food information to build global recommendation systems.

Planet-based diets: improving environmental sustainability of healthy diets

The focus of nutritionists is on improvement of the health impact of current diets. Therefore, it is important to ask the question whether healthy diets are more sustainable. This review provides an overview on the research on synergies between health and sustainability. Synergies are found from shifts from animal-based to plant-based diets, from ultra-processed foods to fresh and whole foods and from reduction of food waste. The importance of looking at sustainability of the present diets has led to steps made in Europe to incorporate sustainability into food-based dietary guidelines. Examples from UK, Nordics, Belgium and the Netherlands are given. World Wildlife Fund has summarised the insides in a future-proof diet: the planet-based diet within planetary boundaries.

Demographic and Socioeconomic Correlates of Disproportionate Beef Consumption among US Adults in an Age of Global Warming

Concern for the environment when making dietary choices has grown as the contribution of the food sector to global greenhouse gas emissions becomes more widely known. Understanding the correlates of beef eating could assist in the targeting of campaigns to reduce the consumption of high-impact foods. The objective of this study was to identify the demographic, socioeconomic, and behavioral correlates of disproportionate beef consumption in the United States. We analyzed 24-h dietary recall data from adults (n = 10,248) in the 2015-2018 National Health and Nutrition Examination Survey (NHANES). Disproportionate beef consumption was defined as an intake greater than four ounce-equivalents per 2200 kcal. Associations of this indicator variable with gender, age, race/ethnicity, education, family income, diet knowledge, and away-from-home meals were assessed using logistic regression, incorporating survey design and weighting. Disproportionate beef diets were consumed by 12% of individuals, but accounted for half of all beef consumed. Males were more likely than females (p < 0.001) to consume these diets. This relationship was seen in all bivariate and multivariable models. Older adults, college graduates, and those who looked up the MyPlate educational campaign online were less likely (p < 0.01) to consume a disproportionate beef diet. While almost one-third of reported consumption came from cuts of beef (e.g., steak or brisket), six of the top ten beef sources were mixed dishes: burgers, meat mixed dishes, burritos and tacos, frankfurters, soups, and pasta. Efforts to address climate change through diet modification could benefit from targeting campaigns to the highest consumers of beef, as their consumption accounts for half of all beef consumed.

Efficacy and utility of a tool for both measurement of vitamin B6, B12, D, folate and iron status and assessment of diet quality in athletes

NutriProfiel® is a tool to measure micronutrient status and to assess diet quality. It consists of measurement of micronutrient status in blood and a short food frequency questionnaire (FFQ) ('Eetscore-FFQ'). Based on the results, individuals receive a dietary advice. In this study, we evaluated the application of NutriProfiel in athletes ('NutriProfiel-Sport') by assessing the coverage of nutrient intake of the Eetscore-FFQ (part 1) and by evaluating athlete's dietary behaviour after using NutriProfiel-Sport and their satisfaction with this tool (part 2). For part 1, data of 419 athletes were used. We evaluated the coverage of nutrient intake of the Eetscore-FFQ using first and second MOMents (MOM1 and MOM2) sum scores of food items in the questionnaire. Forty-eight athletes were involved in part 2. They gave blood samples for micronutrient status measurement and were asked to complete the Eetscore-FFQ at baseline and after 3 months, as well as a questionnaire on their satisfaction with NutriProfiel-Sport. Results showed that for most nutrients, MOM1 and MOM2 scores were above 80 %, meaning that nutrient intake was sufficiently covered by the Eetscore-FFQ. No difference in diet quality was observed between baseline and after 3 months. Nevertheless, a majority of athletes reported the NutriProfiel-Sport results and advice as useful. On a scale from 0 to 10, NutriProfiel-Sport was graded with a mean (±sd) score of 7⋅6 (±0⋅8). In conclusion, NutriProfiel-Sport is a potential valuable and appreciated tool for athletes and the Eetscore-FFQ as part of this tool sufficiently covers nutrient intake in athletes.

Exploring healthy and climate-friendly diets for Danish adults: an optimization study using quadratic programming

Background

A transition to healthy and sustainable diets has the potential to improve human and planetary health but diets need to meet requirements for nutritional adequacy, health, environmental targets, and be acceptable to consumers.

Objective

The objective of this study was to derive a nutritionally adequate and healthy diet that has the least deviation possible from the average observed diet of Danish adults while aiming for a greenhouse gas emission (GHGE) reduction of 31%, corresponding to the GHGE level of the Danish plant-rich diet, which lays the foundation for the current healthy and sustainable food-based dietary guidelines (FBDGs) in Denmark.

Methods

With an objective function minimizing the departure from the average observed diet of Danish adults, four diet optimizations were run using quadratic programming, with different combinations of diet constraints: (1) nutrients only (Nutri), (2) nutrients and health-based targets for food amounts (NutriHealth), (3) GHGE only (GHGE), and finally, (4) combined nutrient, health and GHGE constraints (NutriHealthGHGE).

Results

The GHGE of the four optimized diets were 3.93 kg CO₂-eq (Nutri), 3.77 kg CO₂-eq (NutriHealth) and 3.01 kg CO₂-eq (GHGE and NutriHealthGHGE), compared to 4.37 kg CO₂-eq in the observed diet. The proportion of energy from animal-based foods was 21%-25% in the optimized diets compared to 34% in the observed diet and 18% in the Danish plant-rich diet. Moreover, compared to the average Danish diet, the NutriHealthGHGE diet contained more grains and starches (44 E% vs. 28 E%), nuts (+230%), fatty fish (+89%), eggs (+47%); less cheese (-73%), animal-based fats (-76%), total meat (-42%); and very limited amounts of ruminant meat, soft drinks, and alcoholic beverages (all-90%), while the amounts of legumes and seeds were unchanged. On average, the mathematically optimized NutriHealthGHGE diet showed a smaller deviation from the average Danish diet compared to the Danish plant-rich diet (38% vs. 169%, respectively).

Conclusion

The final optimized diet presented in this study represents an alternative way of composing a nutritionally adequate and healthy diet that has the same estimated GHGE as a diet consistent with the climate-friendly FBDGs in Denmark. As this optimized diet may be more acceptable for some consumers, it might help to facilitate the transition toward more healthy and sustainable diets in the Danish population.

Interventions to Strengthen Environmental Sustainability of School Food Systems: Narrative Scoping Review

School food systems play a role in the wider food system, but there is a scarcity of literature exploring interventions that aim to improve the environmental sustainability of school food systems. The present review aimed to understand and describe the types of interventions that have previously been explored to strengthen the sustainability of school food systems along with their impact. We applied a scoping review methodology guided by Arksey and O'Malley, which included a review of the online database Scopus and the grey literature. Information relating to intervention design, study population, evaluation method and impact were extracted. In total, 6016 records were screened for eligibility, 24 of which were eligible for inclusion. The most common types of interventions were school lunch menus designed to be more sustainable; school food waste reduction; sustainable food system education using school gardens; and dietary interventions with added environmental components. This review highlights a range of interventions which could positively influence the environmental sustainability of school food systems. Further research is needed to explore the effectiveness of such interventions.

Cross-Sectional Study to Map Nutritional Quality of Meat, Fish, and Dairy Alternatives in Dutch Supermarkets According to the Dutch Food-Based Dietary Guidelines and Nutri-Score

Due to a growing challenge to feed the world's population and an increased awareness to minimize the impact of our food choices on climate change, a more plant-based diet has gained popularity with a growing number of plant-based products on the market. To stimulate a plant-based diet that also improves long-term health, data are needed to monitor whether these products are healthy alternatives to animal-based foods. Therefore, this study inventoried 916 plant-based meat, fish, and dairy alternatives from eight Dutch supermarkets. The nutritional quality of each product was assessed by (1) the Dutch food-based dietary guidelines and (2) the Nutri-Score. The results show that over 70% of meat, fish, and dairy alternatives have an A/B Nutri-Score (indicating high nutritional quality), but do not comply with the Dutch dietary guidelines. This is mainly due to high salt and low vitamin B12 and iron content (meat and fish alternatives) or low protein and calcium levels (dairy alternatives). In conclusion, the majority of plant-based products are nutritionally not full alternatives of the animal-based equivalents; however, there are still opportunities for reformulation. To aid the consumer in making healthy plant-based food choices, a better alignment between the Nutri-Score and the recommended dietary guidelines is needed.

Clusters of lifestyle behaviours and their associations with socio-demographic characteristics in Dutch toddlers

PURPOSE

This study aimed to identify clusters of lifestyle behaviours in toddlers and assess associations with socio-demographic characteristics.

METHODS

We used data from the Dutch National Food Consumption Survey 2012-2016 and included 646 children aged 1-3 years. Based on 24-h dietary recalls and a questionnaire, a two-step cluster analysis was conducted to identify clusters in the intake of fruit, vegetables, sugar-sweetened beverages and unhealthy snacks, physical activity and screen time. Logistic regression models assessed associations between socio-demographic characteristics and cluster allocation.

RESULTS

Three clusters emerged from the data. The 'relatively healthy cluster' demonstrated a high intake of fruit and vegetables, low sugar-sweetened beverage and unhealthy snack intake and low screen time. The 'active snacking cluster' was characterised by high unhealthy snack intake and high physical activity, and the 'sedentary sweet beverage cluster' by high intake of sugar-sweetened beverages and high screen time. Children aged 1 year were most likely to be allocated to the 'relatively healthy cluster'. Compared to children of parents with a high education level, children of parents with a low or middle education level were less likely to be in the 'relatively healthy cluster', but more likely to be in the 'sedentary sweet beverage cluster'.

CONCLUSION

Clusters of lifestyle behaviours can be distinguished already in children aged 1-3 years. To promote healthy lifestyle behaviour, efforts may focus on maintaining healthy behaviour in 1-year-olds and more on switching towards healthy behaviour in 2- and 3-year-olds.

Blood metabolite profiles linking dietary patterns with health-Toward precision nutrition

Diet is one of the most important exposures that may affect health throughout life span. Investigations on dietary patterns rather than single food components are gaining in popularity because they take the complexity of the whole dietary context into account. Adherence to such dietary patterns can be measured by using metabolomics, which allows measurements of thousands of molecules simultaneously. Derived metabolite signatures of dietary patterns may reflect the consumption of specific groups of foods or their constituents originating from the dietary pattern per se, or the physiological response toward the food-derived metabolites, their interaction with endogenous metabolism, and exogenous factors such as gut microbiota. Here, we review and discuss blood metabolite fingerprints of healthy dietary patterns. The plasma concentration of several food-derived metabolites-such as betaines from whole grains and n - 3 polyunsaturated fatty acids and furan fatty acids from fish-seems to consistently reflect the intake of common foods of several healthy dietary patterns. The metabolites reflecting shared features of different healthy food indices form biomarker panels for which specific, targeted assays could be developed. The specificity of such biomarker panels would need to be validated, and proof-of-concept feeding trials are needed to evaluate to what extent the panels may mediate the effects of dietary patterns on disease risk indicators or if they are merely food intake biomarkers. Metabolites mediating health effects may represent novel targets for precision prevention strategies of clinical relevance to be verified in future studies.

Double- and triple-duty actions in childhood for addressing the global syndemic of obesity, undernutrition, and climate change: A scoping review

Obesity, undernutrition, and climate change constitute a global syndemic that disproportionately affects vulnerable populations, including children. Double- and triple-duty actions that simultaneously address these pandemics are needed to prevent further health, economic, and environmental consequences. Evidence describing the implementation and evaluation of such actions is lacking. This review summarized the literature on whole-of-population actions targeting children that were designed or adapted to be double or triple duty. Six academic databases were searched (January 2015-March 2021) using terms related to 'children', 'intervention', 'nutrition', 'physical activity', and 'climate change'. Data were extracted from 43/15,475 studies, including six randomized controlled trials. Most (58%) described triple-duty actions targeting food systems in schools such as implementing guidelines for healthier and environmentally sustainable school meals programs, and 51% reported engaging community in the design, implementation, and/or evaluation of actions. Changes in dietary intake, diet composition, greenhouse gas emissions, and food waste were the most frequently reported outcomes and 21 studies (three randomized controlled trials) showed positive double- or triple-duty effects. This review is the first to demonstrate that double- and triple-duty actions for addressing the global syndemic in childhood have been implemented and can have a positive impact on obesity, undernutrition, and climate change.

The Effect of Tailored Short Message Service (SMS) on Physical Activity: Results from a Three-Component Randomized Controlled Lifestyle Intervention in Women with PCOS

This analysis of secondary outcome measures of a randomized controlled trial was conducted to study the effect of a one-year three-component (cognitive behavioural therapy, diet, exercise) lifestyle intervention (LSI), with or without additional Short Message Service (SMS) support, on physical activity and aerobic capacity in overweight or obese women with polycystic ovary syndrome (PCOS). Women diagnosed with PCOS and a BMI > 25 kg/m² were randomly assigned to LSI with SMS support (SMS+, n = 60), LSI without SMS support (SMS-, n = 63) or care as usual (CAU, n = 60) in order to lose weight. Based on results from the International Physical Activity Questionnaire (IPAQ), we found a significant within-group increase after one year for SMS+ in the high physical activity category (+31%, p < 0.01) and sitting behaviour decreased (Δ -871 min/week, p < 0.01). Moreover, the peak cycle ergometer workload increased within SMS+ (Δ +10 watts, p < 0.01). The SMS+ group also demonstrated a significantly different increase in walking metabolic equivalent of task minutes (METmin)/week compared with CAU after one year (Δ 1106 METmin/week, p < 0.05). Apart from this increase in walking activity, no other between-group differences were found in this trial. Overall, based on within-group results, SMS support seemed to help with improving physical activity and aerobic capacity and decreasing sedentary behaviour.

Food-Evoked Emotions and Optimal Portion Sizes of Meat and Vegetables for Men and Women across Five Familiar Dutch Meals: An Online Study

Portion size manipulation is well known to be effective in increasing vegetable intake in adults, whereas less is known about the effects of portion size manipulation on reducing meat intake. This online study investigated the effects of recommended and regularly consumed portion sizes of vegetables and meat in five familiar Dutch meals. Participants evaluated 60 food pictures of five meals and used a 100 mm VAS to measure expected liking, satiety, food-evoked emotions, and the perceived normal portion size. The results show that both regular and recommended portions scored above 55 on the 100 mm VAS on expected liking and satiety. Similarly, both portion sizes scored high (55–70 on the 100 mm VAS) in positive emotions (i.e., happy, relaxed, and satisfied). Regarding the perceived amount of meat, men consistently preferred larger portions of meat than women. However, the optimal portion sizes of vegetables were similar for men and women. Furthermore, the recommended portion sizes led to positive food-evoked emotions, implying that the effective implementation of portion size strategies for increasing vegetable and limiting meat intake requires a careful, holistic approach focusing on the sensory characteristics of food products as well as the emotions evoked by the total food experience.

Nutritional impact of excluding red meat from the Canadian diet

The objective of the study was to examine differences in nutrient intake between consumers and non-consumers of red meat and to assess nutritional adequacy of consumers relative to Recommended Daily Allowance (RDA) in Canada. Matching estimators were used to identify differences in nutrient intake between the two groups. Statistically significant differences were observed in nutrient intake between red meat consumers and non-consumers, including lower daily intake of protein, riboflavin, niacin, vitamin D, and zinc and a higher daily intake of dietary fiber, folate, and magnesium among Canadians who did not consume red meat. Further, red meat consumers and non-consumers had nutrient intakes below RDA for dietary energy, fiber, and calcium. While individuals who did not consume red meat were at increased risk of calcium, vitamin D, energy, and potassium inadequacy, those who consumed red meat were at increased risk of dietary fiber, vitamin A, and magnesium inadequacy.

Comparison of Four Dietary Pattern Indices in Australian Baby Boomers: Findings from the Busselton Healthy Ageing Study

The assessment of dietary patterns comprehensively represents the totality of the diet, an important risk factor for many chronic diseases. This study aimed to characterise and compare four dietary pattern indices in middle-aged Australian adults. In 3458 participants (55% female) from the Busselton Healthy Ageing Study (Phase Two), a validated food frequency questionnaire was used to capture dietary data between 2016 and 2022. Four dietary patterns [Australian Dietary Guideline Index 2013 (DGI-2013); the Mediterranean Diet Index (MedDiet); the Literature-based Mediterranean Diet Index (Lit-MedDiet); and the EAT-Lancet Index], were calculated and compared by measuring total and sub-component scores, and concordance (𝜌c). Cross-sectional associations between the dietary indices and demographic, lifestyle, and medical conditions were modelled with linear regression and restricted cubic splines. Participants had the highest standardised scores for the DGI-2013 followed by the EAT-Lancet Index and the MedDiet, with the lowest standardised scores observed for the Lit-MedDiet. The DGI-2013 had the lowest agreement with the other scores (𝜌c ≤ 0.47). These findings indicate that the diets included in this Australian cohort align more closely with the Australian Dietary Guidelines than with the other international dietary patterns, likely due to the wide variation of individual food group weightings in the construction of these indices.

The Alignment of Recommendations of Dietary Guidelines with Sustainability Aspects: Lessons Learned from Italy's Example and Proposals for Future Development

The main objective of this paper is to describe the process of the inclusion of sustainability in the Italian Dietary Guidelines (IDGs). In the IDGs' sustainability chapter, particular emphasis was put on the selection of foods, recommending a plant-based diet with a large quota of vegetable proteins. Advice was also given on the selection of local seasonal products, with low growth input, such as fertilizers, artificial light and heating. Reduction of animal food was recommended, to be substituted with lower impact foods (poultry, milk, eggs and Mediterranean fish including aquaculture). Food waste was largely addressed. Recommendations were made for food purchase planning, food storage and the reuse of leftovers as strategies to reduce waste and save money. The IDGs sustainability recommendations were related to the 16 guiding principles of a sustainable healthy diet and their contribution to the achievement of the Sustainable Developing Goals was provided. The inclusion of sustainability in dietary guidelines requires a multidisciplinary approach to cover the wide range of aspects of a sustainable diet. In the IDGs, it was possible to show that practical recommendations for improving sustainability behavior can be passed on to consumers. Methodological aspects for developing recommendations are not definitive.

Pregnancy Outcomes in Women with PCOS: Follow-Up Study of a Randomized Controlled Three-Component Lifestyle Intervention

Women with polycystic ovary syndrome (PCOS) and excess weight often present with reproductive derangements. The first-line treatment for this population is a multi-component lifestyle intervention. This follow-up study of a randomized controlled trial based on data from the Dutch Perinatal registry was conducted to study the effect of a one-year three-component (cognitive behavioral therapy, healthy diet, and exercise) lifestyle intervention on pregnancy outcomes in women with PCOS and overweight or obesity. Women diagnosed with PCOS, a BMI ≥ 25 kg/m², and a wish to conceive were randomized to either three-component lifestyle intervention (LSI, n = 123), and care as usual (CAU, n = 60) where they were encouraged to lose weight autonomously. Conception resulting in live birth was 39.8% (49/123) within LSI and 38.3% (23/60) within CAU (p = 0.845). In total, 58.3% conceived spontaneously. Gestational diabetes (LSI: 8.2% vs. CAU: 21.7%, p = 0.133), hypertensive disorders (LSI: 8.2% vs. CAU 13.0%, p = 0.673), and preterm birth (LSI: 12.2% vs. CAU: 17.4%, p = 0.716) rates were all lower in LSI compared to CAU. This follow-up study showed no significant differences in conception resulting in live birth rates between LSI and CAU. Nonetheless, a large proportion eventually conceived spontaneously. Moreover, after LSI, the number of uneventful pregnancies was lower compared to care as usual.

Effect of increasing plant protein intake on protein quality and nutrient intake of US adults

Three cycles of NHANES (2013-2018) were used to assess protein intake, protein quality (protein digestibility-corrected amino acid score; PDCAAS), protein cost, and nutrient intakes across quartiles of plant protein intake (Q1: <28.2%; Q2: 28.2% to <32.1%; Q3: 32.1 to <36.2%; Q4: ≥36.2%) over a 24 h period (≥19 years, n = 14 888). Grains represented the primary source of plant protein across quartiles and increased from 5.01% (Q1) to 13.5% (Q4). Across all the USDA's Food and Nutrient Database for Dietary Studies (FNDDS) food groups, grains were the most economical source of protein (24.3-26 g protein/$1). Legumes were the most economical plant-based protein (28-37.7 g protein/$1) within the "Protein Foods" FNDDS group. Absolute protein intake (96.6 g/day) and PDCAAS (0.91) of diets were progressively lower from Q1 to 72.0 g/day and 0.8 in Q4, respectively. Modelling the replacement of 50% of amino acids from grains in the diet with amino acids from legumes increased the PDCAAS by 10% in Q4. Intake levels of fibre, folate, iron, and zinc, were higher in Q2-Q4 compared to Q1 but had lower intakes of vitamins B12 and D. Amino acid complementation is required to effectively integrate higher levels plant protein into US diets.

Exploring culturally acceptable, nutritious, affordable and low climatic impact diet for Japanese diets: proof of concept of applying a new modelling approach using data envelopment analysis

A future sustainable dietary pattern for Japanese is yet undefined. This study aimed to explore more sustainable Japanese diets that are nutritious, affordable and with low greenhouse gas emissions (GHGE) and particular emphasis on cultural acceptability. A newly developed data envelopment analysis (DEA) diet model was applied to 4-d dietary record data among 184 healthy Japanese men and 185 women volunteers aged 21-69 years. Alternative diets were calculated as the linear combinations of observed diets. Firstly, for each individual, four modelled diets were calculated that maximised cultural acceptability (i.e. minimise dietary change from observed diet), maximised nutritional quality assessed by the Nutrient-Rich Food Index (NRF), minimised monetary diet costs or minimised diet-related GHGE. The final modelled diet combined all four indicators. In the first four models, the largest improvement was obtained for each targeted indicator separately, while relatively small improvements or unwanted changes were observed for other indicator. When all indicators were aimed to optimise, the NRF score and diet-related GHGE were improved by 8-13 % with the lower monetary cost than observed diets, although the percentage improvement was a bit smaller than the separate models. The final modelled diets demanded increased intakes for whole grains, fruits, milk/cream/yogurt, legumes/nuts, and decreased intakes for red and processed meat, sugar/confectioneries, alcoholic and sweetened beverages, and seasonings in both sexes. In conclusion, more sustainable dietary patterns considering several indicators are possible for Japanese, while total improvement is moderate due to trade-offs between indicators and methodological limitation of DEA diet model.

Incorporating environmental and sustainability considerations into health technology assessment and clinical and public health guidelines: a scoping review

Healthcare systems account for a substantial proportion of global carbon emissions and contribute to wider environmental degradation. This scoping review aimed to summarize the evidence currently available on incorporation of environmental and sustainability considerations into health technology assessments (HTAs) and guidelines to support the National In stitute for Health and Care Excellence and analogous bodies in other jurisdictions developing theirown methods and processes. Overall, 7,653 articles were identified, of which 24 were included in this review and split into three key areas - HTA (10 studies), healthcare guidelines (4 studies), and food and dietary guidelines (10 studies). Methodological reviews discussed the pros and cons of different approaches to integrate environmental considerations into HTAs, including adjustments to conventional cost-utility analysis (CUA), cost-benefit analysis, and multicriteria decision analysis. The case studies illustrated the challenges of putting this into practice, such as lack of disaggregated data to evaluate the impact of single technologies and difficulty in conducting thorough life cycle assessments that consider the full environmental effects. Evidence was scant on the incorporation of environmental impacts in clinical practice and public health guidelines. Food and dietary guidelines used adapted CUA based on life cycle assessments, simulation modeling, and qualitative judgments made by expert panels. There is uncertainty on how HTA and guideline committees will handle trade-offs between health and environment, especially when balancing environmental harms that fall largely on society with health benefits for individuals. Further research is warranted to enable integration of environmental considerations into HTA and clinical and public health guidelines.

Recognizing the importance of protein quality in an era of food systems transformation

A transformation of current food systems is needed to nourish the growing global population in more sustainable ways. To support this, some are advocating for a shift to plant-based or -exclusive diets. These recommendations – typically borne out of concerns for the environment – often fail to account for unintended nutritional consequences, which could be particularly pronounced for protein intake. While there is enough protein to meet current global needs, the issue of protein quality is often overlooked and oversimplified. High-quality protein, including from animal source foods (ASF), is needed to meet nutritional demands in low- and middle-income countries (LMIC), particularly among vulnerable population groups. In high-income countries (HIC), protein quality is important for at-risk populations who have higher protein requirements and lower energy and/or protein intakes. Further, as the global population increases, driven primarily by population growth in LMIC, it is possible that protein production will need to increase in HIC to support exports to help feed the global population. The global dialogue and resulting dietary recommendations must therefore become more nuanced to consider the interaction between nutritional value and environmental impact to help better reflect trade-offs across multiple domains of sustainability. Nutritional life cycle assessments are one way to help accomplish this nuance and evaluate how all types of food production systems should be refocused to improve their environmental efficiency and nutritional impact.

A comparative analysis of sustainability of the usual food intakes of the Iranian population, Iranian food-based dietary guidelines, and optimized dietary models

Promoting sustainable diets might contribute toward achieving sustainable development goals. Considering the importance of national food-based dietary guidelines (FBDGs), this study aimed to assess and compare the sustainability dimensions of the usual Iranian dietary intakes with sustainable optimal diets based on Iranian (2006 and 2015 versions), Mediterranean, and vegetarian FBDGs. The usual dietary intakes of Iranian households were estimated using household expenditure survey data. Diet sustainability, including environmental (water, carbon, and land) footprints, cost, and nutrient-rich food (NRF) index, was calculated for the usual diet and compared with those of different FBDGs. Using linear and goal programming, optimal food models were calculated by minimizing environmental footprints and cost and maximizing NRF simultaneously for each FBDG, while maintaining nutritional considerations recommended by the FBDGs. Replacing the usual dietary intake of Iranians with the optimal diet based on the 2016 Iranian FBDG was associated with reductions equal to 20.9% for water footprint, 22.48% for carbon footprint, 20.39% for land footprint, 31.83% for cost, and 7.64% increase in NRF index. The optimal model based on the 2016 Iran FBDG was 10% more sustainable compared with the 2005 version. Changing the usual consumption of Iranians to the optimal model based on the Mediterranean pyramid was accompanied by the highest NRF index, lower environmental footprints, and cost compared to other models. The recent Iranian FBDG, compared with the older one, was more sustainable. Considering the dimensions of a sustainable diet for future FBDG revisions is recommended.