Cost-Effectiveness of a New Nordic Diet as a Strategy for Health Promotion

Environmental assessment of diets: overview and guidance on indicator choice

Comprehensive but interpretable assessment of the environmental performance of diets involves choosing a set of appropriate indicators. Current knowledge and data gaps on the origin of dietary foodstuffs restrict use of indicators relying on site-specific information. This Personal View summarises commonly used indicators for assessing the environmental performance of diets, briefly outlines their benefits and drawbacks, and provides recommendations on indicator choices for actors across multiple fields involved in activities that include the environmental assessment of diets. We then provide recommendations on indicator choices for actors across multiple fields involved in activities that use environmental assessments, such as health and nutrition experts, policy makers, decision makers, and private-sector and public-sector sustainability officers. We recommend that environmental assessment of diets should include indicators for at least the five following areas: climate change, biosphere integrity, blue water consumption, novel entities, and impacts on natural resources (especially wild fish stocks), to capture important environmental trade-offs. If more indicators can be handled in the assessment, indicators to capture impacts related to land use quantity and quality and green water consumption should be used. For ambitious assessments, indicators related to biogeochemical flows, stratospheric ozone depletion, and energy use can be added.

Measurement of diets that are healthy, environmentally sustainable, affordable, and equitable: A scoping review of metrics, findings, and research gaps

Introduction

Research on the impacts of dietary patterns on human and planetary health is a rapidly growing field. A wide range of metrics, datasets, and analytical techniques has been used to explore the role of dietary choices/constraints in driving greenhouse gas (GHG) emissions, environmental degradation, health and disease outcomes, and the affordability of food baskets. Many argue that each domain is important, but few have tackled all simultaneously in analyzing diet-outcome relationships.

Methods

This paper reviews studies published between January 2015 and December 2021 (inclusive) that examined dietary patterns in relation to at least two of the following four thematic pillars: (i) planetary health, including, climate change, environmental quality, and natural resource impacts, (ii) human health and disease, (iii) economic outcomes, including diet cost/affordability, and (iv) social outcomes, e.g., wages, working conditions, and culturally relevant diets. We systematically screened 2,425 publications by title and abstract and included data from 42 eligible publications in this review.

Results

Most dietary patterns used were statistically estimated or simulated rather than observed. A rising number of studies consider the cost/affordability of dietary scenarios in relation to optimized environmental and health outcomes. However, only six publications incorporate social sustainability outcomes, which represents an under-explored dimension of food system concerns.

Discussion

This review suggests a need for (i) transparency and clarity in datasets used and analytical methods; (ii) explicit integration of indicators and metrics linking social and economic issues to the commonly assessed diet-climate-planetary ecology relationships; (iii) inclusion of data and researchers from low- and middle-income countries; (iv) inclusion of processed food products to reflect the reality of consumer choices globally; and (v) attention to the implications of findings for policymakers. Better understanding is urgently needed on dietary impacts on all relevant human and planetary domains simultaneously.

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.

High impact health service interventions for attainment of UHC in Africa: A systematic review

African countries have prioritized the attainment of targets relating to Universal Health Coverage (UHC), Health Security (HSE) and Coverage of Health Determinants (CHD)to attain their health goals. Given resource constraints, it is important to prioritize implementation of health service interventions with the highest impact. This is important to be identified across age cohorts and public health functions of health promotion, disease prevention, diagnostics, curative, rehabilitative and palliative interventions. We therefore explored the published evidence on the effectiveness of existing health service interventions addressing the diseases and conditions of concern in the Africa Region, for each age cohort and the public health functions. Six public health and economic evaluation databases, reports and grey literature were searched. A total of 151 studies and 357 interventions were identified across different health program areas, public health functions and age cohorts. Of the studies, most were carried out in the African region (43.5%), on communicable diseases (50.6%), and non-communicable diseases (36.4%). Majority of interventions are domiciled in the health promotion, disease prevention and curative functions, covering all age cohorts though the elderly cohort was least represented. Neonatal and communicable conditions dominated disease burden in the early years of life and non-communicable conditions in the later years. A menu of health interventions that are most effective at averting disease and conditions of concern across life course in the African region is therefore consolidated. These represent a comprehensive evidence-based set of interventions for prioritization by decision makers to attain desired health goals. At a country level, we also identify principles for identifying priority interventions, being the targeting of higher implementation coverage of existing interventions, combining interventions across all the public health functions-not focusing on a few functions, provision of subsidies or free interventions and prioritizing early identification of high-risk populations and communities represent these principles.

Adoption of healthy and sustainable diets in Mexico does not imply higher expenditure on food

The relative cost of healthy and sustainable diets is key for their adoption in different countries. Using a newly developed modelling tool that generates different diet baskets, we compared the costs of diets following the EAT-Lancet healthy reference diet, the Mexican dietary guidelines and locals' current food intake. On average, the cost of the EAT-Lancet healthy reference diet baskets was 21% lower than that of the Mexican dietary guidelines baskets, and 40% lower than that of the current intake baskets (29% lower if the comparison was isocaloric). Findings were similar over time (2011-2018) and by geographic region. The higher cost associated with the larger amount of fruits, vegetables, legumes and nuts in healthy and sustainable diets was surpassed by the savings associated with their lower amount of animal protein sources, sugar-sweetened beverages and discretionary foods. We conclude that transitioning to better diets in Mexico is possible without a higher expenditure on food.

Food Safety Implications of Transitions Toward Sustainable Healthy Diets

Despite increased political attention, foodborne diseases still cause a substantial public health, economic, and social burden worldwide. Children younger than 5 years, people living in developing regions, and in the poorest areas of the world are disproportionally affected, bearing a large proportion of the global burden of foodborne disease. Yet, food safety is a prerequisite to ensuring food security globally: Foods that are responsible for important food safety problems are also crucial to ensure food security in some regions and are essential sources of nutrition. Moreover, together with calls for action to meeting international sustainable development goals, global efforts to promote food security and healthy diets have now highlighted the need to modify food systems globally. This article therefore explores the food safety dimensions of transitions toward food systems that promote sustainable healthy diets. The current body of evidence points to the combined health and environmental benefits of shifting toward a more plant-based diet, including vegetables and fruits, nuts, pulses, and whole grains. As a shift toward more plant-based diets may also lead to higher exposures to chemicals or pathogens present in these foods, an evaluation of food safety implications of such transitions is now imperative. We conclude that several synergies between public health, environmental, and food safety strategies can be identified to support dietary transitions.

Measures and metrics of sustainable diets with a focus on milk, yogurt, and dairy products

The 4 domains of sustainable diets are nutrition, economics, society, and the environment. To be sustainable, foods and food patterns need to be nutrient-rich, affordable, culturally acceptable, and sparing of natural resources and the environment. Each sustainability domain has its own measures and metrics. Nutrient density of foods has been assessed through nutrient profiling models, such as the Nutrient-Rich Foods family of scores. The Food Affordability Index, applied to different food groups, has measured both calories and nutrients per penny (kcal/$). Cultural acceptance measures have been based on relative food consumption frequencies across population groups. Environmental impact of individual foods and composite food patterns has been measured in terms of land, water, and energy use. Greenhouse gas emissions assess the carbon footprint of agricultural food production, processing, and retail. Based on multiple sustainability metrics, milk, yogurt, and other dairy products can be described as nutrient-rich, affordable, acceptable, and appealing. The environmental impact of dairy farming needs to be weighed against the high nutrient density of milk, yogurt, and cheese as compared with some plant-based alternatives.

Integrating nutrient bioavailability and co-production links when identifying sustainable diets: How low should we reduce meat consumption?

Background

Reducing the consumption of meat and other animal-based products is widely advocated to improve the sustainability of diets in high-income countries. However, such reduction may impair nutritional adequacy, since the bioavailability of key nutrients is higher when they come from animal- vs plant-based foods. Meat reduction may also affect the balance between foods co-produced within the same animal production system.

Objective

The objective was to assess the impact of introducing nutrient bioavailability and co-production links considerations on the dietary changes needed − especially regarding meat ‒ to improve diet sustainability.

Methods

Diet optimization with linear and non-linear programming was used to design, for each gender, three modeled diets departing the least from the mean observed French diet (OBS) while reducing by at least 30% the diet-related environmental impacts (greenhouse gas emissions, eutrophication, acidification): i) in the nutrition-environment (NE) model, the fulfillment of recommended dietary allowances for all nutrients was imposed; ii) in the NE-bioavailability (NEB) model, nutritional adequacy was further ensured by accounting for iron, zinc, protein and provitamin A bioavailability; iii) in the NEB-co-production (NEB-CP) model, two links between co-produced animal foods (milk–beef and blood sausage–pork) were additionally included into the models by proportionally co-constraining their respective quantities. The price and environmental impacts of individual foods were assumed to be constant.

Results

‘Fruit and vegetables’ and ‘Starches’ quantities increased in all modeled diets compared to OBS. In parallel, total meat and ruminant meat quantities decreased. Starting from 110g/d women’s OBS diet (168g/d for men), total meat quantity decreased by 78%, 67% and 32% for women (68%, 66% and 62% for men) in NE, NEB and NEB-CP diets, respectively. Starting from 36g/d women’s OBS diet (54g/d for men), ruminant meat quantity dropped severely by 84% and 87% in NE and NEB diets for women (80% and 78% for men), whereas it only decreased by 27% in NEB-CP diets (38% for men). The share of energy and proteins of animal origin was similar for the 3 modeled diets (approximately 1/5 of total energy, and 1/2 of protein) and lower than in OBS diet (approximately 1/3 of total energy, and 2/3 of protein).

Conclusions

Decreasing meat content was strictly needed to achieve more sustainable diets for French adults, but the reduction was less severe when nutrient bioavailability and co-production links were taken into account.

Modelling the cost differential between healthy and current diets: the New Zealand case study

Background

Evidence on whether healthy diets are more expensive than current diets is mixed due to lack of robust methodology. The aim of this study was to develop a novel methodology to model the cost differential between healthy and current diets and apply it in New Zealand.

Methods

Prices of common foods were collected from 15 supermarkets, 15 fruit/vegetable stores and from the Food Price Index. The distribution of the cost of two-weekly healthy and current household diets was modelled using a list of commonly consumed foods, a set of min and max quantity/serves constraints for each, and food group and nutrient intakes based on dietary guidelines (healthy diets) or nutrition survey data (current diets). The cost differential between healthy and current diets was modelled for several diet, prices and policy scenarios. Acceptability of resulting meal plans was validated.

Results

The average cost of healthy household diets was $27 more expensive than the average cost of current diets, but 25.8% of healthy diets were cheaper than the average cost of current diets. This cost differential could be reduced if fruits and vegetables became exempt from Goods and Services Tax. Healthy diets were cheaper with an allowance for discretionary foods and more expensive when including takeaway meals. For Māori and Pacific households, healthy diets were on average $40 and $60 cheaper than current diets due to large energy intakes. Discretionary foods and takeaway meals contributed 30-40% to the average cost of current diets.

Conclusion

Healthy New Zealand diets were on average more expensive than current diets, but one-quarter of healthy diets were cheaper than the average cost of current diets. The impact of diet composition, types of prices and policies on the cost differential was substantial. The methodology can be used in other countries to monitor the cost differential between healthy and current household diets.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0648-6) contains supplementary material, which is available to authorized users.

How to Obtain Forty Percent Less Environmental Impact by Healthy, Protein-Optimized Snacks for Older Adults

It is well known that meals containing less meat are more sustainable, but little is known about snack-meals, which typically do not contain meat. This study investigates the diversity in environmental impacts associated with snack production based on 20 common recipes optimized for protein content, energy content and sensory aspects for older adults. The purpose is to improve sustainability of public procurement by serving more sustainable snack-meals. Public procurement serves Danish older adults over millions of snack-meals every year, and millions more are served in countries with a similar social service. The environmental impact of snack production was estimated by consequential life cycle assessment. The average impact of producing the 10 least environmentally harmful snacks was 40% less than the average impact of producing the 10 most harmful snacks. This is true whether the functional unit was mass, energy, or protein content, and whether the environmental impact was measured as global warming potential or the monetized value of 16 impact categories. We conclude that large-scale public procurement of snack-meals by private and municipal kitchens can be reduced by up to 40% if the kitchens evaluate the environmental impact of all their snacks and serve the better half more frequently.