Territorial and Sustainable Healthy Diets

Sustainable and Healthy Diets Supplement Territorial and Sustainable Healthy Diets Fatima Hachem, PhD 1 , Davy Vanham, PhD 2 and Luis A. Moreno, PhD 3,4 Abstract The rapid changes that societies have gone through in the last few decades have led to the increase in the prevalence of malnutrition in all its forms and to the degradation of natural resources and the environment. The change in the dietary habits and production systems are responsible for much of this change. Some territorial diets have been shown as potentially capable of reversing these trends by positively contributing to the health of people and the environment such as the Mediterranean Diet and the New Nordic Diet. In this paper, we review the contribution of these 2 diets to health and nutrition and to environmental, sociocultural, and economic sustainability proposing pertinent indicators. Learning from a culturally established diet and a constructed one, tradeoff could be reached to ensure better health and sustainability outcomes. Strong factors for achieving this goal lie in building on the sociocultural appropriation of diets, having the proper tools and indicators, investing in cross-sector collaboration and policy coherence, and having the necessary political support to push the agenda of sustainability forward. Keywords Mediterranean diet, New Nordic diet, sustainable healthy diets, environmentally sustainable diets, territorial diets Introduction One of the major challenges of our times is malnutrition in all its forms (undernutrition, micronutrients deficiencies, and overweight and obesity). The latest available numbers of the malnourished show the extent of this challenge: 821 million people have hunger, 2 billion people have micronutrient deficiencies; and over 2 billion persons are overweight or obese. 1 While the underlying causes of malnutrition are complex and multifaceted, diets remain one of its major direct causes. Recent research also shows that unhealthy diets top the list of the main risk factors for the global burden of disease. 2 On the other hand, what we eat influences to a large extent what and how we produce, procure, distribute, and dispose of food and impacts the natural resources used along such processes. At the global level, food production accounts for the use of 48%and 70%of land and fresh water resources, respectively. 3 Research also shows that different types of diets contribute to greenhouse gas emissions differently. 4 1 Food and Agriculture Organization of the United Nations, Rome, Italy 2 European Commission, Joint Research Centre (JRC), Ispra, Italy 3 Universidad de Zaragoza, Zaragoza, Spain 4 Centro de Investigaci´ on Biom´ edica en Red de Fisiopatolog´ ıa de la Obesidad y Nutrici´ on (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain Corresponding Author: Fatima Hachem, Nutrition and Food Systems Division (ESN), Food and Agriculture Organization of the United Nations (FAO), Viale delle Terme di Caracalla, Rome 00153, Italy. Email: [email protected] Food and Nutrition Bulletin 2020, Vol. 41(2S) S87-S103 ªFAO 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0379572120976253 journals.sagepub.com/home/fnb Facing such challenges, healthy diets that can play a role in addressing both malnutrition and environmental concerns while being anchored in economic and sociocultural contexts that privilege their uptake by the concerned populations, are of great relevance to global and national agendas related to sustainability. The Second International Conference on Nutrition 5 showed that food systems are responsible for not delivering healthy diets and a global call for their transformation was launched. In this paper, we argue that some territorial diets (sometimes called regional) can be a catalyst in this transformative process by playing an active role in shifting consumption and production in a way that strikes a balance between health and nutrition and the different dimensions of sustainability, that is, environmental, economic, and cultural. Two such diets, the Mediterranean Diet (MD) and the New Nordic Diet (NND), are becoming increasingly interesting for this catalytic role, especially within the context of Sustainable Development Goals (SDGs). The Mediterranean Diet The MD is a territorial diet that has its roots entrenched in the history of the Mediterranean Sea and its region that was for centuries a meeting point and melting pot for different cultures and civilization; each conferring some of its specificities to the evolving diet of the region. It became known as a healthy diet in the early 1960s as a result of the work of Ancel Keys who showed the protective effects of the diets eaten in Southern Europe against coronary heart disease. 6 The traditional MD was defined originally as a diet with high consumption of whole cereals, legumes, vegetables, fruits, nuts and olive oil, a low to mild consumption of dairy products, and a low consumption of meat and poultry. 7 In 2010, UNESCO added the MD to its list of intangible cultural heritage of humanity, not only because of its nutritional attributes but also because of it being a way of life that encompasses “a set of skills, knowledge, practices and traditions from landscape to table, including crops, harvesting, fishing, conservation, processing, preparation and, in particular, food consumption.” 8 These additional dimensions have a value of their own and are also proving to be important for health and nutrition outcomes. Today, research points to how commensality supports healthy food habits and reduces the risk of overweight and obesity, especially among children. 9,10 Despite its constancy over time and space, the MD was shaped by the specificities of its local contexts and manifested itself in different local versions reflecting the diversity of local food systems and cultural contexts across countries while preserving the main characteristics of the traditional MD. New Nordic Diet The NND is a new constructed diet built with strong anchorage onto the Nordic food traditions to positively contributing to both health and the environment. It was launched in 2004 by a group of reputable chefs from the Nordic region who embarked on rediscovering local produce. 11 It is characterized by a high content of local fruits and vegetables (especially berries, cabbages, root vegetables, and legumes), fresh herbs, potatoes, plants and mushrooms, whole grains, nuts (native), fish and shellfish, seaweed, free-range livestock (including pigs and poultry), and game. 12 It comprises foods traditionally sourced in the Nordic countries and focuses on those from the wild countryside and from the sea and lakes. The NND knew a fast-paced diffusion in the Nordic region possibly because it was conceived as an identity movement. However, the support it received from the Nordic Council of Minsters 13 because it was seen as an opportunity for Nordic cooperation and as a new source of shared Nordic identity 11 contributed to its wide-spread uptake by the public. The Nordic food culture was purposefully promoted in national and global events by the Nordic diplomacy and policy makers. Local national versions of the NND emerged and were used in national media and political discourse. The valorization of the national food traditions in each of the Nordic countries helped in the cultural appropriation and in increasing the number of adapts to a label without a previous history in the culinary domain. The incorporation of concerns for environmental sustainability and planetary health in the NND has also contributed to the uptake of this new diet as a way of life. S88 Food and Nutrition Bulletin 41(2S) Health Benefits of Selected Territorial Diets The Mediterranean Diet The literature on the relationship between the MD and positive health outcomes is abundant. Adherence to the MD has been associated with a significant reduction in total mortality, mortality form cardiovascular disease (CVD) and cancer, and with cancer-risk lowering potential. 7,14-16 A recent review 6 has confirmed the favorable influences of the MD on the risk for metabolic syndrome, obesity, type 2 diabetes mellitus, cancer, and neurodegenerative diseases. In 2017, a meta-analysis of observational studies in relation to CVD showed a 27%lower risk of CVD incidence when comparing high to low MD adherence categories; the results showed that the MD reduced the risk of CVD incidence by 45%. 17 On the other hand, for CVD mortality, a 25% lower risk was found when comparing high versus low adherence to the MD pattern as well as 41%decreased risk of CVD mortality. The MD is believed to have favorable effect in reducing blood pressure in hypertensive or healthy individuals; however, there is not enough information to estimate the strength of the observed effect, and therefore, more studies are necessary in this regard. 18 Evidence however exists that people who adhere to the MD have lower incidence of cancer. Except for pancreatic cancer, all other cancers of the digestive tract showed significantly reduced incidence with the MD. 19 A recent systematic review on the effect of MD in relation to cognitive function 20 showed inconsistent results for cognitive function and brain morphology or connectivity. However, a significant and clinically relevant effect sizes were found for cognitive composites in the Prevenci´on con Dieta Mediterr´anea (PREDIMED) study. 21 Four studies assessing the association between MD and the risk of frailty were identified in a systematic review. Higher adherence to an MD was associated with significantly lower incident frailty risk than lower adherence. 22 Nonalcoholic fatty liver disease (NAFLD), 23 which has inflammation and oxidative stress as major risk factors, has been studied in relation to MD. With the MD being low in saturated fats, animal protein, high in antioxidants and fibers, and having an adequate omega-3 to omega-6 fatty acids balance, it has been suggested to be effective in NAFLD. Although the results from the available studies are encouraging, there is still need of trials with larger sample size. 24 A systematic review on the management and prevention of rheumatoid arthritis in human prospective studies reported improvement in the pain visual analogue scale and a decrease in the score for health assessment questionnaire for rheumatoid arthritis, in the MD groups. One study reported a reduction in the 28 joint count disease activity score for rheumatoid arthritis for the MD group. 25 In Spain, it was observed that a 10-point increase in the adherence to the Spanish Food Pyramid recommendations was associated with a 14%(odds ratio [OR] ¼0.86; 95%CI: 0.79-0.94) lower odds of obesity in men. The odds of abdominal obesity also decreased globally by 12% (OR ¼0.88; 95%CI: 0.84-0.93). 26 As was mentioned previously, different versions of the MD exist in the Mediterranean region at present. Researchers have used different indices to characterize the different MD patterns employing sometimes different food groups in each. In 28 studies included in 6 meta-analyses evaluating the relation between the MD dietary pattern and primary prevention of CVDs, some typical foods were identified. 27 Table 1 shows 10 such indices and their associated food groups. The 10 a priori indexes are tMed, 14 m-Med, 15 a-Med, 28 r-Med, 29 MAI, 30 MDS, 31 PREDIMED score, 32 score according to Bertoia, 33 Italian Mediterranean Index, 34 and score according to Yau and Hankey. 35 In children, the KIDMED index 36 was the most widely used score to assess adherence to the MD. 37 New Nordic Diet Evidence on the health benefits of the NND are less abundant than the MD. However, the dietary components of the NND benefit from a wellestablished and substantial evidence of healthpromoting properties. 12 Recent investigations into the associations between the local versions Hachem et al S89 Table 1. Selected Scores for Measuring the Adherence to the Mediterranean Diet and Their Corresponding Foods/Food Groups. Index Reference Cereals Whole grains M/S PþM/S Vegetables Olive oil Legumes Fruits Nuts Fish Meat Dairy Alcohol Wine Sugar sweetened beverages t-Med (Trichopoulou et al, 2003) þþþþþþþþ m-Med (Trichopoulou et al, 2005) þþþþþþ* a-Med (Fung et al, 2005) þþ þ þþþþ þ r-Med (Buckland et al, 2009) þþþþþþþþ MAI (Alberti-Fidanza et al, 1999) þþþþþþþ MDS (Panagiotakos et al, 2006) þþþþþþþ PREDIMED score (Schroder et al, 2011) þþþþþþ þ  Bertoia score (Bertoia et al, 2014) þþþ þþþþþ Italian Mediterranean index (Agnoli et al, 2011) þþþþþþþ Yau and Hankey score (Yau and Hankey, 2011) þþþþþþþþ  Abbreviations: MAI, Mediterranean Adequacy Index; MDS, Mediterranean Diet Score. S90 of the NND and health outcomes show an inverse relationship with several cardiovascular risk factors, 38 abdominal obesity, 39 body fat, 40 inflammatory markers and serum lipids, 41 colorectal cancer risk, 42 and total mortality. 43 Adherence to the NND has been shown to lower cause-specific mortality among Swedish women 44 and facilitate optimal gestational weight gain and fetal growth 45 in Norwegian women participating in the Mother and Child Cohort Study. Other studies have shown that adherence to a healthy Nordic food index was inversely associated with the risk of type 2 diabetes 46 and that NDD improves blood pressure, cholesterol, and triglycerides in comparison to a control diet. 47 Sustainability Interest in the relationship between diets and sustainability is not new. It goes back to the late 1980s when the case was made for the need to consider environmental concerns and the protection of natural resources in dietary guidelines. 48 This idea was revived in 2010 by FAO that gave a definition to sustainable diets as those diets with low environmental impacts which contribute to food and nutrition security and to healthy life for present and future generations. Sustainable diets are protective and respectful of biodiversity and ecosystems, culturally acceptable, accessible, economically fair and affordable; nutritionally adequate, safe and healthy; while optimizing natural and human resources. 49 An impetus has been given again to the importance of consumption in sustainability discussions following the Second International Conference on Nutrition 5 that highlighted the role of dietary consumption in the malfunctioning of our food systems. This recognition rose to a higher level with the adoption of the 2030 Sustainable Development agenda. While the FAO definition provided a holistic framework for analysis, where diets’ sustainability was considered in its contribution to health and nutrition, economic, and sociocultural aspects while preserving the environment, the lack of guiding principles for operationalizing the concept and the associated indicators needed for this to happen made using the concept very complicated, especially for countries. The following section will focus on the indicators to use in assessing the sustainability of diets, considering the 3 dimensions of sustainability: environmental, social, and economic. Relevant Indicators In order to assess the sustainability of diets, an indicator framework is necessary. Relevant indicators need to represent the whole system and identify trade-offs. In this respect, an internationally acknowledged indicator framework is the SDG indicator framework. The first global-scale analysis quantifying the performance of national food system of 156 countries, considered 7 dimensions of sustainability (nutrition, environment, food affordability and availability, sociocultural well-being, resilience, food safety, and waste) employing 25 sustainability indicators across different dimensions. 50 Recently, a workshop that brought together 23 international environmental footprint experts from 17 institutions defined an environmental footprint family relating to the planetary boundaries concept. As a result, a paper 51 was produced defining which footprint indicators are relevant for a footprint family (Figure 1) and clarifying the difference between pressure and impact indicators, as indicated by 2 other studies. 54,55 The former quantifies resource use and/or pollution, like carbon or water footprints (WF). The latter quantifies impact, such as water stress. 56 Environmental footprints are thus pressure indicators but can include in a second stage an impact assessment. Life cycle assessment (LCA) is generally impact-oriented, although it also has an inventory stage. In 2018, a study 57 conducted the first global assessment of the relation of the food system with 5 of these footprints (carbon, land, water, N, and P). Footprints have the advantage that they measure pressure along the whole supply chain, up to the consumer level. They can therefore be used to assess environmental sustainability of whole diets, not only products. To measure environmental and social sustainability, Tables 2 and 3 propose a list of relevant indicators within these 2 dimensions of Hachem et al S91 sustainability. Relevant indicators on economic sustainability include food affordability, poverty index, or income equality. 50 Such a list can be extended with many more indicators. But selection needs to occur on (1) relevance, (2) possibility of quantification/measurement, and (3) assessment of trade-offs between indicators. It is noted that only certain indicators are also SDG indicators, whereas some (in)directly relate to specific SDG indicators. Some of these indicators have already been included in national food-based dietary guidelines (FBDG) as in the revised FBDG of the Netherlands 63 and Flanders (Belgium), 64 which include indicators perceived as important by consumers and are easy to communicate like carbon and WFs and animal welfare. Sustainability Assessment of the MD and NND Sustainability of the MD. In general, the MD is associated with lower environmental pressures in relation to other healthy diets containing meat but not when compared to pescetarian or vegetarian diets. A study 65 assessed the WF related to food consumption in 13 Mediterranean cities, for the current diet and 3 diet scenarios (MD including meat, pescetarian, and vegetarian diets based on MD). An MD leads to WF reductions of 19%to 43% with respect to the current diet. A pescetarian and vegetarian diet scenarios lead to WF reductions of 28%to 52%and 30%to 53%, respectively. Both green and blue water components are included. For these components separately, consistent reductions are observed but are bigger for green as compared to blue water. For Ankara and Istanbul, the total WF of the MD (3090 liters per capita per day or l/cap/d) is significantly lower as compared to the diet recommended by national Turkish FBDG (4115 l/cap/d). Another study 66 quantified the WF related to food consumption in the EU South zone (Portugal, Spain, Italy, Slovenia, Croatia, Greece, Malta, Cyprus), for current diets and 3 diet scenarios (MD including meat and vegetarian diet based on MD). With respect to current diets, the Figure 1. A, Planetary boundaries (Steffen et al, 2015) 52 with indication relevance of environmental footprint indicators, as displayed in (Vanham et al, 2019) and (B) DPSIR (Driver-Pressure-State-Impact-Response) framework (OECD, 2003) 53 and its relationship with pressure and impact indicators, adapted from (Vanham et al, 2019). S92 Food and Nutrition Bulletin 41(2S) Table 2. Selected Indicators That Are Relevant to Measure the Environmental Sustainability of Diets/the Food System. a Indicator Relevance Listed in (Chaudhary et al, 2018) Listed in (Vanham et al, 2019)— only environmental sustainability Relevant for crops Relevant for livestock products Relevant for fisheries products (wild catch) Relevant for fisheries products (aquaculture) GHG emissions (carbon or GHG footprint) Climate change Yes Yes Yes Yes Yes (Parker et al, 2018) 58 Yes Water footprint Limited amount of water resources available Yes, only blue water footprint Yes, both blue and green water footprint Yes Yes Limited, generally water use for energy used along the supply chain (especially fuel) Yes, through pond evaporation (freshwater fish) and water for feed and energy (Pahlow et al, 2015) 59 Land footprint/ ecological footprint Limited amount of agricultural land, deforestation Yes Yes Yes Yes Limited, generally land use for energy used along the supply chain (especially fuel) Yes, through land for feed and energy Nitrogen footprint N pollution No Yes Yes Yes Limited, when biofuels are used as fuel Yes, through feed and energy Phosphorus footprint P as resource and pollution No Yes Yes Yes Limited, when biofuels are used as fuel Yes, through feed and energy Chemical footprint Chemical pollution, including from pesticides (insecticides and herbicides) No Yes Yes Yes No Yes Biodiversity footprint Biodiversity is a resource. Currently high rate of biodiversity loss (WWF, 2018) 60 Yes, as land use– induced biodiversity loss Yes, biodiversity is listed as biodiversity loss as impact Yes Yes Yes Yes Nonrenewable energy use Climate change Yes No, specific overlap with carbon footprint. Alternatively, total energy could be used as indicator Yes Yes Yes Yes Fisheries maximum sustainable yield, as, eg, measured by (STECF, 2018) 61 Overfishing of fish stocks and other aquatic animals stocks No No No No Yes No Ecosystem status Pressure on ecosystems, biodiversity loss Yes No Yes Yes Yes Yes a Selection based upon relevance and ability to quantify/measure. The relevance of each indicator for the production of crops, livestock products, wild fisheries, and aquaculture is given. S93 Table 3. Selected Indicators That Are Relevant to Measure the Social Sustainability of Diets/the Food System. a Indicator Relevance Listed in (Chaudhary et al, 2018) Relevant for crops Relevant for livestock products Relevant for fisheries products (wild catch) Relevant for fisheries products (aquaculture) Animal health and welfare An increasing number of consumers are sensitive to this issue Yes No Yes Potentially (only during catch). Also for bycatch (eg, dolphins, turtles, ...) Yes Use of antibiotics Overuse of antibiotics. Increase in antibiotic resistance (Jørgensen et al., 2018) 62 with great risk for public health No No Yes No Yes Candidates: Gender equity, extent of child labor, respect for community rights as described in (Chaudhary et al, 2018), food self-sufficiency; Global Slavery Index (GSI), a national-level indicator, as a proxy for modern slavery and labour abuses in fisheries (Tickler et al, 2018), ... a Selection based upon relevance and ability to quantify/measure. The relevance of each indicator for the production of crops, livestock products, wild fisheries and aquaculture is given. This list does not include nutrition indicators. S94 WF decreases by 30%for an MD and by 41% for a vegetarian diet, when green and blue WF are considered. For only the blue WF component, the reductions are 26%and 36%, respectively. A new assessment for 9 countries—Spain, France, Italy, Greece, Turkey, Egypt, Tunisia, Algeria, and Morocco—finds that the MD reduces the WF of the European countries and Turkey within the range of 18%to 35%. Within the Maghreb countries and Egypt, the MD WF is quite similar to current diets WF, but the proportions of food product groups differ. 67 A study 68 compared the WF of the MD with the American diet as recommended by the United States Department of Agriculture, with application to Spain and the USA. The American diet showed a 29%higher WF in comparison with the MD, regardless of products’ origin. The researchers used blue, green, and gray WF. A group of researchers 69 found that adherence to the MD in Spain would reduce greenhouse gas emissions (72%), land use (58%), energy consumption (52%), and to a lower extent water consumption (33%). The fish and seafood group was not considered in the water and land use footprints because it was assumed that all fish is wild catch. For the energy and carbon footprints, this food group was considered. Another study 70 estimated that the shift from a modern Italian diet to an MD would reduce the carbon footprint by 30%,the ecological footprint by 24%, and the WF by 18%. In the case of the Netherlands, a study 71 found that the MD has a 6%lower carbon footprint and 17%lower land footprint than the diet recommended by the 2006 Dutch Dietary Guidelines. Vegetarian and vegan diets, on the other hand, had lower environmental pressures than the MD. For Italy, and comparing to a healthy diet according to the national dietary guidelines, a study 72 showed that the energy and carbon footprints of the MD are 4%and 5%lower, respectively, than the recommended healthy diet. A vegetarian diet had carbon footprint 7%lower than the MD. Taking global warming potential and biodiversity loss scores as criteria, a study 73 found that a vegan diet fares better than an MD on both. Sustainability of the NND. In general, the NND is associated with lower environmental pressures and/or impacts in relation to other healthy diets containing meat but not when compared to pescetarian or vegetarian diets. A study 74 assessed the WF related to food consumption in 9 Nordic cities, for the current diet and 3 diet scenarios (NND including meat, pescetarian, and vegetarian diets). An NND leads to WF reductions of 9%to 24%with respect to the current diet. A pescetarian diet leads to WF reductions of 29%to 37%. A vegetarian diet leads to WF reductions of 36%to 44%. Both green and blue water components are included. In Denmark, a study 75 calculated the carbon footprint of 3 diets: the Average Danish Diet (ADD), a diet based on the Nordic Nutrition Recommendations (NNR), 76 and a diet based on the NND. All 3 diets were adjusted to contain a similar energy and protein content. For all scenarios, taking into account food transport or not (locally produced versus imported food), or taking into account a high fraction of organic agriculture in the NNR or not, the carbon footprint of the NND and NNR were lower than for the current Danish diet. Another study 77 evaluated the environmental impact of the ADD and NND, by means of 16 environmental impact categories (LCA) which were monetized to evaluate the overall socioeconomic effect of a shift from an ADD to an NND. Three features—composition, transport (rate of import), and type of production (conventional or organic, the latter being to a high level characteristic for the NND)—were separately investigated. When both diet composition and transport were taken into account, the NND reduced the environmental impact relative to the ADD measured by all 16 impact categories. Choosing the NND results in a cost saving of 32%of the overall environmental cost of 835 €/person/year associated with the ADD. This reduction is mainly driven by reduced meat consumption but higher quality meat consumption and less imported commodities from long distance. When the actual 8%content of organic produce in the ADD andthe 84%content of organic produce in the NND were also taken into account, the NND reduced the environmental impact relative to the ADD on only 10 of the 16 impact categories, whereas 6 increased. 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