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A Consensus Proposal for Nutritional Indicators to Assess the Sustainability of a Healthy Diet: The Mediterranean Diet as a Case Study



Background There is increasing evidence of the multiple effects of diets on public health nutrition, society, and environment. Sustainability and food security are closely interrelated. The traditional Mediterranean Diet (MD) is recognized as a healthier dietary pattern with a lower environmental impact. As a case study, the MD may guide innovative inter-sectorial efforts to counteract the degradation of ecosystems, loss of biodiversity, and homogeneity of diets due to globalization through the improvement of sustainable healthy dietary patterns. This consensus position paper defines a suite of the most appropriate nutrition and health indicators for assessing the sustainability of diets based on the MD. Methods In 2011, an informal International Working Group from different national and international institutions was convened. Through online and face-to-face brainstorming meetings over 4 years, a set of nutrition and health indicators for sustainability was identified and refined. Results Thirteen nutrition indicators of sustainability relating were identified in five areas. Biochemical characteristics of food (A1. Vegetable/animal protein consumption ratios; A2. Average dietary energy adequacy; A3. Dietary Energy Density Score; A4. Nutrient density of diet), Food Quality (A5. Fruit and vegetable consumption/intakes; A6. Dietary Diversity Score), Environment (A7. Food biodiversity composition and consumption; A8. Rate of Local/regional foods and seasonality; A9. Rate of eco-friendly food production and/or consumption), Lifestyle (A10. Physical activity/physical inactivity prevalence; A11. Adherence to the Mediterranean dietary pattern), Clinical Aspects (A12. Diet-related morbidity/mortality statistics; A13. Nutritional Anthropometry). A standardized set of information was provided for each indicator: definition, methodology, background, data sources, limitations of the indicator, and references. Conclusion The selection and analysis of these indicators has been performed (where possible) with specific reference to the MD. Sustainability of food systems is an urgent priority for governments and international organizations to address the serious socioeconomic and environmental implications of short-sighted and short-term practices for agricultural land and rural communities. These proposed nutrition indicators will be a useful methodological framework for designing health, education, and agricultural policies in order, not only to conserve the traditional diets of the Mediterranean area as a common cultural heritage and lifestyle but also to enhance the sustainability of diets in general.
August 2016 | Volume 3 | Article 371
published: 29 August 2016
doi: 10.3389/fnut.2016.00037
Frontiers in Nutrition |
Edited by:
Carola Strassner,
Münster University of Applied
Sciences, Germany
Reviewed by:
Youssef Aboussaleh,
Ibn Tofail University, Morocco
Susanne Gjedsted Bügel,
University of Copenhagen, Denmark
Adam Drewnowski,
University of Washington, USA
Lorenzo M. Donini
Specialty section:
This article was submitted to Nutrition
and Environmental Sustainability,
a section of the journal
Frontiers in Nutrition
Received: 22May2016
Accepted: 15August2016
Published: 29August2016
DoniniLM, DerniniS, LaironD,
Serra-MajemL, AmiotM-J,
delBalzoV, GiustiA-M,
BurlingameB, BelahsenR, MaianiG,
PolitoA, TurriniA, IntorreF,
TrichopoulouA and BerryME (2016)
A Consensus Proposal for Nutritional
Indicators to Assess the Sustainability
of a Healthy Diet: The Mediterranean
Diet as a Case Study.
Front. Nutr. 3:37.
doi: 10.3389/fnut.2016.00037
A Consensus Proposal for Nutritional
Indicators to Assess the
Sustainability of a Healthy Diet: The
Mediterranean Diet as a Case Study
Lorenzo M. Donini1,2*, Sandro Dernini2,3, Denis Lairon2,4, Lluis Serra-Majem2,5,
Marie-Josèphe Amiot2,4, Valeria del Balzo1,2, Anna-Maria Giusti1,2, Barbara Burlingame6,
Rekia Belahsen7, Giuseppe Maiani8, Angela Polito8, Aida Turrini8, Federica Intorre8,
Antonia Trichopoulou9 and M. Elliot Berry2,10
1 Sapienza University of Rome, Rome, Italy, 2 CIISCAM-International Inter-University Center for Mediterranean Food Culture
Studies, Rome, Italy, 3 Food and Agriculture Organization of the United Nations, Rome, Italy, 4 INRA 1260, INSERM 1062, Aix
Marseille University, Marseille, France, 5 CIBER OBN, Instituto de Salud Carlos III, University of Las Palmas de Gran Canaria,
Las Palmas, Spain, 6 Deakin University, Melbourne, Australia, 7 Chouaib Doukkali University, El Jadida, Morocco, 8 Council for
Agricultural Research and Economics-Research Center on Food and Nutrition (CRA-NUT, formerly INRAN), Rome, Italy,
9 Hellenic Health Foundation, Athens, Greece, 10 Braun School of Public Health, Hebrew University-Hadassah Medical
School, Jerusalem, Israel
Background: There is increasing evidence of the multiple effects of diets on public
health nutrition, society, and environment. Sustainability and food security are closely
interrelated. The traditional Mediterranean Diet (MD) is recognized as a healthier dietary
pattern with a lower environmental impact. As a case study, the MD may guide innovative
inter-sectorial efforts to counteract the degradation of ecosystems, loss of biodiversity,
and homogeneity of diets due to globalization through the improvement of sustainable
healthy dietary patterns. This consensus position paper denes a suite of the most
appropriate nutrition and health indicators for assessing the sustainability of diets based
on the MD.
Methods: In 2011, an informal International Working Group from different national and
international institutions was convened. Through online and face-to-face brainstorming
meetings over 4 years, a set of nutrition and health indicators for sustainability was
identied and rened.
Abbreviations: ADER, average dietary energy requirement; BMI, body mass index; CIHEAM, Centre International de Hautes
Etudes Agronomiques Méditerranéennes; CIISCAM, International Inter-University Studies Centre on Mediterranean food
culture; DALY, disability-adjusted life years; DDS, Dietary Diversity Score; DES, dietary energy supply; DGA, dietary guidelines
for Americans; DVS, Dietary Variety Score; EUROSTAT, statistical oce of the European Union; FAO, Food and Agriculture
Organization of the United Nations; FBDG, food-based dietary guidelines; FBS, food balance sheets; FFQ, Food Frequency
Questionnaire; GHG, green house gas; GPAQ, Global Physical Activity Questionnaire; HBS, Household Budget Surveys;
HDDS, Dietary Diversity Score at the household level; IDDS, Individual Dietary Diversity Score; IDS, Individual Dietary
Surveys; IFMED, International Foundation of Mediterranean diet; INRAN, Italian National Institute of Food and Nutrition;
IPAQ, International Physical Activity Questionnaire; JaNUS, just a nutritional screening; LIM, nutrients to be LIMited; MAR,
mean adequacy ratio; MDS, Mediterranean Diet Score; MED, Mediterranean diet; MER, mean excess ratio; MNA, mini nutri-
tional assessment; NDS, Nutrient Density Score; SAIN, Score d’Adéquation Individuel aux recommandations Nutritionnelles;
UNESCO, United Nations Educational, Scientic and Cultural Organization; WC, waist circumference; WHO, World Health
Donini et al. Nutritional Indicators for Sustainability of Healthy Diet
Frontiers in Nutrition | August 2016 | Volume 3 | Article 37
Results: Thirteen nutrition indicators of sustainability relating were identied in ve areas.
Biochemical characteristics of food (A1. Vegetable/animal protein consumption ratios;
A2. Average dietary energy adequacy; A3. Dietary Energy Density Score; A4. Nutrient
density of diet), Food Quality (A5. Fruit and vegetable consumption/intakes; A6. Dietary
Diversity Score), Environment (A7. Food biodiversity composition and consumption; A8.
Rate of Local/regional foods and seasonality; A9. Rate of eco-friendly food production
and/or consumption), Lifestyle (A10. Physical activity/physical inactivity prevalence; A11.
Adherence to the Mediterranean dietary pattern), Clinical Aspects (A12. Diet-related
morbidity/mortality statistics; A13. Nutritional Anthropometry). A standardized set of
information was provided for each indicator: denition, methodology, background, data
sources, limitations of the indicator, and references.
Conclusion: The selection and analysis of these indicators has been performed (where
possible) with specic reference to the MD. Sustainability of food systems is an urgent
priority for governments and international organizations to address the serious socioeco-
nomic and environmental implications of short-sighted and short-term practices for agri-
cultural land and rural communities. These proposed nutrition indicators will be a useful
methodological framework for designing health, education, and agricultural policies in
order, not only to conserve the traditional diets of the Mediterranean area as a common
cultural heritage and lifestyle but also to enhance the sustainability of diets in general.
Keywords: sustainable diets, nutrition indicators, Mediterranean diet, dietary energy density, dietary nutrient
density, dietary diversity, physical activity, non-communicable chronic diseases
ere is increasing evidence of the multiple eects and cost of
diets on public health nutrition, society, and environment (14).
Sustainability and food security are closely interrelated (5).
Food systems around the world are changing rapidly, with
profound implications for diets and nutritional outcomes. e
sustainable diets concept (6) highlights the role of sustainable
consumption as a driver of sustainable production, for food sys-
tems’ transformation toward more sustainable food consumption
and production patterns, which are among the most important
drivers of environmental pressures (7, 8). Food systems need to
grow within the framework of nite and oen reduced funds and
need to make use of natural resources and skills in a sustainable
manner to conserve the fragile ecosystem balance. ere is an
increasing need to develop a holistic view on sustainable food
systems, from production to consumption and diets. is can be
achieved through linkage to the enhancement of more sustain-
able dietary models. In the early 1980s, the notion of “sustainable
diets” arose to recommend diets, which would be healthier for
both the environment as well as for consumers (9). With food
globalization and the increased industrialization of agricultural
systems, the concepts of sustainable diets and agro-food systems
had been neglected. In the last decade, the interest in sustainable
diets has been revived by a growing body of scientic evidence
of the non-sustainability of current dietary trends (1013).
However, it is not clear that high nutritional quality is always
associated with low environmental impact (14).
e traditional Mediterranean Diet (MD) has been studied in-
depth and recognized as a healthier dietary pattern characterized
by a lower environmental impact (1518).
e health benets of the MD in preventing chronic diseases
have been well recognized by the scientic community, since
the pioneer Seven Countries Study, conducted by Ancel Keys,
established the association of a traditional Mediterranean dietary
pattern with markedly reduced coronary heart disease mortality
(1921). Later, additional benets of the MD have been widely
reported scientically for diseases other than cardiovascular, such
as obesity, diabetes, cancer, depression, cognitive decline as well
as improved quality of life (2230).
But, despite these well-documented health benets and the
low environmental impact of the MD, current surveys show
a decline in its adherence in Northern, Southern, and Eastern
Mediterranean countries, because of multifactorial inuences –
lifestyle changes, globalization of food markets, and economic
and sociocultural factors (26, 3139).
e three main domains of sustainability – economic, social,
and environmental – need to be integrated into the dimensions of
nutrition, health, and culture. During several recent international
seminars, four main thematic areas of sustainability have been
identied (1) nutrition, health, and lifestyle; (2) environment
including agro-biodiversity; (3) economy; (4) society and culture
(40). e assessment and development of sustainable diet models
requires awareness among consumers, producers, and govern-
ments that agriculture, food, nutrition, health, culture, environ-
ment, and sustainability are strongly interdependent.
TABLE 1 | Milestones for the denition of nutritional indicators of
sustainability of Mediterranean Diet.
CIHEAM MAI–Bari International Workshop on “Guidelines for Improving the
Sustainability of the Mediterranean Diet,” Bari, November 28–29, 2011
FAO/CIHEAM discussion paper on “Towards the Development of Guidelines
for Improving the Sustainability of Diets and Food Consumption Patterns in
the Mediterranean Area” (40, 45)
CIHEAM/FAO Seminar on “Food Systems and Sustainable Diets: The
Mediterranean Diet as a Pilot Study” in preparation of the ninth Meeting of
CIHEAM Ministers of Agriculture, Malta, September 25–26, 2012 (46)
CRA/FQH International Workshop on “Assessing Sustainable Diets within
the Sustainability of Food Systems,” Rome, September 15, 2014;
CIISCAM/Sapienza University of Rome, fourth Carlo Cannella Meeting,
Rome, February 26, 2015.
Donini et al. Nutritional Indicators for Sustainability of Healthy Diet
Frontiers in Nutrition | August 2016 | Volume 3 | Article 37
e MD, as a case study, may guide innovative inter-sectorial
eorts to counteract the degradation of ecosystems, loss of biodi-
versity, and homogenization of diets due to globalization through
the improvement of sustainable dietary patterns with their health
benets. For this purpose, it is necessary to dene the sustain-
ability of diets through the analysis of evidence, development
of methods and indicators, and the development/promotion of
policy guidelines.
In particular, in the context of sustainable consumption and pro-
duction, indicators are necessary to monitor time-trends whether
a society’s consumption and production patterns lead to more
socially equitable and environmentally sustainable development.
ey are also necessary to evaluate the impact of dietary patterns
on long-term health status and, in particular, on the pathogenesis
and incidence of non-communicable chronic diseases. A number
of international organizations, as well as dierent governments,
have developed sets of indicators for sustainable consumption and
production, mostly as attempts to monitor sustainable develop-
ment, but also as part, or in support, of dedicated sustainable
consumption and production strategies (41).
However, from a methodological approach, there are at
least three diverging criteria to dene sustainability indicators.
(1) According to the International Institute for Sustainable
Development “an indicator quanties and simplies phenomena
and helps us understand complex realities” (42). (2) According to
the Organization for Economic Cooperation and Development,
an indicator is “a parameter, or a value derived from parameters,
which points to, provides information about, or describes the
state of a phenomenon/environment/area, with a signicance
extending beyond that directly associated with its value” (43). (3)
According to Food and Agriculture Organization of the United
Nations (FAO), an indicator does not reduce to the data on which
it is based; it generally comprises elements (a cuto value, a frame
of reference, a mode of expression, etc.), which allow a relatively
universal appreciation of the information it supplies and also
facilitate comparison in time and space (4446).
is consensus position paper attempts to dene a non-
exhaustive ensemble or suite of the most appropriate nutrition
and health indicators for assessing the sustainability of diets,
using the MD as a case study.
An International Working Group was informally developed in
2011 with the contribution of dierent national and international
institutions – FAO; Sapienza University of Rome, Italy; University
of Marseille, France; Hebrew University of Jerusalem, Israel;
University of Las Palmas, Spain; Chouaib Doukkali University,
El Jadida, Morocco; Centre International de Hautes Etudes
Agronomiques Méditerranéennes (CIHEAM); International
Inter-University Center for MEDITERRANEAN Food Culture
Studies (CIISCAM); Council for Agricultural Research and
Economics-Research Center on Food and Nutrition (formerly
INRAN) (CRA-NUT), Rome, Italy; International Foundation
of Mediterranean Diet (IFMED); Hellenic Health Foundation –
Greece; and Forum on Mediterranean Food Cultures. Its pur-
pose was to dene the nutritional and health indicators relevant
to assessing the sustainability of the diets, and in particular, of
the MD.
rough online and face-to-face brainstorming meetings,
held from November 2011 to April 2015, a set of nutrition and
health indicators of sustainability was identied. e denitions
and the characteristics of the nutrition and health indicators were
progressively rened based on the recursive comments of the
participants (Table1).
e process for the production of the present document
began in the second half of 2014. e manuscript dra was then
circulated among the participants of the dierent institutions. An
agreement on the nal version of the document was reached in
April 2015 in Rome.
Dierent instruments were used to have a comprehensive pic-
ture of the eating patterns (Ta b l e  2 ). Individual Dietary Surveys
(IDS), Household Budget Surveys (HBS), and food balance sheets
(FBS) vary in the methodology that leads to dierent levels of
disaggregation and detail. Usually, for one food item (aer
alignment), the mathematical relation in relation to quantities is
FBS>HBS>IDS, because FBS items are calculated excluding
reuse and stock variation (national account budgets); they repre-
sent what food items are available per capita, but not obviously
what is necessarily consumed. HBS do not include meals eaten
outside the home but does include kitchen wastes and leovers.
IDS refer to edible part (excluding wastes and leovers) of food
and include eating at home and outside of home (47). Finally FBS
overestimated food consumption and nutrient intake compared
to IDS. Results between HBS and IDS are quite similar, except
for sh, meat, pulses, and vegetables, which are underestimated
by HBS, and sugar, honey, and cereals, which are overestimated.
e worldwide data FBS1 and the European data HBS2 are
current statistics. An overall view of HBS with the aim of har-
monizing data codes for nutritional analysis can be found in the
publication related to the DAFNE project3 (48), and the results
are also published in the “European Nutrition and Health Report
2009”4 (49).
TABLE 2 | Data sources and criteria used for the denition of nutritional
indicators of Mediterranean Diet.
FBS and commodity balances provide data for domestic availability of
a food, or food component in the case of protein. The contributing data
include the sum of production and imports, with exports and non-food use
subtracted. New modules to the FAOSTAT family of databases, including
land use, emission, pesticide, fertilizer, and irrigation, will provide more data
on environmental sustainability when analyzed with protein ratio data. Food
consumption studies, national nutrition surveys, household budget surveys,
etc., will be available in some countries to provide accurate individual data
instead of FAO FBS data. It is noted that FBS data represent what food is
available per capita on a national scale, but not what is actually eaten.
HBS are national surveys mainly focusing on consumption expenditure.
They are conducted in all EU Member States and their primary aim
(especially at national level) is to calculate weights for the consumer price
index. They were launched in most EU Member States at the beginning
of the 1960s, and Eurostat has been collating and publishing these
survey data every 5years since 1988. The two last collection rounds were
2005 and 2010. Although there have been continuous efforts toward
harmonization, differences remain.
IDS is a class of methodologies including methods with various precision
level (food record, 24-h recall, Food Frequency Questionnaire, dietary
history, food propensity questionnaires, and combinations) usually not
carried out at regular interval time except for some national reality as, e.g.,
the NHANES program in the USA (
or the NDNS (
summary.pdf) in the UK. The European Food Safety Authority has launched
the EU Menu (
htm) program to push Member States of the European Union to harmonize
dietary surveys. FBS and HBS for Europe are the source complying with
the denition of indicators (see “Criteria for Selecting Indicators”).
Donini et al. Nutritional Indicators for Sustainability of Healthy Diet
Frontiers in Nutrition | August 2016 | Volume 3 | Article 37
Important information on Agri-environmental indicators
(AEIs), HBS, and from farm to fork statistics may also be col-
lected from Eurostat.5
To select the most eective indicators, the following criteria were
considered (41):
1. Relevant to the question being asked. e indicator should be
the best indicator currently available to answer the question;
2. Understandable, i.e., clear, simple, and unambiguous;
3. Graphically representable;
4. Readily interpretable, i.e., clear, which direction the indicator
should develop to lead to greater sustainability;
5. Relevant in most Economic European Area Member and col-
laborating countries, i.e., not restricted to an issue, which is
limited to a few member countries;
6. Monitorable, i.e., based on data that are readily available in
member and collaborating countries, or could be made
available at reasonable cost–benet ratio and with regularity
within time frame of policy cycle (i.e., updated each year and
with maximum 4-year time delay);
7. Reliable and consistent, i.e., data collection and analysis meth-
odologies should preferably be consistent from country to
country, and at very least, be consistent within a given country
from year to year;
8. Representative, i.e., can be taken to represent current sustain-
able consumption and production trends within a given
sector, nal consumption cluster, etc.
A set of nutrition indicators of sustainability was identied by the
Working Group, and thirteen indicators, from A1 to A13, were
characteristics of food
A1. Vegetable/animal protein consumption ratios
A2. Average dietary energy adequacy
A3. Dietary Energy Density Score
A4. Nutrient density of diet
Food quality A5. Fruit and vegetable consumption/intakes
A6. Dietary Diversity Score
Environment A7. Food biodiversity composition and
A8. Rate of local/regional foods and seasonality
A9. Rate of eco-friendly food production and/or
Lifestyle A10. Physical activity/physical inactivity prevalence
A11. Adherence to the Mediterranean dietary
Clinical aspects A12. Diet-related morbidity/mortality statistics
A13. Nutritional anthropometry
For each indicator, the following set of information is provided:
denition, methodology, background, data sources, limitations of
the indicator, and references.
A1. Plant and Animal Protein
Consumption Ratios
is indicator is a ratio of the relative intakes of protein from
plant and animal sources, assessing adherence to an optimal
dietary pattern, and a proxy for environmental impact of diets.
Parameter considered is as follows:
ratio of plant (cereals, vegetables, pulses, fruit) and animal
(meat, sh, eggs, dairy products) proteins in the diet using
existing data.
Adherence to an optimal ratio, including the MD, can be
judged by simple comparison, and the trend can be monitored
over the time series of available data, regardless of the data source.
Data Sources
FAOSTAT FBS and commodity balances provide data for
domestic availability of a food, and food component in the case
of protein (50). e contributing data include the sum of produc-
tion and imports, with exports and non-food use subtracted. New
modules to the FAOSTAT family of databases, including land
use, emission, pesticide, fertilizer, and irrigation, will provide
Donini et al. Nutritional Indicators for Sustainability of Healthy Diet
Frontiers in Nutrition | August 2016 | Volume 3 | Article 37
more data on environmental sustainability when analyzed with
protein ratio data. Food consumption studies, National Nutrition
Surveys, HBS, etc., will be available in some countries to augment
or replace FAOSTAT data.
Limitations of the Indicator
FAOSTAT data from FBS and commodity balances reect domes-
tic availability of foods, not consumption or production perse.
While these data have proven useful for assessing nutritional
adequacy of diets, with a long history of use, they may signi-
cantly misrepresent sustainability issues. For example, livestock
production has a greater role in GHG emission than livestock
consumption. If meat is imported rather than domestically pro-
duced, the calculation of environmental impact may be skewed
if using food balance or commodity balance datasets. Similarly,
National Nutrition Surveys do not address the issue of production.
Food losses and waste not accounted for in the datasets will aect
the calculations and interpretation. Additionally, the advantages
of using plant:animal protein ratio, as opposed to plant:animal
dietary energy ratio or plant:animal ratio in grams per person per
day, need to be elaborated (51, 52).
A2. Average Dietary Energy Adequacy
e indicator expresses the dietary energy supply (DES) as a
percentage of the average dietary energy requirement (ADER) in
the country. Each country’s or regions average supply of calories
for food consumption is normalized by the ADER estimated for
its population, to provide an index of adequacy of the food supply
in terms of calories. is indicator was proposed by FAO as new
approach for the measurement of food security (53).
Parameters considered are as follows:
– dietary energy supply (kilocalories/capita/day): average sup-
ply available for each individual in the total population (it does
not indicate what is actually consumed by individuals);
average dietary energy requirement (kilocalories/capita/day):
the amount of food energy needed to balance energy expendi-
ture in order to maintain body size, body composition, and
a level of necessary and desirable physical activity consistent
with long-term good health.
Data Sources
Data can be downloaded from
ess/ess-fs/ess-fadata/en/#.VPhu3y7K1i0. Otherwise, DES can be
obtained from National IDS, HBS, FBS, and ADER from National
Energy Requirements, FAO Human Energy Requirements.
Limitations of the Indicator
National IDS using food diaries or dietary recalls estimate the
actual consumption (i.e., the dietary energy intake), provide
the best evidence on food consumption, and constitute the
best method for assessing energy intake, and more generally,
dietary patterns and evaluating diet–disease associations. Being
expensive and labor-intensive, these surveys are undertaken
only in a limited number of countries, oen at regional or
local level or in specic population groups; furthermore, it is
dicult to accomplish comparability at the international level,
because the assessment methods are variable, self-reported,
and consequently subject to considerable measurement errors.
In order to overcome these problems, the per capita DES can
be used instead of the dietary energy intake. Data on DES can
be gathered from FBS and HBS. FBS and HBS overestimate
energy intake, although not in a linear way; while FBS includes
eating out, HBS does not; food losses and waste should be
considered. In order to reduce the impact of possible errors in
estimated DES, due to the diculties in properly accounting of
stock variations in major food, the indicator is calculated as an
average over 3years (for example, 2010–2012, 2011–2013, and
Average dietary energy requirement is a reference for adequate
nutrition in the population. e recommended level of dietary
energy intake for a population group is the mean energy require-
ment of the healthy, well-nourished individuals who constitute
that group. e estimates of requirements derived from meas-
urements of a collection of individuals of the same age, gender,
body size, presumed body composition, and physical activity
are grouped to give the average energy requirements for a class
of people or a population group. ese requirements are used
together to predict the requirements of other individuals with
similar characteristics, but on whom measurements have not
been made. Consequently, application of these results to any one
individual for clinical or other purposes may lead to errors of
diagnosis and improper management (54). On the other hand,
data on the size of consumed food portion that inuence energy
intake need to be evaluated (55), as positive relationships between
portion size and energy intake have been demonstrated in adults
A3. Dietary Energy Density Score
is indicator measures the amount of energy (kcal or kJ) in a
given weight (g, 100g, or kg) of diet as a proxy for healthy dietary
Parameter considered is as follows:
– dietary energy density (kilocalories/gram) calculated by
dividing total dietary energy by the edible weight of foods and
caloric beverages consumed. e primary data are as follows:
the mean amounts of various foods/beverages or food
groups consumed daily.
the energy provided by weight unit of the foods/beverages
or food groups as provided by food composition databases.
It will be expressed as the amount of energy (kilocalories
or kilojoules) in 100g or 1k of daily diet.
Data Sources
National IDS, HBS, and FAO FBS.
Donini et al. Nutritional Indicators for Sustainability of Healthy Diet
Frontiers in Nutrition | August 2016 | Volume 3 | Article 37
Limitations of the Indicator
Individual Dietary Surveys provide the most accurate gures for
actual daily food consumption. Data obtained from FBS do not
reect the eective food intake, because they relate to the food
quantities theoretically available for consumption; the amount of
food consumed is lower than those reported in FBS, due to the
degree of losses of edible food and nutrients in the household,
e.g., during storage, in preparation, and cooking, as plate waste
or quantities fed to domestic animals and pets, or thrown away.
Depending on data sources and studies, the level of accuracy and
units used can vary.
Also, the data obtained even from National Dietary Surveys do
not reect the portion size. Indeed, there is evidence that larger
portion size of energy-dense and nutrient-poor foods is involved
in the increase of overweight and obesity that accompany the
changes in dietary patterns in children and adults (57, 58).
A4. Nutrient Density of Diet and Foods
e nutrient density of a composite diet is the amount of vari-
ous necessary nutrients and bers present in a given daily diet
expressed in weight (or evenly in energy).
Parameters considered are as follows:
a daily diet:
mean adequacy ratio (MAR) based on the mean per-
centage of the recommended intakes for 29 key needed
nutrients, alone or in combination with the mean excess
ratio (MER) for nutrients to limit.
general purpose:
the amount of every nutrient present in a unit of a given
food/beverage or food group as provided by food compo-
sition databases;
Nutrient Density Scores referring to either 100 g,
100kcal/kJ, or cost/kg or L of a given food: ex simplied
SAIN/LIM scoring (Score d’Adéquation Individuel aux
Recommandations Nutritionnelles – SAIN; nutrients to
be limited – LIM) (10).
Some publications cited in the reference list provide examples
of calculations and interpretations (12, 59).
Data Sources
National IDS, HBS, and FAO FBS (see indicator A2 for a compre-
hensive description).
Limitations of the Indicator
All scores designed to evaluate the nutrient density of either
individual foods or whole diet have advantages and limitations.
ey must be taken into account depending on the precise con-
text and objective considered. e limitations are (i) the need for
accurate and quantitative dietary intake data and food composi-
tion databases; (ii) comparisons between countries are limited by
possibly dierent daily recommended intakes (energy, nutrients,
and ber); and (iii) comparisons between studies need the use of
the same nutrients and total number of nutrients.
It has to be considered that the MAR normally should be 29,
but because of the lack of composition tables, the number is usu-
ally less. In France, for example, 23 includes the dierent lipids.
A5. Fruit and Vegetable Consumption/
is indicator is the measure of the consumption (grams/capita/
day) of fruits and vegetables, including pulses, nuts, and seeds
(12), directly applicable to assessing adherence to MD, and as a
proxy for a healthy diet and specic micronutrient intakes.
Parameter considered is as follows:
– measure of the consumption (supply, availability, intake) of
fruits and vegetables (grams/capita/day), including pulses,
nuts, and seeds.
Data Sources
National IDS, HBS, and FAO FBS.
Limitations of the Indicator
Data obtained from FBS do not reect the eective food intake,
because they relate to the food quantities available to the con-
sumer (but not necessarily consumed). us, the amount of food
consumed is usually lower than those reported in FBS (59), due to
the degree of losses of edible food and nutrients in the household/
catering, e.g., during storage, in preparation, and cooking, as plate
waste or quantities fed to domestic animals and pets, or thrown
away. However, when National IDS are not available, the HBS
and/or FBS provide good indicators by which to compare several
countries and dierent time periods.
Although it is not specied in ocial documents, considering
the high proportion of waste oen present in preparations of
plant foods, it should be specied that the weight of 400g daily
refers to edible product net of waste (12, 60).
When using national supply data, the reference value could be
increased to take into account that goods include inedible parts.
Moreover, 500g per day are also recommended in some dietary
guidelines6 and for ischemic heart disease prevention (61, 62).
A6. Dietary Diversity Score
Dietary diversity is a qualitative measure of the household access
and consumption of a wide variety of foods. It is an indicator that
reects the households’ diet quality and is also a proxy for the
adequacy of nutrient intake of the diet for individuals (6365).
is concept is based on the fact that the needs in nutrients are
6 e.g.,
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not covered by a single food, but by a diet composed of several
It is associated with household socioeconomic status and food
security (energy availability at the household level). A greater
dietary diversity was also reported to protect dierent households
against the double burden of malnutrition known in countries in
nutrition transition (6668).
Parameters considered are as follows:
Dietary Diversity Scores (DDS) dened as the number of food
groups consumed over a reference period:
Individual Dietary Diversity Score (IDDS) used as proxy
of the nutritional quality of individual diet has for aim to
assess the adequacy of nutrient intake;
Dietary Diversity Score at the household level (HDDS) is
used, on the other hand, as proxy of the socioeconomic
level of the household and intends to reect the economic
ability of a household to consume a variety of foods.
– Dietary Variety Score (DVS) (69) corresponding to the num-
ber of foods consumed among a list of foods.
– US Healthy Food Diversity index (70), a tool for the simul-
taneous measurement of dietary variety, quality, and propor-
tionality at individual level.
Data Sources
Usually, specic questionnaires are administered. e use of
National IDS, HBS, and FAO FBS need to be experimented.
Limitations of the Indicator
Even if there is a preference for the DDS based on food groups,
the issue of the number and the choice of these food groups has
not yet been resolved. e selection of food groups can be guided
by the objectives for which the scores are used.
For example, if the score of diversity is used to identify popula-
tions at risk of micronutrient deciency, the classication used
should distinguish food groups depending on their content in
micronutrients. In this case, it is obvious that comparisons
between studies or countries are more dicult.
Moreover, it has to be considered that the diversity scores
have been designed specically for developing countries without
regularly carried out national statistics about this topic.
A7. Food Biodiversity Composition
and Consumption
Biodiversity covers diversity within species, between species, and
of ecosystems; synonyms are biological diversity and ecological
diversity. For the purposes of human nutrition, biodiversity refers
to foods identied at the taxonomic level below species (e.g., cul-
tivar, breed) or by local varietal name, and wild, neglected, and/
or underutilized species. Biodiversity is distinctly dierent from
dietary diversity,” which reects intake at the level of aggregate
food groups.
Parameters considered are as follows:
food composition: a count of the number of foods:
at variety/cultivar/breed level for common foods with at
least one value for component found in published and
unpublished sources.
at species level for wild/indigenous/underutilized foods
with at least one value for component found in published
and unpublished sources.
food Consumption:
the taxonomic diversity of foods, as for food composition,
reported in food consumption/dietary intake surveys.
Data collected and reported include:
the study instrument (e.g., diet history, food f requency)
with details (scope, date, number, and description of
subjects, geographical/ethnic coverage; reference, total
number of studies examined);
the qualifying biodiverse foods reported (number of
foods, food lists);
the number of surveys with at least one reported food
counting for biodiversity.
Data Sources
Food and Agriculture Organization of the United Nations/
International Network of Food Data Systems (INFOODS)
compile data and report periodically (71). For food composition,
data are obtained by searching peer-reviewed journals using the
search engines Scopus and Science Direct, and through a call for
data conducted via INFOODS. ese data are then compiled in a
Biodiversity Food Composition Database (72).
For food consumption, data are obtained from all surveys,
including National Nutrition Surveys, market surveys, ethno-
biological investigations, and inventory studies. All published
and unpublished available resources are searched, including
peer-reviewed journals, ocial international/regional/national/
subnational survey reports, conference presentations, and
published matter, including posters, abstracts published from
meetings, and theses.
Limitations of the Indicators
e development and reporting on the indicators are recent, and
only two to three time points are available. e usefulness of the
indicators should be assessed in the future and judged against
market survey data as well as nutritional outcomes. For the
moment, the results represent a reection of the attention being
paid to biodiversity by researchers designing food composition
studies and dietary surveys. Monitoring and reporting on the
biodiversity indicators is the responsibility of FAO/INFOODS. It
is a time-consuming activity, and, for the 2014–2015 biennium,
FAO has put few or no resources into the continuation of this
A8. Local/Regional Foods and Seasonality
e term “local food system” (or “regional food system”) is used
to describe a method of food production and distribution that
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is geographically localized, rather than national and/or interna-
tional. Food is grown (or raised) and harvested close to consum-
ers’ homes, then distributed over much shorter distances than is
usual in the conventional globalized industrial food system with
long-distance transportation. In general, local/regional food
systems are associated with the sustainable agriculture concept,
but not systematically. In particular, it is based on purchases at
short distance from the producer (from few to 100km or miles)
and directly from the producer or with one intermediate between
the consumer and producer.
Production “in season” means that minimum articial condi-
tions are used to grow the products (essentially plant products:
vegetables and fruits), without heated greenhouses in the local
agro-environmental conditions and no long-term cold storage).
Parameters considered are as follows:
the distance between consumer purchase location and
producing area; it is usually considered that it should be at
maximum 150km (around 100miles).
the number of intermediates between producer and consumer
with zero when direct from producer, one when one inter-
mediate is present (one can be considered as a cut point for
the consumer choice:
directly to local/regional producers (on-farm, farmers
market/shop, food baskets made of local foods) as a share
of total food purchases,
share of fresh vegetables or fruits consumed coming from
open eld or unheated greenhouse cultivation.
the duration between fruit harvest (known or estimated from
agriculture statistics of the concerned growing location or
country) and purchase of fresh fruit, as a direct reect of dis-
tance from seasonal production (and cold storage duration).
Data Sources
e information necessary to assess these indicators can be only
obtained from dedicated studies where such specic questions are
addressed. It is the case in some national human cohort surveys
or more local/regional consumption studies. e growing interest
in such consumption approaches will stimulate more investiga-
tions in this domain.
e parameters to use are still under debate and need further
testing. e present availability of data can be restricted to a
limited number of studies, but this gure is expected to markedly
improve in the next future.
A9. Organic/Eco-friendly Production
and Consumption
Nowadays, most agro-food productions based on agro-ecological
principles are called as “organic” and are certied and labeled at
national and continental levels (73).
ese well-characterized, controlled, and certied methods
of food productions exclude the use of chemical fertilizers,
pesticides, GMOs, and intensive animal husbandry (7479).
ese methods are acknowledged to better protect environment,
biodiversity, and potentially, health consumers.
Parameters considered are as follows:
the percentage of consumers buying organic foods and the
frequency of consumption.
organic food consumption in percentage of total food amount
or money per capita (e.g., Bionutrinet Cohort Survey in
the percentage of the organic market volume.
the percentage of land use under organic certication.
Data Sources
In most industrialized countries, data on the organic market vol-
ume as well as the market shares are available as well as recorded
(73). Detailed data for specic food types can be available too.
During some consumer cohort surveys or in national con-
sumption surveys, individual data are collected on organic food
consumption (e.g., Germany, France).
Furthermore, national yearly data are now available and
continuously recorded (73) regarding the importance of organic
food production (number of farms, acreage, volume of foods
produced) and share of total. In some countries, agricultural
production data (at local/regional/national) are also available
along with organic food import/export data (73).
Limitations of the Indicator
In some countries, organic production can be marginal only or
data on organic production or consumption are not available at
national or regional level. But, the availability of data has been
and will be increasing (73).
A10. Physical Activity/Physical
Inactivity Prevalence
As physical activity is a key determinant of energy expenditure, it
is fundamental to energy balance and weight control. Although
there are doubts on considering it as a nutritional indicator or
a cofactor of nutritional status, the Working Group decides to
consider it in the list of nutritional indicators of sustainability.
Anyway, it is important to underline that MD, and more in
general, diet needs to be considered a lifestyle, and the regular
practice of physical activity is a key component of it.
Physical activity is dened as any bodily movement produced
by skeletal muscles that require energy expenditure. e term
“physical activity” should not be mistaken with “exercise.” Exercise,
is a subcategory of physical activity that is planned, structured,
repetitive, and purposeful in the sense that the improvement or
maintenance of one or more components of physical tness is
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the objective. Physical activity includes exercise as well as other
activities, which involve bodily movement and are done as part
of working, active transportation, house chores, and recreational
activities (80).
Several physical activity indicators have been proposed (81).
On the basis of available data, the physical inactivity prevalence
has been selected as an indicator of physical activity, using the
denition of not meeting any of the following criteria: at least
30min of moderate-intensity activity per day on at least 5days
per week, or at least 20min of vigorous-intensity activity per day
on at least 3days per week, or an equivalent combination (82).
Parameters considered are as follows:
Attributable disability-adjusted life years (DALYs) from
physical inactivity;
– Physical Activity Questionnaires [e.g., WHO Global Physical
Activity Questionnaire (GPAQ); International Physical
Activity Questionnaire (IPAQ), etc.].
Data Sources
National surveys and WHO Global Infobase.
Limitations of Indicator
It is dicult to use questionnaires across that are comparable
across cultures. All the questionnaires dealing with physical
activity presents some limitations in particular, considering the
shorter-forms and the versions to be used without personal inter-
view (83). Moreover, data on population-based physical inactivity
may be limited in some countries. As an indicator should be, by
the way, “monitorable,” it should be based on the data that are
readily available, but most of the available data may be dicult
to interpret due to dierences in the way physical inactivity is
e use of objective methods, such as pedometers, is becom-
ing more feasible, especially with the use of mobile technology
and apps that provide such information. However, at the moment,
for surveillance activity, the objective methods were rarely used,
and there are not available data. Moreover, pedometer is spe-
cically designed to assess walking only; it is enabled to record
non-locomotor movements and to examine the rate or intensity
of movement. On the other hand, accelerometer is suitable for
all populations and is an objective indicator of body movement
(acceleration) but is an inaccurate assessment of a large range of
activities, and the nancial cost may prohibit assessment of large
numbers of participants.
Finally, considering the cost–benet ratio, the Working Group
suggests to promote the collection of using harmonized method-
ologies, such as the same physical activity questionnaire, in all
countries (i.e., GPAQ) supported by pedometer or accelerometer.
A11. Adherence to the Mediterranean
Dietary Pattern
Adherence to the traditional MD, or, to diets that resemble the
Mediterranean pattern, have been expressed through indexes or
scores, dened apriori, which operate by combining conceptu-
ally and computationally the dietary components that capture the
essence of this dietary pattern.
Parameter considered is as follows:
Mediterranean Diet Score (MDS) (it ranges from 0 – minimal
adherence to the traditional MD – to 9 – maximal adherence):
for the ve components, which are representative of the
MD and are presumed to be consumed in large quantities
(vegetables, legumes, fruits and nuts, cereal, and sh), a
value of 1 is assigned to persons whose consumption is at
or above the components’ sex-specic medians based on
the considered sample, and 0 otherwise;
a sixth component of the score is the ratio of monounsatu-
rated lipids to saturated lipids, reecting the principal role
of olive oil consumption in the traditional MD: a value
of 1 is assigned to persons whose consumption is at or
above the sample-specic median of this lipid ratio and
0 otherwise;
for the following two components that are presumed to
be consumed in low/moderate quantities in the MD (all
meats and all dairy products, which are rarely non-fat
or low-fat in Mediterranean countries), persons whose
consumption is below the median are granted with a value
of 1, and persons whose consumption is at or above the
median are penalized with a value of 0;
for alcohol, a value of 1 is assigned to men who consume
between 10 and 50 g of ethanol per day and to women
who consume between 5 and 25g per day, expressing the
moderate ethanol consumption in the MD.
Data Sources
e MD indexes were estimated in their majority from informa-
tion collected through detailed Food Frequency Questionnaires
(FFQ) or repeated measures of 24-h recall dietary questionnaires,
which are not easy to be dealt with, especially from the general
e previous-indicated approach has been very valuable in order
to express the whole of a dietary pattern, and specically of MD.
e limitation of the approach is that usually cuto points used
in most scores are sample-dependent, making the interpretation
of any identied association of this pattern with health outcomes
dicult to generalize. Second, since many MD indexes exist, a
natural question is whether some work better than others with
respect to capturing the adherence to MD, as well as, to iden-
tifying associations of this diet with a specic health outcome.
However, to decide which of these numerous MD indexes is
optimal” is rather dicult, since such a decision would require
one to evaluate the predictive ability of the various indexes with
respect to dierent outcomes using one population, and then
validate the results to dierent populations. e issue becomes
even more complicated due to the population-specic and not
Donini et al. Nutritional Indicators for Sustainability of Healthy Diet
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universal cuto values that have been used for discriminating
the low/high consumptions for each of the MD components, as
described previously. Notwithstanding the scientic value of such
an approach, any “optimal” MD scale should also be character-
ized by its simplicity in the construction of the index as well as in
the use of this index widely in public health as well as in clinical
practice. Such an investigation would be very important for future
studies, which wish to assess the association of MD with health.
A12. Diet-Related Morbidity/Mortality
is indicator monitors mortality and morbidity (occurrence of
cardiovascular events, type II diabetes, dyslipidemia, hyperten-
sion, osteoporosis, neurodegenerative diseases, and some types of
cancer) as a proxy for the consumption of healthy diets.
Parameters considered are as follows:
prevalence of individuals having physician-diagnosed obesity,
cardiovascular diseases (CHD, stroke, and hypertension),
type II diabetes, osteoporosis, neurodegenerative diseases,
and obesity-related cancers.
disability-adjusted life year as a measure of overall disease
burden expressed of years lost due to illness, disability or early
death associated with nutrition-related factors: high blood
pressure, high cholesterol (total and LDL), high blood sugar
(insulin resistance and/or diabetes).
Data Sources
National surveys and WHO World Health Statistics (84, 85).
Limitations of the Indicator
Some pathologies can be undiagnosed or underreported in some
countries. Data may not be available for the same age groups. If
data are not available, mortality prevalence will be used.
A13. Nutritional Anthropometry
is indicator is based on the body mass index (BMI) and the
waist circumference (WC), which are used in a wide variety of
contexts as simple methods to assess how much an individual’s
body weight departs from what is normal or desirable for a person
of his or her height (86).
Body mass index in both men and women represents a measure
of underweight (<18.5kg/m2) or dierent levels of overweight
(25–29.9, 30–34.9, 35–39.9, 40kg/m2).
Waist circumference in both men and women represents a
measure of visceral adiposity (>88cm in women and 102cm in
men). Increased WC can be a marker for increased risk, even in
persons of normal weight associated with insulin resistance.
Overnutrition and undernutrition frequently coexist. Weight
loss, real to ideal weight ratio, and specic nutritional assessment
tools (Mini Nutritional Assessment – MNA, Just a Nutritional
Screening – JANUS) (87, 88) may be useful to detect the presence
of malnutrition.
Parameters considered are as follows:
– undernutrition: prevalence of individuals having a BMI
<18.5kg/m2 calculated from self-reported weight and height;
overweight or obesity: prevalence of individuals having a BMI
25.0kg/m2 calculated from self-reported weight and height
and/or WC >88cm in women and 102cm in men.
Classication of overweight and obesity by BMI, waist circum-
ference, and associated disease risks.
Disease riska relative to normal weight and waist circumference
Men 102cm or less
Women 88cm
or less
Men >102cm
Women >88cm
Underweight <18.5 –
Normal 18.5–24.9 – –
Overweight 25.0–29.9 Increased High
Obesity 30.0–34.9 I High Very high
35.0–39.9 II Very high Very high
40.0+III Extremely high Extremely high
aDisease risk for type 2 diabetes, hypertension, and CVD (
Data Sources
WHO Global Database and data locally available through
National surveys (8993).
Limitations of Indicator
Individuals tend to overestimate their height and underestimate
their weight, leading to underestimation of BMI and of the
prevalence of overweight and obesity. Moreover, anthropometric
measurements have to be performed by skilled personnel accord-
ing to a standardized procedure.
Self-reported national surveys might be subject to systematic
error (lower reported weight and higher reported height) result-
ing from non-coverage (e.g., lower telephone coverage among
populations of low socioeconomic status), non-response (e.g.,
refusal to participate in the survey or to answer specic ques-
tions), or measurement (e.g., social desirability or recall bias).
Data could not be available for some countries.
It is hoped that data of BMI less than 18.5kg/m2 will be avail-
able soon from the WHO to measure the rates of undernutrition
in these populations.
is paper has identied and summarized some of the most rel-
evant nutritional indicators to measure the sustainability of food
consumption. e purpose is, together with additional indicators
for the other three sustainability dimensions (environment,
economic, and sociocultural), to formulate recommendations for
cross-sectoral policy instruments, allowing the comparability and
improvement of the sustainability of the diets and food systems
Donini et al. Nutritional Indicators for Sustainability of Healthy Diet
Frontiers in Nutrition | August 2016 | Volume 3 | Article 37
in dierent countries. e selection and analysis of each indicator
has been done (wherever possible) with specic reference to the
MD as a case study. e sustainability of food systems represents
an urgent action area for governments and international organi-
zations to tackle the serious socioeconomic and environmental
consequences of short-sighted behaviors and practices involving
agricultural land and rural communities (94). It requires devel-
oping a set of comprehensive, coherent, integrated, and holistic
policies that simultaneously consider the relative priorities (and
trade-os) between dierent sectors: nutrition, health, lifestyle,
society, culture, economy, environment, and agro-biodiversity.
e proposed nutrition indicators outlined in this paper will be
useful for further developing a methodological framework for
designing policies in order, not only to conserve and preserve the
traditional diet, such as the MD, as a common cultural heritage and
lifestyle but also to enhance the sustainability of dietary models.
e MD, in its various national forms, may be used as a case study:
a model to describe, understand, and improve the sustainability
of current food consumption because of the high and increas-
ing pressure on its fragile natural resources exacerbated by the
changes of Mediterranean food consumption patterns (15, 95).
A medium term research and action framework needs to
be implemented to analyze the sustainability of the diets in the
Mediterranean area (40, 45). e use of the selected indicators
and their validation may represent a rst step of a “pilot sustain-
ability laboratory” aimed at the denition of a validated proce-
dure that will help governments and policy makers to formulate
sustainability-sensitive policies in the promotion of sustainable
food systems development in dierent areas.
e Mediterranean area can be considered as a case study
because of its passage through a “nutritional transition” in which
problems of undernutrition coexist with overweight, obesity,
and food-related chronic diseases (37). Undernutrition is still
signicant in the South of the Mediterranean: 9.2 million people
in 2001–03, 3.9% of the population of the zone, compared with 7.3
million people in 1990–92, 3.8% of the population (96). e rate of
stunting among children less than 5years of age is also very high in
many countries in the South: 18% in Algeria, 21% in Egypt, 12% in
Lebanon, 24% in Morocco, 12% in Tunisia, and 16% in Turkey. At
the same time, according to WHO, overweight and obesity rates
in Mediterranean countries continue to rise. Currently reported
rates for overweight and obesity range, respectively, from 45.5 and
16.0% in Algeria to 67.9 and 33.1% in Egypt (51).
e indicators that were selected can be attributed to ve
domains related to nutritional aspects of the diet: biochemical
quality of food (A3. Vegetable/animal protein consumption
ratios; A4. Average dietary energy adequacy; A6. Dietary Energy
Density Score; A7. Nutrient density of diet); food quality (A2.
Fruit and vegetable consumption/intakes; A5. Dietary Diversity
Score); environment (A8. Food biodiversity composition and
consumption; A12. Rate of Local/regional foods and seasonality;
A13. Rate of eco-friendly food production and/or consumption);
lifestyle (A10. Physical activity/Physical inactivity prevalence;
A11. Adherence to the Mediterranean dietary pattern), and
clinical aspects (A1. Diet-related morbidity/mortality statistics;
A9. Nutritional Anthropometry). e choice of the indicators
is indeed a compromise between what is desirable and what is
practical and available in which countries. In one sense, these
indicators represent an “ideal” list; it remains to be seen how
useful they are for practical application.
In this paper, we refer to databases: FAOSTAT, HBS,
EUROSTAT, etc. e quality of the data can be highly variable,
and this may represent a limit of the procedure. Anyhow, there is
no means to avoid these diculties, and the presence of dierent
databases may minimize, at least partly, the eects of the decien-
cies of each single database.
us, the next phase of this work will be:
Collecting data sets from individual countries to ascertain
what gures are available for analysis.
e validation of the indicators that were selected by the expert
group. us these indicators will be performed versus sustain-
ability or versus an outcome variable that can be considered a
proxy of it.
– e denition of a mathematical model that will be able to
combine all the indicators belonging to a single area (e.g.,
nutritional indicator). In this phase, it will be necessary to
verify that all the indicators add some new information to the
model, to attribute to each indicator a weight, to avoid col-
linearity (when a variable can be linearly predicted from the
others, it has to be omitted respecting the lex parsimoniae).
– Following these steps, we might consider organizing the
groups of indicators into a composite index to quantify and
monitor sustainability over time. e methodology has been
established as a two stage approach to determine rst, within
each dimension, the relative weightings of the indicators
selected and then the weightings between each dimension
to enable building a composite index, which may be easily
disaggregated into the four dimensions of sustainable diets
(45, 97). is methodological approach is suciently exible
to allow modifying the type and number of indicators in each
dimension as new data accrue.
Recent surveys show that many countries in the Mediterranean
area are driing away from the traditional MD healthy pattern,
and current food consumption habits show a decline in their
adherence to the MD (26, 3134, 36). Because of such waning in
adherence to the MD, there are major concerns, including health
risks [due to an increase in the consumption of lipids (e.g., meat,
dairy products, etc.), an increase in the consumption of processed
foods, simple carbohydrates (e.g., beverages and foodstus with
a high carbohydrate content), and a decrease in the consumption
of complex carbohydrates (e.g., cereals and legumes) leading
to chronic nutrition-related diseases, disability, and increased
mortality]; environmental issues (due to an exacerbate ecological
footprint as a consequence of a more prevalent consumption
of foods from animal sources), and loss of biodiversity (due
to the globalization of food production/consumption and the
homogenization of eating patterns; the dietary diversity is linked
to nutrient composition diversity between foods and among
varieties/cultivars/breeds of the same food; dietary diversity may
guarantee healthy diet through an adequate presence of nutrients
and bioactive molecules) (98). Also, in a time of abundance,
Donini et al. Nutritional Indicators for Sustainability of Healthy Diet
Frontiers in Nutrition | August 2016 | Volume 3 | Article 37
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be useful in promoting more ecacious interventions to preserve
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e Working Group has selected thirteen indicators from a
broader framework of indicators. In this wider group were listed
some other indicators, such as food composition, frugality,
household food security, level of food processing, nutrient pro-
le, global nutritional index, food losses, and waste, that could
be considered a proxy of those selected or overlapping, at least
in part, with them. e Working Group will attempt to consider
them in the future.
All authors listed have made substantial, direct, and intellectual
contribution to the work and approved it for publication.
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Conict of Interest Statement: e authors declare that the research was con-
ducted in the absence of any commercial or nancial relationships that could be
construed as a potential conict of interest.
Copyright © 2016 Donini, Dernini, Lairon, Serra-Majem, Amiot, del Balzo, Giusti,
Burlingame, Belahsen, Maiani, Polito, Turrini, Intorre, Trichopoulou and Berry.
is is an open-access article distributed under the terms of the Creative Commons
Attribution License (CC BY). e use, distribution or reproduction in other forums
is permitted, provided the original author(s) or licensor are credited and that the
original publication in this journal is cited, in accordance with accepted academic
practice. No use, distribution or reproduction is permitted which does not comply
with these terms.
... The focus of dietary guidelines in the past was largely based on meeting nutrient requirements regarding how people should eat in their specific socio-ecological contexts to support nutrition and health (Magni et al., 2017). In more recent times, it has been acknowledged that dietary guidelines have the potential to not only support citizens on how to make healthier choices about food (and sometimes about physical activity), they can also serve to guide consumers in a country to make food choices that support the multiple dimensions of sustainable diets (Garnett, 2014;Donini et al., 2016;Nelson et al., 2016). The role of dietary guidelines has broadened in view of the multiple environmental constraints that put pressure on the food system and the resulting need to preserve natural resources and ecosystem health (Fischer and Garnett, 2016;Nelson et al., 2016). ...
... This finding supports the overarching goal of dietary guidelines which has been to support human health (Magni et al., 2017). More recently, dietary guidelines have been recognized to have the potential to also support the multiple dimensions of sustainable diets (Garnett, 2014;Donini et al., 2016;Nelson et al., 2016). However, our findings did not support the hypothesis that countries that are recognized to explicitly integrate sustainability into their dietary guidelines demonstrate greater presence of the ecological, economic, and socio-cultural and political sustainability sub-dimensions. ...
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... In 2013, the Mediterranean Diet was presented as a food sustainability model (Dernini et al., 2013). In 2016, criteria were established for the evaluation of food sustainability based on the Mediterranean Diet (Donini et al., 2016). In 2028, the Mediterranean Diet will be a vehicle for biodiversity promotion. ...
... There are several recommendations in most of the official documents for the preservation of the environment. On the other hand, the Mediterranean Diet is frequently associated with food sustainability, as an example of a sustainable diet (Dernini et al., 2013;Dernini and Berry, 2015;Donini et al., 2016). However, is not easy to measure the indicators for this association, therefore, there is not enough evidence in this area to demonstrates this relationship. ...
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... Even though the FAO definition recognized the social and economic aspects of sustainable diets, most sustainability-related dietary guidelines have tended to rely narrowly on evidence from the health and environmental domains. On the health side, there is considerable literature linking individual nutrients, food groups, food patterns, and diet quality metrics with mortality and an array of health outcomes, including the risk of obesity and other non-communicable diseases [2]. On the environmental side, a well-accepted life-cycle assessment (LCA) methodology has been deployed to develop such indicators as land use, water use, and greenhouse gas emissions (GHGe). ...
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Technical Report
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Kenya, such as other African countries, is particularly concerned about the achievement of the Sustainable Development Goal #2 (SDG #2: zero hunger), and its associated consequences for the society. Empirical evidence about food security and nutrition in Kenya accounts for deficiencies in food access, food sufficiency and food quality at the household level. These deficiencies are among others the causes of all forms of malnutrition (stunting, wasting and overweight), which can lead to cognitive impairment, limited immunity to diseases, low educational performance, increased risk of chronic disease and even mortality cases of children in this country. To solve the food security and nutrition problems in Kenya is a challenging issue because of the different dimensions to be tackled (economic, environmental, educational, health and sanitation) and also because of the heterogeneity that characterizes households (income and food expenditure, education level of households’ head, regional sanitation coverage, access to potable water / waste water system, etc.). In the recent past, the Government of Kenya supported the construction of a roughly €1.1 billion fertilizer plant in Eldoret in the framework of a fertilizer cost reduction strategy aiming at stabilizing fertilizer prices and making fertilizer more accessible through local manufacturing, blending and bulk procurement. Increasing the domestic production of fertilizers should reduce the price of fertilizer, making them more accessible for farmers. Co-authors of this report, employing the STatic Applied General Equilibrium for DEVelopment (STAGE-DEV) Computable General Equilibrium (CGE) model, calibrated on a Social Accounting Matrix Kenya 2014, evaluated the impact on food security of the creation of the fertiliser plant together with three additional policy scenarios (market access, extension and subsidies removal). For the purpose of this study, we developed a macro-micro simulation model, based on the previously developed CGE and policy scenarios and on microsimulations using the Kenya Integrated Household Budged Survey 2015/2016. The objective is to produce new set of food security indicators using macro-micro model linkages and it is purely methodological. The policy results, which should be taken with some caution, are discussed in terms of initial economic (per capita income), food security (household dietary diversity and dietary energy consumption) and children’s nutritional (stunting, wasting) status at the household level. Furthermore, national results are disaggregated by metropolitan areas (Nairobi and Mombasa) and the rest of urban and rural zones of the country. Main results suggest that increasing fertilizers’ availability coupled with increasing market access through the improvement of infrastructures and the reduction of transport costs (market access scenario) will increase overall purchasing power. Supporting pro-poor growth, this development will benefit the most those households with lower diet diversity and higher stunting rates. This policy scenario also leads to the largest increases in diet energy consumption, with similar distributive results as for the purchasing power impact. Increasing fertilizers’ availability paired with improving crops productivity in agricultural practices (extension scenario) leads to the largest increase in energy consumption, particularly from fats in the diet, among households with low diet diversity. Average protein and carbohydrate consumption at national level increase the most within the market access scenario. The results confirm the findings of the previous report. Increasing fertilizer availability in Kenya is not enough to improve food security in the country. The contribution of complementary policies, such as increasing the market access for fertilizers and agriculture by improving the rural infrastructure or improving the extension services to train small-holder farmers about fertilizer and land use, that give farmers better access to input and output markets is needed.
... The sustainable diets framework developed in this study allows researchers and policy makers to expand their effort in order to integrate a more all-inclusive views of the food system [12]. In developing this framework, in addition to a literature review of both peer reviewed and grey literature, that other researchers' descriptions about sustainable diet were also included [8,9,13,14]. ...
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Background Todays, due to the impact of human food choices on increasing greenhouse gas emissions, water consumption and environmental degradation, there is a new thinking about changing the pattern of food production and consumption, including sustainable food and nutrition system related to consumption. This study aimed to explore the dimensions of a sustainable diet among the determinants of people's food choices. Methods This qualitative study was carried out using an in-depth interview with 33 individuals aged 30-64 years old living in different areas of Tehran. Data gathering, data analysis and theoretical conceptualization were performed simultaneously and from the beginning of the research, and for managing and organizing the data, the MAXQDA 10 software was used. Results In this paper, the findings are categorized according to the key components of a sustainable diet in five themes: "Health and Nutrition", "Food and Agriculture Security", "Environment and Ecosystems", "Markets, food trade and production chains", "social, cultural, and policy factors" were categorized. Meanwhile, the components of the "Health and Nutrition" domain had the highest contribution and the components of the two domains "food and agriculture" and "environment and ecosystems" had the lowest role among the statements of the participants in this study. Conclusion considering to the low importance of the dimensions of a sustainable diet in food choices of the community, promoting the individual awareness of sustainable diet components, clarifying the importance of food choices in creating environmental impacts and leading the national macro policies in the field food and nutrition toward sustainable diet goals are essential.
... Previous consensus papers addressed the Mediterranean diet as a healthy and sustainable dietary pattern [44]. The scientific literature provides convincing evidence of the beneficial effect of this dietary pattern on human health [45]. ...
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Background: Current scientific literature suggests healthy dietary patterns may have less environmental impact than current consumption patterns, but most of the studies rely on theoretical modeling. The aim of this study was to assess the impact on resources (land, water, and energy) use and greenhouse gas (GHG) emissions of healthy dietary patterns in a sample of Italian adults. Methods: Participants (n = 1806) were recruited through random sampling in the city of Catania, southern Italy. Dietary consumption was assessed through a validated food frequency questionnaire (FFQ); dietary patterns were calculated through dietary scores. The specific environmental footprints of food item production/processing were obtained from various available life-cycle assessments; a sustainability score was created based on the impact of the four environmental components calculated. Results: The contribution of major food groups to the environmental footprint showed that animal products (dairy, egg, meat, and fish) represented more than half of the impact on GHG emissions and energy requirements; meat products were the stronger contributors to GHG emissions and water use, while dairy products to energy use, and cereals to land use. All patterns investigated, with the exception of the Dietary Approach to Stop Hypertension (DASH), were linearly associated with the sustainability score. Among the components, higher adherence to the Mediterranean diet and Alternate Diet Quality Index (AHEI) was associated with lower GHG emissions, dietary quality index-international (DQI-I) with land use, while Nordic diet with land and water use. Conclusions: In conclusion, the adoption of healthy dietary patterns involves less use of natural resources and GHG emissions, representing eco-friendlier options in Italian adults.
... Food production, distribution, and consumption are arguably the major human activities with a direct impact not only on human health but also on environmental sustainability [11]. Environmental footprints (EFPs) characterized by land, water, and energy use, along with greenhouse gas (GHG) emissions, are the major environmental impacts of personal food consumption and are expected to become even more prominent with the rapidly growing human population [12][13][14]. ...
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Many Mediterranean countries, including Lebanon, are experiencing a shift in food consumption away from the traditional Mediterranean diet (MD), concomitant with the escalating burden of non-communicable diseases and dwindling environmental resources. Objective: to examine the adherence to the MD and its association with environmental footprints (EFPs), including water use, energy use, and greenhouse gas (GHG) emissions, among Lebanese adults. Data of Lebanese adults were drawn from the national food consumption survey (n = 2610). Assessment of dietary intake was conducted using a food-frequency questionnaire. Adherence to the MD was examined using four published MD scores. Metrics for the EFPs were calculated using a review of existing life cycle assessments (LCAs). For all MD scores, less than 13% of participants were in the highest tertile. After adjustments for covariates, two of the MD scores were associated with lower water use. For GHG, significant inverse associations were observed with all MD scores. Energy use was not associated with MD scores. Overall, low adherence to the MD among Lebanese adults was observed, together with an inverse association between adherence to the MD and water use and GHG emissions. These findings support and enforce ongoing efforts that aim to increase adherence to the MD in order to address health issues, as well as tackle environmental sustainability.
... Además, la DM ha conocido una existencia social desconectada del contexto cultural de su "descubrimiento" (SILVA, 2016). Finalmente, cabe notar que estudios recientes (DONINI et al., 2016;DERNINI;BERRY, 2015) asocian la DM a la sostenibilidad, atribuyéndole valores éticos, ecológicos y económicos. En resumen, podemos ver que el concepto va ganando otras acepciones y valores, asumiendo nuevas perspectivas y discursos. ...
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Resumen El presente estudio analiza, a través de una aproximación cualitativa, las representaciones sociales de la Dieta Mediterránea a partir de los discursos de dietistas y mujeres legas de nacionalidad española que residen en la ciudad de Barcelona (Cataluña, España). La comparación de los discursos permite comprender cómo un grupo profesional y un grupo lego manejan e incorporan discursos médicos y sociales en sus prácticas alimentarias. En la modernidad alimentaria, el proceso de medicalización de la alimentación ha contribuido a la emergencia progresiva de una racionalidad científica-nutricional. En este contexto la Dieta Mediterránea emerge en el campo médico encarnando de forma utópica una norma nutricional y moral. Al mismo tiempo, la modernidad alimentaria caracterizada por transformaciones sociales, como la industrialización y la instauración de espacios comunes transnacionales, ha provocado una especie de nostalgia respecto a ciertas prácticas alimentarias consideradas “tradicionales”. En este contexto, la Dieta Mediterránea gane importancia como una herencia cultural a proteger. En este caso, percibimos que los discursos médicos y sociales se fusionan, se complementan y se confunden, generando nuevas normas, representaciones y prácticas alimentarias.
Ancel Keys has named the Mediterranean Diet and since that time, many scientific studies have been carried out, the remarkable events and the advances in what is this cultural model. To know these milestones means to perceive a little better the context in which the definition of the Mediterranean Diet has developed over the years, one of the most striking events being the distinction as Intangible Cultural Heritage of Humanity by the United Nations Educational, Scientific and Cultural Organization. This article traces the history of the Mediterranean Diet since the genesis of its designation, revealing that the attributed distinction has created the opportunity for the population to rediscover the Mediterranean Diet and promote the rapprochement of peoples and regions, preserve cultures and strengthen sustainability in the food industry sector. The greatest challenge will be to preserve the Cultural Heritage inherent in the Mediterranean Diet and to continue to promote it for the new generations, so that the concept does not deteriorate and lose.
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The increase in the prevalence of obesity has coincided with an increase in portion sizes of foods both inside and outside the home, suggesting that larger portions may play a role in the obesity epidemic. Although it will be difficult to establish a causal relationship between increasing portion size and obesity, data indicate that portion size does influence energy intake. Several well-controlled, laboratory-based studies have shown that providing older children and adults with larger food portions can lead to significant increases in energy intake. This effect has been demonstrated for snacks and a variety of single meals and shown to persist over a 2-d period. Despite increases in intake, individuals presented with large portions generally do not report or respond to increased levels of fullness, suggesting that hunger and satiety signals are ignored or overridden. One strategy to address the effect of portion size is decreasing the energy density (kilojoules per gram; kilocalories per gram) of foods. Several studies have demonstrated that eating low-energy-dense foods (such as fruits, vegetables, and soups) maintains satiety while reducing energy intake. In a clinical trial, advising individuals to eat portions of low-energy-dense foods was a more successful weight loss strategy than fat reduction coupled with restriction of portion sizes. Eating satisfying portions of low-energy-dense foods can help to enhance satiety and control hunger while restricting energy intake for weight management.
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Objective: To systematically review all the prospective cohort studies that have analysed the relation between adherence to a Mediterranean diet, mortality, and incidence of chronic diseases in a primary prevention setting. Design: Meta-analysis of prospective cohort studies. Data sources: English and non-English publications in PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials from 1966 to 30 June 2008. Studies reviewed Studies that analysed prospectively the association between adherence to a Mediterranean diet, mortality, and incidence of diseases; 12 studies, with a total of 1 574,299 subjects followed for a time ranging from three to 18 years were included. Results: The cumulative analysis among eight cohorts (514,816 subjects and 33,576 deaths) evaluating overall mortality in relation to adherence to a Mediterranean diet showed that a two point increase in the adherence score was significantly associated with a reduced risk of mortality (pooled relative risk 0.91, 95% confidence interval 0.89 to 0.94). Likewise, the analyses showed a beneficial role for greater adherence to a Mediterranean diet on cardiovascular mortality (pooled relative risk 0.91, 0.87 to 0.95), incidence of or mortality from cancer (0.94, 0.92 to 0.96), and incidence of Parkinson's disease and Alzheimer's disease (0.87, 0.80 to 0.96). Conclusions: Greater adherence to a Mediterranean diet is associated with a significant improvement in health status, as seen by a significant reduction in overall mortality (9%), mortality from cardiovascular diseases (9%), incidence of or mortality from cancer (6%), and incidence of Parkinson's disease and Alzheimer's disease (13%). These results seem to be clinically relevant for public health, in particular for encouraging a Mediterranean-like dietary pattern for primary prevention of major chronic diseases.
The problem of the availability of food consumption data relative to one or more populations is not a new one. Because of the need in each country for a reliable data bank for intakes of nutrients and non-nutrients, for an updated evaluation of factors affecting food intakes, for nutrition education interventions and for a better approach to food policy plans, the problem of precise knowledge of food intakes becomes actual and pressing. It is well known in fact that industrialized countries have several sources of data on food intakes. They range from “Food balance sheets” (FBS) to National surveys, to more specialized and centered surveys. The methodological approaches are different as is the ability to provide better or poorer knowledge on food intake [1].
To the Editor: The interventional nutritional study by Estruch et al. (April 4 issue)(1) is limited by low primary composite cardiovascular outcome rates (3.8% and 3.4% in the intervention groups vs. 4.4% in the control group) with minor absolute risk differences (range, 0.6 to 1%). Given these small margins of risk, there were at least four statistically significant differences in baseline characteristics between the groups, which could contribute substantially to these minor absolute differences in risk. There were significantly higher percentages of men (+5.7%), obese persons (+4.7%), diuretic use (+3.5%), and oral hypoglycemic use (+3.2%) in the control group than ...