The Role of Healthy Diets in Environmentally Sustainable Food Systems

Abstract

Background
The global food system is directly linked to international health and sustainability targets, such as the United Nation’s Sustainable Development Goals, Paris Agreement climate change targets, and the Aichi Biodiversity Targets. These targets are already threatened by current dietary patterns and will be further threatened by 2050 because of a growing population and transitions toward diets with more calories, animal-source foods, and ultra-processed foods. While dietary changes to healthier and predominantly plant-based diets will be integral to meeting environmental targets, economic, social, and cultural barriers make such dietary transitions difficult.

Objective
To discuss the role of healthy diets in sustainable food systems and to highlight potential difficulties and solutions of transitioning toward healthier dietary patterns. To do so, we synthesize global knowledge and conduct a series of case studies on 4 countries that differ in their social, economic, political, and dietary contexts: Brazil, Vietnam, Kenya, and Sweden.

Conclusions
No single “silver bullet” policy solution exists to shift food choices toward sustainable healthy diets. Instead, simultaneous action by the public sector, private sector, and governments will be needed.

Full text

Sustainable and Healthy Diets Supplement
The Role of Healthy Diets in
Environmentally Sustainable
Food Systems
Michael Clark, PhD
1
, Jennie Macdiarmid, PhD
2
,
Andrew D. Jones, PhD
3
, Janet Ranganathan, MSc
4
,
Mario Herrero, PhD
5
, and Jessica Fanzo, PhD
6
Abstract
Background: The global food system is directly linked to international health and sustainability
targets, such as the United Nation’s Sustainable Development Goals, Paris Agreement climate change
targets, and the Aichi Biodiversity Targets. These targets are already threatened by current dietary
patterns and will be further threatened by 2050 because of a growing population and transitions
toward diets with more calories, animal-source foods, and ultra-processed foods. While dietary
changes to healthier and predominantly plant-based diets will be integral to meeting environmental
targets, economic, social, and cultural barriers make such dietary transitions difficult.
Objective: To discuss the role of healthy diets in sustainable food systems and to highlight potential
difficulties and solutions of transitioning toward healthier dietary patterns. To do so, we synthesize
global knowledge and conduct a series of case studies on 4 countries that differ in their social, eco-
nomic, political, and dietary contexts: Brazil, Vietnam, Kenya, and Sweden.
Conclusions: No single “silver bullet” policy solution exists to shift food choices toward sustainable
healthy diets. Instead, simultaneous action by the public sector, private sector, and governments will be
needed.
Keywords
diets, environmental sustainability, health, food system transitions, solutions
Introduction
Food systems—The entire range of actors and their
interlinked value-adding activities involved in the
production, aggregation, processing, distribution,
consumption, and disposal of food products—
range from local to global in scale. In 2010, the
FAO defined sustainable diets as those with “low
environmental impacts which contribute ...to
healthy life for present and future genera-
tions ...[and] are protective and respectful of bio-
diversity and ecosystems, culturally acceptable,
1
Big Data Institute, University of Oxford, Oxford, UK
2
University of Aberdeen, Aberdeen, UK
3
University of Michigan, Ann Arbor, MI, USA
4
World Resources Institute, Washington DC, USA
5
Commonwealth Scientific Industrial Research Organisation,
Brisbane, Queensland, Australia
6
Johns Hopkins University, Baltimore, MD, USA
Corresponding Author:
Michael Clark, Big Data Institute, University of Oxford, Old
Road Campus, Oxford OX3 7LF, UK.
Email: michael.clark@npdh.ox.ac.uk
Food and Nutrition Bulletin
2020, Vol. 41(2S) S31-S58
ªThe Author(s) 2020
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sagepub.com/journals-permissions
DOI: 10.1177/0379572120953734
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accessible, economically fair and affordable;
nutritionally adequate, safe and healthy.”
1
Sustain-
able food systems vary by scale and by local envi-
ronmental, economic, cultural, political, and
institutional contexts. The context-dependent
nature of sustainability means that developing food
systems that are sustainable at local to global scales
will be a complex challenge.
Many international health and sustainability
goals—such as the Sustainable Development
Goals (SDGs),
2
the Paris Agreement,
3
or Aichi
Biodiversity Targets
4
—are linked to food sys-
tems. In many cases, meeting these goals will not
be possible with current food systems. For health,
while the global food system provides food for
over 7.5 billion people, poor dietary quality is
simultaneously the largest source of poor health.
5
Less than half of the world’s adult population has
a healthy body mass (body mass index 18.5 and
< 25) and micronutrient deficiencies are common
in low-, middle-, and high-income countries,
thereby risking achievement of SDG2 and
SDG3.
6
Air pollution from food production threa-
tens SDGs 3, 7, and 11. For environment, the
global food system occupies *30%of Earth’s
land surface and is the leading source of land use
change. Food systems emit *20%to 35%of all
greenhouse gas (GHG) emissions, threatening
global temperature targets (SDGs 13 and Paris
Agreement).
7
Unsustainable rates of fertilizer
application and resultant nutrient pollution,
8
combined with unsustainable water withdrawals,
8
land use change,
8
and the overuse and misuse of
pesticides
9
threaten biodiversity targets (SDGs 14
and 15, Aichi Biodiversity Targets) as well as our
ability to provide adequate amounts of safe drink-
ing water (SDG 6).
In this paper, we focus on how dietary transi-
tions toward sustainable healthy diets can help
achieve health- and environmental-oriented sus-
tainability targets. We first discuss how current
dietary trajectories will increasingly impact
human and environmental health. We then high-
light how transitions to healthier diets could help
meet environmental targets. Third, because tran-
sitions to sustainable food systems will differ due
to local and national contexts, we use a series of
4 case studies to discuss how adoption of healthy
diets might contribute to sustainable food system
in countries that vary in their environmental,
human health, and sociopolitical contexts.
Fourth, we discuss how governments and busi-
ness can shift individuals toward sustainable
healthy diets. We conclude by discussing com-
plexities and potential difficulties of creating
sustainable food systems as well as some unan-
swered questions that might hinder or facilitate
their development.
Using Recent Dietary Trends
to Gain Insight into Future
Dietary Transitions
Diets have changed rapidly over the past several
decades.
10
Here, we discuss dietary trends from
1975 to 2013 using food supply data, which is
measured as the amount of food available for
human consumption, due to its geographic and
temporal coverage. However, it is important to
note that consumption is less than food supply
and that an increase in food supply may not
translate to an equivalent increase in food
consumption.
From 1975 to 2013, global average per capita
calorie supply increased by 25%.
10
Supply of cer-
tain foods increased more rapidly. For example,
per capita supply of animal-source foods (meat,
dairy, and eggs), fruits and vegetables, and vege-
table oils increased by 40%,98%,and80%,
respectively,
10
although it is important to note
that consumption of fruits and vegetables remains
below-recommended levels despite recent
increases in supply.
11
Supply of processed foods
also increased, depicted by the rapid increase in
fats and sugars, while changes in per capita sup-
ply of staple foods, such as cereals and starchy
roots and tubers, have been smaller.
10
Dietary transitions have occurred at different
rates and different times in different countries
(Figure S1).
10
In low-middle and middle-income
countries, such as those in North Africa, East Asia,
and South and Southeast Asia, nutrition transitions
toward diets with more calories, fresh fruits and
vegetables, and animal-source foods occurred as
populations became more affluent. From 1975 to
2013, supply of animal-source foods (meat, fish,
dairy, and eggs) increased more rapidly than other
S32 Food and Nutrition Bulletin 41(2S)

foods, particularly in East Asia (310%increase),
South America (72%increase), and North Africa
(100%increase).
10
Per capita supply of fresh fruits
and vegetables also increased in these regions,
although current consumption often remains
below dietary recommendations.
11
While Figure
S1 and the text discuss the proportional change in
the per capita supply of calories, it should be noted
that absolute supply varies between countries,
with a lower baseline supply in low-income
countries.
10
High-income regions, such as Europe, North
America, Australia, and New Zealand, have expe-
rienced smaller dietary changes since 1975.
10
This is primarily because nutrition transitions in
high-income countries occurred before 1975, and
that supply of calories, fruits and vegetables, and
animal-source foods was already high. While the
supply of fruit and vegetables has increased since
1975, consumption typically remains below diet-
ary recommendations.
10
In short, recent and
on-going nutrition transitions in low-middle and
middle-income nations are causing diets to
become more similar to those consumed in higher
income nations.
12
The least affluent regions have not yet experi-
enced large nutrition transitions but are beginning
to experience them as populations become more
affluent and urbanized.
13
From 1975 to 2013, per
capita total caloric supply in sub-Saharan Africa
increased 16%from 2130 to 2460 calories per day,
while supply of animal-source foods increased 13%
from 168 to 190 calories per day.
10
However, while
nutrition transitions have typically been slow in
sub-Saharan Africa, some of the more affluent
countries experienced more rapid dietary changes:
Since 1975, total caloric supply increased by >40%
in 9 countries while supply of animal-source foods
increased >50%in 13 countries.
10
Future dietary
trends in sub-Saharan Africa are likely to follow
similar trends those that have previously recently
occurred in more affluent regions.
13
Diets globally are projected to continue
changing in the coming decades, particularly
in lower income regions.
14
Large increases in
animal-source foods and for calories from
energy-dense (which are often, but not always,
nutrient poor foods; eg, oils, animal fats,
alcohol, and sugar) are expected. Between
2010 and 2050, average total per capita caloric
supply is projected to increase 15%, while sup-
ply of meat is projected to increase >25%, sup-
ply of dairy and eggs >50%, and supply of
calories from oils, alcohol, and sugar >60%.
14
However, although future nutrition transitions
are projected to be largest in many low- and
low-middle-income countries, future per capita
supply of total calories and animal-source
foods in these countries is projected to remain
lower than current supply in many middle- and
high-income countries.
14,15
We have necessarily focused on trends in con-
sumption and supply of different food groups due
to data availability, although, as discussed later,
the health and environmental impacts of foods
within these groups can be variable. However,
this does not mean that dietary patterns in
high-income nations are unlikely to change in the
next decades or that trends in food production
follow similar trends to food consumption and
supply. In contrast, consumption patterns in these
countries are changing rapidly but is not captured
by the coarse-grained FAO data. For instance,
sales of nondairy milks in the United States
increased 61%from 2012 to 2017 and are now
consumed by nearly a quarter of Brits
16
; con-
sumption of sugar-sweetened beverages is
decreasing, often as a result of policy reform
17,18
;
and poultry is being substituted for beef and pork
in many countries.
10
In addition, within a country,
trends in production may follow different patterns
due to increasing international trade. For
instance, there is an increasingly large gap
between meat production and consumption in
some of the world’s highest producing countries
such as Brazil, the United States, and Australia.
10
Environmental and Health
Impacts of Future Diets
Environmental Impacts
Foods differ greatly in their environmental
impacts (Figure 1).
19,20
Meat from ruminants has
the largest environmental impact for most envi-
ronmental indicators, for instance having GHG
emissions, land use, and nutrient pollution
impacts 100 times larger than whole grain
Clark et al S33

cereals.
19,20
Poultry and pork have environmental
impacts several times larger than plant-based
foods, as do most fish.
19,20
However, the environ-
mental impacts of fish are variable because of the
wide variety of fish and fish production sys-
tems.
19
Dairy and eggs have lower environmental
impacts than meat but higher environmental
impacts than most plant-based foods.
19,20
While there can be large variation around the
mean environmental impact of a given food, the
lowest impact animal-source food typically has
higher environmental impacts than the highest
impact plant-based food.
20
While systems that dif-
fer in production methodology (eg, intensive and
extensive, organic, and nonorganic systems) or
location can have different environmental impacts
(see Box 1 for further discussion), these differ-
ences are small compared to the difference in
impacts between animal and plant-based
foods.
19-21
The trend in environmental impact
between foods is similar across the different nutri-
tional units (eg, per calorie or per gram) often used
to express a food’s environmental impact.
19
Animal-source foods have larger environ-
mental impacts than plant source foods because
livestock are inefficient at converting feed into
food.
19,20
Meat from ruminants has the highest
impact for many environmental indicators, in
part because producing it requires *15 to 20
calories of feed per calorie of edible meat pro-
duced,
12
but also because it is land-intensive
and because ruminants release methane,
19,20
a
GHG more potent than carbon dioxide, when
digesting food. Pork and poultry production
have lower environmental impacts than rumi-
nant meat production, largely because they use
less feed and therefore less land to produce the
same amount of food, while egg and dairy
production typically have environmental lower
impacts and use less feed than pork and
poultry.
12
Dietary transitions to diets that include more
calories and larger quantities of animal-source
foods are projected to lead to larger environmen-
tal impacts (Figure 2).
22,23
The largest propor-
tional and absolute increases in per capita
impacts are projected in currently low-income
and lower middle-income countries.
22,23
Although future diets in low-income and lower
middle-income countries are projected to
Figure 1. Greenhouse gas, land use, energy use, acidification potential, and eutrophication potential impacts per
calorie, g protein, serving, or gram of production of different foods. Dot indicates mean environmental impact, and
error bars indicate one standard error around the mean. NR Aqua, non-recirculating aquaculture; NT Fishery,
non-trawling fishery; Recirc Aqua, recirculating aquaculture. Figures reprinted from the study by Clark and
Tilman.
19
Impacts follow similar trends when reported per kcal, protein, or serving.
S34 Food and Nutrition Bulletin 41(2S)

Figure 2. Current and projected per capita diet-related GHG emissions. Countries are labeled by ISO3 code (https://unstats.un.org/unsd/tradekb/knowledgebase/
country-code), separated by WHO income groups, and are ordered by current 2010 per capita diet-related GHG emissions within each panel. The start of each
segment indicates estimated per capita GHG emissions in 2010, whereas tip of the arrow indicates projected emissions in 2050 if current dietary trajectories
continue. Downward facing arrows indicate that per capita diet-related GHG emissions are projected to decrease from 2010 to 2050. Horizontal dashed line
indicates average per capita GHG emissions in high-income countries. Data are obtained from the study by Springmann et al.
23
GHG indicates greenhouse gas.
S35

contain fewer calories from animal-source foods
than current diets in high-income regions, future
per capita diet-related environmental impacts in
these regions are projected to be similar to current
impacts in upper middle and high-income coun-
tries.
24
This is primarily because food production
in less affluent countries has higher environmental
impacts per unit of food produced than in more
affluent countries,
20,25
although the gap may nar-
row as agricultural production practices change.
Smaller changes in per capita impacts are projected
in upper middle and high-income countries, largely
because future dietary changes in these regions are
projectedtobesmall.
22
However, because current
per capita diet-related environmental impacts in
high-income countries are greater than in most
other countries, reducing the per capita impacts
in middle- and high-income nations is as impor-
tant, if not more important (and likely also a more
equitable approach), than is slowing increases in
per capita impacts in less affluent regions.
22
Dietary transitions combined with an expected
*2.5 billion person increase in global population
means that global diet-related environmental
impacts are likely to increase rapidly. By 2050,
global GHG emissions from food production are
projected to increase by 50%to 80%, equivalent to
12%to 20%of current global GHG emissions.
23
Cropland use is projected to increase by 200 mil-
lion to 700 million hectares, which will also result
in GHG emissions from deforestation and other
land use change.
23,26,12
Nitrogen and phosphorus
fertilizer applications are projected to increase by
35%and 70%by 2050, respectively,
23
while pes-
ticide applications are also likely to increase.
Increased GHG emissions, agricultural-driven
land use change, and nutrient and pesticide runoff
will further stress biodiversity, particularly in less
affluent regions such, as sub-Saharan Africa and
Central and South America, and for species that
require large amounts of minimally disturbed habi-
tat,
27
while increased demand for fish will likely
further threaten the already stressed status of fresh-
water and marine fisheries.
28
Health
Future dietary changes are expected to negatively
impact human health.
22
Diet-related disease and
mortality risk is projected to increase as a result
of increased consumption of foods high in sodium
combined with low intakes of whole grains, fruits
and vegetables, and weight gain resulting from
increased caloric intake above metabolic require-
ments.
22
Increased consumption of excess red and
processed meat is also expected to increase disease
risk but to a smaller extent.
22
Prevalence of
diet-related mortality is projected to increase most
rapidly in lower middle and upper middle coun-
tries, where diets are changing most rapidly
22
(Fig-
ure 3). In contrast, prevalence of diet-related
mortality is projected todecrease in other countries
because increased consumption of plant-based
food and changes in caloric consumption mean
that total caloric consumption is projected to
become more similar to metabolic needs.
22,24
Consumer Dietary Choice as a
Lever to Improve Health and
Environmental Outcomes
Consumer-driven transitions toward diets associ-
ated with improved health could provide global
environmental benefits (eg,
11,12,22,24
). In this sec-
tion, we specifically highlight the traditional
Mediterranean diet, a lower-meat/flexitarian diet,
a pescetarian diet, and a vegetarian diet because
these diets have consistently been shown to be
associated with reduced disease incidence and
risk of mortality in the United States, the Eur-
opean Union, and other high -income nations (see
Willett et al
11
for an in-depth discussion).
These diets are primarily composed of whole
grain cereals, fruits, vegetables, nuts and seeds,
legumes, healthy oils and fats (eg, oils high in
mono- and polyunsaturated fatty acids
29
),
*1 to 2 servings per day of animal-source foods,
and limited amounts of added sugars, sweeteners,
and alcohol. The Mediterranean diet is based on
what used to be the traditional diets in Mediterra-
nean communities, where prevalence of
diet-related diseases was low and life span was
among the highest in the world.
30
Lower meat/
flexitarian diets contain small amounts of meat,
11
pescetarian diets contain fish but no other meat,
vegetarian diets do not contain any fish or meat,
and vegan diets contain no animal-based foods.
S36 Food and Nutrition Bulletin 41(2S)

Figure 3. Current and projected prevalence of diet-related related chronic diseases. Countries are labeled by ISO3 code (https://unstats.un.org/unsd/tradekb/
knowledgebase/country-code), separated by income WHO income group, and are ordered by current prevalence of diet-related diseases within income groups.
Projected increase in percent of the population that has diet-related diseases of diet-related diseases. Downward facing arrows indicate that prevalence of diet-
related diseases is projected to decrease from 2010 to 2050. Horizontal dashed lines indicate average diet-related disease prevalence in high-income countries.
Data are obtained from the study by Springmann et al.
24
S37

Importantly, there is flexibility for consumers
to modify Mediterranean, pescetarian, vegetarian,
and vegan diets to accommodate personal food
preferences, availability, culture, and socioeco-
nomic values. For instance, the New Nordic Diet
is an example of a Mediterranean-like diet mod-
ified for the culture, values, and food preferences
of the Nordic region.
31
However, it cannot be
assumed that transitioning toward one of these
diets will improve health if consumer dietary
choices do not also follow healthy eating guide-
lines or if animal-source foods are replaced with
plant-based foods high in refined grains, sugars,
and fat.
32
Likewise, while diets composed pri-
marily of plant-based foods can have low envi-
ronmental impacts, this cannot be assumed,
33
as
some plant-based foods associated with improved
health outcomes can also have a high environ-
mental impact, as is the case with nuts and
water use.
34
Consumers can begin transitioning toward
these diets by emphasizing consumption of
“win-win” foods—that is, foods that are benefi-
cial for health and have low environmental
impacts (Figure 4).
34
Whole grain cereals, fruits
and vegetables, legumes, and most nuts and seeds
are good examples. It is also important to identify
foods that might be “win-lose” (beneficial for
health but have high environmental impacts) or
“lose-win” (detrimental to health but have low
environmental impacts) to avoid unintended con-
sequences. Fish is a good example of a potential
win-lose, being associated with improved health
but a relatively high environmental impact
depending on how it is produced. Some nuts
(especially pistachios and almonds) could be con-
sidered win-loses because of their high water use
even though they have low impacts for most other
environmental outcomes.
35
Sugar and some oils
(particularly those containing trans fats) are lose--
wins—bad for health but have low environmental
impacts—if they do not result in land use change.
If production of sugar and oils results in land use
change—as has often occurred in the tropics—
then it is more likely that these foods are lose--
loses.
20
Red and processed meat are clear
lose-loses, being associated with increased dis-
ease risk and having among the highest environ-
mental impacts for all environmental indicators
examined. The complexity and tradeoffs of the
joint health and environmental impacts of foods
is why it is important for dietary recommenda-
tions to jointly consider health and environment.
Global adoption of a diet primarily composed
of foods that are win-wins—such as a Mediterra-
nean, low-meat/flexitarian, pescetarian, or vege-
tarian diet—has been estimated to have large
benefits relative to projected future diets.
36
By
2050, the diets highlighted here are estimated to
reduce future diet-related GHG emissions by 25%
to 60%relative to projected future dietary pat-
terns.
11,23
The estimated health and environmen-
tal benefits of these potential dietary changes
vary by region, with larger benefits estimated in
higher income countries where current diets often
exceed caloric and protein recommendations and
contain large quantities animal-source foods.
23,24
In contrast, smaller benefits are estimated in less
affluent regions because diets in these regions
contain fewer calories in excess and smaller
quantities of foods known to be associated with
poor health.
24
These diets are also projected to
offer health benefits, for instance by reducing risk
of diet-related diseases such as type 2 diabetes,
coronary heart disease, and stroke.
24
In contrast,
increasing consumption of meat, fish, dairy, and
Figure 4. Health and environmental impacts of
consuming an additional serving per day of different
foods. Health data are primarily drawn from higher
income contexts; environmental data are as globally
representative as possible given data limitations.
Closed circles indicate foods associated with significant
changes in health outcomes. Reproduced from the
study Clark et al.
34
S38 Food and Nutrition Bulletin 41(2S)

eggs could be beneficial in low-income contexts
where undernourishment is prevalent: increasing
consumption of these foods can be critical in fill-
ing nutrient gaps, for example, iron and zinc.
37
While there is sometimes concern about insuffi-
cient protein intake when transitioning to more
plant-based diets, this concern is largely
unfounded in most countries: Average protein
consumption exceeds international recommenda-
tions in all but 11 countries where inadequate
caloric consumption is common
38
(see Box 1 for
a longer discussion).
Case Studies
This section presents a series of case studies
examining potential pathways and barriers to
adoption of sustainable healthy diets in 4 coun-
tries. The countries we’ve chosen—Brazil,
Kenya, Vietnam, and Sweden—vary in diets,
socioeconomic status, political, cultural, eco-
nomic, and social structures. In each case study,
we discuss recent dietary changes, the associated
health and environmental impacts, and potential
opportunities to transition to healthier and more
environmentally sustainable diets. We highlight
issues that might be unique to these nations as
well as current and potential barriers to adopting
healthier and more sustainable diets.
Brazil—Deforestation to Feed a
Growing Desire for Meat
Changing dietary patterns in Brazil. Nutrition transi-
tions are occurring in Brazil.
39
Notably, the
increase in consumption of animal-based products,
especially meat; the per capita supply of meat has
steadily increased from approximately 38 kg/yr in
1985 to 98 kg/yr in 2013.
10
Traditional diets com-
prising unprocessed plant-based foods (eg, beans,
rice, potatoes, fruits, vegetables) are changing, with
people preferring to eat diets containing more ani-
mal products and energy-dense ultra-processed
foods, which are high in added sugar, salt, or fat.
40
These dietary patterns are more common in urban
areas than in rural areas, where incomes are higher
and these foods are more readily available. A sur-
vey conducted in Sa
˜o Paulo (2008/9) reported that
while approximately 80%of people ate less than
recommended intakes of milk and dairy, fruit, cer-
eals, and roots, only 8%ate less than the maximum
recommendation for meat and eggs,
41
with beef
being 1 of the 5 most commonly consumed foods.
42
These dietary patterns are leading to high pre-
valence of obesity and associated diet-related
non-communicable diseases, such as type 2 dia-
betes, cancer, and heart disease. In Brazil, the
prevalence of overweight and obesity increased
from 34.1%in 2006 to 48.1%in 2011,
43
with
overweight and obesity being 3 times more com-
mon than underweight.
44
Without any interven-
tion, the prevalence is projected to continue
increasing, and that, by 2050, annual
obesity-related health care costs will double to
approximately $10 billion.
45
These health out-
comes combined with greater recognition of the
environmental impact of these emerging dietary
patterns, especially the increase in consumption
of animal-based products lead to the revision of
national dietary guidelines.
The Brazilian dietary guidelines were revised in
2015, which in line with the recent FAO/WHO
guiding principles for sustainable health diets,
46
recommend reducing meat consumption and
increasing plant-based foods to improve health and
the environment.
47
A recent study investigating
awareness of the link between meat consumption
and climate change found that there was greater
awareness in Brazil than in the United States and
United Kingdom.
48
People were reportedly
concerned about the environmental impact of live-
stock production, specifically related to deforesta-
tion and air pollution. However, they were also
concerned that reducing meat consumption would
be regressive, which could exclude them from
social activities and marginalizing them from peer
groups. As with many countries going through
economic growth, meat consumption is symbolic
of social and economic progress, which can con-
tribute to the reluctance of some people to eat less
meat.
49
This creates multiple health, environmen-
tal, social, and economic trade-offs to be consid-
ered, not least because livestock production is a
major source of income in Brazil.
Deforestation to feed a growing desire for meat. Bra-
zil is notable for production of livestock and ani-
mal feed to meet the ever-increasing national and
Clark et al S39

global demand for meat. Brazil is the largest
exporter of beef in the world. Approximately
20%of global beef exports currently come from
Brazil, which is predicted to increase to 23%
(2.9 million metric tons) by 2028.
50,51
The pro-
duction and export of poultry meat has rapidly
increased since the 1980s, with production of
poultry now exceeding production of beef. The
massive export market was driven in part by the
establishment of the Southern Common Market
(MERCOSUR) in 1991 that opened export mar-
kets, resulting beef exports in Brazil increasing
approximately 6-fold and poultry exports almost
12-fold.
10
Approximately 30%of Brazil’s export
revenue comes from agricultural products.
52
However, the increase in agricultural production
and easier access to export markets has come at
the expense of the environment, as seen with land
expansion and deforestation in the Amazon rain-
forest, Cerrado, Pantanal, and Atlantic Forest for
both grazing cattle and production of feed. In
addition to cattle farming, competition for land
(and therefore deforestation) is increasing with
the growth in other major agricultural exports
such as soya (including for animal feed), sugar-
cane (mainly for ethanol), coffee, and maize.
52
There has also been a shift from small-scale farm-
ing to more intensive and mechanized production
systems that has increased use and runoff of agri-
chemicals such as fertilizer and pesticides.
53
Agricultural expansion has led to a complex
economic and environmental policy conflict over
production of commodities. As part of the Paris
Agreement in 2015, Brazil made a commitment
to reduce GHG emissions by 37%and 43%below
2005 levels by 2025 and 2030,
3
respectively.
Their mitigation strategies included reducing
GHG emissions in the agriculture sector (the sec-
ond largest contributor to GHG emissions in Bra-
zil) and a target of zero illegal deforestation in the
Brazilian Amazon by 2030.
54
At the same time,
the More Ranching Plan (MRP 2014) was drawn
up, which set out to intensify beef production
(based on the concept of land sparing), thereby
increasing livestock production through growing
herds and higher livestock densities for national
supply and for export markets.
55
The conflict
between economic development through agricul-
tural production and environmental degradation
continues to grow. As a means to conserve natural
ecosystems, The Forest Code was first passed in
1965 requiring landowners to maintain 30%to
80%of their land as native vegetation, then
revised in 2012, then over turned by new admin-
istration in 2018.
Another dietary recommendation is to avoid
eating ultra-processed and mainly eat natural and
unprocessed foods. Ultra-processed foods are typi-
cally energy-dense, comprising unhealthy ingredi-
ents such as sugar, saturated fat, or salt (and are
often referred to as “fast foods” or convenience
foods).
40
Production of many of the ingredients
in is also having an impact on the environment,
including contributing to deforestation for agricul-
tural land, increased monocropping (eg, for soy,
oils, and sugar), fertilizer application, and pollu-
tion. Global demand for ultra-processed and
energy-dense foods is increasingly creating an
export market for these ingredients with signifi-
cant economic for Brazil. As with meat produc-
tion, there is a complex trade-off between
protecting the environment and economic growth.
Summary. The current Brazilian food system is
currently environmentally unsustainable.
Ongoing nutrition transitions towards diets con-
taining more meat and processed energy-dense
foods are contributing to an increase in
ill-health (eg, obesity and diabetes) and environ-
mental degradation, particularly deforestation
and resultant biodiversity loss. The conflict
between economic growth from agriculture, cul-
tural values, nutrition security, and the environ-
ment risks progress toward improving dietary
quality and reducing diet-related environmental
impacts. Not only in Brazil but globally, the
demand for meat needs to reduce to prevent
deforestation. As with other countries, agricul-
tural, nutrition and health, and environmental pol-
icies will have to be aligned to create a healthy
and sustainable food system.
Vietnam—The Current and Future
Role of Aquaculture
The nutrition transition in Vietnam. Like most low-
and middle-income countries, Vietnam has
undergone a marked nutrition transition in recent
S40 Food and Nutrition Bulletin 41(2S)

decades.
39
Total daily per capita caloric supply
increased 47%from 1975 to 2013 (from 1868 to
2745 calories per day), while per capita consump-
tion of processed food increased nearly 300%
from 1999 to 2012 from 10.7 kg per capita in
1999 to 38.7 kg in 2012.
10,56
Per capita supply
of sugar and other sweeteners increased 36%
from 1975 to 2013, while consumption of satu-
rated fats, largely from animal-source foods
nearly tripled. The rising dominance of
animal-source foods in Vietnamese diets is strik-
ing. In 1975, per capita caloric supply from
animal-source foods was 5.5%(103 calories per
day) and had increased to 20.9%(490 calories per
day) by 2013. Increasing availability of pork,
beginning in the early 1990s, is responsible for
most of this increase, with per capita pork supply
increasing >600%. Increased supply of other
animal-source foods was observed over the same
period, with caloric supply of poultry, bovine
meat, and fish increasing by 560%,367%,and
173%, respectively.
These dietary changes have been driven in part
by increasing urbanization and per capita afflu-
ence as well as changes in retail food environ-
ments. Following the “Doi Moi” structural
reforms, a series of reforms in the mid-1980s
aimed at transitioning Vietnam to a more
market-oriented economy, GDP growth averaged
6.4%from 1985 to 2017, while the country’s
poverty headcount ratio (percent of the popula-
tion with <$1.90 GDP Purchasing Power Parity)
declined considerably from 52.9%in 1992 to
2.0%in 2016.
57
These changes in welfare were
paralleled by increases in internal migration from
rural to urban areas (Vietnam has among the
highest rates of rural-urban migration in Asia),
cross-border migration from other countries in
Southeast Asia, and changes in the retail food
environment. The diffusion of modern food retail,
characterized by increased supply of
energy-dense and ultra-processed foods, reached
Vietnam in the late 1990s and early 2000s. These
changes were spurred by the liberalization of
retail foreign direct investment and food safety
concerns, resulting in sales from modern food
retail chains increasing by 1900%from 2001 to
2009.
58,59
The convergence of increased per
capita affluence, internal and cross-border
migration, and introduction of food retail chains
has contributed to recent and ongoing changes in
dietary patterns.
Recent changes in dietary patterns have been
linked to changing nutritional status. Over the
past 2 decades, the prevalence of stunting
(defined as low height-for-age) among children
under 5 years of age decreased from 61.4%in
1993 to 24.6%in 2015.
57
This decline has been
spurred not only by rapid economic growth but
also by specific government efforts to prioritize
nutrition, including a National Nutrition Strategy,
explicit policies to improve infant and young
child feeding practices, and measures to reduce
prevalence of micronutrient deficiencies.
60
Paral-
lel to these reductions in undernutrition, however,
is increasing prevalence of overweight and obe-
sity. Between 1980 and 2013, prevalence of over-
weight and obesity doubled from 6.2%to 12.3%
among adult women (20 years), tripled among
adult men from 4.3%to 13.6%, and increased by
500%since 2000 among preschool-aged children
to 4.8%in 2010, which is similar to prevalence of
childhood overweight in other countries in South-
east Asia.
57,61
While prevalence of overweight
and obesity among adults is less than half that
of most neighboring countries, the marked
increase observed in recent years is of concern.
Like many lower middle-income countries, Viet-
nam currently faces multiple burdens of malnu-
trition. Recent and unprecedented changes in
Vietnam’s food system offer both challenges and
opportunities to meeting global sustainability tar-
gets, and fisheries in Vietnam are uniquely posi-
tioned to guide progress toward these targets.
Fisheries and aquaculture in Vietnam. Nearly 8 mil-
lion people, or about 9%of Vietnam’s popula-
tion, derived their main income from the
fisheries sector in 2012.
62
The economic impor-
tance of Vietnam’s fisheries is perhaps not sur-
prising given the country’s more than 3000
kilometers of coastline, numerous inland capture
fisheries, and a rich food culture in which fish and
fish sauces play a central role. Since the Moi-Doi
reforms, fish production in Vietnam increased
more than 500%.
10
By 2020, fish production is
expected to reach 7 million tons, with much of
this production destined for export, because of a
Clark et al S41

recent 5-year government plan aimed at increas-
ing investment in and supporting development of
major fishing centers.
62
Fish exports have
increased rapidly since the Moi-Doi reforms,
increasing from 4%of production in 1985 to
47%in 2013,
63
and currently accounting for an
estimated 4%to 5%of Vietnam’s GDP.
64
While
recent increases in fish production have been eco-
nomically beneficial, they have not occurred
without negative environmental impacts. Viet-
nam’s marine and inshore fisheries, on which
millions of low-income fishers depend for their
livelihoods, are consistently over exploited.
65
Aquaculture has become a key strategy for
increasing fish production in Vietnam. In 1985,
aquaculture accounted for 16%of overall fish
production but accounted for 60.4%in 2013
(130 000 tons in 1985 to 3 220 000 tons in
2013).
10,63
By 2023, domestic aquaculture pro-
duction is expected to reach 5 million tons.
66
Brackish water production of whiteleg shrimp
(Penaeus vannamei) is widespread, as is fresh-
water, semi-intensive monoculture production of
catfish (Pangasius subspecies) and tilapia.
63,65
Integrated polyculture systems in ponds or rice
fields producing carp are common, as is marine
aquaculture production of finfish and mollusks
to a lesser extent.
Reliance on aquaculture production to meet
increasing demand is not a panacea and has raised
numerous environmental concerns. While fresh-
water aquaculture in the form of integrated poly-
culture systems is largely environmentally sound
and contributes to farm diversification, coastal
aquaculture has contributed to loss of mangroves
through wetland conversion (which also emits
GHG emissions and reduces protection against
coastal flooding), water quality deterioration
through discharge of effluent, adverse impacts
on wild fisheries due to collection of wild seed,
and dramatic increases in the use of “trash fish”
(low-value fish that are not often used for human
consumption) as feed in aquaculture systems.
65
Aspirations for sustainable diets and the role of
fisheries and aquaculture. As Vietnam continues
to experience economic growth and macroeco-
nomic stability,
67
demand for animal-source
foods will continue to rise. Solutions that meet
increasing demand while preserving and protect-
ing natural ecosystems and supporting the liveli-
hoods of farmers and fishers are required. Proper
management of fisheries and aquaculture is
essential, and several actions might be consid-
ered: (1) protection of and investment in inland
fisheries for poor and landless rural dwellers;
(2) improved aquaculture management practices,
especially in the shrimp production subsector,
including improved disease surveillance systems,
improved environmental performance, technical
support for production of improved quality feed
and seed, and decreased mangrove removal; and
(3) improved management of overexploited off-
shore fisheries in the country’s exclusive eco-
nomic zone, including demarcation of fisheries,
monitoring of marine resources, enforcing license
limitations, defining gear restrictions, allocating
rights-based access to fisheries, and supporting
democratic fisheries associations within the coun-
try (ie, the Fisheries Association of Vietnam
[VINAFIS]).
65
Implementing measures to increase the environ-
mental sustainability of fish production will be
important. Freshwater use in aquaculture produc-
tion remains a significant challenge, and improve-
ments in land, feed, and energy use as well as
reductions in diseases, water pollution, and gene
contamination from aquaculture to wild popula-
tions need to be addressed to lower aquaculture’s
environmental impacts.
68
In Vietnam, the changes
in production management practices noted above
are priorities, as is increasing access of aquaculture
production to low-income households.
The environmental consequences of projected
dietary changes in Vietnam must also be assessed
in relation to sustainability targets. Dietary
changes are projected to result in an increase in
per capita diet-related GHG emissions of 45%,
largely due to an increase in consumption of beef,
pork, poultry, and other animal-source foods,
while land use, water use, and nutrient application
and pollution are also projected to increase.
23
Therefore, demand-side interventions to shift
diets away from higher intakes of pork and beef
will likely be needed in addition to supply-side
management solutions that target production
practices. If populations are unwilling to substi-
tute plant-based foods for meats, promoting fish
S42 Food and Nutrition Bulletin 41(2S)

consumption is another potential way to reduce
diet-related environmental impacts. Farmed fin-
fish and filter-feeding carp and mollusks, for
example, use similar or less feed and can have
much lower environmental impacts than other
meats,
19
while filter-feeders have the added ben-
efit of simultaneously improving water quality.
Summary. Vietnam is experiencing a double bur-
den of malnutrition where undernutrition and
overnutrition are common. Current nutrition tran-
sitions toward diets with more calories and
animal-source foods, if continued into the future,
will likely reduce the prevalence of undernutri-
tion and inadequate caloric intakes but at the cost
of increased prevalence of overnutrition and
diet-related environmental impacts. Increasing
fish consumption in place of increased consump-
tion of higher impact animal-source foods such as
pork and ruminant meat could reduce diet-related
environmental impacts. However, increases in
fish production will likely need to come from
aquaculture systems rather than inland or marine
fisheries as many fisheries are already over-
exploited. Increasing fish production could also
have economic benefits: fish production is the
main source of income for 8%of Vietnam’s pop-
ulation, while improving the sustainability of
existing fishery and aquaculture systems would
likely improve the likelihood of long-term eco-
nomic security of individuals who produce fish.
In total, Vietnam’s positive economic growth,
abundant natural resources, and advances in
reducing undernutrition leave it well-positioned
to transition toward a sustainable dietary future.
Investments in fisheries and the changing role of
fish in Vietnamese diets relative to other
animal-source foods will likely play a significant
role in determining the success of this transition.
Kenya—Balancing the Role of Livestock
Since 1961, Kenya’s population has increased by
nearly 500%(from 8.1 to 48.5 million), putting
pressure on the national food system.
10
Despite a
>60%increase in land devoted to crop produc-
tion, total per capita caloric supply decreased
from 2249 to 2160 calories per day.
10
Per capita
meat supply also decreased (from 96 to 85
calories per day) but per capita milk supply
increased from 123 to 165 calories per day. Food
availability is variable throughout Kenya, with
higher availability in urban than rural regions,
and for higher income than lower income popula-
tions.
69
While food availability in urban areas is
typically higher than in rural areas, food and
nutrition security in low-income urban popula-
tions is particularly low, an issue that is likely
to become increasingly problematic as lower
income rural populations migrate to urban
centers.
69
Despite recent changes to the food system and
increases in per capita affluence, malnourishment
in Kenya remains prevalent. Over 24%of the
population is undernourished, with higher propor-
tions among rural and low-income urban popula-
tions.
69
Micronutrient deficiencies are also
widespread: Over 75%of the adult population is
zinc deficient, 15%is anemic, with higher rates of
undernourishment for rural and low-income
urban populations, as well as among pregnant
women. However, Kenya, as do many other lower
income countries, faces a double burden of dis-
ease. Overweight and obesity prevalence exceeds
25%and has been increasing by 0.5%per year
over the previous decade.
57
Unequal food distri-
bution and caloric consumption combined with
inadequate consumption of fruits, vegetables,
nuts and seeds, and whole grain cereals are hur-
dles to achieving a food system that nurtures
human health.
70
Recent changes to the food system have
stressed Kenya’s natural capital. Over 60%of the
world’s large mammals (body mass >10 kg) and
25%of the world’s large birds (body mass > 2 kg)
are found in Kenya.
71
While many of these spe-
cies are not yet threatened with extinction, recent
increases in human population sizes, livestock
grazing intensities, fence construction to delimit
pastures, and hunting and poaching have been
linked to population declines for many of these
species.
71
The Coastal Forest is an ecosystem that
has been particularly effected by Kenya’s agricul-
tural sector, having lost >90%of its original
extent.
72
Kenya’s fish are faring no better: fish
captures, introduction of invasive species, and
pollution from surrounding agricultural lands
have resulted in rapid changes in fish community
Clark et al S43

composition in Lake Victoria, the world’s second
largest freshwater lake.
73
Agriculture in Kenya is an important source
of economic security. Nearly 40%of Kenya’s
population is employed in agriculture, and agri-
culture accounts for over 30%of Kenya’s
GDP.
57,74
However, while agriculture positively
benefits nutrition and economic security in
regions with affordable inputs and access to
markets and innovation,
75
agriculture is simul-
taneously a major driver of environmental
degradation in Kenya, including habitat loss,
biodiversity declines, GHG emissions, and
nutrient pollution resulting from fertilizer appli-
cation. A food system transformation that
addresses the current and ongoing health, eco-
nomic, and environmental aspects of Kenya’s
agricultural sector will require multisectoral col-
laboration so that health-, environmental-, and
economic-oriented policies are not antagonistic.
Kenya’s current agricultural system. Changing Ken-
ya’s agricultural and food systems will be integral
in improving diet-related health and environmen-
tal outcomes while maintaining food culture and
economic security. Most food production in
Kenya comes from mixed crop-livestock sys-
tems
76
consisting of smallholder units with 1 to
4 cows and with several plots of crops grown in
intercropping. Maize, beans, and some vegetables
are typically grown, both for home consumption
and for selling. Milk is the predominant
animal-source food—accounting for *50%of
protein supply from animal-source foods—and
is primarily produced for home consumption.
Because many families farm for subsistence
and because 80%of food is sold through informal
markets (eg, food distribution is often limited
subnationally),
77
improving productivity on
smallholder and subsistence farms will be inte-
gral. However, smallholder farming is difficult
and problematic but is also often the only option
for rural populations in Kenya and elsewhere
sub-Saharan Africa. Among the difficulties is the
need to strike a balance between competing
objectives: maximize labour productivity, pro-
vide livelihoods, and reduce land and soil degra-
dation to ensure productivity for future
generations. Balancing these is becoming more
difficult, largely because of declining farm sizes
and naturally low levels of soil fertility. Declining
farm sizes is a critical restraint to long-term agri-
cultural production because it prevents replenish-
ment of soil fertility through fallow rest periods
78
and is antagonistic to food and economic security
because a smaller amount of land needs to pro-
vide for the same amount of people. Poverty char-
acterizes many subsistence households and
threatens the hope for a better standard of living
for rural populations.
Production of cash crops might be viewed as
a potential route to increase household income
and thus reduce food insecurity. Elsewhere in
sub-Saharan Africa, production of cash crops
has not had a consistent impact on food secu-
rity.
79
In some locations, cash crop production
increases food insecurity by competing with
nutrient-dense foods land. Conversely, in other
locations, cash crop production can decrease
food insecurity by increasing household income.
While there is limited evidence on the associa-
tion between cash crop production and food
insecurity in Kenya, it is likely that this associ-
ation in Kenya is similarly complicated as it
elsewhere in sub-Saharan Africa.
The potential for improved subnational food
distribution. Increasing capacity for food distribu-
tion could help alleviate food and nutrition inse-
curity. Because most of Kenya’s food production
is commercialized through informal and local
markets, food and nutrition security is often tied
to the ability of communities to produce food.
77
While reliance on locally produced foods is not
inherently detrimental to nutrition security, high
rates of undernutrition in Kenya indicate that
many communities cannot currently provide ade-
quate nutrition. Decreasing farm sizes and
expected increases in climatic variations (and
thus crop production) threaten to further exacer-
bate this problem.
80,81
Increasing capacity for
food distribution has potential to mitigate the
nutrition impact of and increase resilience to
future shocks in agricultural production.
The potential for agricultural intensification. Agricul-
tural intensification could be beneficial to food
and economic security in Kenya and also has the
S44 Food and Nutrition Bulletin 41(2S)

potential to have environmental benefits includ-
ing but not limited to reduced land use change.
Average crop yields in Kenya are much lower
than potential yields, or what yields could be
under ideal cropping conditions.
82
Crop yield
gaps, or the difference between current yields and
potential yields, are particularly large for staple
cereal grains, with current maize, millet, and sor-
ghum yields being 38%,40%, and 25%of poten-
tial yields, respectively. For environment,
agricultural land use change is one of the major
stresses to biodiversity; increasing crop yields
could help decrease future rates of land use
change.
Altering agricultural management to more
efficiently use existing resources (eg, fertilizer,
manure, water, etc) could help improve crop
yields. Adjusting timing of nutrient applications
such that they match crop nutrient demands could
increase crop yields while decreasing nutrient
runoff from fertilizer application, although
improving and increasing access to agricultural
inputs will be needed to do so. Fertilizer subsidy
programs in other sub-Saharan African countries
have resulted in large crop yield increases in other
countries, including in Malawi, Rwanda, Zambia,
Ghana, Mali, and Senegal.
83
A similar program,
but tailored to Kenya’s food system, is one
approach to improving productivity on existing
agricultural lands. In regions where fertilizer
access is likely to remain limited, increasing crop
yields is possible by integrating nitrogen-fixing
legumes or nitrogen-fixing trees into existing
agricultural landscapes. Field trials in Kenya
found that rotating cereals with legumes
increased crop yields by 17%to 24%and eco-
nomic profits by 32%to 49%.
84
However, incor-
porating legumes into crop rotations will require
consideration of existing dietary preferences,
food traditions, and economic production values,
with preference being given to legumes—such as
Rosecoco or kidney beans—that are a part of
existing food culture and have high market prices.
Increasing production on existing agricultural
lands is not a panacea. Intensification via
increased fertilizer application can increase rates
of fertilizer runoff, potentially leading to biodi-
versity declines and decreased water quality, par-
ticularly if fertilizers are applied in excess.
85
Some of the negative impacts of increased ferti-
lizer application can be mitigated by agricultural
outreach programs and adopting management
strategies such as cover cropping.
86
Similarly,
increasing food production does not ensure
increased food availability for Kenya’s most
at-risk populations, especially those that do not
produce their own food. Low-income urban
populations, for instance, currently experience
among the highest rates of food insecurity,
69
but
increasing food production may not alleviate food
insecurity for this population.
87
Summary. Kenya faces a double burden of under-
and overnutrition, and recent changes to the food
system have stressed Kenya’s natural capital.
Population growth and increasing affluence will
likely further stress the health and environmental
sustainability of Kenya’s food system. Increasing
crop and livestock yields through improved man-
agement and access to agricultural inputs has
potential to improve food and economic security
while avoiding the negative environmental
impacts of land use change and habitat conver-
sion. Finding and implementing policies that
positively affect the food, economic, and environ-
mental sustainability of Kenya’s food system will
be a difficult challenge.
Sweden—Reducing Already Large
Per Capita Impacts
Sweden, like many other high-income countries,
has large per capita diet-related environmental
impacts, primarily because of high consumption
of meat, dairy, and eggs.
23
Current dietary pat-
terns in Sweden are also associated with poor
health, partially because of excess consumption
of calories as well as inadequate consumption of
fruits, vegetables, nuts and seeds, legumes, and
whole grain cereals.
70
Shifting dietary patterns in
Sweden and other high-income countries will be
integral to meeting sustainability targets.
11
The new Nordic diet. Sweden’s government
integrated environmental sustainability and
helped develop the “New Nordic Diet,” at least
partially in response to high diet-related environ-
mental impacts.
31
The New Nordic Diet is
Clark et al S45

designed to be healthier (and has been shown to
be associated with reduced risk of diet-related
diseases
88
) and have lower environmental
impacts than current dietary patterns while being
culturally, gastronomically, and regionally appro-
priate. One aspect of the New Nordic Diet is to
source locally produced foods for food culture
and sovereignty, although locally sourced foods
are not necessarily more environmentally sustain-
able than those produced further away (Box 1).
The New Nordic Diet is characterized by high
consumption of fruits (>300 g/d) and vegetables
(>400 g/d), with particular emphasis on locally
available produce such as berries, cabbages, root
vegetables, and legumes, potatoes (>140 g/d),
whole grain cereals (>75 g/d), nuts (>30 g/d), fish
and shellfish (>43 g/d), free-range livestock
(85-100 g/d), and some wild game.
31
Adopting the New Nordic Diet will require a
significant transition from current diets, including
large reductions in meat (*50%reduction)
paired with increases in fruits (*30%increase),
vegetables (*130%increase), and nuts (150%
increase).
31
Because sourcing foods locally and
regionally is an important aspect of the New Nor-
dic Diet, consumption within food groups will
need to change to emphasize foods produced
regionally, such as berries, apples, plums, pears,
root vegetables, and brassicas such as cabbages
and brussel sprouts. If the New Nordic Diet were
to be widely adopted in Sweden and elsewhere in
the Nordic region, regional food production sys-
tems would need to change to meet changing
consumer demand.
Is the new Nordic diet adequately ambitious?. The
potential benefits of adopting the New Nordic
Diet in Sweden are unlikely to be sufficient to
meet environmental sustainability targets. Larger
reductions in meat and dairy, as well as changes in
agricultural production practices, will be needed.
11
Reducing consumption of meat, dairy, and calories
(often achieved by reducing consumption of
sugars, unhealthy fats, and processed foods) to
be in line with international recommendations
while simultaneously increasing consumption of
fruits, vegetables, and other plant-based foods is
estimated to have large environmental benefits in
Sweden, including reducing per capita diet-related
GHG emissions by 70%and cropland use by 28%.
These same dietary transitions have also been esti-
mated to improve diet-related health outcomes in
Sweden, including a 21%reduction in premature
deaths avoided.
24
Leading the way for other high and middle income
countries. The Swedish government, and Nordic
Region in general, are uniquely positioned to pro-
vide insight into how governments in high- and
middle-income countries might promote transi-
tions toward healthier and more environmentally
sustainable food systems. While adoption of the
New Nordic Diet has been associated with
reduced environmental impacts and can help
improve health outcomes,
89,90
it remains unclear
how widely the New Nordic Diet is adopted
because it is not apparent whether Swedish gov-
ernment (and Nordic Region) has not collected
these data. Data on adoption of the New Nordic
Diet, as well as the effectiveness of policies
incentivizing adoption of the New Nordic Diet,
will provide insight into which policies promote
transitions to healthier and more environmentally
sustainable diets might be most effective if imple-
mented in other countries.
In general, diet-related health and environmen-
tal impacts in high-income countries are among
the highest in the world (Figures 2 and 3).
24
Small
dietary changes in these countries (and also in
higher income populations of less affluent coun-
tries), such as substituting poultry or pork for an
equivalent amount of ruminant meat could have
large environmental benefits and moderate health
benefits.
20,91
However, more ambitious dietary
transitions, specifically reducing consumption of
total calories, and in particular calories from meat
and dairy, would likely be needed to meet envir-
onmentally focused sustainability targets.
23
Diets in many middle-income countries, such
as in Brazil and Vietnam, are rapidly transitioning
to become similar to those in Sweden and other
high-income countries. Such transitions are linked
with increased prevalence of diet-related diseases
and increased diet-related environmental impacts.
Avoiding these trends and associated impacts will
be necessary. Emphasizing consumption of fruits,
vegetables, and other plant-based foods and mod-
eration of meat, dairy, and eggs, for instance
S46 Food and Nutrition Bulletin 41(2S)

through following dietary guidelines and other
policies could have large global benefits.
Summary. Diet-related health and environmental
impacts in Sweden are large. In response, the New
Nordic Diet was designed and implemented by the
Swedish and other Nordic governments to improve
diet-related outcomes. Yet, from an environmental
perspective, the New Nordic Diet is not adequately
ambitious to meet sustainability targets: larger
reductions in meat, dairy, and eggs would be needed,
improvements in farming practices, and reductions
in food loss and waste will also be needed. While
most high-income countries and middle-income
countries do not incorporate environmental sustain-
ability into dietary guidelines, diet-related environ-
mental impacts in high-income countries are among
the largest in the world, while diet-related impacts in
middle-income countries are rapidly increasing.
Incorporating environmental sustainability out-
comes into national dietary guidelines has the
opportunity to shift diets to become healthier and
have lower environmental impacts than what they
would likely otherwise have.
How to Drive Shifts to
Sustainable Diets?
What we eat has a profound impact on health and
environmental sustainability.
11
Reducing con-
sumption of red meat, especially ruminant meat,
in regions where consumption is above nutri-
tional recommendations would likely provide
large environmental benefits.
11
At the same time,
increasing consumption of fruits, vegetables,
whole grain cereals, and nuts and seeds would
improve human health in most world regions.
70
While changing diets will not be easy, doing so is
necessary to meet the targets set in the SDGs. As
discussed previously, consumer choice is a key
determinant of diet-related health and environ-
mental outcomes. However, consumer awareness
of diet-related health and environmental impacts
is not always adequate to shift diets toward more
positive outcomes if awareness is not supported
by additional actions. How then can govern-
ments, businesses, and nongovernmental organi-
zations help drive shifts toward sustainable
healthy diets?
Going Beyond Providing Information
and Education
Strategies to shift food choices typically rely on
distributing information, but there is limited evi-
dence that this has influenced consumers’ choices
in the past.
92,93
Information distribution strategies
include front- and back-of-the pack nutrition
labels, dietary guidelines, public health cam-
paigns about the benefits of different food types,
and calls for abstinence (eg, vegetarianism or
Meatless Mondays). Instead, food choices are
influenced by multiple interacting factors, includ-
ing a food’s price and taste, the age, gender,
social identity, and cultural values of the food
purchaser, food geography, access to supermar-
kets and restaurants, and exposure to marketing
and media.
Considering how people make choices about
what to eat, it’s not surprising that information is
insufficient to shift dietary choices. Consumers
tend to be highly routinized in their purchasing
and consumption habits, especially in retail or
food service environments.
94
Few people notice
information and even fewer remember and
respond to it. What ends up on the plate is more
often a result of habit and unconscious mental
processing, than rational, informed decisions.
To drive large-scale dietary shifts, govern-
ments, business, and civil society need to expand
their repertoire of interventions beyond informa-
tion distribution. This includes investing to
understand the motivationbehindconsumers’
food choices, using approaches, such as beha-
vioral change and marketing strategies, to design
interventions that work in tandem, and policy
implementation. However, given the limited
experience of shifting diets at large scales, it is
important to adopt an experimental approach to
interventions, developing baselines of current
diets, setting targets, and monitoring outcomes.
What Actions Can National Governments
Take?
Much of the early action to shift diets has been in
high-income countries. Yet, given the large and
growing health and environmental footprint of
the food system, all governments need to act,
Clark et al S47

especially if the health and environmental prob-
lems experienced by high-income nations are to
be avoided. What actions can governments take
to shift diets to become healthier and more
sustainable?
First, governments can assess the economic
case for shifting to more sustainable diets. The
health and environmental costs associated with
poor dietary quality are large. For example, in
China, the indirect costs of overweight and obe-
sity due to disability and mortality were estimated
at 3.6%of GNP (Gross National Product) in 2000
and are projected to grow to 8.7%of GNP in
2025 as diets shift to include more calories,
animal-source foods, and ultra-processed foods.
95
Second, governments can set measurable tar-
gets for transitioning to healthier and more sustain-
able diets. Country-specific information on the
economic costs of unhealthy and unsustainable
diets coupled with the benefits of shifting diets can
build support for targets and interventions needed
to achieve them (Box 2). Targets can take several
forms, including reducing consumption of
resource-intensive foods and increasing consump-
tion of healthier and more sustainable foods. While
many countries have national nutritional targets
and dietary guidelines, few have targets or guide-
lines that combine nutritional and environmental
objectives.
96
Sweden, Germany, the Netherlands,
Brazil, and China are exceptions. Governments
can conduct assessments of dietary patterns and
trends by age, income, ethnic group, urban/rural,
and so on, and benchmark the results with peers.
The resulting information, along with WHO
guidelines for a healthy diet, can inform national
targets, help identify shifts with the greatest poten-
tial to generate health and environmental benefits,
and establish baselines to monitor progress.
Third, governments can experiment with a
range of interventions to shift diets (Table 1).
Interventions should target populations that over-
consume or under-consume relative to dietary
recommendations. To date, governments have
typically relied on interventions toward the right
side of Table 1, particularly information and per-
suasion. This is changing. The City of London,
for example, has banned new fast-food establish-
ments from opening within 400 meters of schools
to help reduce high levels of childhood obesity
because 40%of children in London are over-
weight or obese when they finish primary
school.
97
Government fiscal measures, such as
farm subsidies, often support production of
resource-intensive foods, such as animal foods
and feed. This is also starting to change in some
countries, creating opportunities to align with
promoting healthier and more sustainable diets.
Organisation for Economic Cooperation and
Development countries, for example, have halved
agricultural subsidies since the 1980s, shifting
them from production to the support of environ-
mental or social objectives. Diet-related policies
focused on reducing meat and dairy consumption
and reducing calorie intake have been tried
in several countries, including a “junk-food” tax
in Hungary and Mexico, and taxes on sugary
drinks in Chile, Mexico, and several US states.
Two years after taxes were introduced in Mexico,
purchases of sugary drinks fell by 8.2%, while
purchases of junk food fell by 6.0%.
98,99
In Hun-
gary, 40%of junk food manufacturers eliminated
or reduced unhealthy ingredients from their prod-
ucts in response to taxes.
Fourth, governments can ensure coherence
among agriculture, health, water, and environ-
mental policies. This is especially important
given the potential for synergies between sustain-
able diets and achievement of other national pol-
icy goals, such as health, food security, water,
biodiversity, and climate change. One way to
facilitate policy coherence is to establish an inter-
disciplinary cross-agency task force to identify
policies and regulations that influence food
choices; assess whether they are aligned with pro-
moting sustainable healthy diets; and recommend
changes to ensure alignment. Key agencies to
involve include agriculture, health, environment,
education, forests, water, and the lead agency for
implementing the s SDGs. This taskforce can also
be charged with setting targets, monitoring prog-
ress, evaluating the effectiveness of interventions,
and scaling up those that prove effective.
What Actions Can Business, Especially Food
Service Providers, Take?
First, like governments, business can set measur-
able targets, such as increasing the share of plant
S48 Food and Nutrition Bulletin 41(2S)

Table 1. Types of Interventions for Shifting Food Choices.
a
Type of
interventionn
Restricting/
promoting access Fiscal measures Trade rules Public procurement
Persuasion/
campaigns Information
Research and
development
Examples Advertising limits
Ban on saturated
fats or carbonated
drinks in schools
Limiting fast food
chains near
schools
Promoting
availability of
desirable foods in
public facilities
Standards on
default options in
food services
sector
Tax on fat, sugar,
meat
Subsidies on
sustainable
foods/vouchers
for people on
income support
Carbon tax
Aligning
production
subsidies with
sustainable food
goals
Food import/
export controls
Alignment of
domestic
support/
investment
liberalization
Procurement
standards and
criteria, that is, in
hospitals,
schools, prisons,
and other public
facilities
Meatless
Mondays
National Dietary
Guidelines
Food labels,
certification
programs
Education
program, that is,
in schools, clinics
Funding for
research on how
to shift diets in
different
contexts and
geographies
Technology
support for
plant-based meat
substitutes
Comments This involves
restricting access
to unsustainable
foods while
promoting access
to sustainable
foods
Children and
youth are an
important target.
They are especially
influenced by
advertising and
their habits are still
being formed.
Empirical
evidence is
limited on the
effectiveness of
fiscal
instruments.
Taxes can be
regressive
Combining taxes
on less
sustainable food
with subsides on
more sustainable
alternatives can
be more effective
A convergence
toward
Western-style
diets is linked to
industrialized
agriculture,
global food
chains, trade
liberalization, and
mass media
Governments
can review their
trade rules for
alignment with
supporting
sustainable food
choices
Procurement
policies can
specify food
types as well as
production
methods and
location
Public spending
on information is
likely to be
dwarfed by
countervailing
private sector
advertising
Consumers can
find package
labels difficult to
comprehend
Product labeling
can drive food
companies to
reformulate
products
Food choices are
largely driven by
habit not
information
Public funding for
research on
actions to shift
diets tends to be
limited even
though such
actions can
deliver multiple
benefits to the
UN Sustainable
Development
Goals
a
Adapted from Table 6 from the study by Ranganathan et al.
100
S49

source foods in sales relative to animal-source
foods or reducing diet-related environmental
impacts. The food industry, especially the retail
and food services sector, can play an active role in
the transition to healthier and more sustainable
diets. In addition to supporting environmental
goals, shifts to sustainable diets can contribute
to commitments around employee or customer
health and wellness.
Second, business can experiment with
approaches to shifting consumer choices. Shifting
behavior requires strategies that work in combi-
nation with how and why consumers purchase
food. Global food companies are experienced in
using behavioral economics and commercial mar-
keting strategies to influence consumer choices.
These same strategies can be deployed to promote
more sustainable food choices, especially if they
improve (or do not negatively impact) profitabil-
ity. In the food services sector, increasing the
share of plant-based proteins can reduce costs,
as animal-based ingredients can be more expen-
sive than plant-based foods.
101
Third, businesses can collaborate with govern-
ment and civil society to drive shifts to more
sustainable diets. The Cool Food Pledge platform
convened by World Resources Institute, for
example, brings together companies, universities,
hospitals, and other public facilities to reduce
diet-related GHG emissions by 25%by 2030. If
business finds that there is not a financial case for
acting, it can call upon governments to enact leg-
islation such that their incentives are aligned with
promoting sustainable food choices.
The Shift Wheel (Figure 5, S2) provides a
framework that businesses can use to shift con-
sumers to more sustainable diets.
100
It is informed
by previous successful shifts and 4 complemen-
tary approaches to shift consumption:
Minimize disruption to consumer’s existing
habits, including minimizing changes to
taste, look, texture, smell, packaging, and
the food’s location in a retail environment.
For example, companies have created sub-
stitutes for animal-based foods from plant-
or fungal-based proteins, replicating the
taste and texture of chicken, eggs, ground
beef, and fish as closely as possible. Others
have blended in new ingredients within
current formats. In Mauritius, the country’s
subsidized cooking oil (ration oil) was
reformulated from palm to soybean oil to
improve health outcomes and resulted in
significant reductions in both saturated fat
consumption and blood serum cholesterol
levels.
102
Another way to minimize disrup-
tion is to replicate familiar packaging and
in-store location. Several soya milk brands,
for example, have packaging that looks
similar to packaging for fresh milk and
have placed their product in retailers’ chil-
lers alongside fresh milk.
Sell a compelling benefit to appeal to
consumers, such as health or affordability.
For example, Birds Eye marketed its
pollock-based fish fingers (fish sticks), a
more sustainable alternative to cod fish fin-
gers, as healthier “Omega 3 Fish Fingers.”
Language and framing of plant-based foods
can encourage meat eaters to choose
plant-based foods from a menu. Indeed,
changing the names of vegetable dishes to
sound more indulgent, for example,
“slow-roasted caramelized zucchini bites”
increased consumption by 25%to 41%per-
cent compared to traditional names, for
example, “zucchini” or healthy names, for
example, “nutritious green zucchini.”
103
Location on a menu also affects choices: put-
ting plant-based foods in a vegetarian box on
the menu reduced orders by 56%.
104
Maximize awareness, including increasing
the visibility of a product through memorable
advertising or by enhancing its availability
and display.Creating memorable advertising
involves building consumers’ memory asso-
ciations with a specific food to increase the
probability of it being remembered and pur-
chased. Coca-Cola, for example, is associ-
ated with red, its distinctive bottle shape, its
logo script, and its ability to refresh on a hot
day. Memorable marketing programs for
plant-based foods could play an important
role in shifting consumption.
Evolve social norms, including adapting or
changing the underlying social and cultural
norms through informing and educating
S50 Food and Nutrition Bulletin 41(2S)

consumers, along with efforts to make the
more sustainable food more socially desir-
able or the less sustainable food less
socially desirable. For some men, eating
meat can be a way that they affirm their
masculinity.
105
Consumer studies in Aus-
tralia have shown that men are more likely
to believe that primarily plant-based diets
are neither nutritious nor tasty and that
these foods do not provide enough energy
or protein.
106
By better barriers to
increased consumption of plant-based
foods, food companies can design market-
ing campaigns that shift social perceptions.
Conclusion
The global food system threatens achievement of
international health and environmental
sustainability targets. Achievement of these tar-
gets will be further threatened by growing popu-
lations demanding larger quantities of less
healthy and higher impact foods. Finding solu-
tions to this diet, health, and environment tri-
lemma is a global challenge. This challenge
needs to be addressed at local to global scales.
For example, identifying where, when, and in
which countries crops might be most environ-
mentally sustainably grown could contribute to
the concept of global seasonality.
107
Dietary change presents a unique opportunity
to meet multiple SDGs. Adopting sustainable
healthy diets rich in plant-based foods could
slow, and potentially reverse, the growing impact
diets are having on human health and the envi-
ronment, although it must not be assumed that
healthy diets will have a low environmental
impact.
23,12
Dietary guidelines must integrate
Figure 5. The Shift Wheel provides a framework of 4 complimentary approaches businesses can use to shift
consumers to more sustainable diets. Reproduced from Ranganathan et al.
100
See Figure S2 for a color version
available in the online supplement.
Clark et al S51

health and environment for sustainable healthy
diets to minimize the chance of unintended con-
sequences.
33
Other changes to the food system,
such as reducing food loss and waste, technolo-
gical adaptation, or changes in food formulation,
processing, and preparation, could also improve
the environmental sustainability of food sys-
tems.
23
It is, however, unclear which food system
changes might be most feasible because eco-
nomic costs and barriers to implementation to
food system changes will vary by context both
between and within countries. Such changes
should be paired with monitoring efforts to ensure
that they improve sustainability without creating
unwanted trade-offs.
No single “silver bullet” solution exists to the
ongoing and increasing diet-related health envi-
ronmental sustainability challenges. A combina-
tion of coordinated and multisectoral actions will
be needed by the public, private sectors, and
governments to shift diets, with context specific
solutions required to account for the unique chal-
lenges and food cultures, dietary preferences, and
institutional structures present in each country.
To transition to more environmentally sustain-
able diets, governments can start by conducting
assessments of current dietary patterns and trends
by age, income, ethnic group, urban/rural, and so
on, and benchmark the results with peers. The
resulting information can inform context-specific
targets, identify shifts with the greatest potential
to generate health and environmental benefits, and
establish baselines to monitor progress. Efforts will
need to be coordinated across multiple agencies
(eg, agriculture, health, education, and environ-
ment), given the potential for synergies between
environmentally sustainable diets and the achieve-
ment of other national policy goals. But if success-
ful, shifting to sustainable healthy diets offers a rare
win-win approach for health and environment.
Boxes
Box 1: Common Food Myths That are not Always True.
a) How and where a food is produced matters more than the type of food. Food production matters,
but food type is typically a larger indicator of its environmental impact than is how or where it
is produced.
20
The GHG impacts of food processing and transportation are small compared
to the emissions resulting from food production. Similarly, the difference in impact of organic
and nonorganic foods are often small and vary across environmental indicators (eg, GHG
emissions and land use).
21
b) Shifting to more plant-rich diets risks people not getting enough protein. The majority of people are
consuming more protein than required to meet their nutritional needs. Consuming more
protein is thus not necessarily better, unless an individual is malnourished. International
nutritional guidelines recommend adults consume 0.83 g of protein per kg of body weight,
or *58 g of protein per day for 70 kg adult.
38
In 2009, the average person in over 90% of the
world’s countries consumed more protein than what was recommended in nutritional guide-
lines, with protein intake in many middle- and high-income nations far exceeding recommen-
dations.
100
For instance, the average American adult consumed 66% more protein per day in
2012 than the average estimated daily requirement, but 21% of adults still considered them-
selves protein deficient in a 2014 survey.
108,109
c) There is no need to reduce meat consumption, we can just produce it more efficiently. We need to
do both. Increasing efficiency is an essential element of sustainable food systems, but new
technology and production methods will likely not be adequate to meet environmental
targets.
11
Given projected growth in meat demand, reducing meat consumption among
high-meat consumers is needed for health and environment, and to create space for
under-consumers to eat more.
S52 Food and Nutrition Bulletin 41(2S)

Authors’ Note
All authors conceptualized the project; MC, JM, AJ,
JR, MH, and JF wrote the original draft; and all authors
contributed to the review and editing of the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publi-
cation of this article.
Funding
The author(s) disclosed receipt of the following finan-
cial support for the research, authorship, and/or
publication of this article: This paper was made poss-
ible with funding from FAO.
ORCID iD
Michael Clark https://orcid.org/0000-0001-7161-
7751
Supplemental Material
Supplemental material for this article is available
online.
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