A multifaceted approach to global health.

World Health Day underscores the scientific community's commitment to achieving health equity for all. It is paramount to eliminate bias in research that has traditionally focused on men, neglecting the specific needs of diverse populations. Innovative clinical trial designs are being developed with more inclusive enrollment. Ensuring equitable access to essential antibiotics, coupled with robust infection prevention and control measures, is vital to safeguarding public health. The pursuit of health equity extends beyond the realm of medicine. Investments in local food production and robust social safety nets are critical for mitigating the effects of climate change on access to healthy diets. Additionally, in times of polycrisis, prioritizing the unique needs of children and empowering community-led healthcare initiatives in conflict zones are essential steps. By taking these actions, we can move closer to realizing everyone's fundamental right to health.

Toward healthy and sustainable diets for the 21st century: Importance of sociocultural and economic considerations.

Four years after the EAT-Lancet landmark report, worldwide movements call for action to reorient food systems to healthy diets that respect planetary boundaries. Since dietary habits are inherently local and personal, any shift toward healthy and sustainable diets going against this identity will have an uphill road. Therefore, research should address the tension between the local and global nature of the biophysical (health, environment) and social dimensions (culture, economy). Advancing the food system transformation to healthy, sustainable diets transcends the personal control of engaging consumers. The challenge for science is to scale-up, to become more interdisciplinary, and to engage with policymakers and food system actors. This will provide the evidential basis to shift from the current narrative of price, convenience, and taste to one of health, sustainability, and equity. The breaches of planetary boundaries and the environmental and health costs of the food system can no longer be considered externalities. However, conflicting interests and traditions frustrate effective changes in the human-made food system. Public and private stakeholders must embrace social inclusiveness and include the role and accountability of all food system actors from the microlevel to the macrolevel. To achieve this food transformation, a new "social contract," led by governments, is needed to redefine the economic and regulatory power balance between consumers and (inter)national food system actors.

Four ways blue foods can help achieve food system ambitions across nations.

Blue foods, sourced in aquatic environments, are important for the economies, livelihoods, nutritional security and cultures of people in many nations. They are often nutrient rich1, generate lower emissions and impacts on land and water than many terrestrial meats2, and contribute to the health3, wellbeing and livelihoods of many rural communities4. The Blue Food Assessment recently evaluated nutritional, environmental, economic and justice dimensions of blue foods globally. Here we integrate these findings and translate them into four policy objectives to help realize the contributions that blue foods can make to national food systems around the world: ensuring supplies of critical nutrients, providing healthy alternatives to terrestrial meat, reducing dietary environmental footprints and safeguarding blue food contributions to nutrition, just economies and livelihoods under a changing climate. To account for how context-specific environmental, socio-economic and cultural aspects affect this contribution, we assess the relevance of each policy objective for individual countries, and examine associated co-benefits and trade-offs at national and international scales. We find that in many African and South American nations, facilitating consumption of culturally relevant blue food, especially among nutritionally vulnerable population segments, could address vitamin B12 and omega-3 deficiencies. Meanwhile, in many global North nations, cardiovascular disease rates and large greenhouse gas footprints from ruminant meat intake could be lowered through moderate consumption of seafood with low environmental impact. The analytical framework we provide also identifies countries with high future risk, for whom climate adaptation of blue food systems will be particularly important. Overall the framework helps decision makers to assess the blue food policy objectives most relevant to their geographies, and to compare and contrast the benefits and trade-offs associated with pursuing these objectives.

Ethical and economic implications of the adoption of novel plant-based beef substitutes in the USA: a general equilibrium modelling study.

BACKGROUND: Slowing climate change is crucial to the future wellbeing of human societies and the greater environment. Current beef production systems in the USA are a major source of negative environmental impacts and raise various animal welfare concerns. Nevertheless, beef production provides a food source high in protein and many nutrients as well as providing employment and income to millions of people. Cattle farming also contributes to individual and community identities and regional food cultures. Novel plant-based meat alternatives have been promoted as technologies that could transform the food system by reducing negative environmental, animal welfare, and health effects of meat production and consumption. Recent studies have conducted static analyses of shifts in diets globally and in the USA, but have not considered how the whole food system would respond to these changes, nor the ethical implications of these responses. We aimed to better explore these dynamics within the US food system and contribute a multiple perspective ethical assessment of plant-based alternatives to beef. METHODS: In this national modelling analysis, we explored multiple ethical perspectives and the implications of the adoption of plant-based alternatives to beef in the USA. We developed USAGE-Food, a modified version of USAGE (a detailed computable general equilibrium model of the US economy), by improving the representation of sector interactions and dependencies, and consumer behaviour to better reflect resource use across the food system and the substitutability of foods within households. We further extended USAGE, by linking estimates of the environmental footprint of US agriculture, to estimate how changes across the agriculture sector could alter the environmental impact of primary food production across the whole sector, not only the beef sector. Using USAGE-Food, we simulated four beef replacement scenarios against a baseline of current beef demand in the USA: BEEF10, in which beef expenditure is replaced by other foods and three scenarios wherein 10%, 30%, or 60% of beef expenditure is replaced by plant-based alternatives. FINDINGS: The adoption of plant-based beef alternatives is likely to reduce the carbon footprint of US food production by 2·5-13·5%, by reducing the number of animals needed for beef production by 2-12 million. Impacts on other dimensions are more ambiguous, as the agricultural workforce and natural resources, such as water and cropland, are reallocated across the food system. The shifting allocation of resources should lead to a more efficient food system, but could facilitate the expansion of other animal value chains (eg, pork and poultry) and increased exports of agricultural products. In aggregate, these changes across the food system would have a small, potentially positive, impact on national gross domestic product. However, they would lead to substantial disruptions within the agricultural economy, with the cattle and beef processing sectors decreasing by 7-45%, challenging the livelihoods of the more than 1·5 million people currently employed in beef value chains (primary production and animal processing) in the USA. INTERPRETATION: Economic modelling suggests that the adoption of plant-based beef alternatives can contribute to reducing greenhouse gas emissions from the food system. Relocation of resources across the food system, simulated by our dynamic modelling approach, might mitigate gains across other environmental dimensions (ie, water or chemical use) and might facilitate the growth of other animal value chains. Although economic consequences at the country level are small, there would be concentrated losses within the beef value chain. Reduced carbon footprint and increased resource use efficiency of the food system are reasons for policy makers to encourage the continued development of these technologies. Despite this positive outcome, policy makers should recognise the ethical assessment of these transitions will be complex, and should remain vigilant to negative outcomes and be prepared to target policies to minimise the worst effects. FUNDING: The Stavros Niarchos Foundation, the Bill & Melinda Gates Foundation, Johns Hopkins University, the Commonwealth Scientific and Industrial Research Organisation, Cornell University, and Victoria University.

Sustainability of Diets in Mexico: Diet Quality, Environmental Footprint, Diet Cost, and Sociodemographic Factors.

Background: Little is known about the current intake of sustainable diets globally and specifically in middle-income countries, considering nutritional, environmental and economic factors. Objective: To assess and characterize the sustainability of Mexican diets and their association with sociodemographic factors. Design: Dietary data of 2,438 adults within the National Health and Nutrition Survey 2012 by integrating diet quality measured by the Healthy Eating Index (HEI-2015), diet cost, and four environmental indicators were analyzed: land use (LU), biodiversity loss (BDL), carbon footprint (CFP), and blue water footprint (BWFP). We defined healthier more sustainable diets (MSD) as those with HEI-2015 above the overall median, and diet cost and environmental indicators below the median. Logistic regression was used to evaluate the association of sociodemographic factors with MSD. Results: MSD were consumed by 10.2% of adults (4% of urban and 22% of rural), who had lower intake of animal-source foods, unhealthy foods (refined grains, added sugar and fats, mixed processed dishes and sweetened beverages), fruits, and vegetables, and higher intake of whole grains than non-MSD subjects. Characteristics of MSD vs. non-MSD (urban; rural) were: HEI-2015 (62.6 vs. 51.9; 66.8 vs. 57.6), diet-cost (1.9 vs. 2.8; 1.9 vs. 2.5 USD), LU (3.3 vs. 6.6; 3.2 vs. 5.9 m2), BDL (105 vs. 780; 87 vs. 586 species × 10-10), BWFP (244 vs. 403; 244 vs. 391 L), and CFP (1.6 vs. 4.4; 1.6 vs. 3.7 kg CO2eq). Adults from rural vs. urban (OR 2.7; 95% CI: 1.7, 4.1), or from the South (OR 2.1; 95% CI: 1.1, 3.9), Center (OR 2.3; 95% CI: 1.3, 4.4) vs. the North were more likely to consume MSD, while adults with high vs. low socioeconomic status were less likely (OR 0.17; 95% CI: 0.09, 0.3). Conclusions: The MSD is a realistic diet pattern mainly found in disadvantaged populations, but diet quality is still sub-optimal. Increased consumption of legumes, fruits, and vegetables, and a reduction in unhealthy foods, is required to improve nutritional quality of diets while ensuring their environmental sustainability.

A collective call to strengthen monitoring and evaluation efforts to support healthy and sustainable food systems: 'The Accountability Pact'.

There is widespread agreement among experts that a fundamental reorientation of global, regional, national and local food systems is needed to achieve the UN Sustainable Development Goals Agenda and address the linked challenges of undernutrition, obesity and climate change described as the Global Syndemic. Recognising the urgency of this imperative, a wide range of global stakeholders - governments, civil society, academia, agri-food industry, business leaders and donors - convened at the September 2021 UN Food Systems Summit to coordinate numerous statements, commitments and declarations for action to transform food systems. As the dust settles, how will they be pieced together, how will governments and food corporations be held to account and by whom? New data, analytical methods and global coalitions have created an opportunity and a need for those working in food systems monitoring to scale up and connect their efforts in order to inform and strengthen accountability actions for food systems. To this end, we present - and encourage stakeholders to join or support - an Accountability Pact to catalyse an evidence-informed transformation of current food systems to promote human and ecological health and wellbeing, social equity and economic prosperity.

Equity, technological innovation and sustainable behaviour in a low-carbon future.

The world must ambitiously curtail greenhouse gas emissions to achieve climate stability. The literature often supposes that a low-carbon future will depend on a mix of technological innovation-improving the performance of new technologies and systems-as well as more sustainable behaviours such as travelling less or reducing waste. To what extent are low-carbon technologies, and their associated behaviours, currently equitable, and what are potential policy and research implications moving forward? In this Review, we examine how four innovations in technology and behaviour-improved cookstoves and heating, battery electric vehicles, household solar panels and food-sharing-create complications and force trade-offs on different equity dimensions. We draw from these cases to discuss a typology of inequity cutting across demographic (for example, gender, race and class), spatial (for example, urban and rural divides), interspecies (for example, human and non-human) and temporal (for example, future generations) vulnerabilities. Ultimately, the risk of inequity abounds in decarbonization pathways. Moreover, low-carbon innovations are not automatically just, equitable or even green. We show how such technologies and behaviours can both introduce new inequalities and reaffirm existing ones. We then discuss potential policy insights and leverage points to make future interventions more equitable and propose an integrated research agenda to supplement these policy efforts.

Sustainable food systems and nutrition in the 21st century: a report from the 22nd annual Harvard Nutrition Obesity Symposium.

Food systems are at the center of a brewing storm consisting of a rapidly changing climate, rising hunger and malnutrition, and significant social inequities. At the same time, there are vast opportunities to ensure that food systems produce healthy and safe food in equitable ways that promote environmental sustainability, especially if the world can come together at the UN Food Systems Summit in late 2021 and make strong and binding commitments toward food system transformation. The NIH-funded Nutrition Obesity Research Center at Harvard and the Harvard Medical School Division of Nutrition held their 22nd annual Harvard Nutrition Obesity Symposium entitled "Global Food Systems and Sustainable Nutrition in the 21st Century" in June 2021. This article presents a synthesis of this symposium and highlights the importance of food systems to addressing the burden of malnutrition and noncommunicable diseases, climate change, and the related economic and social inequities. Transformation of food systems is possible, and the nutrition and health communities have a significant role to play in this transformative process.

Rights and representation support justice across aquatic food systems.

Injustices are prevalent in food systems, where the accumulation of vast wealth is possible for a few, yet one in ten people remain hungry. Here, for 194 countries we combine aquatic food production, distribution and consumption data with corresponding national policy documents and, drawing on theories of social justice, explore whether barriers to participation explain unequal distributions of benefits. Using Bayesian models, we find economic and political barriers are associated with lower wealth-based benefits; countries produce and consume less when wealth, formal education and voice and accountability are lacking. In contrast, social barriers are associated with lower welfare-based benefits; aquatic foods are less affordable where gender inequality is greater. Our analyses of policy documents reveal a frequent failure to address political and gender-based barriers. However, policies linked to more just food system outcomes centre principles of human rights, specify inclusive decision-making processes and identify and challenge drivers of injustice.

Global food systems transitions have enabled affordable diets but had less favourable outcomes for nutrition, environmental health, inclusion and equity.

Over the past 50 years, food systems worldwide have shifted from predominantly rural to industrialized and consolidated systems, with impacts on diets, nutrition and health, livelihoods, and environmental sustainability. We explore the potential for sustainable and equitable food system transformation (ideal state of change) by comparing countries at different stages of food system transition (changes) using food system typologies. Historically, incomes have risen faster than food prices as countries have industrialized, enabling a simultaneous increase in the supply and affordability of many nutritious foods. These shifts are illustrated across five food system typologies, from rural and traditional to industrial and consolidated. Evolving rural economies, urbanization and changes in food value chains have accompanied these transitions, leading to changes in land distribution, a smaller share of agri-food system workers in the economy and changes in diets. We show that the affordability of a recommended diet has improved over time, but food systems of all types are falling short of delivering optimal nutrition and health outcomes, environmental sustainability, and inclusion and equity for all. Six 'outlier' case studies (Tajikistan, Egypt, Albania, Ecuador, Bolivia and the United States of America) illustrate broad trends, trade-offs and deviations. With the integrated view afforded by typologies, we consider how sustainable transitions can be achieved going forward.

Balancing a sustained pursuit of nutrition, health, affordability and climate goals: exploring the case of Indonesia.

BACKGROUND: To guide the transformation of food systems to provide for healthy and sustainable diets, countries need to assess their current diet and food supply in comparison to nutrition, health, affordability, and environmental goals. OBJECTIVES: We sought to compare Indonesia's food utilization to diets optimized for nutritional value and cost and to diets that are increasingly plant-based in order to meet further health and environmental goals, including the EAT-Lancet planetary health diet, to explore whether multiple goals could be achieved simultaneously. METHODS: We compared 13 dietary scenarios (2 current, 7 optimized, 3 increasingly plant-based, 1 EAT-Lancet) for nutrient content, cost, greenhouse gas emissions (GHGe), and water footprints, using the FAO food balance sheet, Indonesia Household Income and Expenditure Survey household food expenditure, food composition, life cycle assessment, food losses, and trade data. RESULTS: The diversity of modeled scenarios was higher than that of current consumption, reflecting nutritional deficiencies underlying Indonesia's burden of different forms of malnutrition. Nutrient intake targets were met best by nutrient- and cost-optimized diets, followed by the EAT-Lancet diet. Those diets also had high GHGe, although less than 40% of a scenario in which Indonesia would adopt a typical high-income country's diet. Only the low food chain diet had a GHGe below the 2050 target set by the EAT-Lancet commission. Its nutrient content was comparable to that of a no-dairy diet, slightly above those of fish-and-poultry and current diets, and somewhat below those of the EAT-Lancet diets. To meet nutrient needs, some animal-source foods had to be included. Costs of all except the optimized diets were above the current national average food expenditure. No scenario met all goals simultaneously. CONCLUSIONS: Indonesia's consumption of rice and unhealthy foods should decrease; food production, trade, and processing should prioritize diversification, (bio)fortification, and limiting environmental impacts; and consumer and institutional demands for healthy, nutritious, and sustainable foods should be stimulated. More granular data and tools are required to develop and assess more detailed scenarios to achieve multiple goals simultaneously.

Beyond price and income: Preferences and food values in peri-urban Viet Nam.

Sub-optimal diets are one of the most important risk factors contributing to the global burden of disease. Developing a better understanding of the drivers of food choice, including the role of individual preferences, is important to address this issue. The objective of this mixed methods research was to identify the relative importance of preferences for different food quality attributes (e.g. nutrition, food safety, price and convenience) that might influence shopping habits and food choice in the context of a rapidly changing peri-urban food environment in Hanoi Province, Viet Nam. A total of 264 women were randomly selected and interviewed using Best-Worst Scaling to elicit preferences among food quality attributes for different food groups (leafy green vegetables, fruits, instant foods, snack foods). A subset of these respondents (n = 40) participated in focus group discussions in order to explore their preferences and food values in more detail. The food quality attributes considered to be most important varied by food group with nutrition and food safety (both immediate and future health) ranking highest for leafy green vegetables and fruits, convenience for instant foods, and taste for snack foods. Price was considered least important across all food groups. Focus group discussions reinforced these results with additional insights particularly regarding trade-offs between nutrition, food safety, convenience, and price. This research demonstrates the feasibility of identifying important drivers of consumption in a South East Asian context using Best-Worst Scaling. These results could help inform the design of behavior change interventions and guide food system policies that seek to shift consumer choices towards healthier diets.

Compound climate risks threaten aquatic food system benefits.

Aquatic foods from marine and freshwater systems are critical to the nutrition, health, livelihoods, economies and cultures of billions of people worldwide, but climate-related hazards may compromise their ability to provide these benefits. Here, we estimate national-level aquatic food system climate risk using an integrative food systems approach that connects climate hazards impacting marine and freshwater capture fisheries and aquaculture to their contributions to sustainable food system outcomes. We show that without mitigation, climate hazards pose high risks to nutritional, social, economic and environmental outcomes worldwide-especially for wild-capture fisheries in Africa, South and Southeast Asia, and Small Island Developing States. For countries projected to experience compound climate risks, reducing societal vulnerabilities can lower climate risk by margins similar to meeting Paris Agreement mitigation targets. System-level interventions addressing dimensions such as governance, gender equity and poverty are needed to enhance aquatic and terrestrial food system resilience and provide investments with large co-benefits towards meeting the Sustainable Development Goals.

Gaps and priorities in assessment of food environments for children and adolescents in low- and middle-income countries.

School-aged children and adolescents have complex interactions with their food environments-the point of engagement of individuals with the food system-and are influenced by a diversity of individual, household and organizational factors. Although a wide range of methods have been proposed to define, monitor and evaluate food environments, few are tailored to school-aged children and adolescents. Here, we interrogate published literature on food metrics and methodologies for the characterization of food environments for school-aged children and adolescents living in low- and middle-income counties. We identify key priority actions and potential indicators for better monitoring and evaluation to galvanize policymaking to improve the healthiness of these interactions, which are so crucial to future adult well-being.

Articulating the effect of food systems innovation on the Sustainable Development Goals.

Food system innovations will be instrumental to achieving multiple Sustainable Development Goals (SDGs). However, major innovation breakthroughs can trigger profound and disruptive changes, leading to simultaneous and interlinked reconfigurations of multiple parts of the global food system. The emergence of new technologies or social solutions, therefore, have very different impact profiles, with favourable consequences for some SDGs and unintended adverse side-effects for others. Stand-alone innovations seldom achieve positive outcomes over multiple sustainability dimensions. Instead, they should be embedded as part of systemic changes that facilitate the implementation of the SDGs. Emerging trade-offs need to be intentionally addressed to achieve true sustainability, particularly those involving social aspects like inequality in its many forms, social justice, and strong institutions, which remain challenging. Trade-offs with undesirable consequences are manageable through the development of well planned transition pathways, careful monitoring of key indicators, and through the implementation of transparent science targets at the local level.

The Role of Healthy Diets in Environmentally Sustainable Food Systems.

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.

Nutrition Transition and Climate Risks in Nigeria: Moving Towards Food Systems Policy Coherence.

PURPOSE OF REVIEW: The purpose of this review is to describe the combined impacts of the nutrition transition and climate change in Nigeria and analyze the country's national food-related policy options that could support human and planetary health outcomes. RECENT FINDINGS: This paper uses a food systems framework to analyze how the nutrition transition and climate change interact in Nigeria affecting both diets and the double burden of malnutrition, resulting in what has been termed the syndemic. Interactions between climate change and the nutrition transition in Nigeria are exacerbating diet-related inequities and will continue to do so if food systems continue on their current trajectory and without significant transformation. Siloed policy actions that attempt to mitigate one aspect of food system risk can create a negative feedback loop in another aspect of the food system. Our analysis finds that Nigeria has five national policies that include actionable steps to address food system insufficiencies; however, each of these policies is constrained by the boundaries of singular nutrition, climate change, and agricultural objectives. The country should consider a coherent policy environment that explicitly identifies and links underlying systemic and institutional drivers between climate change and malnutrition that simultaneously and comprehensively address both human and planetary health outcomes of food systems. The systemic and institutional outcomes of this emerging syndemic-undernutrition, obesity, and climate change-are inexorably linked. Nigeria lacks a coherent policy environment taking on this challenging syndemic landscape. The analysis in this paper highlights the need for Nigeria to prioritize their national nutrition and agricultural and climate policies that uncouple feedback loops within food systems to address climate change and malnutrition in all its forms.

Global drivers of food system (un)sustainability: A multi-country correlation analysis.

At present, our ability to comprehend the dynamics of food systems and the consequences of their rapid 'transformations' is limited. In this paper, we propose to address this gap by exploring the interactions between the sustainability of food systems and a set of key drivers at the global scale. For this we compile a metric of 12 key drivers of food system from a globally-representative set of low, middle, and high-income countries and analyze the relationships between these drivers and a composite index that integrates the four key dimensions of food system sustainability, namely: food security & nutrition, environment, social, and economic dimensions. The two metrics highlight the important data gap that characterizes national systems' statistics-in particular in relation to transformation, transport, retail and distribution. Spearman correlations and Principal Component Analysis are then used to explore associations between levels of sustainability and drivers. With the exception of one economic driver (trade flows in merchandise and services), the majority of the statistically significant correlations found between food system sustainability and drivers appear to be negative. The fact that most of these negative drivers are closely related to the global demographic transition that is currently affecting the world population highlights the magnitude of the challenges ahead. This analysis is the first one that provides quantitative evidence at the global scale about correlations between the four dimensions of sustainability of our food systems and specific drivers.

Can Diets Be Healthy, Sustainable, and Equitable?

PURPOSE: The purpose of this study was to review the evidence on global dietary intake and trends in dietary patterns over time and to examine associations between diets and health, environment, and equity. RECENT FINDINGS: Diets now serve as a significant risk factor for the global burden of disease and death. Diet-related non-communicable disease and rising obesity are increasingly prevalent, affecting much of the global population. At the same time, the food system is producing food in ways that are not aligned with planetary health. Inequity restricts access to healthy diets and is associated with broad social determinants. Current dietary patterns are increasingly unhealthy, unsustainable, and inequitable for many populations. Multi-pronged interventions are needed to address the impacts of diets in order to improve human and planetary well-being.